Attention focused in north

13th December 1996 at 00:00
Children are the same the world over, the way they are treated makes the difference. Cyril Hellier says.

Children are no different wherever you go; this I know, having supported pupils in three relatively affluent western countries. However, the identification process and resulting response to their recognised needs is bound to be influenced by local economic, political and cultural factors. It is important to be aware of these influences when considering the growth of attention deficit hyperactivity disorder (ADHD) across the United Kingdom and particularly in Scotland.

Closer to home, given recent publicity one must conclude that Scotland is a very different context in which to work and to receive education. Fundamental issues and practices have been raised for scrutiny in England and Wales including the teaching of literacy in mainstream education, the adequacy of teacher training, the methods of managing disruptive pupils and involving parents (from caning to contracts), the relative responsibilities of local authorisation and governing bodies and the role of trade unions taking high profile stances over pupil disruption; the list is endless. Ronnie Smith, general secretary of the Education Institute of Scotland which represents the majority of teachers in Scotland has responded by affirming the relatively inclusive and comprehensive nature of state education in Scotland, in contrast to England and Wales.

This may help to explain why the recent publication of a British Psychological Society report on ADHD was responded to in such different terms in England and Wales. The scale of media interest and the polarised nature of the debate was in sharp contrast to the lack of a particular Scottish perspective. The former was characterised by considerable simplification of the issues suggesting that "naughty children" should not be drugged. "Drug him when he teases" sums up this extreme view. In contrast many distressed parents were paraded across the media pointing out the failures of services to respond over many years. As the Scottish representative on the working party which produced the report, I was involved in radio broadcast and interviews, both national and international, at the time of its launch in September. None were on Scottish networks.

At a recent conference in Edinburgh held by the International Psychology Service, a private company, a well-attended audience composed principally of teaching staff with a few community paediatricians listened to the detailed descriptions of diverse disturbances in human attention which one might encounter. No one could fail to start identifying pupils, colleagues, family members and possibly oneself, who might, on occasion, display some of the traits; the loosely defined American categories of inattentionimpulsivity with or without hyperactivity represent one major difficulty associated with the inferred condition.

All were less impressed however, when the speaker admitted that there is no teaching response specific to such behaviour; the poor quality of awkwardly-presented American videos only served to reinforce the difficulties inherent in transferring US practices to the UK. Mainstream class teaching practices are very different in Scotland from those in America; here in Scotland, considerable focus upon pupil self-regulation already exists in negotiating curricular demands, in marked contrast to the didactic methods characteristic of the US.

Positive guidance, feedback and parental training, will be helpful in the vast majority of cases, whatever the diagnosis. As a result many of the prescriptions referred to in the research literature are either irrelevant or unexceptional as they could apply to any child experiencing difficulties.

It is a fact that there are pockets of practice in some parts of England, where a similar phenomenon of proliferating ADHD assessment in private clinics is leading to a burgeoning incidence of pupils on medication in certain schools and communities. This represents an Americanisation of services, where up to 10 per cent of the child population is currently in receipt of psychostimulant medication for this diagnosed condition; so much so in the US, that the Drug Enforcement Agency is expressing serious concerns about its overuse and its possible abuse in street culture, ritalin being added to the cocktail of dangerous drugs already available. In parts of Australia a similar picture is emerging. Scotland presents a patchy picture at present with evident increases in requests for diagnosis.

At the end of the day all children presenting disturbances of attention and activity in school need to be understood and responded to as individuals along a continuum of emotional and social development. There is no intervention specific to ADHD which is non-medical. The BPS report concludes in objective vein that more research is needed to clarify the conceptualisation of ADHD and to evaluate non pharmacological interventions.

The wealth of media coverage south of the border has correctly reported its criticism of the overuse of the diagnosis and consequent medical response. However, the report does also support the fact that evidence exists to demonstrate the positive influence of medication, especially when other strategies have been shown to be ineffective. The main requirement however is that agencies recognise that the American influence is here to stay; the predisposition of UK diagnosticians to underuse the more conservative World Health Organisation's term "hyperkinesis" requires to be addressed in the light of the media and parent driven use of more inclusive American categories.

They need to work closely together in the early stages of intervention in order to determine in which cases the addition of medication might be beneficial. It is essential to rule out other explanatory causes in this process - the challenge being to improve the effectiveness of existing services in working together.

Perth and Kinross has developed an ADHD forum comprising child psychiatry, community paediatrics, clinical psychology, behaviour support and educational psychology. These agencies are often involved in responding to children who might be seen as potential ADHD candidates; some are. The result has been to improve communication across the agencies and to develop more efficient procedures of referral and information sharing with parental permission. In such a forum, experience of positive casework is shared to help develop working systems: the 11-year-old boy who no longer fails to follow instructions or constantly take work home to a stressed household; the nine-year-old girl who for the first time has experienced promotion in class maths groups and is only now playing happily with her peers in the playground; the 13-year-old boy whose behaviour is so radically improved in all lessons since taking medication in the morning - however when he forgets to take his tablet for the afternoon session he is banned from practical lessons and is unable to concentrate in any lesson. All testify to the value of medication in addition to existing strategies and provide a challenge to the sceptics.

Given the recency of this phenomenon's arrival in the UK, teachers and others have a lot to learn. However, I am glad that I am working in Scotland when responding to children who may be diagnosed with ADHD; in this context it is more likely to be dealt with in a constructive, relatively objective manner.

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