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Ritalin Over Prescribed?

According to the Daily Mail, Wednesday 24th February 1999, "British Doctors were yesterday warned to curb the use of a 'miracle drug' which is being given to thousands of hyperactive children. The International Narcotics Control Board - a United Nations agency - reported that the number of prescriptions for Ritalin doubled in this country last year." This article followed similar reports on BBC News and Radio this week and culminated in a further article in the Daily Mail on Saturday 27th February.

In an interview with Simon Hensby of adders.org, Dr.Geoffrey Kewley, one of the country's leading ADHD specialists, hit back stating that, "rather than over prescribing, Ritalin is being grossly under prescribed in this country". Using Professor Eric Taylor's figure of 1% of children in the UK having severe ADHD, as published in the British Medical Journal, this would mean at the very least, 120,000 children suffer from the condition in the United Kingdom. The INCB's figures, however, suggest 15,000 children are being prescribed Ritalin in the UK. In the same Daily Mail article they quoted a generally more accepted figure, of 5% of boys and 2% of girls that are thought to have the disorder. This would give a figure of around 600,000 likely child sufferers. By anyone's calculations even 15,000 children being prescribed Ritalin against at the very least 120,000 (12.5%) or a more likely figure of 600,000 (2.5%) children who should be taking it, this is hardly a basis for describing this as over prescribing.

Dr.Kewley stated that "rather than calls for it to be curbed; we should be looking at why it is grossly under prescribed. It is essential to relate any discussion of the use of Ritalin to the severity of the condition being treated and to it's incidence.

Academics are often those making such decisions - people who are not in touch with the reality of living with a child with significant untreated ADHD and possibly associated ODD, which is so destructive to families and relationships.

ADHD must be seen as a significant, Child and Adult Mental Health issue and it is grossly misleading to merely emphasise medication issues, without relating them to the reality of the condition and its impact on sufferers and their families".

Dr.Kewley added, "if these figures of incidence against actual diagnosis were related to inhalers being prescribed for child asthmatics then there would be a huge public outcry".

The Daily Mail also stated that fears had been growing about the long term effects of Ritalin in that it could lead to children being prone to addictions. Dr.Kewley stated that "he had been assessing, diagnosing and managing ADHD for many years and had never come across such a case. Indeed untreated, people with ADHD are predisposed to alcohol and substance abuse, often in an unwitting attempt to self medicate their condition". In all the patients he sees at his clinic, The Learning Assessment Centre in Horsham, West Sussex, 95% of the children prescribed Ritalin have found it to be of tremendous benefit, whilst only 5% have had some short term side effects, such as, loss of appetite and sleep problems. He added that he had "never come across a child who had had a craving for his Ritalin".

Is the INCB saying that parents would allow their children to be on this type of medication for probably the rest of their lives, if it wasn't necessary or effective?

Click on the link to read Dr.Kewley's article for the British Medical Journal entitled "Attention deficit hyperactivity disorder is underdiagnosed and undertreated in Britain"

Dr.Kewley recently published book is called "ADHD: Recognition, Reality and Resolution", which is one of the few from an UK perspective. Price £12.50 plus £1.50 postage UK (£2.50 Europe, £6.00 overseas) from The Learning Assessment Centre, 2nd Floor, 44 Springfield Road, Horsham, West Sussex. RH12 2PD. Fax: 01403 260900

Comment by Dr.Billy Levin from South Africa

Overview Ritalin and ADHD

There is a world of information , written by experts that is available for the purpose of enlightening people who have an interest in this field. The amount of information is inconceivable and it is accurate and scientific. There is equally as much , if not more, mis-information that is made public. This needs to be addressed very seriously. For many reasons it would appear that the mis-information is more readily read than the facts. This can only be a tragedy where patients are involved. This is not only my opinion. It can be justified with references. It would be vital for any committee sitting to deliberate about the use of Ritalin , the pros the cons, the methods of assessment and diagnosis, to obtain correct information from authoritative sources and so counter mis-use due to ignorance.

Mis-use of Ritalin has many forms:

A child who should have it, and is not getting it.

A child who is getting it, and should not be getting it.

A child who is getting it, but incorrectly dosed.

A child who is getting it, correctly dosed but incorrectly managed.

All these factors need to be considered when we justify the use of Ritalin.

It is necessary to have a knowledge of developmental norms in children, clinical criteria for diagnosis, systems for evaluation, knowledge of neuronatamy, a knowledge of pharmacology and more. Parent and teacher education plays a very important part in the treatment of children with ADHD who are placed on Ritalin. Initially on a trial basis, not to establish if it safe,( it is safe,) but to establish whether the child benefits. There are specific methods and systems that can be used to assertion this.

