Read the Ritalin label with caution

11th February 2005 at 00:00
Mass medication cannot be a cure-all for pupils with complex conditions, says Gwynedd Lloyd

A Scottish inquiry into the use of medication in treatment of children diagnosed with Attention Deficit Hyperactivity Disorder (ADHD) was announced in December after new figures showed a tenfold increase in the use of the psychoactive drug methylphenidate. Increasingly, large numbers of children in Scotland are diagnosed with ADHD and prescribed medication, mainly in the form of methylphenidate (often, but not always the commercial brand Ritalin). This process of labelling and medication has been happening very quickly and without the opportunity for serious professional review, or public debate, of the wisdom of such large-scale use of psychoactive medication with children.

Most schools will now have pupils on such medication, raising issues about safe and effective administration and comprehensive monitoring of the impact and effects. ADHD is a contested concept, subjectively measured by professionals, with considerable reliance on behaviour checklists. Yet the substantial literature aimed at parents and teachers tends to present clear pictures of an uncontroversial disorder, its diagnosis, treatment and medication.

At the same time as financial pressures on the pharmaceutical companies led to active marketing of Ritalin and other stimulant medication, new managerial approaches to education led to pressures on schools for early attainment in basic skills, a reduction in physical exercise and creative arts in primary schools, and league tables not only of attainment but also of school exclusion.

It was often easier to argue for funding of support for learning in schools when pupils had medical diagnoses. Parents who had experienced difficulties with their children, often criticised by teachers, felt relieved and supported by this kind of diagnosis. Economically disadvantaged families could be further supported by a disabled living allowance.

There was also a wider range of reasons why some children might experience such difficulties, for example pressures on parents created by changing family structures; increasing use of illegal substances by a generation who have themselves become parents; physical and sexual abuse. Working hours for many families have also become much longer. Family diet and eating patterns have changed. In Scotland, larger numbers of children have recently been referred to children's reporters on grounds of neglect or lack of care.

Rapid developments in electronic technology mean that children have access to constant rapid stimulation through games and television - at the same time many children have much less access to free outdoor play. Thomas Armstrong, writing in a book we are editing on ADHD, discusses the television makers' term "jolts", the prevailing view among television and commercial producers in the United States being that anything less than a dozen jolts per minute is boring. Sports reporting programmes show five or six separate moving pictures and information screens simultaneously.

There are many and complex reasons why children's behaviour may be challenging or why they may experience difficulties with concentration.

ADHD is frequently co-diagnosed with a range of other identified difficulties such as depression, specific learning difficulties, tics, Tourette's syndrome and other behavioural problems (often requiring cocktails of medication).

Diagnostic and prescribing patterns vary substantially between NHS boards, suggesting professional or subjective judgment and preference rather than measurable incidence of children's difficulties. Yet, as I have argued above, the literature for parents and children tends to represent this complex set of interrelating factors as straightforward - ADHD is described as a disease caused by biological factors, probably inherited. But we know from child development that children's brains continue to grow, change and develop through their childhood and adolescence. Their growth reflects their experience. Where there are clearly identified biological predispositions for other mental health difficulties, these are often expressed in an individual as a result of social and family experiences.

If early life experiences shape neuronal and organisational connections in the brain, then this raises questions about the implications of the use with children of psychoactive medication that may negatively affect critical learning phases and what some psychologists have called windows of opportunity for particular cognitive learning. Nerve connections are also promoted through glucose stimulated by physical activity. The increasingly widespread prescription of methylphenidate to reduce activity may paradoxically reduce the development of the cognitive processes needed by children to promote attention and manage their behaviour.

In the short term, it is clear from a multiplicity of research studies that methylphenidate works for many children (indeed it might help many of us concentrate better, as the many thousands of students who obtain it illegally in the US would argue). It has a number of documented side effects such as eating difficulties, growth concerns, problems with sleep, headaches, tics, depressive feelings - and, worryingly, "behavioural rebound". Rebound means that, when someone comes off medication for a problem, then the problem reappears in a more extreme state, making remedication likely.

My key argument is that we should question the use of methylphenidate even if it does seem to work for some children. The official medical guideline in Scotland suggests that "the use of psychostimulants remains controversial and there are concerns about prescribing such medication to children". It seems, none the less, that medical professionals are rushing to prescribe.

Of course, there are children and young people with genuine difficulties, families who struggle to manage their children, teachers who are faced with challenging behaviour in class. However, I have argued that there is a wide and complex range of reasons for this and that sweeping large numbers of children into one rather oversimplified category and labelling and medicating them may in retrospect seem inappropriate. We should not underestimate the capacity of parents and teachers to understand that ADHD is a contested idea, rooted in complexity.

The methods of intervention in the many books on ADHD and education are not distinctively different from those in books on behaviour management or learning difficulties. There is not any special technology here. Effective intervention with children with challenging behaviour, with attention and concentration problems, will be individualised. There are no ADHD pupils, only individual children with varied family and educational histories, competences, learning styles and preferences. Teachers and parents need help in developing appropriately supportive interventions that take account of what works for children with complex individual lives, not labels that lead to mass medication of children.

Gwynedd Lloyd is head of educational studies at Moray House School of Education, Edinburgh University, but writes in a personal capacity.

Critical New Perspectives on ADHD, edited by Lloyd, Cohen and Stead, will be published by Routledge in June.

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