Powerful medications are not a quick fix for ADHD, and we should use a more collaborative approach to treatment
Two years ago, I stood in front of the TUC at its annual conference and explained why I am so concerned about how children and young people diagnosed with attention deficit hyperactivity disorder (ADHD) are treated and supported. The crux of the argument was this: we run the risk of failing to provide the best possible support to young people if we do not adopt better and more collaborative ways of working, and in particular, if we are drawn into a situation where treatment involves only the perceived quick fix of giving medication.
While figures vary, many studies suggest that up to five per cent of children and young people are affected by ADHD, with around one in a hundred being severely affected. The best figures available from the Department of Health show that the number of prescriptions for some of the medications used to treat ADHD has increased from 158,000 in 1999 to 610,000 in 2009 – a rise of nearly 260 per cent. Although these figures refer to the total number of prescriptions rather than just those for children, given the frequency with which we see ADHD diagnosed in children, it seems reasonable to suggest that many of these prescriptions have been for younger members of the population. What’s more, new diagnostic criteria to be introduced this year – known as DSM-5 – will lead to more inclusive definitions of mental health.
There are serious concerns about these new diagnostic criteria. It is important that there continues to be very careful judgment exercised in the diagnosis of children and young people to ensure that we do not reach a situation where children exhibiting behaviours within the normal range are considered to have some form of mental health disorder. A child can, for example, be sad or angry without that being an indication of depression or ADHD, and s/he may require entirely different types of support. Put bluntly, with the adoption of DSM-5, we may see more and more children and young people diagnosed with conditions such as ADHD.
Problems with medication
ADHD is frequently treated with psychotropic medications, the most common of which is Ritalin. I am not suggesting that medication should never be used to support those diagnosed with ADHD. Clearly, in some cases, it is an appropriate intervention, and has very positive results for children, their families and friends. Rather, the concern is over the potency of these medications and the long-term neurological effects they could have on the developing brains of young children.
NICE guidelines recommend that medications such as Ritalin should not be given to children under the age of six, but this is not necessarily reflected in practice. There have been anecdotal reports of very young children being prescribed psychotropic medications to address ADHD. The lack of available data makes it impossible to make a proper judgment on the extent to which NICE guidelines are being followed, or to track any particular patterns in diagnosis or treatment. This will concern many professionals with responsibility for children and young people. Equally concerning is the lack of evidence as to the effect of such medications on children’s long-term neurological development. More work must urgently be done to establish these effects and make sure that children are not unnecessarily put at risk.
We need to ensure that the use of medications such as Ritalin is only one of a number of options for helping children and not, as can be the case, the first port of call for parents and professionals. Perhaps it is part of the consumer culture in which we live, but in almost every walk of life there is a tendency for us to look for an easy solution – the one that meets our demands and expectations most quickly. In the case of ADHD, this tendency can result in the prescription of medication that, while potentially helpful in the short-term, may not be the most appropriate long-term solution and may create more problems in the future. There is always the danger of developing a dependence on medication as a form of treatment. Moreover, if, over time, the medication ceases to be as effective as it was, there may be a great temptation to increase its dosage or potency. Clearly, though, this cannot, and should not, be done ad infinitum.
What is the solution?
While medication can play a role in the support and treatment process, what we really need is a greater emphasis on collaborative working between parents and all the professionals involved, including GPs, educational psychologists, teachers and healthcare professionals.
A collaborative approach focuses on the needs of the individual and allows for the consideration of different therapies or interventions that might better suit that individual. In the first instance this means collecting reports about a child’s behaviour in a range of settings, such as school, home or at leisure, in order to build a comprehensive picture of his/her needs. The involvement of different professionals can then allow consideration and implementation of a range of measures, including but not limited to individual work such as cognitive behaviour therapy, counselling or building skills for resilience. Measures may also include changes at school, including altering classroom practices or differentiation of the curriculum, and work with a child’s family, which could involve parenting courses.
Success is most likely if the agreed approach incorporates a combination of some or even all these interventions, and involves the whole family. While this can also sometimes include the use of medications, developing successful strategies not only helps to provide the best learning environment for a child, but can also help bring about long-term changes in their environment and people around them which can then reduce or eliminate the need for drug support.
With the adoption of the DSM-5 criteria, we can expect to see more instances of children and young people being diagnosed with ADHD in the future. So it is vital that we protect against the use of medication becoming a standard practice that ignores the valuable contributions of a range of professionals, valuable alternative therapies, and even the needs of the individual. Medication has an important role in the treatment process, but the simple truth is that there is no quick fix for ADHD.
Kate Fallon is the General Secretary of the Association of Educational Psychologists, the professional body and trade union for educational psychologists in the UK: