Acta Pxdiatr Scand 67: 449-452, 1978
FREQUENCY OF PSYCHOTROPIC DRUG PRESCRIBING FOR CHILDREN IN TAMPERE, FINLAND ERIKA KREULA and ELINA HEMMINKI From the Department of Public Health Sciences, University of Tampere, Finland
ABSTRACT. Kreula, E. and Hemminki, E. (Department of Public Health Sciences, University of Tampere, Finland). Frequency of psychotropic drug prescribing for children in Tampere, Finland. Acta Paediatr Scand, 67: 449, 1978.-The purpose of the present study was to determine the frequency with which psychotropic drugs are prescribed for children under 10 years of age in outpatient care in Finland. This frequency was estimated from the reimbursements paid by the Social Insurance Office of Tampere City in 1974. Every third psychotropic drug prescribed for children born in 196574 was included. This resulted in 319 children with 375 psychotropic drug prescriptions. About 4% of children under 10 years old in the Tampere area had received within one year’s time one or more psychotropic drugs in outpatient care. About half of the psychotropic drugs were prescribed by general practitioners. Sedatives were the most frequently prescribed drugs, especially in the younger age groups. Antidepressants and antiepileptics were common in the older age groups. The most commonly specified indications were fever and restlessness. KEY WORDS: Psychotropic drugs, children, outpatient, survey
The abundant prescribing of psychotropic drugs has often been discussed. The use of these drugs in outpatient care has aroused particular interest (see e.g. Hemminki (6)), though research has been concentrated mainly on problems concerning adults. Data on psychotropic drug consumption among children are scant and even the frequency with which psychotropic drugs are prescribed for this population is not known. Determining the efficacy and adverse effects of drugs is more difficult among children, and the indications for psychotropic drugs in this group are not well established. These problems have been discussed in particular in the United States, and the focus has been on enuresis and hyperactivity (2, 3,4, 9, 10). The purpose of the present study was to establish the frequency with which psychotropic drugs are prescribed in outpatient care in Finland. The city of Tampere in southern Finland was chosen for the survey area. With 30-782874
its 165978 inhabitants in 1974, Tampere ranks as the second largest city in Finland. MATERIAL AND METHODS The frequency of psychotropic drug prescriptions was estimated from the reimbursements paid by the Social Insurance Ofice of Tampere City. Apart from Tampere itself the social insurance district consists of the neighbouring rural communes Pirkkala and Ylojarvi. In 1974 the population 0-9 years old was as follows: Tampere 22 281 (10898 girls and 11 383 boys), Pirkkala 1422 (662+760) and Ylojarvi 1693 (852+841) (7). All prescribed psychotropic drugs are eligible for reimbursement. If the person has her social security card with her, reimbursement is done in pharmacies in the connection of the purchase. Otherwise the person can get the reimbursement afterwards. In general, very few persons do not use their right to reimbursement. When a person buys drugs outside Tampere, the drugs are not reimbursed by the Tampere Social Insurance Office. Purchases made in Tampere by citizens of other social insurance districts, are reimbursed by the Tampere Social Insurance Office. Every third psychotropic drug ordered for children born in 1965-74 and filed in 1974 was examined. The next, non-psychotropic drug prescription in the file for children in this age group was selected as a control. When the sample included several psychotropic drugs for the same Acta Paediatr Scand 67
450
E. Kreula and E. Hemrninki
Table 1 . Distribution of psychotropic drug presciptions by sex
Boys Girls Total
N
%
Rate per 100 children in the Tampere area
190
60 40 100
4.4 3. I 3.8
129 319
3. Antipsychotic drugs (1 lc) 4. Psychostimulants, antidepressants ( 1 Id) 5. Drugs for migraine ( 1 lg) 6. Antiepileptics, anticonvulsants ( 1 I h) 7. Hidden psychotropic drugs. Preparations which include psychotropic drugs in addition to other active incredients and which are not classified as psychotropic drugs. The ages of the children in the sample were calculated from the year of the birth. When estimating the prescription frequency the number of children reimbursed in each age group was multiplied by three and divided by the number of the children of that age in the Tampere area.
