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Wednesday 26 October 2011




£32 million released by Minister for Counselling and Psychological interventions to avoid drugs.
A letter to all doctors reminding them of NICE Guidelines for

-NOT TO USE WITH PRESCHOOLERS i.e. under the age of 6







McFadden (Wolverhampton South East) (Lab): It is a pleasure to see you chairing the debate, Mr Howarth. I secured the debate because I want to talk about how we treat behavioural problems such as attention deficit hyperactivity disorder in children, and, in particular, about the increasing use of drugs to treat those problems.

I have been tabling questions on this issue for some months. I am sure that it is a complete coincidence that this morning, just a few hours before the debate, the Government announced an extra £32 million for children’s mental health therapy, including talking therapies. That news will be welcomed by parents and professionals, because it is important—a point that I want to stress—to have a range of treatments available for young children who suffer from this condition. Will the Minister confirm whether that is new money, or whether it is part of the wider £400 million announcement, made in February, on mental health? If it genuinely represents extra resources for mental health therapy for children, that is of course welcome. I also welcome its happy coincidence with this debate today.

My main focus is on the use of drugs to treat ADHD and similar conditions. The main drug that we usually talk about in this field is Ritalin. Ritalin is a brand name for methylphenidate hydrochloride, and it is this whole family of drugs that I want to talk about. I want to set out the trend of increasing use of these psychotropic drugs to treat ADHD, and the growth in their use for very young children—sometimes in breach of National Institute for Health and Clinical Excellence guidelines. I want to spell out why many in the field believe that this trend is likely to continue. Finally, I will issue a plea to the Minister to carry out a proper, comprehensive review of the use of these drugs involving professionals from the medical, psychology and teaching fields, as well as the families of those who have been prescribed the drugs.

Paul Flynn (Newport West) (Lab): Had the young Mozart been on Ritalin and the young Beethoven been on anti-depressants, we would probably never have heard of them. Does my right hon. Friend agree that trying to drug children into conformity and uniformity is the enemy of creativity?

Mr McFadden: My hon. Friend makes an eloquent point. I do not take the view that the drugs cannot work. I am not qualified to say that, but there are serious questions to be asked about the growth in their use.

The increasing use of these drugs has not just happened in the period since last year’s general election. I am not here to make a party political point. This has been going on for many years and is part of an international picture, so it is not the responsibility of a single party or a single set of politicians. Some professionals and parents believe that these kinds of drugs can be effective and have a role to play where ADHD is correctly identified, although it is also true that some psychologists believe that there is significant over-identification and diagnosis of ADHD in children. The real question is whether the drugs are considered alongside other appropriate treatments,and are used as a first option, or only after alternatives have been properly explored and considered. Let us look at the trend in the number of prescriptions in England in recent years.

A written answer in July showed that between 1997 and 2009 there was a more than sixfold increase in the number of prescriptions for methylphenidate to the point where, in 2009, 610,000 prescriptions were issued. The number had almost doubled in five years. There is no doubt that there is an increasing reliance on these drugs to treat behavioural problems in children. Methylphenidate is not always used on its own. It can often be combined with other drugs, so that the child ends up taking a cocktail of powerful drugs to control their behaviour in different ways during the course of the day.

What lies behind this trend towards the medicalisation of child behaviour problems? Why are we prescribing more and more drugs to treat such problems? Do we really believe that there has been a sixfold increase in the occurrence of ADHD and similar disorders in recent years, or are these drugs being used to treat behavioural patterns that were dealt with in different ways by parents and teachers in the past? Is the increasing labelling and categorisation of behavioural problems increasing the tendency to treat children with drugs?

Sue Morris, director of professional training and educational psychology at the University of Birmingham, recently said:

“It’s not uncommon for the diagnosis of ADHD to be based on parental reports - without observation of the child in a home or school environment. The prescription of drugs certainly shouldn’t be the first step in treating the disorder. Sometimes drugs are being used in the absence of talking therapy and psychological assistance, and that is wrong.”

There is clear guidance from NICE on the use of these drugs:

“Drug treatment should only be initiated by an appropriately qualified healthcare professional with expertise in ADHD and should be based on a comprehensive assessment and diagnosis.”

NICE also makes it clear that methylphenidate

“is not currently licensed for use in children less than 6 years old”.

NICE makes it clear that it should be discontinued if there is no response after one month, and that treatment should be suspended periodically to assess the patient’s condition. What evidence does the Minister have that this guidance is being adhered to? Are these drugs always used as part of a comprehensive assessment and diagnosis? Are they used as the first option, or only after alternatives are considered? Are they given only to children aged six and over? Are children routinely taken off them after one month if they are not effective? Is their use periodically suspended to assess the patient’s condition?

