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Hereunder we articulate a series of objections raised by the “sponsors” of the pharmaceutical solution, in favor of dispensing psychiatric drugs to children and teenagers. As a balanced formation/information campaign, “Giù le Mani dai Bambini” ® (Hands off our children) aims to awaken the citizenship towards a consent which should, desirably, be truly informed about the risks of such kind of therapies; but we believe it fair to guarantee an expression space also for those theses which promote a therapeutic pattern based on psychotropic drugs. According to these theses, psycho-stimulants like Ritalin (a derivative of amphetamine; it is not the only psychotropic drug dispensed to children) would be necessary for the cases presenting the severest symptomatology, even in the paedriatic age; they would represent an important and decisive therapeutic resource, as scientific literature has been remarking for the last forty years, and as was categorically outlined by Russell Barkley, in an article appeared in 1996 on “Psychiatric Times”, stating that “the stimulant medications have demonstrated their efficacy in several hundred well-controlled scientific studies, making them not only one of the few success stories in child psychiatry of this century but the best – studied of any psychiatric (and other) medication prescribed for children”[1]

The Attention Deficit Hyperactivity Disorder (ADHD) – which, in its ordinary symptomatology, is characterized by lack of attention, impulsiveness and motor hyperactivity – appears to be the most widespread neuropsychiatric disease of the evolutive age among the paedriatic population. The epidemiological studies conducted so far do not permit to precisely estimate the occurrence of the disease; however, in all those countries where studies were conducted with constancy in the past years, the prevalence of ADHD is rated at 3-5% of the population of school age, even if the disease can persist also throughout teenage and adult age, in 50-60% of cases.  Such disease is supposed to compromise numerous stages in the child’s development and social integration, and to represent the major cause of behavioral diseases and an important predictive factor of lack of success in life. The worldwide study and research field involves not only every aspect of the disease, but also the different treatment interventions (psycho-educational, psycho-social, behavioral and, much more effective, pharmacological intervention through psycho-stimulants and alternative psychiatric drugs).

According to these theses, ADHD would therefore be an heterogeneous and complex disease, connected to other syndromes in the 80% of cases; a circumstance which would aggravate the symptoms and complicate the diagnosis and the therapy. In fact, in 70-80% of cases the disease would be associated to other psychiatric diseases like behavioral diseases, oppositional-provocative diseases and anxiety and mood disorders. From the parents’ witnesses, it emerges how this disease can throw the social life of those affected and their respective families into crisis.

The researches conducted on this disease in the past forty years led to the consideration and the study of numerous factors at its origins (it is in fact a multi-factorial disease) and, among these, genetic factors, cerebral morphological factors, prenatal and perinatal factors, traumatic factors, social factors.

The diagnosis of ADHD is presently based on the classification by the psychiatric manual “DSM IV”, through an evaluation of the child conducted by psychiatrists and neuropsychiatrists. The evaluation is extremely complex, since it must involve, in addition to the child, his/her parents and teachers also; this in order to gather information, from multiple sources and in relation to several contexts, on the behavior and the functional damage of the child. The evaluation of cultural factors, and of the living environment where the child dwells, is included in such analysis. There is a tendency to state that ADHD is a disease which is diagnosed on the basis of symptoms alone, and not of clinical diagnostic tests. It should be specified that any neuropsychiatric disease is diagnosed on the basis of symptoms, and no specific clinical investigation, capable of detecting the disorder, is currently available for any of them. In the case of the ADHD, however, such analysis makes use of standardized tools, such as questionnaires and interviews.

According to the supporters of therapies based on psychiatric drugs, an ADHD diagnosis which is not obtained in good time can lead to an everyday reality made of ineffective therapies, psychotherapies extended for years without results, and charges filed against the parents for the damages produced by their children. They argue that a child suffering from ADHD, and not subjected to therapy, will become a seriously psychiatrically diseased teenager, and an adult who will be more vulnerable to behavioral, depressive or anxiety disorders. Therefore, as demonstrated by the scientific literature, the psychotropic drug is certainly the best, most effective and fastest among all possible solutions, as a remedy to these diseases. Literature, and especially psychiatric literature, would actually appear to agree when addressing psychiatric drugs as a decisive therapeutic resource, effectively and directly tested on children.

