Doctors, leave them kids alone

7th May 2010 at 01:00
Transforming a disruptive, angry child into a model pupil is a tempting prospect for any teacher. But while some support medical intervention for those with symptoms of ADHD, many argue that we are too quick to medicalise challenging behaviour

Susan Carter* suspected David* of having ADHD (Attention Deficit Hyperactivity Disorder) when he wouldn't stop banging his head on the floor. Other clues were the fact that the eight-year-old could not sit still. Ever. Instead, he would constantly rock himself back and forth. He would swear incessantly and appeared physically incapable of listening to, or following, orders.

Then he started taking methylphenidate, a drug better known as Ritalin. "He was totally transformed," Ms Carter says. "I could not believe it - he was like a different boy.

"He could listen, co-operate and write. He went on to study A-level science at college, which I would never have thought possible when he was eight."

Ms Carter, who teaches in a primary school in the West Country, is convinced David benefited through taking the drug.

When the pupil was late with taking his medication, "he went loopy, angry, aggressive, or talked gibberish", she says. When he took it correctly, his behaviour normalised.

Following the publication of similar success stories, swathes of pupils with ADHD are being prescribed these so-called wonder drugs. While Ritalin is the best known, others have emerged in its wake: Concerta XL, Equasym XL, Medikinet and the non-stimulant Strattera to name but a few.

But is this "miracle cure" too good to be true? While the drug may work wonders in calming hyperactive children, there are significant concerns about its impact on users.

As well as some of the more "typical" side-effects of medication - insomnia, headaches, lethargy and digestive problems - the drugs have been linked to stunted growth and loss of appetite. And something even more disturbing has been reported: excessively lively children can start to act like zombies.

Tom Bennett, a teacher at Raine's Foundation School in east London, saw the effects of Ritalin first-hand at a school where he worked previously. One of his pupils could not pay attention in class and was always messing about. "His book was a disaster zone of scrawls and graffiti," Mr Bennett recalls.

Once he started the medication, his behaviour quickly flatlined. "He became a ghost of his former self and drifted around school and through lessons for years. He wasn't exactly sharp as a knife to begin with, but even so he seemed to have lost the will to live."

Sally Wright*, a primary teacher, has seen similar effects on her pupils. Although some have responded well to medication, it has gone terribly wrong for others.

"Some children just need some good old-fashioned discipline that the parents can't or don't give," she says. "When they are given Ritalin, it either saps them of their personality and turns them into almost zombie- like children, or it has hardly any effect at all. In my experience, it is virtually impossible to generalise the impact it will have."

So why do so many teachers - and parents - support the use of medication that can have such a negative effect on young people? Probably because, without the drugs, ADHD sufferers can make their teachers' lives a nightmare.

The textbooks describe ADHD sufferers as having abnormally high levels of impulsivity, hyperactivity and inattention. In practice that means a child who is extremely difficult to control. In scenarios like this, drugs may seem to be the only answer.

Ritalin, along with its related medications, is an amphetamine-like drug, not dissimilar to the recreational drug speed. But it has the paradoxical effect of calming down hyperactive children. Some teachers, parents, doctors - and even pupils - rhapsodise about its effects.

Its popularity has fuelled a staggering leap in demand. Reliable figures on the number of children who have been diagnosed with ADHD are hard to come by, but the number of times doctors have prescribed Ritalin to children has more than doubled in recent years. Figures from primary care trusts (PCTs) in England show doctors prescribed Ritalin 461,000 times in 2007, up from 199,000 in 2003.

But this masks a wildly inconsistent picture across the country. A study published in Health Service Journal in 2008 found that Wirral PCT dispenses one Ritalin prescription for every seven children under 16 (this does not equate to one in seven children on Ritalin, as one child can have repeat prescriptions). By contrast, Stoke-on-Trent PCT dispenses one prescription for every 159 children. Across England, the average is one for every 23 children.

What is fuelling this disparity? Is the Wirral an ADHD hotspot? Are doctors there simply better at picking up on the condition, or are they more likely to be turning behavioural problems into a medical condition?

There are similar levels of variation in Scotland. In Fife, the prescription rate for five to 14-year-olds with ADHD is almost double that of the rest of the country. Figures from NHS Scotland show there was an increase of more than 6 per cent in the number of prescriptions for ADHD in the years 200708 and 200809.

"There is a tenfold difference in diagnostic and treatment rates around the UK," says Dr Tim Kendall, director of the National Collaborating Centre for Mental Health and a consultant psychiatrist in Sheffield.

He believes that, under pressure from parents, doctors are prescribing drugs as a "quick fix". He is uncomfortable with the high number of children on drugs, which have the potential to leave them behaving like the zombies of Tom Bennett's experience.

The increasing willingness to turn to medication for solutions ignores the benefits of psychological therapy and training for parents, Dr Kendall adds. Even though they are often more effective than drugs, talking therapies are harder to come by and expensive, and will not "cure" a pupil overnight.

