IMAGINE the scenario: your son is disruptive at home and at school, doesn鈥檛
keep still or concentrate for more than a few minutes, speaks out of turn in
class and is learning next to nothing. Is this just naughtiness, you ask
yourself, or is it a symptom of mental illness? Do I let it pass and hope he
grows out of it, or should I send him on a course of therapy with a child
psychiatrist? Should I, perhaps, allow a doctor to prescribe him drugs to calm
him down?
As a child psychiatrist, I deal with questions like these every day. Deciding
what is normal behaviour and what is excessive and requires treatment is one of
our greatest challenges. The trouble is that most childhood psychiatric
disorders differ from normal naughty behaviour only in degree. So diagnosing the
cause of a particular child鈥檚 problem can be difficult.
In the US, two million children who have been diagnosed as having attention
deficit hyperactivity disorder (ADHD) are being treated with the drug Ritalin
(methylphenidate hydrochloride). In Britain, medication is used less often, but
it鈥檚 on the increase. It鈥檚 a trend I find worrying, especially as the government
is proposing to revise the Mental Health Act in a way that is likely to
encourage it.
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The existing act gives police and health services powers to detain people
with a mental disorder who display 鈥渁bnormally aggressive or seriously
irresponsible conduct鈥�. The proposed revision to the act extends those powers by
redefining a mental disorder as 鈥渁ny disability or disorder of mind or brain,
whether permanent or temporary, which results in an impairment or disturbance of
mental functioning鈥�. This change could lead to many more people facing
detention鈥攊ncluding children who show disruptive behaviour.
More than ever, the onus will be on doctors to 鈥渋mprove鈥� disruptive behaviour
by the quickest means possible. This can only encourage the use of drugs to
prevent a child from being detained or to hasten their release.
One particularly worrying possibility is that the authorities may want to
detain children who are not mentally ill, but are suffering from behavioural
problems. Such conditions respond best to psychotherapy, and for them drugs
should not be the first option. An obvious case is what is known as 鈥渃onduct
disorder鈥�: this involves excessively and persistently disruptive and antisocial
behaviour, often combined with reading difficulties. Conduct disorder is
naughtiness taken to an extreme. In most cases, it happens in boys, and it does
not respond effectively to medication.
Contrary to what some parents presume, drugs do not treat bad behaviour
directly. Using drugs to treat conduct disorder exposes the child to unnecessary
side effects and makes it harder to apply more effective methods such as
cognitive behavioural therapy鈥攇etting the child to understand why he
behaves in the way he does鈥攐r therapy involving the child鈥檚 family.
Unlike conduct disorder, ADHD is a psychiatric condition. But many of its
symptoms, such as aggressiveness and impulsiveness, are shared with conduct
disorder, making it hard to tell the two apart. Children with ADHD have genuine
difficulty in concentrating and keeping still. In class they are often out of
their seats, wandering the room and disturbing others. Their impulsiveness can
lead them to shout things out and speak out of turn.
The majority of children with genuine ADHD will improve if they take a
stimulant such as Ritalin or Dexidrine (dexamphetamine). They will concentrate
better and become less hyperactive, and be less verbally and physically
impulsive. But I am convinced that even for ADHD, medication is only part of the
solution. Psychotherapy is an essential part of managing any disorder involving
disruptive behaviour.
So when a child is behaving disruptively in class, is this simple defiance, a
lack of interest, or a symptom of ADHD? Herein lies the danger: if a child is
behaving so badly at school that he is threatened with exclusion, and his
behaviour is drawn to the attention of the mental health services, there will be
considerable pressure to improve behaviour by the quickest means available.
Stimulants act more quickly than psychotherapy, and in cases where a firm
diagnosis is not possible a doctor might feel inclined to prescribe them.
Many parents are reluctant to allow their children to be prescribed
medication. In some cases, however, they can find themselves under huge pressure
to do so, even in cases where it is not appropriate. Disruptive children are
difficult to cope with, and put families under great strain. Some parents are
desperate for a quick solution. 鈥淲ouldn鈥檛 it be great if we could just give
something to little Johnny to calm him down and stop him hitting his sister?鈥�
they ask.
But treating a child with drugs when psychotherapy would be more appropriate
can do real harm. Medication might calm a child down, but unless he is genuinely
suffering from ADHD it will not address the underlying reasons for his
inattention, disruptive tendencies or reading problems. In addition, stimulants
can have serious side effects.
When I worked in a specialist ADHD clinic one of my patients was a boy who
had been diagnosed as having ADHD, and was prescribed stimulants. The drugs were
stunting his growth, so we stopped them for a while so that he could catch up.
During this time we concluded that he had been misdiagnosed, and did not have
ADHD at all.
If this child had not been reassessed, he might have continued on the
medication without a break until it was too late for him to catch up on his
growth. He would have been affected for the rest of his life.
Therapy is often not the easy option, but given a chance it can be very
successful. I hope that the widespread use of medication in the US, combined
with changes in British law, will not undermine the use of therapy for treating
disruptive children. Drugs can help some children, but used inappropriately they
can do more harm than good.