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Rapid Responses: Rapid Responses published:
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The case for the use of stimulants for attention deficit hyperactivity disorder would be much stronger if the author were free of competing interests
- Judith Ronat, judithronat@alum.mit.edu (15 October 2004)
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Is it necessary to have an ADHD child in order to know?
- Paul Verheecke (15 October 2004)
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Photograph confirms misconceptions about ADHD
- Christina A. Oppenheimer (18 October 2004)
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Essential nutrients needed to treat ADHD
- Ellen C G Grant (21 October 2004)
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Treating elderly patients with ADHD
- Olle Hollertz (22 October 2004)
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There are good reasons for ADHD and stimulant use to be controversial
- Sami B Timimi (29 October 2004)
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Judith Ronat, Psychiatrist and Psychotherapist in private practice Kfar Saba, Israel IL-44288, judithronat@alum.mit.edu
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How can an author paid by three drug companies for consultancy, research, and speaking at conferences and reimbursed by two of them for attendance at several conferences be objective? The case for stimulants in Attention Deficine Hyperactivity Disorder would be much more convincing to non-research clinicians, were it presented by someone without competing interests. Competing interests: None declared |
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Paul Verheecke, Chemical pathologist LBS labs, Brussels, Belgium
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My son was diagnosed ADHD (attention deficit hyperactivity disorder)in 1985. His being treated from younger than 4 years made the difference between endless failures at school if he had not been treated and the succesfull university student he is now. My wife founded a parents association. So we witness on a daily basis the disasters being obtained by people, among them experienced pediatricians, who call themselves "cautious". Competing interests: Father of an ADHD child |
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Christina A. Oppenheimer, Consultant in Obstetrics and Gynaecology Leicester Royal Infirmary LE1 5WW
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I welcome the publication of a debate about the diagnosis and management of ADHD (Attention Deficit Hyperactivity Disorder) in the British Medical Journal (1) in the light of inequity and lack of depth of knowledge about the condition in both health and education sectors in many areas. However the photograph used to the support the text, although a very powerful image, does not reflect the reality of life with ADHD. Firstly, although parents with children with this condition recognise that the features are present from early in a child's life, in the UK there is a reluctance to diagnose before the age of five, and therefore management of any kind is denied increasingly desperate parents, carers and teachers. Secondly the expression and demeanour of the child are not typical. The child with ADHD is not classically naughty, nor a monster, as such an image might imply. Much more powerful would be a child isolated in the playground with bewildered parents and exhausted teachers. Use of photographs is a powerful tool to reinforce text. What they should not do is reinforce prejudices about a vulnerable group with very particular needs. It might be a more powerful support for such people to indicate that with the correct multi-modal management with support for families and good working between parents and professionals they can be happy fulfilled individuals. Reference : BMJ 2004; 329 :907-908 Competing interests: Parent of child with ADHD |
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Ellen C G Grant, physician and medical gynaecologist 20 Coome Ridings, Kingston-upon-Thames, KT2 7JU
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For decades the incidence of attention deficit hyperactivity disorder (ADHD) has been increasing.1 It is therefore a pity that neither Coghill nor Markovich, in their debate about psychoactive drug use,2,3 mention the “burgeoning” clinical and basic research finding significant deficits of zinc and essential fatty acids (EFAs) in affected children.4-7 Recent randomised controlled trials demonstrate that nutritional supplements improve children’s brain function and behaviour. Ward et al found significantly lower zinc levels in the urine, scalp hair, serum, 24-hour urine and fingernails of hyperactive children.8 Tartrazine induced a reduction in serum and saliva zinc and increase in urinary zinc, with a corresponding deterioration in behaviour/ emotional responses of the hyperactive children. In our study, among dyslexic children, who also usually had attention difficulties and hyperactivity, all were zinc deficient in their passive sweat.9 Each dyslexic child had a lower sweat zinc level than their age and sex matched control partner from the same school and neighbourhood. Repletion of deficient nutrients cannot undo developmental damage to a child’s brain caused by maternal zinc deficiency in early pregnancy, and is therefore vitally important to allow affected children to have greater mental concentration and improved brain function with monitored nutritional repletion.10 If zinc is deficient, EFA pathways are likely to be blocked and B vitamins are likely to be deficient.11 Rather than give drugs to one in six of all children why not simply ensure children’s brains and lymphocytes are fed? Impaired brain function and adverse allergic, behavioural or mental reactions to common foods and chemicals can be prevented physiologically. Repletion of essential co- factors and high protein-low allergy-additive-free diets allow maintenance of normal homeostatic mechanisms, with adequate levels of endogenous psychoactive amines and unblocked amine pathways, which can respond flexibly to all types of stress. There is no excuse for ignoring this work and continuing to prescribe ever more drugs to children with undiagnosed and therefore untreated deficiencies. 