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Rapid Responses: Rapid Responses published:
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Parental (and the child's) views are also important!
- Ashok Nathwani (20 October 2000)
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Evidence and belief in ADHD
- Marie France Muir (4 November 2000)
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Re: Parental (and the child's) views are also important!
- Edmund Kingston (4 November 2000)
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Acknowledge role of parents
- Murray Bodin (6 November 2000)
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The reintroduction of Methylphenidate in Italy needs careful monitoring
- Maurizio Bonati (8 November 2000)
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Ashok Nathwani, Consultant Paediatrician, Community Child Health Portsmouth Healthcare NHS Trust, U.K.
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I read your editorial on "Evidence and belief in ADHD" with great interest (1). There is no doubt that this is an area which can generate a great deal of divergent views amongst professionals. The collaborative multimodal treatment (2) study of children, in spite of the methodological flaws highlighted, is an important study that may inform tretamnet choices. However, what is important to also consider when the treatment on offer may help the child is to discuss the evidence with the family. In my practice these families are at the end of their tether and on breaking point. It is one of the most satisfying experience of your working life to see a couple of tablets of methylphenidate make such a fantastic difference to that child's life. I have had children say to me - "I don't like when my mum forgets to give me my tablets. They make me better". Even if the effect is short term, that is what the families are most desperate for. The second point I would like to make is in response to the last paragraph of your editorial and is related to shared care with primary care physicians. I am not sure what happens in other districts, but in my district general practitioners are unanimous in not helping in prescribing any medications for ADHD. Even those who were happily prescribing in cases where there had been a major impact on the child's life have stopped doing so this year. I only hope that the long awaited NICE report might help common sense prevail. Reference: 1.Zwi M, Ramchandani, Joughin C. Evidence and belief in ADHD. BMJ 2000;321:975-976) 2. MTA Cooperative Group. A 14 month randomised clinical trial of treatment strategies for attention deficit/hyperactivity disorder. The MTA Cooperative Group. Multimodal treatment study of children with ADHD. Arch Gen Psychiatry 1999; 56: 1073-1086 |
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Marie France Muir
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Editor - Zwi et al highlight the lottery parents and children face in obtaining information about ADHD and the variety of professionals with whom they may come into contact. However, they conspicuously fail to mention the role of teachers. (1) The teachers involved in the care of these children are in contact with them over long periods of time during the day and have an unrivalled opportunity to see them react and behave in a variety of settings and to observe e.g. the effects of their medication. They may well be responsible for ensuring the children take this medication and their overall management of the child will have a profound effect on the extent to which symptoms and associated problems are regarded as manageable or not. In addition they are an important source of support and advice to parents. In the interests of the child and the family it is important that clinical specialists do not fail to appreciate the need to involve non-medical professionals. Teachers who care for these children need support from other professionals and should be involved as part of a team-based approach to their management. Marie France Muir 1. Zwi M, Ramchandani P, Joughin C. Evidence and belief in ADHD. BMJ 2000; 321:975-6 |
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Edmund Kingston, parent
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In many cases the intervention of such medications such as Ritalin have proved to be a success where other interventions have not been tried.My biggest fear is that it does not address the cause of the hyperactivity. In many cases stimulants in food and drink have been proved to have an effect on many children. We have seen a great improvement in our childs attention will strong dietary modification and the withdrawal of casein and gluten from his diet,tests having proved that he had a high urinary peptide profile and therefore was unable to break down these molecules. It is time for the medical proffession and others to look at the investigations into these areas rather than prescribing a long term drug. It cannot be coincidental that the large increases in these disorders can be related to our modern lifestyles and other enviromental factors. It is medical fact that many hormones that affect mood,concentration are produced in the digestive system, yet non of these drug treatments treat this a a primary cause of the problem. I could go into greater depth, but suggest before prescribing drugs pediatricians might look at the work of Rosmary Waring and sulphation, Paul Shattock and urinary Peptides at the University of sunderland, The Royal Free's work on Vaccines and Dr V.Singh of Utah State University, and all the parents involved with Allergy induces Autism. Edmund Kingston |
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Murray Bodin retired
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Since ADHD has a genetic component, shouldn't there be a discussion about the role of the generally undiagnosed ADHD parent? |
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Maurizio Bonati, Laboratory head Istituto di Ricerche Farmacologiche "Mario Negri", Milano
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Dear Editor, we read with interest Zwi et al's. editorial in which they emphasised that informed decision on the use of stimulants for ADHD's treatment must be based on studies with good methodology. (1) Two weeks after publication of the editorial, the BMJ reported that the National Initiative for Clinical Excellence (NICE) suggested that methylphenidate should be used as part a comprehensive treatment programme for children with ADHD. (2) In Italy, methylphenidate was withdrawn from the market in 1989 by the producer itself, and since then children with ADHD have received unevidence-based treatments of tricyclics, benzodiazepines or a plethora of questionable drugs. This situation has recently (October 2000) led a group of primary care paediatricians to lobby the National Health Department (NHD) for the immediate reintroduction of methylphenidate. As a consequence, the drug will once again be marketed in Italy. The news has been reported as a success for primary care paediatricians, and appears as thus also in the e-mail contents posted to the main Italian paediatric online discussion group ( www.pediatria.it). All interventions were "enthusiastic" about the forthcoming availability of methylphenidate and none contained warnings about the possibility of an overuse of this stimulant or, more importantly, about the need to better educate primary care paediatricians in the comprehensive management of ADHD. This creates concern for the Italian situation, taking into account the lack of knowledge regarding the syndrome's incidence, the unawareness in general practice of diagnostic criteria and therapeutic guidelines, and the documented adverse reactions arguing for a systematic monitoring. (3) We recently conducted a survey that investigated the knowledge and attitudes towards ADHD of all 86 primary care paediatricians in Turin attending to 77378 children. (4) The results showed that 32% of the 56 respondents did not know about the existence of this disorder, 61% did not know the criteria needed for diagnosis, and only 11% of the paediatricians followed suspected ADHD cases directly. The drug most used for ADHD was niaprazine, an antihistamine drug commonly prescribed in Italy, and in only a few other countries, to treat children with sleep disorders. Thus, we agree with Zwi et al's conclusions that stimulants should be prescribed judiciously and monitored carefully. This is especially true for the Italian context, where primary care paediatricians so far have a limited experience in the effective management of ADHD. Their role in initiating prescribing for this condition therefore needs to be thoroughly examined, also by means of specific, "real world", research initiatives. (5) Maurizio Bonati, Head Piero Impicciatore, Senior Research Fellow Chiara Pandolfini, Research Fellow Laboratory for Mother and Child Health, Istituto di Ricerche Farmacologiche "Mario Negri", Via Eritrea 62, 20157 Milano, Italy mother_child@irfmn.mnegri.it References 1. Zwi M, Ramchandani P, Joughin C. Evidence and beliefs in ADHD. BMJ 2000;321:975-6. 2. Dobson R. NICE issues new guidelines on Ritalin. 2000;321:1100. 3. Barkley RA, McMurrey MB, Edelbrock CS, Robbins K. Side effects of methylphenidate in children with attention deficit hyperactivity disorder: a systemic, placebo-controlled evaluation. Pediatrics 1990;86:184-92. 4. Marchini L, Puzzo F, Pirella A, Pandolfini C, Campi R, Impicciatore P, Bonati M. Se non sta fermo solo in USA scatta la ricetta. Occhio Clinico Pediatria 2000;4:12-14. 5. Thomas P. The research needs of primary care. BMJ 2000;321:2-3. |
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