I suspect that the Minister does not know the answers to many of these questions. In fact, when it comes to the number of children under the age of six being prescribed the drugs, I know that he does not know because the Department of Health has already told me. That is not a reflection on him personally, but it exposes a gap in our knowledge that must be filled. Why is it, despite the clear guidance from the Department of Health about the appropriate age for use of these drugs, that the Department does not know how many children under the age of six are being prescribed the drugs?

Evidence from the Association of Educational Psychologists suggests an increase in the use of methylphenidate for very young children. An informal survey of their members in the west midlands suggests that more than 100 children under the age of six in that region alone are on some form of psycho-stimulant medication. As we do not ask for someone’s age when a prescription is written, the Department of Health has told me that it cannot say whether its own guidance is being adhered to. I am sure the Minister would agree that that is an unsatisfactory situation. We have clear guidance from the Government, but no clear knowledge about whether that guidance is being breached on a regular basis. That is not an acceptable situation and the Government must establish a clear picture of what is going on.

I am not asking the Minister to ask the age of every person issued with a prescription, but it would be possible, through a proper survey of practitioners, to establish how much prescribing involves very young children. Will the Minister commit today to carrying out a proper research survey of professionals in the field to establish the degree to which the guidance from NICE is being adhered to and to establishing a clearer picture, particularly with regard to the use of these drugs by children under the age of six?

The question of age is not only about the youngest children. The sharp increase in the use of these drugs in recent years means that we now have a generation of teenagers who have taken psychotropic drugs for years. What happens when they reach adulthood? What are the long-term effects and what is the appropriate alternative treatment for people trying to come off these drugs after a number of years? In its review, NICE concluded:

“Given that ADHD is a chronic condition which may require long-term treatment, there is a need for further data on long-term outcomes of drug treatments.”

There is significant regional variation in prescribing patterns, with the BBC reporting a few years ago that the highest prescribing area prescribed 23 times more than the lowest. I can understand that in any health system in which people are asked to use their judgment prescribing patterns will not be uniform, but 23 times more is a very large difference, and there is similar variation abroad. In the United States, for example, the closer someone lives to the east coast the more likely they are to be diagnosed with ADHD and prescribed these kinds of drugs.

An important feature of the growth in the use of methylphenidate to treat behavioural disorders is the American Psychiatric Association’s “Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition”—DSM-IV. The manual breaks down and categorises various psychological and behavioural disorders and has significant international influence. In 2013 it will be replaced by DSM-V.

Some people believe that such publications exacerbate a trend towards the over-medicalisation of behavioural problems. The British Psychological Society, for example, has expressed serious concerns about DSM-V. Its response to the impending introduction of the fifth edition states:

“The Society is concerned that clients and the general public are negatively affected by the continued and continuous medicalisation of their natural and normal responses to their experiences; responses which undoubtedly have distressing consequences which demand helping responses, but which do not reflect illnesses so much as normal individual variation. 

It goes on:

“Diagnostic systems such as these therefore fall short of the criteria for legitimate medical diagnoses. They certainly identify troubling or troubled people, but do not meet the criteria for categorisation demanded for a field of science or medicine”.

What is the Department of Health’s response to those serious concerns? How does the Department intend to work with the professions on the introduction of DSM-V, and does the Minister share the concerns of the Association of Educational Psychologists and the British Psychological Society that it might exacerbate the trend towards the medicalisation of behavioural problems?

It is for all those reasons—the growth in the number of prescriptions, the evidence that they are being given to very young children, the wide regional variations in their use, and the lack of firm data and evidence about the long-term effects of combining these drugs with others—that the Association of Educational Psychologists has called for a review of the use of the drugs. The review should involve paediatricians, child psychiatrists, GPs, teachers, parents and other relevant voices. We must get to the bottom of what lies behind the increased use of the drugs, and establish whether we are dealing with childhood behavioural problems as best we can.

The association’s call for a review is a call I echo today, and I hope that the Minister can confirm that the Government will undertake such a review, before the introduction of DSM-V in 2013. I hope also that he will be open-minded about my questions. I welcome the money for children’s mental health therapy that has been announced today, but it does not mean that we should ignore the questions raised in this debate. If recent trends of growth in the use of the drugs were to continue, we could end up with more than 1 million prescriptions for them, each year in England. Would the Minister be comfortable with such an outcome?

Having highlighted the growth in the use of the drugs and raised concerns about their being taken by very young children in particular, I am essentially asking the Minister to do two things. First, will he commit his Department to carry out a proper research project into the use of the drugs, including the age of the children receiving them? Secondly, in the light of the huge growth in prescriptions, will the Government carry out a proper review of practice in the field, as called for by the Association of Educational Psychologists, before the new guidance comes into effect in 2013? Those requests are moderate and measured, and I look forward to a positive response.