1 Grant ECG. Re: A rise in the prevalence of ADHD. http://bmj.com/cgi/eletters/329/7467/643-c#75351, 23 Sep 2004 2 Coghill D. Education and debate Use of stimulants for attention deficit hyperactivity disorder: FOR. BMJ 2004 329: 907-908. 3 Marcovitch H. Education and debate Use of stimulants for attention deficit hyperactivity disorder. AGAINST BMJ 2004;329:908-909. 4 Bilici M, Yildirim F, Kandil S, et al. Double-blind, placebo- controlled study of zinc sulfate in the treatment of attention deficit hyperactivity disorder. Prog Neuropsychopharmacol Biol Psychiatry. 2004; 28: 181-90. 5 Akhondzadeh S, Mohammadi MR, Khademi M. Zinc sulfate as an adjunct to methylphenidate for the treatment of attention deficit hyperactivity disorder in children: a double blind and randomized trial [ISRCTN64132371]. BMC Psychiatry. 2004;4 : 9. 6 Hallahan B, Garland MR. Essential fatty acids and their role in the treatment of impulsivity disorders. Prostaglandins Leukot Essent Fatty Acids. 2004; 71: 211-6. 7 Arnold LE, Pinkham SM, Votolato N. Does zinc moderate essential fatty acid and amphetamine treatment of attention-deficit/hyperactivity disorder? J Child Adolesc Psychopharmacol. 2000 ;10:111-7. 8 Ward NI, Soulsbury KA, Zettel VH, et al. The influence of the chemical additive tartrazine on the zinc-status of hyperactive children – a double-blind placebo-controlled study. J Nutr Med 1990;1:51-57. 9 Grant ECG, Howard JM ,Davies S, Chasty H, Hornsby B, Galbraith J. Zinc deficiency in children with dyslexia: concentrations of zinc and other minerals in sweat and hair. BMJ 1989;296:607-9 10 Grant ECG. Developmental dyslexia and zinc deficiency. Lancet 2004; 364: 247-8. 11 Colquhoun I, Bunday S. Med Hypotheses. A lack of essential fatty acids as a possible cause of hyperactivity in children. Med Hypotheses. 1981; 7: 673-9. Competing interests: None declared |
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Olle Hollertz, Psychatrist Psyk mott, Box 701, S-572 28 Oskarshamn, Sweden
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Since 1999 I have been treating adults with ADHD with stimulants. mainly amphetamine. I believe this is the beginning of a new era in psychiatry, but we need to accumulate much more clinical experience about diagnostics and treatment. 90 % of my patients with ADHD, given stimulants, have a positive effect on the symptoms connected with ADHD. My clinical reflection is that the oldest patients (born 1933 and later) with ADHD have the biggest improvement in quality of life, if they are treated with stimulants. The old patients are survivors, who have realistic expectations from the medical treatment. The youngest adult patients are most difficult to treat with stimulants, because they often expect the medication to solve their social problems and identity problems. I also think that it is a less ethical problem treating old patients with stimulants. Treating young patients with this effective medication give rise to the question if 10-20 % of the young generation is born with amphetamine shortage. Even if I am very biological in my treatment of ADHD I believe we must see ADHD in relation to changes in society Competing interests: None declared |
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Sami B Timimi, Consultant Child and Adolescent Psychiatrist Ash Villa, Sleaford, Lincolnshire NG34 8QA
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As one might expect with an author with such obvious conflicts of interest, Dr Coghill fails to engage the diverse interdisciplinary literature on ADHD and presents a very narrow bio-medical view of the existing scientific evidence. His arguments reach unwarranted conclusions at every stage. With regards the biological underpinnings of ADHD, it is indeed impressive how much biological research has been carried out into this apparent medical condition for so little return. The problem for those who believe that ADHD is a discrete medical condition is that as soon as you get into specifics their arguments start to fall apart. Thus it is argued that molecular genetic variations have been robustly replicated, concluding that ADHD is associated with the dopamine transporter gene (DAT1) and the dopamine receptor gene (D4) (Schachar and Tannock, 2002), yet a recent study of 126 sibling pairs concluded that these two genes if they are involved in ADHD aetiology at all, make only a minor contribution to overall genetic susceptibility (Fisher et al, 2002). With regards physical counterparts in brain structure of children with ADHD, one wonders how there can be known physical counterparts if there is yet to be a study that compares unmedicated children with an age matched control group, with the largest study that claimed to have done this (Castellanos et al, 2002) choosing a control group whose age was on average 2 years older (Leo and Cohen, 2003) and thereby all they scientifically managed to prove was that younger children had smaller brains than older ones! They had a large control group and one wonders why they decided not to use a straightforward age-matched control group. Despite claims for the miraculous effects of stimulants they are not a specific treatment for ADHD, because they are well known to have similar effects on otherwise normal children and other children regardless of diagnosis (Breggin, 2002; Rapoport