The British Psychological Society (BPS) is pleased that the 2018 NICE ADHD GUIDELINE - has been amended to improve SAFEGUARDING OF CHILDREN following its comments

FROM THE BPS WEBSITE 21-03-18

The British Psychological Society (BPS) is pleased that the 2018 NICE ADHD guideline has been amended following our comments during the consultation process.A number of additions relating to child safeguarding have been made, including:

- Environmental factors must be fully accounted for and appropriately adapted prior to a diagnosis of ADHD being made.
- A behavioural baseline must be established.
- Parents of children under five must have completed a recognised and accredited parent training course before a diagnosis of ADHD is considered.
- In the case of under fives, the advice of another qualified tertiary professional should be considered before a diagnosis of ADHD is made.
Dr Brian Apter, who led the Society's response, said:

"I am pleased that the consultation process has borne fruit and a number of safeguarding checks and balances have been added.

This new guidance will stand for 10 years before further revisions are considered, during this time it is vital that psychologists comply with this guidance to ensure the safeguarding of children and young people in the organisations that they work for and with."

Child psychologists are well placed to challenge medical practitioners when there is a Safeguarding concern due to a prescribed drug's side effects in a case where they are co-working.

You can read our full consultation response here.The Society produce responses to a number of consultations - for more information on these, including on how you can get involved, visit our consultations page.

ETHICAL MINDFULNESS - A Reflective Checklist for Child Mental Health Professionals who Prescribe Psychotropic Medicines Endorsed by the DECP Committee of the British Psychological Society - June 2016 and Prof Allen Frances again in March 2018.

A Reflective Checklist for Child Mental Health Professionals who Prescribe Psychotropic Medicines Endorsed by the Division of Educational and Child Psychology Division Committee of the BPS  in June 2016 and subsequently by Professor Peter Kinderman, the then President of the British Psychological Society (See enclosed letter)

This year’s chairperson of the DECP, Brian Apter, as expressed in his ‘Chair’s Notes feels an article outlining the rationale underpinning the development of this Reflective Checklist by the Medicalisation Subcommittee of the Division of Educational and Child Psychology is needed at this stage to inform our members and all psychologists of its development so as to help them effectively challenge practice in cases where they have ethical and long term health concerns about the children with whom they co-work.

The idea for this Reflective Checklist for Mental Health practitioners is for prescribers of psychotropic medications to children in the U.K. to use as an aide-memoire on their desks to better safeguard the wellbeing of children they work with and came from Atul Gawande’s inspirational and practical work on checklists applied to the fields of surgery and neo-natal emergencies in the U.K. which have had profoundly beneficial outcomes on client survival rates. Atul Gawande is a Professor of Surgery at Harvard Medical School and believes that incredibly complex processes and decisions can be improved and made safer by simple prompt questions and common sense practical procedures. His seminal book was 'The Checklist Manifesto.' 2009 which is an international bestseller and has provoked radical approaches in many fields.

The rapidly increasing prescription rates of psychotropic drugs for children by Child Psychiatrists and Paediatricians in the U.K. over the last two decades  has alarmed many mental health practitioners and professional bodies alike such as the Division of Educational and Child Psychology and the Association of Educational Psychologists (AEP) as well as colleagues in America where the situation is even more extreme. In some States the prescription rate for Methylphenidate alone is 16% of the total school population which most professionals would want to avoid in the U.K.

As reflective practitioners and being ‘Ethically Mindful’ of the paramount principle of the Safeguarding Children in our shared care the DECP Medicalisation of Childhood Subcommittee has endeavoured to produce a positive contribution to this critical area of multi-professional debate and good practice. We hope that applying the much celebrated above approach of using simple and thought provoking question prompts could significantly improve the Safeguarding of vulnerable groups in society such as children.

The checklist went through many stages of generating suitable questions and consultation with colleagues about their suitability.The questions were then further refined to improve their face validity and effectiveness at making practitioners consider the importance of midfully making the decision to medicate a child in their often very busy working day. It is still our hope that child psychiatrists and paediatricians, themselves, through consideration by their professional bodies could then be distributed as a desk top aide-memoire which could be situated next to their prescription pad or indeed combined with it as one item. This would act as a significant additional safeguard we feel.

 Obviously we do not want to unnecessarily duplicate procedures, such as the excellent NICE Guidelines for specific conditions for well trained and informed professionals but we do believe that a brief pause where they take stock with a period of reflection may in the long term benefit the client group we all serve.  We hope as many colleagues in the field have already indicated that a few minutes well spent may enhance the decision making at the point of prescription and moderate unnecessary overprescribing to children who may well on reflection fall within the normal range of children experiencing higher levels of mental distress for whatever causal combination of environmental, social and biological factors.