child all these drugs were recorded for this child. The controls for the second and third drugs have been excluded. All information available in the prescriptions was collected including the name of the drug, dose, indication, and physician’s name. The duration of therapy was calculated by dividing the total number of tablets (ml) by the daily dosage. The physician’s specialty was obtained from the catalogue of doctors practising in Tampere. 3 19 children with 375 psychotropic drug prescriptions and 317 children with control drug prescriptions form the sample. If not mentioned otherwise, only the information of the first psychotropic drug is considered in Results. The second and third psychotropic drugs usually belonged to the same drug group as the first. In four cases (in two psychotropic drug prescriptions and two controls) the age of the child was not known, and these were excluded from Table 2. Three psychotropic drugs belongfng to other groups than those listed below were excluded from Tables 2, 3 and 5. The classification of psychotropic drugs was based on Remedia Fennica (5) and following drugs were included. The terms used in the tables and text are in italics, and the symbols in parentheses refer to Remedia Fennica. 1. Sedatives, hypnotics (1 la) 2. Anxiolytic drugs (minor tranquillizers) ( I Ib)
RESULTS Fifty-one percent of the children under 10 years were boys and 49% were girls in the Social Insurance District of Tampere (7). Sixty percent of those who had received psychotropic drugs and 57% of the controls were boys (Table 1). About 4% of children had received one or more psychotropic drugs in outpatient care within one year. The frequencies of psychotropic drug prescribing in different age groups are given in Table 2. Children born in 1972 (about 2 years old) and in 1966 (about 8 years old) had received psychotropic drugs most frequently. The distribution of control drug prescriptions was not similar. Compared with psychotropic drugs these drugs were prescribed more often for children aged 0 to 5.
Table 2. Percentage distribution of different psychotropic drugs by age
Age (years)
Rate per 100 children in Number of the Tampere children area
0 1 2 3 4 5 6 7 8 9 Total
1 25 44 20 24 33 41 35 59 32 314
Acta Paediatr Scand 67
(0.0) 3.3 5.6 2.7 3 .O 4.0 4.6 3.7 6.4 3.6 3.7
Anxiolytic Sedatives drugs
50 55 54 37 14 17 12 9
24 16 20 8 15 24 6 17 9
29
16
44
AntiAntideprespsychotics sants (100)
4 5
3 3
2
5 8 I5 20 32 14 22 13
Migraine drugs
Antiepileptics
11 4 15 10 14 8 16 9
4 10 13 12 7 17 31 28 I5
Hidden psychotropic drugs Total
24 23 10 13 6 20 14 15 13
(100) 100 100 100 100 100 100
16
100
100 100 100
Psychotropic drug prescribing
Table 4. Percentage distribution of drug prescriptions by the prescribing physician’s specialty
Table 3. Percentage distribution of psychotropic drug prescriptions by the mean duration of the therapy Duration of therapy, days
< 10 10-30 >30 Total
1st drug N=316
2nd drug N=43
46 16 35 100
3rd drug N = 13
28 9 63
15 8 71
100
100
451
Psychotropic drug (N=314)
Specialty General practitioner Pediatrics Psychiatry or child psychiatry Otolaryngology Dermatology Other specialities
Table 2 also shows the distribution of various psychotropic drugs by age. As described in Methods, only the first psychotropic drug was included. Sedatives were the most frequently prescribed drugs, especially in the younger age groups. Antidepressants and antiepileptics were common in the older age groups. About 60% of the psychotropic drugs belonged to the first four groups (sedatives, anxiolytics, antipsychotics, and antidepressants). Of the ‘second drugs’ about half were antiepileptics. The ‘third drug’ belonged to this group in about 70% of cases. The mean duration of therapy for the first psychotropic drug prescription was 41 days, 83 days for the second, and 98 days for the third psychotropic drug prescription. (20% of the first psychotropic drugs and 10% of the second and third drugs were ordered to be taken only when needed. For these drugs the duration of therapy was counted as if they were ordered to be taken regularly using the
Control drug (N=317) 74 13
54
21
-
6 6 6 1
8 3 2
100
100
recommended dosage.) In half of the first psychotropic drug prescriptions, the duration of therapy was under 10 days, but in the case of the second and third drug the duration of therapy was longer (Table 3). Antiepileptics had the longest duration of therapy (mean 127 days). The mean duration of therapy was 76 days for antidepressants, 46 days for antipsychotics, 41 days for anxiolytic drugs, and 7 days for sedatives. Table 4 shows the drug prescribing by physicians’ specialty. Fifty-four percent of the psychotropic drugs were prescribed by general practitioners. If the specialties of the prescribers of the control drugs are used as estimations of the frequencies of different physician contacts, we may conclude that reckoned per consultation, pediatricians prescribed