et al., 1978), nor is there any evidence to show that they have any long lasting beneficial impact (Timimi, 2002). A more recent meta-analysis of randomized controlled trials of methylphenidate than the one Dr Coghill cited, found that the trials were of poor quality, there was strong evidence of publication bias, short-term effects were inconsistent across different rating scales, side effects were frequent and problematic and long-term effects beyond 4 weeks of treatment were not demonstrated (Schachter et al, 2001). The potential long-term adverse effects of giving psychotropic drugs to children need to cause us more concern than the author will allow. Stimulants are potentially addictive drugs with cardiovascular, nervous, digestive, endocrine, and psychiatric side effects and occasionally cause death (Breggin, 2002, see also www.ritalindeath.com). With regard to future stimulant abuse, Dr Coghill failed to mention Professor Lambert’s work that the pro-ADHD lobby has been trying to marginalize. Her study (in press) drew on longitudinal data from the largest population of ‘ADHD’ children (nearly 500) with age-matched controls, followed for the longest number of years (on average until they were 27 years old) than any of the studies purporting to show that stimulants do not lead to future substance abuse. Lambert found that childhood use of stimulant treatment is significantly and pervasively implicated in the uptake of regular smoking, in daily smoking in adulthood, in cocaine dependence, and lifetime use or abuse of cocaine and stimulants (see for example www.psychiatrictimes.com/p991201b.html). At a psychological level the use of drug treatment scripts a potentially life-long story of disability and deficit that physically healthy children may end up believing. Children may view drug treatment as a punishment for naughty behaviour and may be absorbing the message that they are not able to control or learn to control their own behavior. Drug treatment may also distance all concerned from finding more effective, long-lasting strategies. The child and their carers may be unnecessarily cultured into the attitude of a “pill for life’s problems” (Timimi et al, 2004). The MTA study that Dr Coghill cites as a good reason to recommend that stimulants be given as a first line treatment sets a dangerous precendent in its conclusion that medication is better than psych-social therapies. This study has been widely criticised on many grounds, including lack of placebo group or blinding, authors being firm advocates of ADHD and well known reciepiants of drug company money, playing down of the numbers of children experiencing side-effects, participants already being ‘cultured’ into believing the children involved had a biological condition, study only lasting 14 months, and the fact that two thirds of those in the poorest outcome group (community treatment) were taking the very same stimulants. This gun-ho approach to evaluating the evidence for the use of stimulants will benefit only the pockets of the drug companies and raises serious ethical questions for our profession to consider. If other less problematic and reasonably effective interventions for ADHD-type behaviours when they are seriously problematic exist (such as family therapy, diet and other lifestyle interventions, educational, behavioural and psychodynamic therapies) (Timimi, 2004), should they not be tried first, even if they are not as quick or perfect? Finally if the argument of critics such as me, that there is no such thing as ADHD in the first place proves to be correct (as the evidence currently indicates) what does this says about the social and political role our profession is performing? Will future generations forgive us for colluding, by our ‘dumbing down’ millions of healthy youngsters exuberant behaviours, with Western culture’s hostility children (particularly boyhood), because we, as a society, are deciding that we can no longer tolerate the diversity, and joyful unpredictability that children bring? References: Breggin, P. (2002). The Ritalin fact book. Cambridge, MA: Perseus Castellanos, F. X., Lee, P. P., Sharp, W., et al (2002) Developmental trajectories of brain volume abnormalities in children and adolescents with attention-deficit/hyperactivity disorder. Journal of the American Medical Association, 288, 1740 -1748 Fisher, S.L., Francks, C., McCracken, J.T., et al (2002). A genome- wide scan for loci involved in Attention Deficit/Hyperactivity Disorder (ADHD). American Journal of Human Genetics, 70, 1183-1196. Leo, J.L., & Cohen, D.A. (2003). Broken brains or flawed studies? A critical review of ADHD neuroimaging research. The Journal of Mind and Behavior, 24, 29-56. Rapoprt, J. L., Buchsbaum, M. S., Zahn, et al (1978). Dextroamphetamine: Cognitive and behavioral effects in normal prepubertal boys. Science, 199, 198–214. Schachar, R., & Tannock, R. (2002). Syndromes of hyperactivity and attention deficit. In Child and Adolescent Psychiatry (4th Edition) M. Rutter & E. Taylor (eds), pp399-418. Oxford: Blackwell. Schachter, H., Pham, B., King, J., et al (2001). How efficacious and safe is short-acting methylphenidate for the treatment of attention- deficit disorder in children and adolescents? A meta- analysis. Canadian Medical Association Journal, 165, 1475–1488. Timimi, S. (2002). Pathological child psychiatry and the medicalization of childhood. Hove, UK: Brunner-Routledge. Timimi, S. (2004) Helping children who could be diagnosed with ADHD and their families: Oscillating between modernist and post-modernist perspectives. Clinical Psychology 40, 24-26. Timimi, S. & 33 co-endorsers (2004a). A critique of the international consensus statement on ADHD. Clinical Child and Family Psychology Review 7, 59-63. Competing interests: None declared |
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