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Children don’t think that stimulant drugs for ADHD rob them of their “authenticity” and moral responsibility

BMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e6947 (Published 15 October 2012) Cite this as: BMJ 2012;345:e6947
  1. Zosia Kmietowicz
  1. 1London

Claims by some observers that stimulant drugs used to treat attention-deficit/hyperactivity disorder (ADHD) rob children of their “authenticity” and moral responsibility have been refuted by a study that was based on interviews with patients.

Responses from 151 children in the United Kingdom and the United States showed that those who were taking stimulants believed that the drugs helped them pause rather than lash out so that they made better decisions and had more control over their behaviour.

Ilina Singh, reader in bioethics and society at King’s College, London, carried out the ADHD VOICES (voices on identity, childhood, ethics, and stimulants) study to investigate some of the controversies over treatment with stimulant drugs such as methylphenidate.1

The study, funded by the Wellcome Trust, involved interviews with children aged between 9 and 14 years who were either taking stimulants for ADHD, had a diagnosis but were not currently taking treatment (they were usually on a medication break), or did not have a psychiatric diagnosis.

Speaking at the launch of the study, Singh said that some people have criticised stimulant drugs for turning children into “robots”—for violating children’s sense of who they were and depriving them of moral development and responsibility because they could always “blame their brain” for their behaviour.

However, the interviews did not substantiate these claims, she said.

“The ethical presumptions about stimulant drugs were largely not supported by this study,” said Singh. “This is not an endorsement of stimulant drugs, but it is an evidence based investigation of harms. We assumed they were harms, [but] we do not find support [for them] from children’s experiences. The prevalence of these assumptions is hurting children; the drugs are not.”

The study found that stigma associated with having ADHD was common in the US and the UK but that bullying was worse in UK schools. But even in the face of taunting by school mates, children with ADHD who were taking stimulant drugs said that they were able to stop and think before responding and that if they chose to fight it was within their control.

However, many children did not understand what ADHD was or why they were being treated. They were weighed and measured when they saw their doctor but wanted these checks to be more meaningful to them.

“A lot of what is done [in the consultation] is a side effect check,” said Singh. “Children did not feel engaged in the clinical session. Given the ethical concerns that arise from ADHD diagnosis and stimulant drug treatments, it is imperative that children are able to openly discuss the value of diagnosis and different treatments with a trusted professional.”

She said that doctors were reluctant to hear from the children because they were worried that they would want to come off their treatment. “But some small studies are finding that when you give children more power as to when to use their medication they will come off it over time. They want to experiment with their medication.”

The ADHD VOICES study found that some children learnt strategies for controlling their behaviour by having breaks from drug treatment, either at the weekends or during school holidays, a practice that is more common in the US than the UK.

The study also found that children wanted more therapy options, including psychological treatments, meditation, and relaxation.

Although the study was too small to be statistically robust, Singh found that children in the UK were more concerned about their conduct, where the main preoccupation was being good, and that those in the US were more concerned with their academic performance. It is concern over such values that led to disagreement about the use of stimulants for treating ADHD, says the report, as some people believed that neither bad behaviour nor poor grades were reasons to prescribe stimulants to children.

A public conversation “on the values that should guide medical professionals, teachers and parents in shaping children’s moral development is essential,” says the report and should include the children themselves.

It adds, “If the conversation is developed systematically and thoughtfully, it can avoid the current pitfalls of accusation, finger-pointing, and polemics. Instead, some genuine understanding will emerge about what common values govern people’s ideas about raising healthy, happy, and good children—and where there are disagreements. This process will also promote more coherent and more relevant national policies on child health and education.”

Notes

Cite this as: BMJ 2012;345:e6947

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