Table 5. Percentage distribution of indications by drug group
Drug group Sedatives Anxiolytic drugs Antipsychotic drugs Antidepressants Migraine drugs Antiepileptics Hidden psychotropic drugs
Indications No. of preRestscriplesstions Fever ness 91 49 7 42 30 46
52
2
-
EnuNausea resis
-
16 8 14 5 -
53 -
-
Allergic sympCough, Head- Epitoms dyspnea ache lepsia
35
17 -
-
-
49
10
6
-
2
-
14
314
17
8
6
5
5
2
No. Indication
Total 100 100 100 100 100 100 100
23 -
17
30 53 86 16 24 83
2
12 6
56 51
2 4
-
100
Acta Paediatr Scand 67
452
E . Kreula and E . Hemminki
psychotropic drugs more frequently than other physicians. Indication was given only in 49% of the psychotropic drug prescriptions (Table 5 ) . The most common indications were fever and restlessness. In each age group the majority of indications could be classified as somatic or psychosomatic diseases: fever, nausea, allergic symptoms, dyspnea, and headache. Prescriptions without indications were most common among the children over 6 year old. Fewest indications were given for antipsychotics, antidepressants and antiepileptics. For instance, in only 17% of antiepileptic drugs were convulsions recorded as an indication. Indications for migraine drugs had been recorded most often. Most of the sedatives were given for fever and for restlessness. Various allergic symptoms were the main indications for anxiolytic drugs. Psychostimulants were often prescribed for enuresis. Various hidden psychotropic drugs were frequently prescribed for cough and dyspnea. . DISCUSSION Psychotropic drugs were prescribed for about 4 % of children under 10 years of age during
the year 1974. More than half of the specified indications were of a somatic or psychosomatic nature (e.g. fever and nausea). Bain (1) has reported similar findings from a Scottish general practice of five doctors. In his material, 6% of children under 12 years of age received one or more prescriptions for psychotropic drugs during 1971 and 13% of all psychotropic drug prescriptions issued during that year were for children. Most common indications in the Scottish study were behavioural disorders and enuresis. Our figure for the frequency of psychotropic drug prescriptions may be an underestimate, since it is possible that reimbursements were not always sought. The purchases outside the area and those made in the Tampere area for children from other communes may bring some further bias, the direction of which is not Acta Paediatr Scand 67
known. But in the case of children, buying drugs outside the home community is considered to be infrequent in Tampere (8). Nevertheless, our survey indicates that the prescribing of psychotropic drugs for children is not rare. This study does not consider the issues of the proportion of these drugs that were really indicated, nor what were the benefits and side-effects of these drugs. Since a child's brain is in the developing stage, both in a somatic and a psychological sense, a future evaluation of these issues would seem both prudent and important in the total assessment of psychotropic drug prescribing for children. ACKNOWLEDGEMENTS We wish to thank the Social Insurance Institution of Finland for their allowing us to use the drug prescription data. We also thank the Tampere Social Insurance Office for help and advice in the course of the study.
REFERENCES I . Bain, D. J.: Prescribing psychotropic drugs for children. J R Coll Gen Pract, 25: 49, 1975. 2. Bazell, R. J.: Panel sanctions amphetamines for hyperkinetic children. Science, 171: 1223, 1971. 3. Prescribing psychotropic drugs for children. Br Med J, iv: 123, 1975. 4. Conners, C. K.: Dean01 and behavior disorders in children: a critical review of the literature and recommended future studies for determining efficacy. Psychopharmacol Bull, special issue: Pharmacotherapy ofchildren, p. 188, 1973. 5. Heinonen, 0. P. (ed.): Remedia Fennica 1974, Helsinki 1974. 6. Hemminki, E.: Prescription of Psychofropic Drugs in Outpatient Care. Acta Universitatis Tamperensis, Ser. A, vol. 58. Tampere 1974. 7. Office of Population Census of Finland. Personal communication, October, 1976. 8. Social Insurance Office of Tampere. Personal communication, February, 1977. 9. Sroufe, L. A. & Stewart, M. A,: Treating problem children with stimulant drugs. N Engl J Med, 289: 407, 1973. 10. Weiss, G., Minde, K., Werry, J . S . , Douglas, V. & Nemeth, E.: Studies on the hyperactive child. Arch Gen Psychiat, 24: 409, 1971. Submitted June 20, 1977 Accepted Oct. 8, 1977 (E. K.) Department of Public Health Sciences University of Tampere Vuolteenkatu 11 00100 Tampere 10 Finland