1.45 pm

Mr Frank Field (Birkenhead) (Lab): I am grateful to my right hon. Friend the Member for Wolverhampton South East (Mr McFadden) for securing this debate and for allowing me to address a simple question to the Minister.

Like my right hon. Friend, I am not qualified to say whether people should be on treatments or not, but I am struck by the increasing number of children in Birkenhead who are given what a group of teachers has referred to as “medical coshes” to keep them quiet. In some instances the drugs are no doubt necessary, and they work, but along with my right hon. Friend I question the growth in the number of prescriptions.

Will the Minister work with his colleagues in the Department for Work and Pensions to consider the moral hazard of someone ensuring that their child is on Ritalin so that the prescription gives them access to disability benefits? Clearly, that was never the Government’s intention, but we now have a system in which, if someone can prove that their child is ill, and keep them ill, the likelihood of the child being passported on to disability benefits increases. I know that this is not in the Minister’s sphere of influence, but in his response to my right hon. Friend’s most detailed points will he tell us whether he will co-ordinate with the relevant Minister in the Department for Work and Pensions to look at the moral hazard of someone proving their child needs to be on Ritalin to increase their chances of getting disability living allowance for that child?

1.47 pm

The Minister of State, Department of Health (Mr Simon Burns): I congratulate the right hon. Member for Wolverhampton South East (Mr McFadden) on introducing a particularly interesting and sensitive subject. He made his points very fairly and very well. In passing, I should, I suppose, declare an interest because a member of my family has for a number of years been on Ritalin and, contrary to the observations of the hon. Member for Newport West (Paul Flynn), the benefits to that person’s education have been immense—the decision was taken on clinical advice, not on the advice of parents.

I am pleased that the right hon. Gentleman has welcomed the announcement by the Minister with responsibility for social care, my hon. Friend the Member for Sutton and Cheam (Paul Burstow), of £32 million to help with children’s mental health. The right hon. Gentleman asked whether that was new money. It comes from within the £400 million that was identified by the Treasury in the spending review last year.

The right hon. Member for Birkenhead (Mr Field) asked about the link between disability allowance, and other entitlements, and children on Ritalin. The entitlement is based not on having a specific health condition diagnosis or treatment, but on what help is needed with personal care as a result of the disability. Nevertheless, I will certainly draw his comments to the attention of my right hon. Friend the Secretary of State for Work and Pensions, whose Department will hopefully get back to him.

Let me set out some of the background to this issue. According to NICE, between 3% and 9% of school-aged children and young people in the UK meet the broad criteria for mild to moderate attention deficit and hyperactivity disorder, and between 1% and 2% suffer from severe ADHD. Methylphenidate, commonly known as Ritalin, and similar drugs are used to treat a range of mental health conditions, including ADHD. The NICE guidelines, published in 2008, recommend that medication should always form part of a holistic package of care, which might include talking therapies. I fully appreciate the concerns raised by the right hon. Member for Wolverhampton South East about the increase in the number of prescriptions for Ritalin and similar drugs. We need better to understand the reason for that. It is

always wrong for doctors to prescribe medication inappropriately, and medication should not be the sole response to an individual’s condition.

I fully appreciate the concerns of those worried about the growth in prescriptions for Ritalin. We do, however, need to acknowledge the fact that too many young people and their families are not getting the support they need. The NICE clinical guidelines on ADHD said, at the time of their publication in 2008, that a minority—fewer than 50%—of all individuals who should be receiving medication and/or specialist care were in receipt of such care. If left untreated, mental health problems can lead to low attainment in school, antisocial behaviour, drink and drug misuse, worklessness and even criminality in adult life. Getting things right for children and their families—through a broad range of support to promote good mental health from the start of life, through the school years and into adulthood—can make a real difference to young lives.

The costs of doing nothing are simply too great. Across hospital and primary care, the prescribing of drugs for ADHD increased by around 12.5% between 2007 and 2010, the latest four years for which data are available, and by around 6% in 2010 alone. Prescribing in primary care alone increased by 22% in that four-year period, reflecting a significant shift in prescribing activity from a hospital setting and into primary care. Looking back further, one sees that prescribing in primary care has tripled in the past 10 years. Some variation in the prescribing of ADHD drugs around the country must be expected in the light of the distribution of specialist services, which might be more likely both to diagnose children with ADHD and to support GPs in taking responsibility from hospital teams for repeat prescriptions; the different local patterns of prescribing across primary care and specialist settings; and demographic factors, such as deprivation, which might be correlated with ADHD.

We do not, however, have good-quality data on the number of children and young people assessed with ADHD, against which prescribing patterns could be compared. If we had, it would be possible to gain a true measure of variations in clinical practice. Prescribing data are not routinely collected by age, but we do need better to understand the position. In the shorter term, we are investigating whether further helpful information can be derived from prescribing research databases. As a result, the data we do have must be interpreted with care and in the context of all the evidence that suggests under-diagnosis and under-treatment of this distressing behavioural disorder.

