New guidance from the National Institute for Clinical Excellence (NICE) recommends
the use of methylphenidate as part of a comprehensive treatment programme for
children with severe attention deficit/hyperactivity disorder (ADHD). The guidance
suggests that thousands of children who do not currently receive the drug should
be on treatment.
Methylphenidate is available in the United Kingdom as Ritalin and Equasym. The
NICE says that treatment with methylphenidate should only be initiated by specialist
child and adolescent psychiatrists or paediatricians with expertise in ADHD.
General practitioners can continue to prescribe it and monitor patients under
shared care arrangements with specialists.
Patients with ADHD have a combination of core symptoms — inattention, hyperactivity
and impulsiveness. A subgroup of ADHD is hyperkinetic disorder (HKD) in which
patients have all three symptoms. HKD is broadly similar to severe ADHD. The
NICE says that it has been estimated that approximately 1 per cent of school-age
children meet the diagnostic criteria for HKD. This is about 73,200 children
aged six to 16 in England and Wales. Of these children, 48,000 are not currently
receiving methylphenidate, it says. If all of these children were to have a
trial of the drug for a year, it would cost an estimated £7m in the first
year for the drug alone. Other care needed would cost an estimated £23m
for initial specialist assessment and £14m for follow-up care for one
year (although some of these costs included services that were already in place),
the NICE adds.
There is evidence from randomised, controlled trials that methylphenidate is
effective at reducing hyperactivity, inattention and impulsiveness in the short
term while children continue to take medication, says the NICE. Direct comparisons
have been of mixed quality but suggest that medication is more effective than
behavioural intervention. Further evidence has suggested that the addition of
medication to behavioural therapy is beneficial. However, there is insufficient
evidence to compare the relative
efficacies of methylphenidate, dexamphetamine and antidepressants.
The NICE says that drug treatment should form part of a comprehensive treatment
programme, but adds that any shortfall in its provision should not be used as
a reason to delay use of medication. It suggests that a treatment programme
should include advice and support for parents and teachers, and possibly psychological
treatment, such as behavioural therapy.
Regular monitoring is important for patients receiving methyl-phenidate and
careful titration is required to determine optimal dose level and timing, says
the NICE. If there is no improvement in symptoms after dose adjustment, the
drug should be discontinued. When improvement occurs and the child’s condition
has been stabilised, treatment can be discontinued at intervals under specialist
supervision to assess progress and the need for further treatment.
The NICE guidance relates only to children and adolescents with ADHD. Methylphenidate
is not licensed for children under the age of six or for children with certain
conditions.
The guidance is available on the NICE website (www.nice.org.uk).