FREQUENCY OF PSYCHOTROPIC DRUG PRESCRIBING FOR CHILDREN IN TAMPERE, FINLAND ERIKA KREULA and ELINA HEMMINKI From the Department of Public Health Sciences, University of Tampere, Finland
ABSTRACT. Kreula, E. and Hemminki, E. (Department of Public Health Sciences, University of Tampere, Finland). Frequency of psychotropic drug prescribing for children in Tampere, Finland. Acta Paediatr Scand, 67: 449, 1978.-The purpose of the present study was to determine the frequency with which psychotropic drugs are prescribed for children under 10 years of age in outpatient care in Finland. This frequency was estimated from the reimbursements paid by the Social Insurance Office of Tampere City in 1974. Every third psychotropic drug prescribed for children born in 196574 was included. This resulted in 319 children with 375 psychotropic drug prescriptions. About 4% of children under 10 years old in the Tampere area had received within one year’s time one or more psychotropic drugs in outpatient care. About half of the psychotropic drugs were prescribed by general practitioners. Sedatives were the most frequently prescribed drugs, especially in the younger age groups. Antidepressants and antiepileptics were common in the older age groups. The most commonly specified indications were fever and restlessness. KEY WORDS: Psychotropic drugs, children, outpatient, survey
The abundant prescribing of psychotropic drugs has often been discussed. The use of these drugs in outpatient care has aroused particular interest (see e.g. Hemminki (6)), though research has been concentrated mainly on problems concerning adults. Data on psychotropic drug consumption among children are scant and even the frequency with which psychotropic drugs are prescribed for this population is not known. Determining the efficacy and adverse effects of drugs is more difficult among children, and the indications for psychotropic drugs in this group are not well established. These problems have been discussed in particular in the United States, and the focus has been on enuresis and hyperactivity (2, 3,4, 9, 10). The purpose of the present study was to establish the frequency with which psychotropic drugs are prescribed in outpatient care in Finland. The city of Tampere in southern Finland was chosen for the survey area. With 30-782874
its 165978 inhabitants in 1974, Tampere ranks as the second largest city in Finland. MATERIAL AND METHODS The frequency of psychotropic drug prescriptions was estimated from the reimbursements paid by the Social Insurance Ofice of Tampere City. Apart from Tampere itself the social insurance district consists of the neighbouring rural communes Pirkkala and Ylojarvi. In 1974 the population 0-9 years old was as follows: Tampere 22 281 (10898 girls and 11 383 boys), Pirkkala 1422 (662+760) and Ylojarvi 1693 (852+841) (7). All prescribed psychotropic drugs are eligible for reimbursement. If the person has her social security card with her, reimbursement is done in pharmacies in the connection of the purchase. Otherwise the person can get the reimbursement afterwards. In general, very few persons do not use their right to reimbursement. When a person buys drugs outside Tampere, the drugs are not reimbursed by the Tampere Social Insurance Office. Purchases made in Tampere by citizens of other social insurance districts, are reimbursed by the Tampere Social Insurance Office. Every third psychotropic drug ordered for children born in 1965-74 and filed in 1974 was examined. The next, non-psychotropic drug prescription in the file for children in this age group was selected as a control. When the sample included several psychotropic drugs for the same Acta Paediatr Scand 67
450
E. Kreula and E. Hemrninki
Table 1 . Distribution of psychotropic drug presciptions by sex
Boys Girls Total
N
%
Rate per 100 children in the Tampere area
190
60 40 100
4.4 3. I 3.8
129 319
3. Antipsychotic drugs (1 lc) 4. Psychostimulants, antidepressants ( 1 Id) 5. Drugs for migraine ( 1 lg) 6. Antiepileptics, anticonvulsants ( 1 I h) 7. Hidden psychotropic drugs. Preparations which include psychotropic drugs in addition to other active incredients and which are not classified as psychotropic drugs. The ages of the children in the sample were calculated from the year of the birth. When estimating the prescription frequency the number of children reimbursed in each age group was multiplied by three and divided by the number of the children of that age in the Tampere area.
