In the emotionally charged crucible where children and prescription drugs mix, a bomb dropped a fortnight ago. Not for the first time, it involved the anti-hyperactivity drug Ritalin, used to control Attention Deficit Hyperactivity Disorder (ADHD).

Children caught in the 'kiddie speed' crossfire

British behaviourist Warwick Dyer was reported to claim a 100 per cent success rate in dealing with maladapted children over the past five years. His drug-free method for dealing with ADHD children was through rewards for good behaviour and sanctions for bad, and an insistence on politeness towards parents while demanding mothers and fathers control their tempers.

Dyer, a former primary school teacher in London's East End who set up his Behavioural Change Consultancy on retirement, says often the problem is parents not behaving as parents and letting children — who are “instinctively artful” — take control.

Parents should accept more blame, move away from chemical responses and change their behaviour towards their children, and demand their children accept rigid parameters for their behaviour.

Dyer's methods are a tough-love, back-to-basics approach, and those who characterise Ritalin (the brand name for methylphenidate hydrochloride) as "kiddie speed" in the same pharmacology as cocaine have hailed his no-nonsense approach.

Janice Hill of Britain's Overload Network said Dyer had shown the idea of ADHD was a myth and demanded doctors stop prescribing Ritalin and start using safe alternative treatments.

A drug-free approach to aberrant and sometimes anti-social behaviour isn't new. Ritalin-sceptics have long suggested that increased prescribing is symptomatic of parental abdication and the power of the pharmaceutical industry, or simply a cry for help from children

Dyer has said he is open-minded about whether ADHD exists, “but what is certainly clear is that a lot of symptoms ascribed to such disorders are in fact easily confused with basic behavioural problems that you don't need to treat with a drug”.

“Well, he can have my son and educate him if he likes. He'd have to re-educate the teachers,” says Jacqui, whose son is at a north Auckland high school and on Ritalin most days.

After spending most of his primary school years being tossed out of class for inattention and inappropriate behaviour, he is finally doing well and Jacqui — who tried behavioural modification, herbal treatments and dietary changes — thanks Ritalin.

She tells how, when her son was in primary school, the family would wake in the early hours. Every light in the house would be on, and he would be in the garage building something.

“As soon as I got on the phone or was distracted, he was building something to get out the window or undo the door latches. I kept a bell on him to know where he was. He has drama classes, rides horses, plays roller hockey ... he has all these things and yet ... he rushes around all the time. At birthday parties he would be the one tearing around doing silly things.”

His primary school years were a nightmare. She says teachers couldn't handle him and he spent most of the time in the playground or outside the principal's office, and wasn't allowed to go on school camps. Aged 8 he went on Ritalin and was a different boy. “I don't like the idea, but he couldn't get an education if he wasn't on it.”

Jacqui is dismissive of Dyer's claims although, like all who work with ADHD sufferers, she concedes behaviour modification must run parallel with medication.

Scrutiny of Dyer's claims reveal his patient list is selective: he works only with parents whose youngsters have been seen by professionals who have suggested parental training is needed. Parents pay £1900 ($5240) in advance and have a major investment in following his strategies faithfully. It is among fee-paying parents he claims the 100 per cent success rate.

“Does that mean he treats some people for nothing and they fail?” asks Dr Pat Tuohy, chief adviser child and youth health at the Ministry of Health. There is little doubt ADHD exists and has a biological basis, says Tuohy, although he concurs with Dyer that the lines can be blurred between ADHD and other behavioural symptoms.

“ADHD is diagnosed as a syndrome based on a number of behaviours, but even though we might be confident about the diagnosis, it may be related to upbringing. Kids brought up in an environment where they are not given boundaries can also exhibit behaviours similar to ADHD. In that situation the use of stimulants may not make any difference to their behaviour.”

In other words, children with behavioural problems may not be ADHD. If they aren't, Ritalin won't help.

Statistics about Ritalin can be alarming: in Britain in 1990, around 3000 were receiving it on prescription, and today more than 345,000 (not all children) are taking it. It costs more than £3 million a year. It is estimated 6 per cent of American children are prescribed it, and between 1987 and 1996, use increased threefold.

New Zealand usage is modest in comparison, around 1.5 per cent under age 12, but we are equal with Australia — behind the US and Canada — as the third-biggest users, according to a report in the Medical Journal of Australia last year. Prescription numbers here have more than doubled in five years - from 32,150 in June 1997 to 75,989 in the year to last month. The cost of prescriptions went from $1.53 million in the year to June 2002 to $1.87 million in the year to this June.

But these figures are not as stark as they seem. With a slow release version of Ritalin available, the rise in prescriptions doesn't mirror increased patient numbers. As some are prescribed both, there can be no direct correlation between the raw data. An educated guess puts the number of Ritalin users (across all age groups, although it is primarily a youth drug) between 6000 and 10,000.

Increased patient numbers may be explained by better diagnosis of mental illness or behavioural problems — in the old days such children may have simply been punished, ostracised or isolated — and a pharmaceutical industry more accurately tailoring drugs and research to identified problems. Doctors are also better able to diagnose ADHD and distinguish it from other behavioural problems.

Tuohy doesn't believe we are over-subscribing Ritalin — child psychiatrist Emeritus Professor John Werry says we are under-diagnosing and under-prescribing psychiatric drugs for children — but for children who have behaviour problems there are good, non-drug treatments available.

Contrary to popular belief, Ritalin isn't easy to get. It is only prescribed by a psychiatrist or consultant paediatrician, although subsequent prescribing can be done by a doctor working as a colleague.

