1. TERAPROOF:User:eoinosullivanDate:27/03/2011Time:21:05:50Edition:28/03/2011ExaminerLiveXX2803Page:15 Zone:XX1
15ANALYSISIrish Examiner
Monday 28.03.2011
XX1 - V1
Jennifer
Hough
explores the
issue of whether
to put a child
on medication if
they have
been diagnosed
with ADHD
‘‘
MATTER
OF LIFE
AND DEBT
The HSE is owed more than a quarter of a billion euro in patient fees. A share of these
much-needed funds will have to be written off, writes Priscilla Lynch
The majority of the outstanding debt is owed by the health
insurance companies... While the prices the HSE charges
the insurers has steadily increased... attempts to speed up
the collection... haven’t been that successful
IT has been revealed that the
HSE is owed a massive
266 million for patient
hospital charges, including
fees for services and accom-
modation for privately-insured
patients, inpatient and long-stay
charges, and emergency department
(ED) and road traffic accident fees.
That’s a lot of money in any terms.
It’s even more than what the
expensive and long-running Moriarty
Tribunal will cost us and the cash-
strapped HSE could certainly do
with this money.
While it managed to stay within
budget last year despite a significant
cut from 2009, this was partly
achieved with bed and ward closures
and cancelled operations, particularly
in the west. This year’s budget was
again reduced and the HSE is facing
another incredibly tough year as
evidenced by the fact that more than
400 ED patients have been forced to
wait on trolleys every day on average,
over the past fortnight and there are
now more than 1.6 million people
with a medical card — a figure that
is continuing to rise.
So why has this essential uncollected
income for our health services been
allowed to increase to such whopping
proportions and what’s been done
about trying to claw back some of this
cash?
Despite the increase in its overall
patient charges debt, the HSE has in-
sisted that it has made increased efforts
over the past few years to ensure that
patients and insurance companies pay
the money they owe.
Speeding up and improving the
rates of collection of patient fees is
one of the key HSE value-for-money
initiatives set for 2011 and debt
collection is also a standing item on
the agenda for the HSE audit com-
mittee, the HSE told the Irish Exam-
iner.
The responsibility for the collection
of charges generally lies with hospital
managers and procedures for collec-
tion can vary from hospital to hospi-
tal. So the HSE’s focus continues to
be on the performance of individual
hospitals in the management of their
patient debt, though it wouldn’t yet
release a breakdown of what hospitals
are the worst at collecting patient
charges, as this information is still
being audited by the Comptroller
and Auditor General.
The majority of the outstanding
debt is owed by the health insurance
companies for private patient treat-
ment fees. While the prices the
HSE charges the insurers has steadily
increased in recent years, its attempts
to speed up the collection of these
charges haven’t been that successful,
while collection by the private hospi-
tals of these fees is much faster.
The HSE says it is actively engaging
with the health insurance companies
about delays in certain hospitals and
wants to reach an agreement with
them that will allow the payment to
hospitals within 30 days, but it has
admitted that none of the three main
health insurers want to sign up to this
proposal and that it continues to have
to wait for up to six months for settle-
ment of these fees.
Part of this problem is that it often
takes quite some time for hospital
consultants to sign off on the needed
claim forms before the HSE can bill
the insurers, though consultants have
claimed this is not their fault and an
easier more streamlined system has
been sought with work now ongoing
on rolling out an electronic system for
submitting and processing these forms.
The HSE has also insisted the
collection of some patient charges
has improved despite the growth of
the overall debt figure.
ED — fees which were introduced
during the tenure of previous health
minister Mary Harney and are now
100 per visit (unless you have a
medical card or referral form from
your GP) — used to be difficult to
collect at first though hospitals now
generally try to collect the cash up-
front. Most offer laser machines to
take cash or credit straight from a pa-
tient’s card while many including
Cork University Hospital have even
installed ATM machines in the foyer
of the ED so there can be no excuses
for not having any cash to hand.
Unfortunately, as a large chunk of
the debt has been outstanding for be-
tween one to three years and beyond
— 54 million has been outstanding
for between 12-36 months while
39m has been outstanding for over
36 months — it is unlikely the HSE
will recoup much of this and it will
have to be written off.
While the HSE does use debt-col-
lection agencies as a last resort, this is
a delicate issue given that they could
be chasing payment from people who
have suffered serious ill health or a
bereavement or simply cannot afford
to pay and the HSE itself acknowl-
edges this, saying it seeks to maximise
the recovery of income “in a socially
responsible, ethical, efficient and cost
effective way”.
However, given the figures revealed
today it is likely the new Health Min-
ister James Reilly will be asking the
HSE for more information on how
the collection of vital patient charges
can be improved and put back into
helping run our stretched health
services.
A study in the US found ‘medication use was a significant marker not of
beneficial outcome, but of deterioration’, for children with ADHD.
A bitter pill for young ADHD sufferers?
THE question has long
dogged the debate on how
to treat attention deficit
hyperactivity disorder (ADHD) in
young people.
Should children be medicated
because of what might just be
hyperactivity or challenging
behaviour? Or are prescription
drugs needed to the treat them?
Characterised by inattentiveness,
over-activity, impulsivity and other
challenging behaviours, ADHD is a
disruptive behaviour condition the
specific causes of which are not
known.