child all these drugs were recorded for this child. The controls for the second and third drugs have been excluded. All information available in the prescriptions was collected including the name of the drug, dose, indication, and physician’s name. The duration of therapy was calculated by dividing the total number of tablets (ml) by the daily dosage. The physician’s specialty was obtained from the catalogue of doctors practising in Tampere. 3 19 children with 375 psychotropic drug prescriptions and 317 children with control drug prescriptions form the sample. If not mentioned otherwise, only the information of the first psychotropic drug is considered in Results. The second and third psychotropic drugs usually belonged to the same drug group as the first. In four cases (in two psychotropic drug prescriptions and two controls) the age of the child was not known, and these were excluded from Table 2. Three psychotropic drugs belongfng to other groups than those listed below were excluded from Tables 2, 3 and 5. The classification of psychotropic drugs was based on Remedia Fennica (5) and following drugs were included. The terms used in the tables and text are in italics, and the symbols in parentheses refer to Remedia Fennica. 1. Sedatives, hypnotics (1 la) 2. Anxiolytic drugs (minor tranquillizers) ( I Ib)
RESULTS Fifty-one percent of the children under 10 years were boys and 49% were girls in the Social Insurance District of Tampere (7). Sixty percent of those who had received psychotropic drugs and 57% of the controls were boys (Table 1). About 4% of children had received one or more psychotropic drugs in outpatient care within one year. The frequencies of psychotropic drug prescribing in different age groups are given in Table 2. Children born in 1972 (about 2 years old) and in 1966 (about 8 years old) had received psychotropic drugs most frequently. The distribution of control drug prescriptions was not similar. Compared with psychotropic drugs these drugs were prescribed more often for children aged 0 to 5.
Table 2. Percentage distribution of different psychotropic drugs by age
Age (years)
Rate per 100 children in Number of the Tampere children area
0 1 2 3 4 5 6 7 8 9 Total
1 25 44 20 24 33 41 35 59 32 314
Acta Paediatr Scand 67
(0.0) 3.3 5.6 2.7 3 .O 4.0 4.6 3.7 6.4 3.6 3.7
Anxiolytic Sedatives drugs
50 55 54 37 14 17 12 9
24 16 20 8 15 24 6 17 9
29
16
44
AntiAntideprespsychotics sants (100)
4 5
3 3
2
5 8 I5 20 32 14 22 13
Migraine drugs
Antiepileptics
11 4 15 10 14 8 16 9
4 10 13 12 7 17 31 28 I5
Hidden psychotropic drugs Total
24 23 10 13 6 20 14 15 13
(100) 100 100 100 100 100 100
16
100
100 100 100
Psychotropic drug prescribing
Table 4. Percentage distribution of drug prescriptions by the prescribing physician’s specialty
Table 3. Percentage distribution of psychotropic drug prescriptions by the mean duration of the therapy Duration of therapy, days
< 10 10-30 >30 Total
1st drug N=316
2nd drug N=43
46 16 35 100
3rd drug N = 13
28 9 63
15 8 71
100
100
451
Psychotropic drug (N=314)
Specialty General practitioner Pediatrics Psychiatry or child psychiatry Otolaryngology Dermatology Other specialities
Table 2 also shows the distribution of various psychotropic drugs by age. As described in Methods, only the first psychotropic drug was included. Sedatives were the most frequently prescribed drugs, especially in the younger age groups. Antidepressants and antiepileptics were common in the older age groups. About 60% of the psychotropic drugs belonged to the first four groups (sedatives, anxiolytics, antipsychotics, and antidepressants). Of the ‘second drugs’ about half were antiepileptics. The ‘third drug’ belonged to this group in about 70% of cases. The mean duration of therapy for the first psychotropic drug prescription was 41 days, 83 days for the second, and 98 days for the third psychotropic drug prescription. (20% of the first psychotropic drugs and 10% of the second and third drugs were ordered to be taken only when needed. For these drugs the duration of therapy was counted as if they were ordered to be taken regularly using the
Control drug (N=317) 74 13
54
21
-
6 6 6 1
8 3 2
100
100
recommended dosage.) In half of the first psychotropic drug prescriptions, the duration of therapy was under 10 days, but in the case of the second and third drug the duration of therapy was longer (Table 3). Antiepileptics had the longest duration of therapy (mean 127 days). The mean duration of therapy was 76 days for antidepressants, 46 days for antipsychotics, 41 days for anxiolytic drugs, and 7 days for sedatives. Table 4 shows the drug prescribing by physicians’ specialty. Fifty-four percent of the psychotropic drugs were prescribed by general practitioners. If the specialties of the prescribers of the control drugs are used as estimations of the frequencies of different physician contacts, we may conclude that reckoned per consultation, pediatricians prescribed
