October 31st 2000 - 21:50 GMT
NICE, The National Institute for Clinical Excellence, published its report on October 31st 2000 on the use of methylphenidate (Ritalin, Equasym) across England and Wales.
In our opinion (adders.org) it is a very responsible report and an excellent set of guidelines, which although already being practised by many health professionals up and down the Country, we hope it will be adopted by all as a sound basis for diagnosis and treatment of ADHD.
Many aspects of the report met with our approval and in particular the following:
1.3 Diagnosis should be based on a timely, comprehensive assessment conducted by a child/adolescent psychiatrist or a paediatrician with expertise in ADHD. It should also involve children, parents and carers and the child's school, and take into account cultural factors in the child's environment. Multidisciplinary assessment, which may include educational or clinical psychologists and social workers, is advisable for children who present with indications of significant comorbidity.
1.4 Treatment with methylphenidate should only be initiated by child and adolescent psychiatrists or paediatricians with expertise in ADHD, but continued prescribing and monitoring may be performed by general practitioners, under shared care arrangements with specialists.
5.2 Health, social and education services will also incur costs for assessment and follow-up of these children. These costs have been estimated at about £23 m for initial specialist assessment (£21.8 m in England and £1.5 m in Wales) and £14 m for follow-up care over one year (£13.4 m in England and £0.9 m in Wales). However, some of these costs relate to services that are already in place, and one hundred percent uptake of medication is unlikely. It is also possible that better treatment for children with ADHD could avoid some health, education and social costs in the longer term.
5.3 Access to child and adolescent mental health services is variable, with long waiting times in some areas. Children with severe ADHD need prompt assessment and treatment. The NHS will wish to consider how it makes provision for adequate specialist services to meet this need. The uptake and effectiveness of methylphenidate should be increased by the availability of improved inter-disciplinary and inter-agency working. Health authorities and trusts should work together with local authority social services and education services and the voluntary sector to ensure appropriate provision.
6.1 Further research is required to determine the best treatment strategy for children with ADHD: a) medication as the first-line, followed by behavioural treatment only if necessary; b) behavioural treatment, followed by medication if necessary; or c) combined medication and behavioural treatment initiated at the same time.
7.3 Trusts managing services specialising in ADHD should ensure that methylphenidate is used as part of a comprehensive treatment programme for children with a diagnosis of severe Attention Deficit/ Hyperactivity Disorder (ADHD). They should ensure that appropriate links are established with those organisations supporting multidisciplinary assessment, which may include educational or clinical psychologists and social workers; and that appropriate management programmes are in place.
With reference to the leaked portion of the report that ended up in The Guardian a few weeks ago, stating that this report recommended the banning of this medication for the under 5's, we could find no reference to this in the report. It does state that "Methylphenidate is not currently licensed for children under the age of six" but this is already the position and as in Adults, for which it is also not licensed, it can be given under clinical judgement. The report adds further in section 6.2 that "Research is needed to clarify the role of medication for children with comorbidities and less severe forms of ADHD, and for children below the age of six." So the clever dicks at the Guardian seem to have got the wrong end of the stick, some might say, "as usual".
Overall we were very pleased with the report and hope that it is used as a benchmark for the treatment of ADHD in the UK. We welcome the research recommendations and the sections 5.3 and 7.3 and hope that the Government will follow through with the necessary funding to allow the report to be of real worth. Not only will we be hoping but we will also be campaigning, along with many other support groups no doubt, to bring pressure to bear on the Government to implement these findings. After all it was the Government that requested the report in the first place.
Simon Hensby for ADDers.org