Even under ideal circumstances, there are still negative influences that hamper progress. Parents are afraid and stop medication because of perverted information. Teachers with the same information will persuade parents to stop treatment or simply refuse to accept that this condition exists. This despite the fact that the Nobel Prizewinner, Roger Sperry has elucidate the neurology of the condition. The teachers consider the child to be lazy , naughty or stupid and belittle the child. These children often get teased because they don't achieve. When given medication the children are labeled as "pill takers" or worse. The teachers often do not appreciate the vital importance of correct timing, correct dosage of medication, or the re-evaluation of these factors that leads to effective treatment. At some stage in the past, the Education Department banned the use of evaluation forms in the schools, despite most textbooks recommending their use. Quite a thought! Luckily this has changed.

There are also other negative situations that need to be considered. Children are often given programs that are not beneficial, or even worse, that are detrimental .These programs, which have been condemned by experts are being peddled to unsuspecting parents, to be used on innocent children only to increase their suffering. There is reference and documentation to this as well.. This whole volatile and emotive situation about the use of Ritalin, and the diagnosis of these childrens' condition has been going on for probably the last 30 years or more without a final solution being reached. Yet throughout these years, one thing has been constant. Experts have always suggested that Ritalin is safe, effective, but needs to be used correctly for the right type of patient. Ritalin is part of the treatment .It is not "THE" treatment.. These children do need motivation especially from the parents, educational help from the teachers and they have a very important role to play in overcoming their own problems. Hard work! This applies to a behavior or a learning problem, or both. Some need even more than this.

While their problems are being solved they, still have to cope with the negativism and ignorance that abounds. This simply acts as, yet another totally unnecessary hurdle.

In the 1970's an international expert, Professor Renshaw from Loyola University, Chicago, stated that it was her fervent wish and hope that the end of the 80ís would achieve an acceptable standard for diagnosis and treatments. I gave a lecture at a National Medical Congress in Cape Town in 1980 on A.D.H.D. I suggested that although I was a fan and a deciple of Professor Renshaw, she was wrong. I doubted that by the end of the century this status would be achieved. 18 Years later, we still do not have that status. Perhaps these meetings that we are holding here, will be a platform to recognize established scientific facts and to achieve for these children. It is my hope and prayer that we succeed. Otherwise I have wasted 25 years of my medical career studying in great detail one condition.

To make wise decisions on a committee such as this requires total knowledge and insight of the whole situation. To be able to sort out from all the available information which is relevant and which is not, which is factual and which is not cannot be easy. I am in a position to make claim with a little bit of flexibility that I am up to date on world literature and update myself every 3rd month. I have been doing it for the past 15 years, although I have been involved in this field of medicine for 25 years. The American Psychological Association claim they have psychologists translating every article published in authoritative journals from the whole world into English and summarizing these into a journal called "PsycScan"L.D/M.R. It is published every 3 months averaging about 2000 to 2500 articles a year. ( +/- 35,.000 articles from one journal alone!). It has been anecdotally stated that more has been written about Ritalin and ADHD than any other condition in all of medicine. I believe this. I would go further and say there is probably more mis-information written than genuine information. Why should this be? We do not see it in other fields of medicine. I think there is a good explanation. There are organizations who are well placed and well funded, who would do everything in their power to undermine, belittle, confuse and pervert the truth for ulterior motives and personal financial gain. As long as this is happening it must be extremely difficult for the truth to surface and for science to prevail.

There is another reason why this field is so confusing to the uninitiated and even to some of the initiated. Who in fact are stakeholders in the treatment of these children? If it is medical, is it a G.P, Psychiatrist, Neurologist, Pediatrician or Physician who should lead the pack? The solution to this has already been forthcoming from the South African Medical and Dental council, but no-one bothers to look at it..... So be it! If it is psychological then why are Doctors interfering? If it is Medical why are the Psychologists interfering ? (I am not taking sides , I am just stating possibilities). Let us not forget the other role players. Is it an educational problem? The previous Minister of Education made a concerted attempt to solve the problem, a few weeks after I had the privilege to visit him. How many teachers know about Study Guide no.7 of 1991. Where do teachers or remedial teachers fit in? Let us spread our wings. What about Pharmacists, Speech Therapists, Occupational Therapists, Optometrists, Dietitians and Homeopaths? There is sufficient research to indicate who should be involved, but few bother to look at it! ... So be it. Yet, everybody wants his or her slice of the cake.

I want to come back to the Medical Fraternity. There are clear guidelines, methods and systems that have been laid down by the experts, and that have been tried repeatedly and have been found to be effective. They are not being used by most of the Doctors who treat these children. Is there a reason? Whatever the answer, there is general confusion and a lack of insight. But, to be sure, there is a better way.

This is not a question of, is too much Ritalin being used. It is more a question of, is Ritalin been correctly used for those who really do need it? This will ensure that the former does not happen. We should not confuse mis-use ,abuse or addiction. They are all totally different. There appears to be substantial misuse, some abuse, no addiction but gross confusion.

As long as there is in fighting with lack of knowledge by team members. As long as there are outside influences and an undercurrent of sabotage there cannot be success. I hope in some small way I can contribute towards clarifying the situation, improving facilities and bringing about the changes that would benefit patients with A.D.H.D and related conditions, while serving on this committee with you all.

DR. B LEVIN




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