The drugs, by contrast, can have an almost instant effect. But it comes at a cost. First, the long-term consequences or safety of taking ADHD drugs is not well known. And even those side-effects that are well-documented are scarcely insignificant.

Children who take the drugs for 36 months are about an inch shorter and six pounds lighter than those who do not, according to American research published in 2007.

There are other worrying ramifications as well. Ritalin's reputation as an appetite suppressant has made it popular with figure-conscious girls. Meanwhile, its "smart drug" status - it is thought to help improve pupils' academic performance by aiding concentration - has fuelled a mini black market in school playgrounds. But the drug's effectiveness over longer periods has been called into question.

T his has not stopped Ritalin and associated drugs from booming in popularity in the US. Diagnosis of ADHD is about ten times as common in the States as it is in the UK, according to Dr Eric Taylor, professor of child and adolescent psychiatry at the Institute of Psychiatry at King's College London and one of the country's leading experts on ADHD.

UK specialists have suggested that the high figures in the US are the result of a desire to pin a medical label on what would previously be considered poor discipline. It may be that a similar tendency is now gaining ground over here.

But the consequences of taking the drugs need to be weighed up against the consequences of not taking them. Without access to drugs, pupils with ADHD are more likely to be condemned to a lonely childhood punctuated by exclusions, drink, drugs and under-achievement, suggests research, including a 2005 study for the Department of Health.

"The outcome for a child with ADHD receiving no treatment is incredibly poor," Dr Kendall agrees. "About half will end up in psychiatric services or enter the criminal justice system at a great cost to society. If they are left untreated they may end up with personality problems or continuing ADHD symptoms into adulthood."

Teaching a child with ADHD can be mentally and physically draining, but is this preferable to teaching a class full of spaced-out pupils?

ADDISS, The National Attention Deficit Disorder Information and Support Service, believes that about 5 per cent of five to 18-year-olds have ADHD. Of those 500,000-odd young people, it says 60,000 will be receiving prescription drugs to control the condition.

Dr Taylor sounds a note of caution to those in the "anti-drugs" lobby. Although over-sedation is a recognised problem, he says it is usually the result of a failure of communication rather than of the drugs themselves.

"Health professionals and teachers should work together to observe the effects of the drug on the pupil and report back," he says.

"If the child is too subdued, that usually means their dose is too high. It only becomes a problem when children are allowed to carry on in that state unchecked."

When a boy in Bethany Pugh's* class was prescribed Concerta, his schoolwork improved almost immediately. But Ms Pugh was asked by the paediatrician to monitor and report back on his behaviour over a 30-day trial period so his dosage could be adjusted.

"It's not a complete cure, but it does give children with hyperactivity disorders a little thinking time so that the hyper and impetuous behaviour tends to be less," she says.

Yet controversy still rages over ADHD, right down to whether the condition even exists. Like dyslexia, there is no single definitive psychological or biological test for ADHD. Instead, diagnosis is placed in the hands of the paediatric services and Child and Adolescent Mental Health Services.

Some professionals are quick to recognise ADHD symptoms and medicate accordingly; others are less so. Ultimately, personal judgment still determines the point at which "normal" childish behaviour ends and "abnormal" behaviour begins. If ADHD is identified, medication is a very real and accessible option.

But is it the most effective solution? The brains of children with attention-deficit disorders respond to on-the-spot rewards in the same way as they do to medication, according to a recent study by Nottingham University. Simple behavioural strategies in the classroom could therefore be a far quicker, cheaper and more effective solution than drugs.

Frank Furedi, professor of sociology at the University of Kent and author of Therapy Culture and Paranoid Parenting, is concerned that medication is becoming a first resort, over and above more typical behaviour management strategies.

"Parents are ambitious for their children and teachers are at a loss about how to manage classroom behaviour so they medicalise it," he says. "Children then construct an identity as ADHD sufferers."

Rather than parents nagging doctors to get a diagnosis for their child, Professor Furedi believes parents at the end of their tether are relieved to discover that neither they nor their child is at fault. Instead, there is a medical condition that can be treated.

"I often find the kids themselves talk about the condition as some sort of masquerade, as if they are in on the deception," Professor Furedi adds. "Mothers who thought they were failing realise that they are not. It is a lifesaving moment for them. They then use the diagnosis to demand extra resources and benefits for their child."

But what harm does a misdiagnosis actually do? If a child without ADHD takes the drugs and becomes better behaved in the process, surely everyone is happy?

Professor Furedi thinks not. Instead of parents and children taking control of their own actions, he argues that responsibility is being outsourced to drug companies. In this brave new world, children have only to reach for happy pills to escape their problems.

"We still don't know to what extent we are disempowering kids when we turn to pharmaceutical solutions to solve our existential problems. If children do not learn how to contain their behaviour in a more nuanced way, we are storing up problems for the future," he says.

Andrea Bilbow, founder of ADDISS, is tired of hearing these sorts of arguments. She says ADHD has been proven to be a medical condition and, far from being over-diagnosed, is significantly under-recognised and under-treated.

"When children receive the medication they so desperately need everyone's lives become easier," she says. "It makes them available to learn."

