ADHD - Simple Diagnosis or Complex Issue?
Background
A Scottish inquiry into the use of medication in treatment of children diagnosed with 'Attention Deficit Hyperactivity Disorder' (ADHD) was announced in December 2004 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 fast 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. There is an increasing literature for teachers on managing the 'ADHD pupil'.
Concepts of ADHD
ADHD is a contested concept - it describes a range of aspects of behaviour clustered together by human judgement into a diagnosis. It is subjectively measured by professionals, with considerable reliance on behaviour checklists. The official medical guideline in Scotland states that 'Considerable controversy therefore surrounds the extent of these disorders, for which there are, as yet, no robust diagnostic tests; thus their definition continues to be debated' (SIGN Guidelines 2001). However the substantial literature aimed at parents and teachers fails to reflect any such debate, tending to present clear pictures of an uncontroversial 'disorder', its diagnosis, treatment and medication.
The concept of ADHD comes from the fourth version of the US Diagnostic and Statistical Manual of the American Psychiatric Association (DSM IV). It's emergence in Britain in the 1990s as a childhood 'disorder' reflects a range of social and economic factors. The increasing use of the Internet made US based ideas and literature available to professionals and to parents, often through web-sites such as the parents' support group CHADD, supported through financial contributions from pharmaceutical companies. The financial pressures on the pharmaceutical companies to find new markets, after reaching saturation in the USA, led to active marketing of Ritalin and other stimulant medication in Europe. There were a number of actively campaigning parents and professionals, some of whom came from the USA or from Australia where the diagnosis and medication is widespread. There were a number of private clinics established to offer diagnosis and treatment to parents who could not find this through the NHS.
Pressure on Schools
At the same time 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 of not only attainment but also school exclusion. It was often easier to argue for funding of support for learning in school 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 associated with the diagnosis.
Changing Social Experiences
There were 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 in the 1980s/90s 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 changed. In Scotland larger numbers of children have been recently referred to Children's Reporters on grounds of neglect /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 in a chapter in a book we are editing on 'ADHD' discusses the television makers' term 'jolts' and the prevailing view amongst US TV and commercial producers that anything less than a dozen jolts per minute is considered boring. Sports reporting programmes show five or six separate moving pictures/ information screens simultaneously.
Too Simple a Picture
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). So we are talking about a diagnosis that is often clouded with other difficulties, where the behaviour identified may be understood in the context of a range of other family, social, educational and other interacting factors. Diagnostic and prescribing patterns vary substantially between NHS Boards, suggesting professional judgement, preference and subjective judgement, 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 inter-relating factors as straightforward - ADHD is a disease caused by biological factors, probably inherited. Such biological determinism is not consistent with much of what we know about child development. 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. So if there is a biological element to our understanding of ADHD this biology itself reflects the interaction between the brain and its complex individual context of family, social and educational experience.
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.
The Role of Medication
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 USA would argue). It has a number of well-documented side effects such as eating difficulties, growth concerns, problems with sleep, headaches, tics, depressive feelings and worryingly also 'behavioural rebound'. Rebound means that when someone comes off medication for a problem then the problem reappears in a more extreme state, making re-medication likely. The US Federal Drug Administration and the International Narcotics Control Board have both frequently stated their concerns about over-prescription and about illegal sale and use of the drug by young people. Other concerns expressed have included the lack of careful monitoring of medication, prescription to children who don't meet the criteria or are younger than the recommended minimum age. Recently reported studies of the administration of methylphenidate to rats (randomly selected rats since rats are not diagnosed with ADHD) suggested that it led to a greater level of depressed behaviour later in life. We cannot, in my view, generalise to human beings from this study but it does indicate concerns. There is a lack of long-term studies of the impact on children but evidence from the USA does indicate an association with the continued use of psychoactive medication in adulthood.
My key argument here is that we should question the use of methylphenidate even if it does seem to 'work' for some children. The SIGN Guideline suggests that 'The use of psychostimulants remains controversial and there are concerns about prescribing such medication to children'. However it seems that nonetheless medical professionals are rushing to prescribe. A further warning here derives from the recent history of 'net-widening' in prescription of 'SSRI's for depression in children and adolescents. The government has recently issued strong warnings about their inappropriate use with an increasingly wide range of young people, rather than only those with serious clinical conditions. Many have been withdrawn from use with children and young people altogether due to findings, previously suppressed, about their association with suicidal ideas and actions.
Effective Intervention
Of course there are children and young people with real difficulties, families who struggle to manage their children, teachers who are faced with challenging behaviour in class. However I have argued that there are a wide and complex range of reasons for this and that sweeping large numbers of children into one rather over-simple category and labelling and medicating them may in retrospect seem inappropriate. We should not under-estimate the capacity of parents and teachers to understand that ADHD is a contested idea, rooted in complexity. The label itself may not lead to improvements in school - one recent large-scale study in England found that the formal labelling of children with ADHD and the communication of this label to teachers was associated with a reduction in attainment. 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 very challenging behaviour, with attention/concentration problems will be individualised. There are no 'ADHD' pupils; there are individual children with very 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, Moray House School of Education, University of Edinburgh but writes here in a personal capacity. The book "Critical New Perspectives on ADHD" edited by Lloyd, Cohen and Stead is published by Routledge (June 2005).
An edited version of this article first appeared in the Times Educational Supplement Scotland in February 2005.