Regarding a possible “addiction” to the drug, a research by the Universities of Massachusetts and Wisconsin (January 2003) states that it was found “no compelling evidence that stimulant treatment of children with attention-deficit/hyperactivity disorder leads to an increased risk for substance experimentation, use, dependence, or abuse by adulthood”.[2]

Regardless of a huge amount of studies and clinical research, of a consolidated, yet always perfectible, multidisciplinary diagnostic protocol, and of a multimodal therapeutic approach, the sponsors of the pharmaceutical solution complain about the doubts that are cast, every now and then, on the scientific reality of ADHD. Unwilling to investigate the most diversified reasons that cause not only journalists, but also healthcare operators to disavow ADHD, they underline with their maximum strength possible how this attitude can actually be fraught with much damaging consequences, including a dangerous misleading of outsiders such as parents and teachers.

This situation is well described in the International Consensus Statement on ADHD of January 2002, published on the Clinical Child and Family Psychology Review, in which professor Russell Barkley declares: “The views of a handful of nonexpert doctors that ADHD does not exist are contrasted against mainstream scientific views that it does, as if both views had equal merit”.[3] The Italian ADHD Consensus National Conference (Cagliari, March 6th-7th, 2003), participated by the majority of scientific companies and associations interested in the disease, also expresses, in its final document, a series of statements that are coherent with the present “state of the art” of psychiatric literature, and with the most advanced therapeutic protocols for the treatment of this disease.

As a conclusion we can recall the declaration of September 27th, 2000, by doctor David Fassler, representing the American Psychiatric Association before the “Committee on Education and the Workforce”. “…It’s estimated to affect between 3 and 5 per cent of school-age children, and it occurs three times more often in boys than in girls. The Surgeon General’s recent conference cited the under-diagnosing and under-treatment of mental disorders in children, particularly in African-American and other minority populations due to lack of access to medical services. […] Let me be very clear. ADHD is not an easy diagnosis to make, and it’s not a diagnosis that can be made in a 5 or 10 minute office visit. Many other problems, including anxiety disorders, depression and learning disabilities can present with signs and symptoms which look similar to ADHD. There is also a high degree of comorbidity, meaning that over half the kids who have ADHD also have a second significant psychiatric problem. In summary, let me emphasize that child psychiatric disorders, including ADHD, are diagnosable and real illness, and they affect lots of kids”.[4]

With regards to this matter, it is convenient to remind that, in Italy, the Italian Register of Children Affected by ADHD has recently been established at the Italian Institute of Health, in order to guarantee diagnostic accuracy and therapeutic appropriateness to the disease, through the scheduling and monitoring of all registered cases of children affected by ADHD in Italy.

According to some, a campaign like “Giù le Mani dai Bambini”® (Hands off our children) would cause concerns, since it favors the “neglect of children”, towards an improperly identified disease cured with pharmaceuticals, as a miserable consequence. On the contrary, it would be appropriate to establish dedicated centers of psychiatric professionals, working together with local pediatricians, in order to ensure all children a proper diagnostic pattern and, subsequently, an appropriate, pharmacological, capillary and throughout therapy.

For the sake of completeness, hereunder we report a few notes brought to the editors’ attention by a reader, and written by an association formed by parents who are in favor of using therapies based on psychiatric drugs on children and teenagers; the association is financially supported by two distinct pharmaceutical companies. However, as a guarantee of a coherent, and as impartial as possible approach to these delicate issues, we invite the reader to carefully surf the “Against” section on our web portal.