Table 5. Percentage distribution of indications by drug group
Drug group Sedatives Anxiolytic drugs Antipsychotic drugs Antidepressants Migraine drugs Antiepileptics Hidden psychotropic drugs
Indications No. of preRestscriplesstions Fever ness 91 49 7 42 30 46
52
2
-
EnuNausea resis
-
16 8 14 5 -
53 -
-
Allergic sympCough, Head- Epitoms dyspnea ache lepsia
35
17 -
-
-
49
10
6
-
2
-
14
314
17
8
6
5
5
2
No. Indication
Total 100 100 100 100 100 100 100
23 -
17
30 53 86 16 24 83
2
12 6
56 51
2 4
-
100
Acta Paediatr Scand 67
452
E . Kreula and E . Hemminki
psychotropic drugs more frequently than other physicians. Indication was given only in 49% of the psychotropic drug prescriptions (Table 5 ) . The most common indications were fever and restlessness. In each age group the majority of indications could be classified as somatic or psychosomatic diseases: fever, nausea, allergic symptoms, dyspnea, and headache. Prescriptions without indications were most common among the children over 6 year old. Fewest indications were given for antipsychotics, antidepressants and antiepileptics. For instance, in only 17% of antiepileptic drugs were convulsions recorded as an indication. Indications for migraine drugs had been recorded most often. Most of the sedatives were given for fever and for restlessness. Various allergic symptoms were the main indications for anxiolytic drugs. Psychostimulants were often prescribed for enuresis. Various hidden psychotropic drugs were frequently prescribed for cough and dyspnea. . DISCUSSION Psychotropic drugs were prescribed for about 4 % of children under 10 years of age during
the year 1974. More than half of the specified indications were of a somatic or psychosomatic nature (e.g. fever and nausea). Bain (1) has reported similar findings from a Scottish general practice of five doctors. In his material, 6% of children under 12 years of age received one or more prescriptions for psychotropic drugs during 1971 and 13% of all psychotropic drug prescriptions issued during that year were for children. Most common indications in the Scottish study were behavioural disorders and enuresis. Our figure for the frequency of psychotropic drug prescriptions may be an underestimate, since it is possible that reimbursements were not always sought. The purchases outside the area and those made in the Tampere area for children from other communes may bring some further bias, the direction of which is not Acta Paediatr Scand 67
known. But in the case of children, buying drugs outside the home community is considered to be infrequent in Tampere (8). Nevertheless, our survey indicates that the prescribing of psychotropic drugs for children is not rare. This study does not consider the issues of the proportion of these drugs that were really indicated, nor what were the benefits and side-effects of these drugs. Since a child's brain is in the developing stage, both in a somatic and a psychological sense, a future evaluation of these issues would seem both prudent and important in the total assessment of psychotropic drug prescribing for children. ACKNOWLEDGEMENTS We wish to thank the Social Insurance Institution of Finland for their allowing us to use the drug prescription data. We also thank the Tampere Social Insurance Office for help and advice in the course of the study.
REFERENCES I . Bain, D. J.: Prescribing psychotropic drugs for children. J R Coll Gen Pract, 25: 49, 1975. 2. Bazell, R. J.: Panel sanctions amphetamines for hyperkinetic children. Science, 171: 1223, 1971. 3. Prescribing psychotropic drugs for children. Br Med J, iv: 123, 1975. 4. Conners, C. K.: Dean01 and behavior disorders in children: a critical review of the literature and recommended future studies for determining efficacy. Psychopharmacol Bull, special issue: Pharmacotherapy ofchildren, p. 188, 1973. 5. Heinonen, 0. P. (ed.): Remedia Fennica 1974, Helsinki 1974. 6. Hemminki, E.: Prescription of Psychofropic Drugs in Outpatient Care. Acta Universitatis Tamperensis, Ser. A, vol. 58. Tampere 1974. 7. Office of Population Census of Finland. Personal communication, October, 1976. 8. Social Insurance Office of Tampere. Personal communication, February, 1977. 9. Sroufe, L. A. & Stewart, M. A,: Treating problem children with stimulant drugs. N Engl J Med, 289: 407, 1973. 10. Weiss, G., Minde, K., Werry, J . S . , Douglas, V. & Nemeth, E.: Studies on the hyperactive child. Arch Gen Psychiat, 24: 409, 1971. Submitted June 20, 1977 Accepted Oct. 8, 1977 (E. K.) Department of Public Health Sciences University of Tampere Vuolteenkatu 11 00100 Tampere 10 Finland