The common-sense and reflective nature of the questions we have posed are, we feel, both practical and ethical in nature .  Sadly despite our best efforts and success at drawing it to the attention of the appropriate professional bodies which initially showed a lot of promise at  high levels within the organisations it seems that the inevitable committee considerations has not reached any positive conclusion at this stage. This in some way mirrors the consideration of new NICE Guidelines that we have also been involvedribers from potential complaint rather than  better Safeguarding Children from what the President of the Royal College of Psychiatry, Sir Simon Wessely has refe in in the intervening period. The worrying trend seems to be a tendancy to protect prescrred to as, ‘over-zealous prescribing.’

We must persist with trying to influence good practice in this regard at both a personal interaction level with the medical colleagues we work with supporting children on our caseloads and at a professional collaboration level in setting up NICE’s preferred model of multi-agency pathways for child behaviour.

Some of the many endorsements received since it has received international coverage in articles include:

1)From the Psychiatric Times website - July 2015 - Professor Allen Frances, ex- editor in chief of DSM-IV states, "Overwhelmed teachers often recommend that parents take their kids to doctors for medicine when the problem may be more in the classroom than in the kid. Dave Traxson, a child and educational psychologist and his colleagues in the United Kingdom, have come up with a terrific suggestion to help contain the epidemic of careless medication in kids. They have developed a checklist of questions doctors should think about before prescribing psychoactive drugs to children."

Prof Allen Frances Psychiatrist 2018:This checklist is the best way to stop doctors from over-prescribing psych meds for kids.Forces them to do more thorough evaluation & to consider the many safer alternatives. LINK: 
https://t.co/unJicQf5r2 (https://twitter.com/AllenFrancesMD/status/978989855655931904?s=03)

Thanks Allen.

2)“ I saw the proposed checklist re: child psych medications in Psychiatric Times. It seems clear, thoughtful and feasible. Thank you.” Lloyd Sederer, MD. Medical Director, NYS Office of Mental Health, Adjunct Professor, Columbia/Mailman School of Public Health. Medical Editor for Mental Health, The Huffington Post.

3)"Thanks for the check list. I wonder how many children would really need medications after working through this check list? I am a child and adolescent psychiatrist , and as the years go by I find fewer and fewer children really need medications, and more and more do so much better without the meds that didn´t really help in the first place. But it is not popular talk around the block."   Lisbeth Kortegaard - Consultant Child and Adolescent Psychiatrist at Child and Adolescent Psychiatry in Hoejbjerg, Central Region, Denmark.  

4) Professor Peter Kinderman - President of the BPS 2016-17 stated -

I am happy personally to endorse the Reflective Checklist that the Division of Educational and Child Psychology approved for limited dissemination at their June Committee meeting, following their consultation with some interested partners and to thank you all for your work on this issue.

The Reflective Checklist having been duly endorsed by the DECP, as well as a range of significant external partners, including the General Secretary, Kate Fallon, of the Association for Educational Psychologists, means I am very happy to join with them in this regard. I agree with your hope and that of Professor Allen Frances (Editor in Chief of DSM-IV) expressed a couple of weeks ago on his blog that, were the Checklist to be used by the two main groups of prescribers for children and young people i.e. child and adolescent psychiatrists and specifically trained paediatricians, that the number of prescriptions of psychotropic medication would become more reasonable over time.

You mentioned that you would also be pleased to remain involved in this initiative and to liaise with me and the DECP Committee where appropriate and to start a conversation with the President of the Royal College of Psychiatrists, Sir Simon Wesseley who is already aware of this initiative, with a view to the RCP using it as a stimulus for meaningful discussion amongst their membership of the concept.

5) Caroline Martin, Chief of the ETB in the City of Dublin as feedback on this post: "This Reflective Checklist designed by Dave Traxson endorsed by the BPS Division of Educational & Child Psychology (amongst several notable others) is an excellent resource. It is targeted for use by those who prescribe psychotropic meds to children. However, I suggest it can also be used by educational & psychological professionals who are responsible for determining and/or implementing interventions for children. We need to stop assuming the source of the problem lies within the child and checklists like this challenge this assumption. Granted, this will make for some more uncomfortable conversations."

AND NOW THE CHECKLIST - DISCUSS ITS BENEFITS

A Reflective Checklist for Child Mental Health Professionals who Prescribe Psychotropic Medicines Endorsed by the Division of Educational and Child Psychology Division Committee of the BPS  in June 2016.

                              PAUSE -  REFLECT  -  REVIEW 

· Are the child’s behavioural differences pervasive, occurring in a wide range of social settings and observed by a range of different individuals in the community?

· Are the child’s difficulties severe, enduring, and significantly impairing?

· Have there been any stresses in the child’s relationships, social context, and recent history which might explain this pattern of behaviours?

