One useful medicament that is stimulating much controversy and criticism is methylphenidate. It is a central nervous stimulant, but differs from the more familiar amphetamine derivatives in being an ester of phenylpiperidine-acetic acid. It was developed as long ago as 1944, and has since been prescribed to improve mental activity during convalescence and in some depressive states, and to counteract the lethargy associated with some therapeutic agents.
What has provoked fierce discussion is the prescribing of the drug for pre-school children suffering from attention deficit hyperactivity disorder. Methylphenidate is not approved for the treatment of children younger than six years. However, in the United States there is a move to extend its use to children aged three to six.
The problems involved have been outlined in a survey in Science for November 17 by Eliot Marshall. First comes the vagueness of the definition of the condition, based on the core symptoms of inattention, hyperactivity and great impulsiveness. Some clinicians distinguish a subgroup which they entitle hyperkinetic disorder. Without a precise diagnosis, physicians tend to prescribe methylphenidate for children who demonstrate embarrassing behaviour involving refusal to pay attention to parents and teachers and violent outbursts of physical activity. The result has been that the prescription of psychoactive medicines, primarily methylphenidate, in the US has rocketed in recent years, and there may be up to 200,000 children aged between two and four years who are taking the drug. Ethically, this has been questioned, since there is a lack of information on doses and safety for children younger than six years, and it is obvious that, when it comes to clinical trials, the informed consent of these patients cannot be obtained.
Nevertheless, a study under the auspices of the US National Institute of Mental Health commences in December, with the involvement initially of some 300 pre-school children who have been diagnosed as suffering from attention deficit hyperactivity syndrome. The main preoccupation of those carrying out the study is with possible effects of treatment upon personality and brain development in the subjects, who are at a particularly vulnerable stage in mental and psychological growth. It has been deemed necessary to adopt a strict definition of the syndrome applicable to three-year-olds.
Inclusion in the trial is permissible only if a specialist physician has assessed the behavioural criteria, a parent and a teacher both consider the child as troubled, and the symptoms have been evident for nine months. Unfortunately, there is no biochemical abnormality in the syndrome, and there is a broad range of behaviour among such children, much of it judged as normal by many physicians. A complication typical of the US is that many lawsuits have been taken up by children's parents who allege that the manufacturers have conspired to promote the use of methylphenidate. However, some clinicians maintain that failure to receive treatment may result in serious harm later in life.
An interesting facet of this problem is that there is a school of thought in the US which maintains that attention deficit hyperactivity disorder has arisen because of cultural changes in our environment dictated by the increased tempo of modern daily life, and the crazy search for more and more speed both in the home and in the outside world. The backing of psychiatrists and drug manufacturers has not helped. It is argued that if parents spent more time in the home with their children and less time at work trying to become rich, so that the tempo of the child's life was reduced, we might encounter fewer of these problems. The idea is worth a little reflection. Moreover, it goes hand in hand with the established fact that a major part of successful treatment of attention deficit hyperactivity disorder consists of special behaviour therapy, supplemented and not replaced by pharmacological agents.