Mr McFadden: The point about age is important. The NICE guidelines on children under 6 could not be clearer. The Minister acknowledges that the Government do not know—I will leave aside whether that is a good state of affairs—how many children are prescribed these drugs. His Department has a research budget, so, rather than trawling other research projects, why can it not commit to research to find out from professionals how many children under 6 have been prescribed such drugs?

Mr Burns: The right hon. Gentleman anticipates my remarks on the NICE guidelines, and I hope that once he has heard them the situation will be clearer.

The 2008 NICE clinical guidelines on the treatment of ADHD are clear that medication is an appropriate treatment for severe ADHD, but that it should be initiated only by a specialist and should form part of a holistic care package that may include talking therapies. The guidelines do not recommend drug treatment for pre-school children, and health care professionals are expected to take the guidelines fully into account when exercising their clinical judgment. They do, however, have the right to prescribe the drugs if they feel it is clinically justified and in keeping with specialist consensus, given the individual circumstances of the child and in consultation with the parent or guardian. Such prescribing can include so-called off licence prescriptions, which means a prescription of medication outside its licensed age indications.

The right hon. Gentleman has asked the Department of Health to conduct a review of the prescription of drugs for the treatment of ADHD, working with families, teachers, medical and mental health professionals. It is, however, for NICE, as an independent organisation, and not for the Department of Health, to review the evidence and to provide national clinical guidance. Between 30 August and 12 September, NICE consulted stakeholders on whether to update its 2008 clinical guidelines. The review is a thorough assessment of the ways in which evidence on ADHD, including pharmacological treatments, has since developed. It will announce a final decision on its review shortly.

In June 2007, the UK led a European review of the risks and benefits of Ritalin and sought advice from independent scientific advisory groups on the available evidence. As a result of that review, the prescribing guidance for patients has been updated to ensure that it contains clear, comprehensive information about the effects of Ritalin and the importance of monitoring children and adolescents throughout their treatment. The safety of Ritalin remains under close review. In addition, the findings of research continue to inform the field and a number of bodies may commission such research, including the National Institute for Health Research. The Government are committed to improving mental health outcomes and have laid down important principles for the future in the strategy, “No health without mental health”, published earlier this year.

The emotional well-being and mental health of children and young people are vital to them as individuals, to their families and to wider society. A principle of the Government's mental health outcomes strategy is the importance of prevention and early evidence-based intervention. Half of those with lifelong mental health problems first experience symptoms before the age of 14, and three quarters of them before their mid-20s. Indeed, today, the Minister with responsibility for social care, my hon. Friend the Member for Sutton and Cheam, has announced £32 million of funding to improve access to psychological therapies for children and young people over the next four years.

Psychological therapies can in some cases form part of the holistic package of care that NICE recommended for children and young people with ADHD. It is important that a range of clinicians—paediatricians and GPs as well as child and adolescent mental health service professionals—are well informed on the diagnosis and treatment of mental health problems in children and young people. I am pleased to tell the right hon. Gentleman that the chief medical officer and the NHS medical director plan to write to clinicians to remind them of the full range of NICE guidelines on conditions—including ADHD—that affect children's mental health. They will highlight the opportunities to support rigorous use of evidence-based treatment through the improving access to psychological therapies programme. High-quality, evidence-based treatment is central to our programme to transform mental health services for children.

The right hon. Gentleman referred to DSM-V. This point goes much wider than ADHD alone and touches on the appropriateness of diagnostic categories that are the subject of international professional consensus through the American Psychiatric Association and through the World Health Organisation. The Association of Educational Psychologists and other concerned professional organisations might wish to make their representations on this issue through the American Psychiatric Association and the World Health Organisation.

The right hon. Gentleman asked what the Government’s response would be, but it is not the responsibility of the Department of Health to respond. The professional bodies respond and reach a broad, scientific consensus on the way forward.

I fully appreciate the concerns of those worried by the increasing number of prescriptions for Ritalin and similar drugs. We are investigating whether further helpful information can be derived from prescribing research databases. It is of course for NICE, not the Department, to review the broader evidence and to consider the case for updating the existing clinical guidelines. That is what it has been doing and we await its conclusion. Furthermore, the NICE clinical guidelines on ADHD state that drug treatment for children and young people with ADHD

“should always form part of a comprehensive treatment plan that includes psychological, behavioural and educational advice and interventions.”

The NICE guidelines do not replace the clinical judgment needed to treat individual cases, but health care professionals are expected to consider fully the guidelines alongside professional consensus when exercising their clinical judgment.

2 pm
Mr Pat

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