Tuohy says ADHD can have serious consequences if it is not managed well. “They can be immediate with regard to the child's self-esteem, their ability to form peer relationships and their ability to learn — all the important things happening in the primary school age group. For children with severe ADHD there is a much higher risk of them being involved in their teenage years with the criminal justice system or having accidents. It's not a trivial condition.”

Good management also isn't easy and requires several parallel approaches. “I don't think we can say, 'It's too expensive to do the counselling so we'll just give them the drugs'. It is important there is a balance. A number of children with ADHD will have co-morbid — or co-existing — conditions, such as conduct disorder, anxiety or depression, which need a different sort of management, and will often need counselling or psychological support.”

While Ritalin is commonly used to moderate ADHD, other approaches are less publicised, which is doubtless why Dyer's methods have received attention.

A mother of an 8-year-old at an Auckland school says her son was “super-active from the day he was born”. Pre-school teachers raised issues about her son's inability to concentrate. “When everyone else was sitting on the mat he'd be hanging from the ceiling pretending to be a fruit bat.” Teachers advised he be assessed by a psychologist, who diagnosed ADHD, and in his final pre-school year she and her husband met his teachers to discuss how their son would manage in the more structured environment of Year One.

“I can't remember someone specifically saying, 'You must put him on Ritalin', but I can definitely remember encouraging comments about how other children with a similar kind of presentation had had great success with Ritalin.”

“I was more open-minded about it than my husband, who was seriously opposed. He felt he didn't want him on drugs to make life easier for the teachers. He was clearly a bright kid and well above average in his classes, and way above his chronological age in spelling and reading.”

“If the struggle to focus had impacted more on his learning then [my husband] might have been [more sympathetic], but his feeling was that it wasn't having a bad impact on his learning — that it was to make life easier for them. And in fairness to them, if you've got 25 kids in a class and one is bouncing off walls, it's difficult for teachers.”

The same teachers accepted their decision to adopt a drug-free approach and suggested a teacher-aid in the classroom with their son. The aid, who also had a son diagnosed as ADHD and was also opposed to chemical treatments, sat with him about 20 hours a week keeping him focused. It was an expensive option but, they went with it as they were able to afford it.

“Over a period of 18 months he settled down and focused more, and two-thirds of the way through Year Two the teachers said he didn't need it any more.”

“He also had a really good teacher that year, which helped. He needed a teacher with firm boundaries and firm consequences and she felt she could handle him without the aid, and she could.”

A year on and her son has good school reports, although does not concentrate on subjects he is bored by, whereas classmates just get on with them.

“I find it hard to know how much of this is just getting older and having better routines and structures which mean he has learned to cope better. These school holidays he drove us absolutely nuts, so maybe we should take him to be assessed. Maybe we should try Ritalin to see if it makes a difference. At times he drives us absolutely spare. We have six kids and none are like him. He can be delightful, exuberant, caring and compassionate — and he can be bloody hard work sometimes.”

She describes her son as “like a 150 per cent boy, very boisterous”, a phrase which some anti-Ritalin groups believe reinforces their opinion of a sexual apartheid applied with Ritalin.

Boys are three times more likely than girls to be prescribed it. Two years ago educationalists in Australia were angered and defensive when Graeden Horsell, president of two South Australian school-based groups, said boys were being disadvantaged by a system comprising 80 per cent middle-aged women teachers. Horsell didn't extend his argument into the Ritalin debate, although in a submission to the Standing Committee on employment, education and workplace relations he noted the tendency in Australian schools to see girls as victims and boys as problems. He also observed that 75 per cent of Ritalin prescriptions for students were for boys. Others have suggested teachers prefer the benign sedation of their students than having to look at their own methods when boys are just being boys.

While conceding research shows boys manifest problems by externalising behaviour (suicide, boisterousness) while girls internalise problems (anxiety, depression), the blanket characterisation of teachers looking for an easy option is not one the Ministry of Health's Tuohy accepts.

“New Zealand school teachers as a group tend to be keener on using behavioural methods. Anecdotally they don't seem to be clamouring for stimulants to manage it. They tend to go through the behaviour support teams the Ministry of Education use. They have a number of strategies to help teachers work with children who have ADHD.”

Tuohy also notes that most referrals come from parents rather than teachers. While we accept boys are more boisterous, “if you look at a group of boys with ADHD and a group without, there is an obvious difference in the level of activity and level of impulsivity. It's not the same, and most teachers are trained well to deal with these behaviours in an appropriate way.”

The Ritalin debate takes place against a backdrop of increasing suspicion that pharmaceutical companies are creating or over-inflating illnesses which drugs have coincidentally arrived to cure or control.

Xenical and Viagra have arrived as baby boomers — notorious for their Peter Pan-like self-belief — have become paunchy and less active sexually. Something called Generalised Anxiety Disorder (GAD) was reported to affect as many as 10 million Americans. Needless to say there was a pill available.

Others see a darker, more nefarious design at work. With biotechnology we are, Huxley-like, changing unsuitable or antisocial behaviours. We are using drugs — Ritalin to slow down boys and Prozac to perk up depressed girls — to create an androgynous generation. Political correctness at the pop of a pill. But for a harried parent whose child is bouncing off walls or being sent to the school corridor every day, that scenario remains in the realm of science fiction.

All they want is something to calm their child and get them settled at school so they can be like their classmates. For many, Ritalin still seems the available, economic and functional option.

By Graham Reid
4 August 2003

http://www.nzherald.co.nz/storydisplay.cfm?storyID=3515959&thesection=news&thesubsection=world

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