Children with ADHD are being put at risk by poorly regulated private clinics that prescribe powerful stimulants without key physical examinations, doctors have warned.
A surge in remote-only assessments has led to what one clinician described as “widespread and unsafe practice”, where children are being diagnosed and medicated via video link. The clinical warnings have now forced health authorities in Greater Manchester to overhaul prescribing rules, mandating face-to-face checks to protect the safety of children.
Rashad Nawaz, a consultant paediatrician 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 had been prescribed stimulants by national online providers without a single in-person check.
Doctors can prescribe stimulants, such as methylphenidate, of which the best-known brand is Ritalin, as well as non-stimulant alternatives.
The benefits of taking drugs for attention deficit hyperactivity disorder outweigh the impact of increases in blood pressure and heart rate, according to a study from the University of Southampton.
But National Institute for Health and Care Excellence guidelines say a full physical assessment, including a cardiovascular history and a 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 referrals to paediatric cardiology, two of the children were found to have “innocent” murmurs but one was diagnosed with a ventricular septal defect (VSD), commonly known as a hole in the heart.
“None of them had symptoms, but the one with a VSD may do in the future,” Nawaz said. “Based on feedback from parents and reports I have seen … children are not having thorough physical assessments prior to medication. This worries me greatly. It is serious clinical risk and negligent.”
The NHS is struggling to cope with record demand for ADHD services. Many families use the “Right to Choose” scheme to access private care funded by the NHS. However, senior clinicians argue that some private companies, many of whom hold lucrative NHS contracts, lack the infrastructure to ensure patient safety.
Prof Marios Adamou, an NHS psychiatrist, said the reliance on online-only providers had created a dangerous clinical vacuum. “Local GPs are frequently asked to perform these checks on behalf of private services or even start treatment,” he said. “This places clinicians in a difficult position, given that the prescribing clinician carries full legal and clinical responsibility for safe prescribing.”
Nawaz also warned of a “deskilling” of the workforce, claiming that health professionals trained primarily in adult care were “medically treating” children without adequate paediatric experience. In one instance, a child was prescribed medication via video link despite a family history of congenital heart disease, a critical detail that was entirely absent from the private provider’s report.
“Most of the big 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 are prescribing medications with just simple measurements (BP and weight, usually provided by the parent) along with a health check tick list, but without a proper physical exam.”
In response to the warnings, NHS Greater Manchester has implemented a new “safety first” pathway. Prof Manisha Kumar, the region’s chief medical officer, said the move was necessary because “children’s safety has to come first”.
She added: “We are now implementing new pathways that require face-to-face assessments and physical health checks before ADHD medication is prescribed.”
While the new system maintains the right to choose, it in effect bars providers from initiating treatment in the region unless they can prove a robust, in-person clinical assessment has taken place.