· Does the child have presenting behaviours that closely conform to an approved usage for the particular medication being considered at this time?

· Is there research evidence on the efficacy and safety of this specific medication with children of the same age, gender, and social grouping?

· Are the child’s presenting behaviours significantly impairing in a range of settings to acceptably balance the possible impact on the child’s developing brain and body from the evidence based side effects of the specific medications being considered?

· Do the child’s parents and involved professionals see the child’s differences as significant enough to require this medication?

· Has a psychological intervention, such as a talking therapy (CBT etc.); a social intervention such as ‘Circle of Friends’ / ‘Buddy System’ or a physical intervention such as participation in sport been tried prior to prescribing this particular psychotropic medication being considered?

· Have there been any reported significant adverse side effects from this specific medication with children of the same age, gender and social grouping?

· Have you carefully weighed up the short and long-term risks and balanced them against possible benefits?

· Have you received valid consent from the parent and the child?

And perhaps the most searching question:

· If a child in your immediate family or circle of friends had the same presenting behaviours that are in front of you now, would you still be prepared to prescribe this drug?

Professor Allen Frances - Editor in Chief of DSM-IV explains why France has less ADHD diagnoses and medication prescriptions then the U.S.

Children in France are not be medicated as an early intervention for ADHD until the age of 7 years of age. The new ADHD Guidelines from NICE 2018 in the U.K. do significantly better Safeguard the under 5s but not children up to 7 years of age.

Professor Allen Frances, Duke University, gives a few clear reasons for why France has much lower #ADHD rates than US:

1)No Big#pharma unregulated advertising in France allowed to mislead/encourage parents & teachers.

2)MD's in France use more psychosocial approaches & less pill driven interventions.

3) School systems in France are less chaotic and children have very good diet/exercise routines in school.

4)French parents are more empowered & better at engaging and disciplining their own kids

5) French professionals/parents have more time for evaluation of the early interventions.

6) They adopt a more psychodynamic approach initially and encourage exercise, therapy etc. as a viable alternative to medication.

Why French Kids Don't Have ADHD?

French children don't need medications to control their behaviour.

Posted Mar 08, 2012

In the United States, at least 9 percent of school-aged children have been diagnosed with ADHD, and are taking pharmaceutical medications. In France, the percentage of kids diagnosed and medicated for ADHD is less than .5 percent. How has the epidemic of ADHD—firmly established in the U.S.—almost completely passed over children in France?

Is ADHD a biological-neurological disorder? Surprisingly, the answer to this question depends on whether you live in France or in the U.S. In the United States, child psychiatrists consider ADHD to be a biological disorder with biological causes. The preferred treatment is also biological—psycho stimulant medications such as Ritalin and Adderall.

French child psychiatrists, on the other hand, view ADHD as a medical condition that has psycho-social and situational causes. Instead of treating children's focusing and behavioral problems with drugs, French doctors prefer to look for the underlying issue that is causing the child distress—not in the child's brain but in the child's social context. They then choose to treat the underlying social context problem with psychotherapy or family counseling. This is a very different way of seeing things from the American tendency to attribute all symptoms to a biological dysfunction such as a chemical imbalance in the child's brain.

French child psychiatrists don't use the same system of classification of childhood emotional problems as American psychiatrists. They do not use the Diagnostic and Statistical Manual of Mental Disorders or DSM. According to Sociologist Manuel Vallee, the French Federation of Psychiatrydeveloped an alternative classification system as a resistance to the influence of the DSM-3. This alternative was the CFTMEA (Classification Française des Troubles Mentaux de L'Enfant et de L'Adolescent), first released in 1983, and updated in 1988 and 2000. The focus of CFTMEA is on identifying and addressing the underlying psychosocial causes of children's symptoms, not on finding the best pharmacological bandaids with which to mask symptoms.

To the extent that French clinicians are successful at finding and repairing what has gone awry in the child's social context, fewer children qualify for the ADHD diagnosis. Moreover, the definition of ADHD is not as broad as in the American system, which, in my view, tends to "pathologize" much of what is normal childhood behavior. The DSM specifically does not consider underlying causes. It thus leads clinicians to give the ADHD diagnosis to a much larger number of symptomatic children, while also encouraging them to treat those children with pharmaceuticals.

The French holistic, psychosocial approach also allows for considering nutritional causes for ADHD-type symptoms—specifically the fact that the behavior of some children is worsened after eating foods with artificial colors, certain preservatives, and/or allergens. Clinicians who work with troubled children in this country—not to mention parents of many ADHD kids—are well aware that dietary interventions can sometimes help a child's problem. In the U.S., the strict focus on pharmaceutical treatment of ADHD, however, encourages clinicians to ignore the influence of dietary factors on children's behavior.

