Radio: Case Notes
Authors: Charles Essex
Journal: BMJ (2003)

Is attention deficit hyperactivity disorder (ADHD) medicalising children's behaviour? Is it simply reframing a problem as a biological/genetic model, which avoids blaming parents or children? A caller to a radio phone in programme last week felt strongly that strict discipline was the answer. Undoubtedly ADHD means that some children and parents are avoiding personal responsibility. But many with ADHD who have not been diagnosed have not fulfilled their potential at school or work.

As the first episode in a new series of the BBC medical affairs radio programme Case Notes reported, the latest statistics suggest that as many as one in 20 UK schoolchildren have ADHD. And as one-third of their siblings also have ADHD, the condition has a genetic component.

After outlining the main features of ADHD—of impulsive behaviour and poor attention—Case Notes and its follow up phone in programme, Check Up (broadcast on Radio 4 on 27 November at 3 pm), focused on treatment, particularly with the stimulant methylphenidate (Ritalin). A neurodevelopmental paediatrician in Case Notes and a child and adolescent psychiatrist in Check Up gave sensible advice about using methylphenidate, monitoring the response, and fine tuning the dosage. There was little discussion about dietary supplements or exclusions, which suitably reflected the role of these in ADHD.

A large 1999 study by the US National Institute of Mental Health, comparing medication and behavioural interventions, alone and in combination, showed that medication with or without behavioural treatment was better than behavioural treatment alone (Archives of General Psychiatry 1999;56: 1073-86 [PubMed]).

Methylphenidate has a short half-life and a top-up dose has to be given at lunch-time. Although teachers are not obliged to give medication to children in school, this is one medication where teachers are usually cooperative because they get the benefit of having a better behaved, less disruptive child in class. Once-daily long acting methylphenidate is now available, but is still not widely used, probably because of a reluctance by doctors and parents to switch a child from a treatment that is working to one that might not. After successful trials in the United States, a non-stimulant, atomoxetine, will probably be launched in the United Kingdom next year.

Behavioural support for children is variable. Colleagues around the country report some child and adolescent mental health services that will not get involved until special educational measures have been put in place and education services that insist the child first has a medical by a paediatrician. However, in the United Kingdom there is a national shortage of child psychiatrists, which will not be rectified in the next decade.

Paediatricians and general practitioners are faced with families desperate for help: children about to be excluded from school; marriages about to break up; and parents unable to cope. There are long waiting lists for behavioural and support services and so doctors prescribe methylphenidate as the sole treatment. However, as the child psychiatrist in Check Up pointed out, there then seems to be a campaign among some professionals to sabotage the efforts of clinicians by denigrating the value of methylphenidate.

Some parents do not want a diagnosis of ADHD because they fear that once the child is “labelled,” he or she will carry this throughout his or her school career, and beyond. The child psychiatrist gave a reasoned approach to diagnosis. Firstly, it helps parents, teachers, and the child if he is old enough to make sense of his behaviour. Secondly, it opens doors to treatment such as medication; support (some professional support is only available for those children diagnosed with ADHD); and increases the likelihood of getting benefits such as Disability Living Allowance.

Case Notes and the follow up phone in programme offered a sensible and practical review of the treatment of ADHD. Children and their families are helped by having a diagnosis of ADHD. These programmes supported the view that, used carefully, treatment with medication such as methylphenidate will remain the most effect treatment for the foreseeable future.