Poorly regulated clinics in England are putting children with ADHD at risk, warn doctors | Attention deficit hyperactivity disorder

Children with ADHD are being put at risk by poorly regulated private clinics that prescribe powerful stimulants without key physical exams, doctors have warned.

The increase in remote assessments has led to what one clinician described as a “widespread and dangerous practice”, in which children are diagnosed and treated via video link. The clinical warnings have now forced health authorities in Greater Manchester to revise prescribing rules, requiring face-to-face checks to protect children’s safety.

Rashad Nawaz, a consultant pediatrician with clinics in Manchester and Liverpool, has written to national regulators and health bodies. He warned that he had treated young patients with potential underlying heart conditions who were prescribed stimulants by national online providers without a single in-person check-up.

Doctors can prescribe stimulants, such as methylphenidate, the most well-known brand of which is Ritalin, as well as non-stimulant alternatives.

The benefits of taking medication for attention deficit hyperactivity disorder outweigh the impact of increased blood pressure and heart rate, according to a University of Southampton study.

But guidelines from the National Institute for Health and Care Excellence say a complete physical assessment, including a cardiovascular history and physical examination of the heart, is mandatory before treatment begins.

Nawaz said he had identified three children in the past year with previously unknown heart murmurs. One was already taking ADHD medication prescribed by a large national provider. After being referred to a pediatric cardiology department, two of the children had “innocent” murmurs, but one had a ventricular septal defect (VSD), commonly known as a hole in the heart.

“None of them showed symptoms, but the one suffering from VSD might have them in the future,” Nawaz said. “Based on parent feedback and reports I have seen…children are not receiving thorough physical assessments before receiving treatment. This concerns me greatly. This is a serious clinical risk and neglect.”

The NHS is struggling to cope with record demand for ADHD services. Many families use the Right to Choose program to access private care funded by the NHS. However, senior clinicians say some private companies, many of which hold lucrative contracts with the NHS, do not have the infrastructure to ensure patient safety.

NHS psychiatrist Professor Marios Adamou said the reliance on online-only providers had created a dangerous clinical void. “Local GPs are frequently asked to carry out these checks on behalf of private services, or even to start treatment,” he said. “This places clinicians in a difficult position, given that the prescribing clinician bears full legal and clinical responsibility for the safety of prescriptions. »

Nawaz also warned of a “de-skilling” of staff, saying health professionals trained primarily in adult care were “medically treating” children without adequate pediatric experience. In one case, a child was prescribed medication via video link despite a family history of congenital heart disease, a critical detail that was completely absent from the private provider’s report.

“Most large national private providers… do not actually see children face to face,” Nawaz wrote in a letter to the Royal College of Paediatrics and Child Health. “Many prescribe medications with simple measurements (BP and weight, usually provided by the parent) along with a health checklist, but without a proper physical exam.”

In response to the warnings, NHS Greater Manchester has implemented a new ‘safety first’ pathway. Professor Manisha Kumar, the region’s chief medical officer, said the move was necessary because “the safety of children must come first”.

She added: “We are now implementing new pathways that require face-to-face assessments and physical health checks before ADHD medications are prescribed. »

Although the new system preserves the right to choose, it effectively prohibits providers from beginning treatment in the region unless they can demonstrate that a robust in-person clinical assessment has taken place.