  • PARENTS WOULD RATHER HAVE HEALTHY KIDS AND AVOID DRUGS. We are parents and nobody is more apprehensive than us about the prescription of drugs, and, overall, the prescription of specific therapies to our children. Actually, nobody more than us, the parents, would want their children to always be healthy, and to do as much as possible without drugs of any kind.
  • THE INITIAL REJECTION OF THE PHARMACOLOGICAL APPROACH BY PARENTS. As parents of children suffering from ADHD and comorbid diseases, when the neuropsychiatrist prescribed our children the methylphenidate or another kind of psychotropic drug, we especially felt this “protective instinct” even stronger. Our witnesses are quite coherent in remembering, at first, an initial instinctive rejection of this therapeutic approach and a request for different therapeutic patterns. For many of us, such rejective position often lasted long, years even: only afterwards, and with more than a few guilty feelings, we realized we had long denied our children this therapeutic resource, which instead proved to be decisive and often fundamental for our children’s lives.
  • THE JOY OF WATCHING OUR KID START TO LIVE. If it is true that nobody can suffer, watching his/her own children assuming drugs, and psychiatric drugs especially, more than us parents, it is equally true that nobody, more than us parents, can rejoice when they see how that very much suffered choice is what allows their kid to finally start living.
  • METHYLPHENIDATE AND ADHD. The ADHD would be (conditional is mandatory) one of those neuro-biological diseases that are “lucky” enough to dispose of a drug (the methylphenidate, and in general, of a category of psycho-stimulants) which, in cases diagnosed correctly and specifically when it is necessary, allows to report drastic improvements in the symptoms, if prescribed, dosed and taken according to its decades-long clinical practice. These very changes finally enable our children to study, play, relate to others, that is, to regain possession of the very life which, even just a few days before, seemed to slip out of their hands, with tremendous isolation and sufferings.
  • PARENTS WOULD ALWAYS PREFER A CANDY INSTEAD OF A DRUG. Some thoughtlessly believed, and still believe, that the joy we feel when we see our children “being born again”, represents “ipso facto” our “blessing” of the drugs, or even some sort of predilection for the pharmacological approach. This conclusion is very rushed, completely false and fundamentally illogic, because nobody would want to substitute the drug, if possible, with a good red raspberry candy, more than us parents.
  • THE PHARMACOLOGICAL CHOICE IS MADE BY THE DOCTOR It is here proper to remark that in case of a pharmacological choice, this is not made by the parent, but by a neuro-psychiatrist, on the basis of his/her clinical practice and of accurate diagnostic protocols validated worldwide and within the field of multimodal therapy.
  • THE DRUG IS A MEAN. In this perspective, as we already stated numerous times and within numerous contexts, we must once again remark how the drug is simply a mean, a therapeutic instrument: therefore it is neither good, nor bad. It can become good, and sometimes excellent, if handled by an expert, just as the scalpel is, when handled by a good surgeon, and the car is, under the lead of an expert driver who follows the highway code. On the other hand the drug, as an instrument, can become “dangerous”, to say the least, if utilized by inexpert doctors or doctors lacking clinical practice, just as a scalpel handled by a freshman medicine student, or a car driven at night time by a drunk. For what concerns the delicate issue of the psychiatric drugs that are prescribed to our children, nobody realizes this fundamental fact more than us parents.
  • PARENTS FEAR AN IMPROPER USE OF DRUGS. Nobody fears the problem of an improper use, or even an abuse, of drugs, more than us parents, for the simple reason that the damaged subjects are our own children; obviously this issue does not concern the drugs in themselves, but the person who is responsible of the diagnosis and the prescription. Nobody can fear, more than us parents, a partial or totally incorrect diagnosis, and the subsequent utilization of an improper psychotropic drug, which not only provides no improvements or even worsens the symptoms, but also presents serious side effects (for instance, the use of an anti-psychotic drug for the ADHD therapy). Nobody can fear, more than us parents, that even when the diagnosis is substantially correct, the drugs that are utilized are not of first choice (this is what happened so far, and what is still happening, in the case of ADHD, due to the lack of methylphenidate and the use of other drugs, for instance of tricyclic antidepressants).
  • PROFESSIONAL ETHICS IN THE USE OF DRUGS. The correct, or vice versa, the incorrect use or even abuse of drugs are not occurrences that depend on the drug in itself, but on the qualification and the clinical training of the doctor exclusively. Nobody, more than us parents, believes that the prescription of psychiatric drugs to children and teenagers (but also to adults) involves profound consequences from the point of view of professional ethics. In such a delicate field, nobody more than us parents will require from doctors a serious clinical practice in diagnosing, and training within the pharmacological as well as cognitive-behavioral approach, also considering the upcoming introduction of the regional Centers for diagnosis and therapy.

We invite the reader to carefully surf this portal for a critical debate on these statements. All the material here available is for free download. Non-technical publications are also available on the portal for electronic download; prints can be requested to the Committee.

 

[1] http://www.aifa.it/miti_adhd.htm –> original http://books.google.it/books?id=6dZ_J4TTrEUC&pg=PA60&lpg=PA60&dq=The+stimulant+medications+have+demonstrated+their+efficacy+in+several+hundred+well-controlled+scientific+studies,+making+them+not+only+one+of+the+few+success+stories+in+child+psychiatry+of+this+century+but+the+best+-+studied+of+any+psychiatric+%28and+other%29+medication+prescribed+for+children&source=bl&ots=5OF8Fkd2Qr&sig=ycoTfBI4_Nvzk04sKEArSxEmxs4&hl=it&ei=uL9jTZ-gMIaUOs2UxNcC&sa=X&oi=book_result&ct=result&resnum=8&ved=0CFUQ6AEwBw#v=onepage&q&f=false

[2] http://www.ncbi.nlm.nih.gov/pubmed/12509561

[3] http://www.russellbarkley.org/adhd-consensus.htm

[4] http://www.giulemanidaibambini.org/stampa/allegato43.pdf page 5