And then, of course, there are the vastly different philosophies of child-rearing in the U.S. and France. These divergent philosophies could account for why French children are generally better-behaved than their American counterparts. Pamela Druckerman highlights the divergent parenting styles in her recent book, Bringing up Bébé. I believe her insights are relevant to a discussion of why French children are not diagnosed with ADHD in anything like the numbers we are seeing in the U.S.

La France ne rend presque pas de médicaments aux enfants pour le TDAH - France hardly medicates any children for ADHD - byDamien Mascret.

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Publié le 16/05/2017 à 18:04

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Trop peu d’enfants souffrant de troubles déficit de l’attention ou d’hyperactivité bénéficient du traitement qu’ils devraient avoir. A l’inverse, trop d’étudiants l’utilisent mal, avec des conséquences importantes.

Depuis sa commercialisation en France en 1996, la Ritaline® et autres psychostimulants du même ordre (Concerta®, Quasym® et Medikinet®) ont permis à des centaines de milliers d’écoliers de suivre un cursus normal alors qu’ils étaient en situation scolaire périlleuse. On estime en effet que de 2 à 5 % des enfants d’âge scolaire souffrent de TDAH ( trouble déficit de l’attention/ hyperactivité), un syndrome d’origine inconnue et qui peut mélanger plusieurs symptômes.

Parfois l’hyperactivité et l’impulsivité prédominent, donnant des enfants incapables de tenir en place, d’attendre leur tour, impatients, ayant besoin d’agir mais le faisant de façon désordonnée et inefficace. D’autres fois, c’est le déficit de l’attention qui est au premier plan, avec une incapacité à terminer une tâche, l’évitement de celles qui nécessitent une attention soutenue et une distractibilité majeure. Et des formes mixtes sont possibles.

D’après les données de l’Assurance-maladie, fondées sur les bénéficiaires du régime général, 48.895 personnes étaient traitées par méthylphénidate en 2014 en France. Surtout des jeunes, puisque 20.000 étaient âgés de 6 à 11 ans et 20.000 autres de 12 à 17 ans. Il est habituel d’interrompre le traitement en périodes de vacances scolaires pour voir si celui-ci est toujours nécessaire.

Risques d’effets indésirables du traitement

Quoi qu’il en soit, 40.000 enfants traités, c’est insuffisant. Dans son dernier rapport sur les données d’utilisation et de sécurité d’emploi en France du méthylphénidate (avril 2017), l’Agence du médicament (ANSM) estime que «le nombre d’enfants souffrant de TDAH en France métropolitaine serait compris entre 190.000 et 480.000 ». Ainsi, plusieurs centaines de milliers d’enfants ne bénéficient pas du traitement qu’ils devraient avoir.

L’ANSM souligne pourtant que le TDAH «est à l’origine d’une altération importante des relations avec l’entourage et de l’apprentissage scolaire, et nécessite une prise en charge psychologique, éducative, sociale et familiale, en particulier quand les symptômes deviennent un handicap et sont une source de souffrance».

Il faut dire que la brochure de l’ANSM destinée aux parents fait frissonner tant elle insiste sur les risques d’effets indésirables du traitement. Sur le plan neuropsychiatrique: l’apparition de tics moteurs ou verbaux, d’agressivité, de manque d’appétit, voire d’hallucinations, de paranoïa ou de dépression. Sur le plan cardio et cérébro-vasculaire: palpitations, maux de tête, etc. La brochure rappelle aussi que «le méthylphénidate pourrait ralentir la croissance et la prise de poids».

Mais ce qui inquiète surtout l’Agence, c’est le mésusage important observé dans de nombreux pays et, à un degré moindre en France. Par des toxicomanes, mais aussi par des étudiants sans TDAH qui espèrent ainsi augmenter leurs facultés de concentration. L’ANSM insiste sur le risque de dépendance et les effets secondaires possibles du médicament.

«Vigilance requise»

Le 12 janvier dernier, la commission des stupéfiants et des psychotropes de l’ANSM se penche sur le méthylphénidate. Ce jour-là, le Dr Samira Djezzar (Centre d’évaluation et d’information sur la pharmacodépendance de Paris), présente les résultats de l’enquête officielle d’addictovigilance. Elle souligne «une tendance générale à la hausse des cas de pharmacodépendance notifiés».

Mais le Dr Luc de Haro, médecin généraliste à Marseille, suivi par d’autres membres de la commission, met en garde: «La vigilance est requise pour ne pas priver du traitement les enfants qui en ont besoin tout en évitant les dérives», fait-il remarquer. Finalement, la commission propose à l’unanimité de rappeler aux médecins et pharmaciens «les conditions de prescription et de délivrance, précisant les différents risques notamment chez l’adulte liés à l’abus et au détournement du méthylphénidate». Prudent, mais sans doute insuffisant pour améliorer l’utilisation chez les enfants.