The Autism News

The Autism News | English

Helen Samuels

By Simon Crompton | The Times Online

I am going to give you a prescription for sleeping pills,” the doctor said, signing the blue chit. He tore it off the pad and handed it to me. “Don’t worry, they will really help.” I fit the stereotype of the exhausted mother, yes, but the prescription — for Circadin tablets, to be taken every night — wasn’t for me. It was for my two-year-old, who at that moment was playing with a box of toys on the floor of the doctor’s office. “I would also like to suggest that he has a closely monitored three-week trial on Ritalin, or a drug like Ritalin,” the doctor — a neuropsychiatrist — continued. “Are you sure?” I asked. “He’s only 2.”

“From what I have seen in my office today, and from the referral letter from his nursery school, I think your son could have ADHD, attention-deficit hyperactivity disorder. This can go hand in hand with other disorders. Ritalin is the most effective course of treatment for cases like these.”

I had heard of Ritalin, of course. It’s often referred to mockingly as the panacea for bad behaviour in American children. According to reports this month the Ritalin craze is sweeping Britain. The number of prescriptions is up 33 per cent since 2005. This has occurred despite National Institute for Health and Clinical Excellence (NICE) guidelines, which advise against using drugs as a first-line treatment for ADHD, except in the most serious cases.

I glanced guiltily at my son with new eyes. Had I put a severe behavioural disorder down to “being very energetic”? Was his nursery school right to suggest a neurological defect when all I saw was “a handful”? In one short meeting, my son had gone from boisterous to special needs, requiring daily medication monitored by a team of specialists.

Ritalin, also known as methylphenidate, stimulates the central nervous system and aids focus and attentiveness in exceptional cases of children with ADHD. NICE guidelines, however, do not recommend it for children under 5. It’s estimated that 3 per cent of children in the UK have ADHD, but medication is considered for only a quarter to a third. Ritalin is the most commonly prescribed drug, with 461,000 prescriptions filled in 2007. But even in America, people might balk at giving it to a two-year-old.

My doctor was dismissive of such concerns. “I’ve given it to pre-school children before,” he said. “It’s best for both the child and for you to get the problem dealt with now.”

An outsider would be forgiven for thinking, “Well, obviously there is something seriously wrong with this child. Why else would the doctor suggest drastic action?” And that’s also what I thought — for about five minutes. And then I thought: don’t be ridiculous. He’s your son, you know him. And he’s 2 years old.

His symptoms are that he wakes up at 5.30am. He has been known to hit, shove and — occasionally — bite other children. He hares around as if his bottom is on fire 70 per cent of the time. This, for those of you who have never experienced “the terrible twos”, is in the normal range of “bad” behaviour. For every whack he has delivered, he has received several in kind from his classmates.

But three things separate him from the others, according to the school: first, his outbursts are “unpredictable”; second, he is amazingly strong for his age, which means that when he does dole out a blow it’s harder; and third, he is fast, which means that his teacher finds him difficult “to catch and to restrain”. Not great if you are his teacher, I fully agree. But does this justify psychiatric assistance?

I am not the first to have had her pre-school child fast-tracked to a shaky diagnosis. Two mothers told me of similar experiences. Six years ago Clare, a mother of three, was told by her nursery school that it suspected that her three-year-old son had Asperger’s syndrome, a form of autism, because he was so difficult to control. “They pushed for him to be referred,” she says, “and I was made to feel terrible for not noticing. They were wrong. Eventually I went to a psychologist, who gave me fantastic help. She said some children need more ‘parenting’ than others. She advised a fixed routine, to set rigid boundaries and to allocate a period of time every day to spend alone with him — even if it was only 15 minutes. It transformed his behaviour.”

Margaret, who is a doctor, was told by her son’s teachers that he had “real problems” when he was only 4. “He is a bright spark but he was the youngest child in his class, born at the end of August,” she says. “The teachers complained that he was no good with the other children, but the gap of understanding was huge.” Margaret says her son’s behaviour levelled out as he matured, but only after a two-year battle to prevent him being given a “special needs” label. “I’ve since discovered anecdotally that this is a common problem with boys,” she says.