It is estimated 60,000 children in
this country have the disorder, and
even that is said to be an
under-estimation.
However, although most child
psychiatrists insist drugs such as the
stimulant Ritalin are essential in
treating the condition, parents have
huge concern about medicating
their young children and some
professionals also question it.
British child psychiatrist Dr Sami
Timimi maintains the medication is
“highly addictive” and has chemical
properties which are “virtually
indistinguishable” from
amphetamines such as cocaine and
speed.
In a academic paper published in
the British Journal of Psychiatry Dr
Timimi, who works for the NHS,
wrote that ADHD is a “cultural
construct” and the result of
speculative “biobabble”.
In a book The Making and
Breaking of Children’s Lives he
wrote that ADHD is a “dumping
ground allowing all of us to avoid
the messy business of understanding
human relationships and institutions
and their difficulties, and our
common responsibility for nurturing
and raising well-behaved children”.
Dr Timimi prefers to examine
what lies behind a child’s
problematic behaviour which could
be learning difficulties, a high sugar
diet, domestic violence, extreme
lack of exercise or poor discipline.
There is a growing school of
thought that diet could have a big
role to play in treating ADHD.
A study published in the Lancet
journal last month found that
almost 80% of the children who
stayed on a strict diet for five weeks
had fewer symptoms. Some were
even able to stop taking medication.
Researchers from the Netherlands
put 50 children with ADHD on a
“restricted elimination diet”
consisting of foods with the least
possible risk of allergic reaction — a
combination of rice, meat,
vegetables, pears and water — and
which was tailored to the
preferences of each child.
The conclusion was that different
foods trigger different behavioural
problems and should be monitored,
In this country, however, the
medical model of treatment is
prevalent with dedicated facilities
for children with ADHD
mushrooming. There are now 37
such clinics to treat children who
have been diagnosed with the
disorder and there are plans for
more.
Indeed such is the concern, that in
its annual audit of services, the HSE
specifically asked community teams
what initiatives are being set up for
children with ADHD, causing one
consultant to ask: “Why is this
group of children singled out, why
not ask about initiatives for
attachment disorder or eating
disorders?”
This raises the question as to
whether there is undue pressure on
parents to comply with what is
called “pharmacotherapy” or
medicating children.
In a letter seen by the Irish
Examiner, a senior HSE registrar
writes that the parent of a
six-year-old boy “remains resistant”
about the consideration of drugs as
a option for her son. This
phraseology certainly seems to
suggest so.
Leading consultant child and
adolescent psychiatrist Dr Keith
Holmes maintains more than half of
children with ADHD will need
medication.
“For children who respond well it
is one of [the] more clearly treatable
and clearly recognisable illnesses.
There are strict criteria for diagnosis
and children undergo a clinical
interview which is often adequate
but sometimes there will be input
from another source such as school
or a speech and language therapist
to be sure.”
According to Dr Holmes, children
present at two main ages. First
about six or seven and again just as
they transfer to secondary school
and problems begin to surface.
“If symptoms are significant
children will be put on medication
at either of those times. At the
younger age it is mainly boys, and
then later the girls, who tend to
come to our attention. ADHD has
an impact on the whole family. It
can be hereditary and there can be
more than one child in a family and
even a parent.”
The most commonly prescribed
drug is still the stimulant drug
Ritalin, followed now by another
non-stimulant medication Strattera.
Dr Holmes says the reason why
ADHD was not diagnosed in the
past and seems to be a new
phenomenon is that it simply wasn’t
recognised before.
“What happened in years gone
past is that these children did not
survive in the school system and
many would not progress beyond
primary school.”
However, Dr Holmes believes
there are questions over who are the
best people to treat the condition.
“In other countries like New
Zealand and Australia, community
paediatricians treat the disorder and
certainly I think kids would rather
that than to be treated by mental
health practitioners.
“Untreated ADHD can be a
devastating problem not only for
families but for population at large.
“There can be implications to
being on medications long term
such as appetite, height, sleep loss,
but not to treat is not risk free.”
“A lot of things happen in school
setting and there are significant
behavioural problems. ADHD
causes significant impairment and
disrupts family life. It interferes with
the child’s ability to sustain
friendships with other children and
places the child at risk of longer
term problems.”
Conversely, US medical author
Robert Whitaker, who visited
Ireland recently for a series of
public talks on mental health says it
is imperative to look carefully at all
the research before continuing with
this model of care.
“The National Institute of Mental
Health in the US ran a long-term
study beginning in the 1990s, and
by the end of three years, and I am
quoting the study here, ‘medication
use was a significant marker not of
beneficial outcome, but of
deterioration’. That is, participants
using medication in the 24-to
36-month period actually showed
increased symptoms during that
interval relative to those not taking
medication”.
According to the study, at the end
of six years, it was much the same.
And as one of the lead investigators,
William Pelham, said: “We had
thought that children medicated
longer would have better outcomes.
That didn’t happen to be the case.
There were no beneficial effects,
none. In the short term, medication
will help the child behave better, in
the long run it won’t. And that
information should be made very
clear to parents.”
Given that long-term stimulant
does carry considerable risk,
according to Whitaker, it is
imperative that Irish doctors look at
that long-term study and carefully
assess whether it is a good idea to
diagnosis children with ADHD and
then put them on medications.
Picture: iStock