The biggest casualty of ADHD is self-esteem, Ms Bilbow adds. "No one wants to medicate their child, but there is not much alternative at the moment. You wouldn't expect to manage diabetes solely by talking it through. It's the same with ADHD."

This argument does a disservice to talking therapies, argues Dr Kendall. While "drug holidays" can help children catch up height-wise, Dr Kendall would like to see more teachers trained in behavioural management techniques for ADHD pupils, plus earlier interventions, rather than a reliance on medication.

Children identified in reception class as having severe ADHD symptoms are shown to fall behind in reading and maths until the end of primary school. Putting strategies in place (see box on page 13) as early as four or five years of age will help to reduce behavioural problems and improve academic progress, says Dr Kendall.

The missing link here is training, both for trainee and experienced teachers. Although many studies have reported the positive impact of classroom-based interventions, a large proportion of new teachers start with little or no knowledge of a condition they will encounter regularly over the course of their career.

But research suggests that teachers need 30 hours of in-service training if changes are to be made and sustained in the classroom, and few schools will have the resources to run courses of this depth.

Providing help and support for parents is perhaps a more realistic option. Parenting programmes, when carried out sensitively, can be extremely effective, Dr Kendall argues.

"The first port of call should be a 10-week parenting programme supported by cognitive behavioural therapy where needed, plus help and advice for teachers," he says. "It's a multi-agency approach."

Those with more severe ADHD symptoms, like Sophie Horricks*, may well need both medication and talking treatments if they are to prosper in later life.

Ms Horricks' earliest memories involve her doing "really bad things", such as poking her mother in the eye with a pencil or ripping up the book she was reading. Her impulsiveness, plus her dyslexia, meant she struggled at school with reading.

"By the time I entered secondary school I had a reputation as being one of those bright but naughty kids, which is what I guess most kids with ADHD were called then," she says. "I gravitated towards similar kids and started experimenting with soft drugs and alcohol at about 11 years old."

Harder drugs, casual sex, fights, truancy and spells in prison followed. It was only when she started seeing a psychiatrist that she was able to put her life back on track. She went to university, where she achieved a first-class English degree and went on to complete a masters. She is now married with a child and has a successful career.

The same happy ending could not be applied to Mr Bennett's former pupil. "Once medicated, his classes were undoubtedly saved from years of further disruption and his teachers spared a world of pain," he says.

"The only loser in the equation was the pupil, who seemed drugged into stupidity. But that has to be weighed up against the fact that he was already facing a future of permanent exclusions and no examination results."

The only clear winner seems to be the pharmaceutical industry. In 2006 alone, about 29 million was spent on prescription drugs for ADHD in England - a 20 per cent increase on the previous year.

Whether or not to prescribe these drugs to children will always be a tough decision, not least because pharmaceutical science is constantly developing. But the upsurge in their use is consistent with society's increasing tendency to turn to science for answers.

"The advances of the 20th century have engendered an irrational faith in medicine as the solution to every ache and pain, not just life threatening emergencies," Mr Bennett adds.

"We have an irrational tendency to label otherwise normal, mainstream behaviours as pathological, simply because they can be identified."

Guidelines from the NHS's National Institute for Health and Clinical Excellence state that ADHD medication should only be prescribed in severe cases and never to children younger than five. The huge variation in the prescription rate of drugs across the UK suggests that some doctors take this advice more literally than others.

Inappropriate medical treatment will not help anyone, Dr Kendall argues. Pupils who can perform well in the classroom, control their behaviour, sit still and maintain friendships most of the time probably do not have a problem worth treating with drugs. By learning how to manage their behaviour without medication, they can become more emotionally self- sufficient.

For those who are more severely affected, a drug programme could be a useful part of a wider treatment package. But it must be well monitored and backed by evidence that there is a significant problem. The risk in handing out drugs to all-comers lies in creating a chemical generation, incapable of functioning without that magic little pill

*Names have been changed

Address ADHD in class

  • Try to sit the pupil in a distraction-free environment (away from windows or doors) and near the teacher.
  • Provide the pupil with a designated quiet area to work in.
  • Get the pupil to work in a pair rather than a group.
  • Provide stimulating activities, broken into small steps.
  • Give concise, clear instructions.
  • Follow a defined, regular timetable.
  • Avoid repetitive tasks.
  • Give frequent positive feedback.
  • Give and remove rewards or incentives depending on behaviour. Isolate the pupil if they misbehave.
    • Source: `Attention-DeficitHyperactivity Disorder: A Practical Guide for Teachers', Cooper amp; Ideus (1996)

      ADHD in nutshell

      • ADHD sufferers have high levels of impulsivity, hyperactivity and inattention.
      • About 3 per cent of children and young people in the UK have ADHD and 2 per cent of adults worldwide*
      • Genetics, environmental factors (including maternal smoking, alcohol consumption and low birth weight), diet and early psychosocial adversity have all been cited as influential factors in causing ADHD.
      • Psychological therapies, dietary measures and medication are used to treat ADHD.
        • *Estimates vary widely.

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