Due care and attention

Is ADHD too readily diagnosed and the drug Ritalin a blunt instrument? Julie Read looks at a growing controversy

The growing battle over the drug Ritalin, prescribed to 200,000 children in the United Kingdom diagnosed with attention deficit hyperactivity disorder (ADHD), is being waged among parents, health and teaching professions alike. ADHD is a clinically recognised condition that makes children impulsive, disruptive and unable to concentrate. Estimates suggest that it affects between 2 and 5 per cent of under-15s in the UK and boys are five times more susceptible to it than girls.

Parents often say they had reached desperation before anyone realised something was wrong, and frequently blame themselves for being unable to understand or handle their children. No wonder, then, that some parents feel relief when they find a doctor who diagnoses a disorder such as ADHD and prescribes methylphenidate, commonly known as Ritalin. Long hailed by its advocates as a psychotropic wonder-drug, Ritalin works on the brain as a mild stimulant, almost immediately making the child calmer.

But Ritalin is classed as a Schedule 2 controlled drug, in the same category as methadone and heroin. It can be prescribed by psychiatric consultants and GPs. Its manufacturer, Novartis Pharmaceuticals, says it should only be given to minors over five years old when non-medicinal treatment has failed. The medical establishment is deeply divided over giving minors such a potent drug. While some doctors hand it out readily, others are vehemently opposed. The situation is further complicated by the uncertainty in medical and educational circles about what ADHD really is. Diagnosing it can be problematic because there is no clear-cut test. Some medical experts believe it is symptomatic of glandular disorders or nutritional problems, and drugs such as Ritalin are a "chemical cosh" that fail to treat the problem.

Harry Zeitlin, professor of child and adolescent psychiatry at University College London, defends the regulated use of Ritalin. He says: "For every 100 children referred to me with possible ADHD, five will be cured by eliminating foods such as sugars or caffeine, 25 will say that food exclusion helps but does not completely cure, and the remaining 70, unable to control their impulsivity and lack of attention, will benefit enormously from Ritalin."

Professor Zeitlin concedes, however, that there may be some doctors in the UK who are overdiagnosing ADHD and overprescribing Ritalin. "It can be an easy way out," he says.

One person who believes it can be too easy is Jean Robb, an educational therapist at the Successful Learning Centre in West Kirby, an after-school unit for children with learning problems. She is co-author of the book Creating Kids Who Can Concentrate: Beating ADHD Without Drugs. She is "horrified" by the latest figures and finds it unimaginable that so many children should be given drugs when, in her opinion, there are likely to be other factors at play. "Food allergies can be a major factor in difficult children and I don't believe ADHD exists. Its symptoms can be explained by other factors," she says.

The behaviour of children with ADHD often pevents them from learning and socialising. But should teachers have to administer pills to sufferers? The National Union of Teachers' advice to its members is against such a responsibility. "The responsibility of teachers lies with the entire class, not handing out drugs to individual children," says a spokeswoman.

The latest debate over the drug and ADHD itself has been fuelled by the Government's reform of the 1983 Mental Health Act, which, as it stands, will give greater powers to psychiatrists to give compulsory treatment. Some mental health charities fear that it will mean the drug may be prescribed to tens of thousands of children against the wishes of their parents. The revisions propose a broader definition of mental disorder, which would affect a wider group of children, young people and adults. Charities fear that doctors would be able to prescribe drugs to those who have "any disability or disorder of the mind or brain, whether permanent or temporary, which results in an impairment or disturbance of mental functioning".

Charities such as YoungMinds, which is not opposed to the use of Ritalin if it is underpinned by a therapeutic approach, believe that the implications for children with ADHD could be considerable. Deborah Loeb, policy and information manager for the charity, says: "Children who show disruptive behaviour such as those deemed to be suffering from ADHD, a condition that is difficult to diagnose, could in principle be compulsorily treated with medication. There are checks and balances within the proposals to try to ensure that such an approach is the last resort but they are nothing like the more sophisticated safeguards that were proposed by the expert committee. It is a worrying proposal and one which we do not support in its current form."

Already, the drug has become so popular that the number of children taking it is, on average, doubling every year, according to the Department of Health. In England, the number of prescriptions has soared from 3,500 in 1993 to 126,500 in 1998. But the backlash against its popularity is becoming increasingly vociferous. One mother who feels that ADHD was a wrong diagnosis for her daughter is Janice Hill. After sending samples of her daughter's blood for testing, she learned that her toddler had been poisoned by organophosphates from sheep dip. Based in Scotland, she has set up the mental health charity Overload and is suing various National Health Service trusts on behalf of 34 parents whose children suffered adverse side-effects while on psychotropic drugs.

As the controversy rumbles on, doctors are cautioning against teachers taking responsibility for handing out Ritalin. Professor Zeitlin, who would like to see the media hype taken out of both the disorder and the drug, has some advice for schools: "While teachers will obviously be on the alert for children with uncontrollable, chaotic behaviour, personally, I don't think that they should be handing out Ritalin to pupils. They are teachers, not diagnosticians."

YoungMinds, tel: 0800 018 2138www.youngminds.org.uk'Creating Kids Who Can Concentrate' by Jean Robb and Hilary Letts is published by Hodder amp; Stoughton, pound;9.99

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