Dr Tim Kendall, a consultant psychiatrist at the Sheffield Care Trust and joint director of the National Collaborating Centre for Mental Health (NCCMH), has heard of “a number of cases” in which children as young as 2 have been prescribed Ritalin.

“I’ve even heard of young children being given antipsychotics,” he adds. “Boys are nine times more likely to be referred for ADHD, which could mean girls are under-referred or that boys are hugely overreferred. If I was growing up today I, too, would have been diagnosed as ADHD.”

Dr Kendall thinks that the diagnosis can be blurred by schools, because “there are often too many kids in the class and suddenly an ‘energetic’ boy becomes an ‘out of control’ boy because the school can’t cope. This is a situational problem. Drugs should be reserved for very serious cases.”

Professor Eric Taylor, of the Institute of Psychiatry, says that “boys tend to be more troublesome, but the purpose of the medication shouldn’t be part of discipline. It’s not a mode of control, it is there to help the child.” Furthermore, he adds, “the younger the child is [below 4], the less helpful the drugs and the higher the risk of sideeffects”. These include cardiovascular disorders, hallucination, dizziness, abdominal pain, decreased appetite, nausea and trouble sleeping.

So, what are the alternatives for parents of a “difficult” child who want to stall on the medication but manage the situation?

Dr Kendall believes that parents, teachers and doctors should follow a three-point plan before going near a prescription pad with very young children. “Parent education is the first point and training programmes are available through the NHS. The next step is to get the parents and school working together and finally ensure that the school has the support it needs.”

I am using simple measures to help my son: a strict routine, firm boundaries and praise where praise is due. He is loving the 15 minutes of uninterrupted “me time” that my friend recommended, when the focus is entirely on him and not his siblings. He’ll tell me if he wants something rather than shouting it. I am also prepared to revise my view of the “ADHD diagnosis” if in the months to come he makes no progress. But I am hopeful. He stands up to greet me when I pick him up from nursery and says, “Mummy, I’ve been a really good boy today!” And his teachers agree. It’s early days but so far, so good. The prescription remains unused.

The name of the author has been changed

The rise and rise of drugs for children

There are thousands of parents of children with ADHD who will rhapsodise about Ritalin — the way the drug allows their child to concentrate and enjoy life without turning him or her into a zombie. But thousands more will say the opposite — that Ritalin made their child confused, scared, depressed, dopey.

Why? The truth is that prescribing medicines is not an exact science. No drug is all good or all bad. All can relieve a disease or cause nasty side-effects. The key is to target exactly the right drug at exactly the right dose, at exactly the right problem, at exactly the right time (or age in children) so that the benefits outweigh the risks.

That targeting is especially difficult when it comes to child mental health because drugs are generally researched on adults, and because problems such as ADHD are ill-defined and poorly understood. Where does childhood wildness end and a behavioural disorder begin? What’s “normal” and what’s “abnormal”? It’s impossible to define, especially when children are changing week by week and develop at different rates.

That means that thousands of children are likely to receive inappropriate medical treatment. Unfortunately, this has evolved into a blunderbuss “use widely enough and you’ll cure somebody” approach in some areas. A study in the Health Service Journal found that some primary care trusts dispense one Ritalin prescription for every seven children under 16.

This is happening because services like psychological therapy and training for parents — which are likely to prove more effective for more children — are scarce and expensive. Time-starved, option-limited GPs are prescribing drugs because they’re available, affordable and provide the supposed “quick fix” that some parents are looking for.

This doesn’t just apply to ADHD, but depression, anxiety and other psychological problems. Five years ago, GPs were told not to prescribe many types of SSRI antidepressants to children: they were being over-prescribed, partly because the counselling that might have been a better option were not available. NICE, the Government’s drug-rationing body, has issued a similar edict on Ritalin: it should be prescribed only in severe cases and never for children younger than five. Non-medical treatments, such as psychological therapy, are generally more effective, it says.

Source: http://women.timesonline.co.uk/tol/life_and_style/women/families/article6923471.ece

Please share this news with friends, family and also with your contact list on Twitter, Facebook and MySpace.

The Autism News English autism, autistic, doctor, prescription, Ritalin, sleeping pills