Whose deficit?

Whose deficit? Dr Michael Gliksman takes a critical look at the epidemic of Ritalin use.

Over the past decade, a disorder known as attention deficit disorder (ADD) or attention deficit hyperactivity disorder (ADHD) has been spreading among our children like an epidemic. During that time the prescription of the drugs used to control this disorder, central nervous system stimulants chemically similar to the amphetamines which can be bought on the streets, has leaped by over 1000%.

Because these drugs have potentially dangerous side-effects particularly in overdose and the results of their long-term use are unknown, determining the cause and mechanism of spread of this epidemic is an important public health issue. The public health physician does this by looking for patient and environmental factors which might be associated with the occurrence of this disorder.

An analysis of these factors suggests we are dealing with a most curious epidemic, for the rapid increase in its diagnosis followed no medical breakthrough. Rather, it most closely followed the publication in 1990 of a book read by many parents with "problem" children: The Hidden Handicap by the late Dr Gordon Serfontein.

Even more curiously, the disorder primarily affects pre-pubertal boys. From prescription data at least 8 times more boys than girls are diagnosed with this disorder. A disproportionate number of the disorder's victims come from single female parent or other households lacking a positive adult male presence. Curiouser and curiouser.

These features are so unlike an ordinary disease as to invite the belief that we are not dealing with one. Since the publication of Dr Serfontein's book, a rapidly increasing number of children whose behaviour does not conform to parental or teacher expectations are being diagnosed as having a neurological disorder requiring drug treatment.

Disruptive behaviour in children, especially boys, is nothing new. It is likely that an unknown percentage of these children have a significant biological or genetic predisposition towards disruptive behaviour, particularly when under stress. Because it is so convenient and guilt relieving to be able to attribute a child's difficult behaviour to a dietary or a neurochemical problem rather than a parenting or broader social problem, there is a risk that this problem will become over-medicalised.

Two decades ago, the fad (like the current one, also imported from the United States) was to diagnose such children as suffering from a neurological condition known as minimal brain dysfunction. The treatment was to place the child on a Dr Feingold's diet. Now, similar behaviours are diagnosed as attention deficit disorder (ADD) or attention deficit hyperactivity disorder (ADHD), depending on symptoms.

Then as now, many parents swore by the treatment's ability to transform their sons' disruptive behaviour. Then as now, the treatment was promoted by many of its exponents with what approached a missionary zeal. But then, the major risk of treatment was dietary boredom.

What is new is the use of powerful, potentially dangerous and addictive drugs to control problematic behaviour in children. We know very little about the safety of these drugs in long-term use in children. Since the first rule of medicine is "above all do no harm", the current approach invites critical examination.

Today, children are under more pressure than ever. Family breakdown, social isolation, the movement of women from the home to the workforce and the longer hours worked by employed men (both due in many cases to economic necessity as much as personal choice), the increase in youth unemployment and homelessness, the feminisation of education and the absence of a positive adult male presence in many children's lives, all have an important role to play in building this pressure.

Clinical experience suggests the drugs used to treat ADD/ADHD are often successful in modifying the behavioural expression of a child's anger and despair. But they do not address or effect the contribution of social stressors to those emotions. Since boys tend to "act out" their anger and despair more readily than girls, the former bear disproportionately the burden of risk of being exposed to those drugs. It is ironic that many of the people who felt understandable anguish at the drug induced death of Anna Wood, are insisting that similar drugs be prescribed for their sons.

In today's climate of isolated, economically and emotionally stressed single parent families, boys who are acting out represent a real threat to the economic and emotional stability of the family unit. Controlling their behaviour by medicating them to achieve compliance with the status quo may be an economic imperative, but it is not always a medical one.

Two years ago, the Australian College of Paediatrics endorsed a policy which made it clear to all doctors that medication should never be used as the first or only treatment for behaviour disorders among children. In many cases, it does not appear these guidelines are being followed.

Paediatricians and other medical practitioners are often placed under pressure to prescribe first and ask questions later. Before allowing your son to be placed on the potentially dangerous medications used to treat ADD, it would be wise to explore alternatives and seek a second opinion.

The problem is compounded by the shortage of adequate public child and family psychological support services, accessible to all on the basis of need. What few public resources exist are inadequate to meet the task. Some, especially the best resourced publicly funded child psychiatry services such as the Arndell Children's Unit of the Royal North Shore Hospital or Westmead Hospital's Redbank House, will not provide equal access to services for children from single parent or other "disrupted" family structures. These agencies preferentially offer their services to children where both parents live at home and who are from middle class socioeconomic backgrounds.

However, professionals don't hold all the answers. In his latest book 'Raising Boys', Steve Biddulph tells the story of a father who, with insightful naivete, thought that his son's diagnosis of ADD meant the boy was not getting enough attention! He decided to spend much more time with his son, with the result that soon after, the boy was able to cease his medication.

Maybe as Steve suggests, in many cases the problem is really a form of DDD (Dad Deficiency Disorder) rather than ADD. If your son is diagnosed with ADD, you might do worse than take it to mean he is not getting enough of your attention and resolve to do something positive about it.

The current extent and pattern of use of the drugs used to control ADD/ADHD suggests we are using medical treatments to deal with social and economic problems. In allowing this to continue, we in the medical profession as well as parents (especially fathers) are doing all children, but especially boys, a great dis-service.

michael@cmed.wh.su.edu.au

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