In 1998 26,500 prescriptions were issued for Ritalin. Last year, that figure had grown to 461,000. Ritalin is the main drug used by clinicians to control the symptoms of attention deficit hyperactivity disorder (ADHD) in children and young people. It accounts for more than three-quarters of prescriptions for the family of medicines used to treat ADHD. The near-twentyfold increase highlights the readiness with which GPs have turned to drug therapies to tackle the condition over the past 10 years.
Heated debate surrounds the use of Ritalin-like drugs because of their effects on children and young people’s mood, appetite and sleep patterns. Ritalin is also said to have no impact on one-third of the children who take it. But new clinical guidelines on the diagnosis and management of ADHD, issued last month by two influential bodies, could significantly change GPs’ prescribing practices.
The key recommendations of the National Institute for Health and Clinical Excellence (Nice) and the National Collaborating Centre for Mental Health (NCCMH) guidelines is for doctors to desist from using drugs “as the first-line treatment for all school-age children and young people with ADHD”. It states such treatment should be reserved for those with severe symptoms and impairment or moderate levels of impairment.
The guidance recommends training and education programmes for parents and carers of children and young people with the condition, as well as psychological interventions for the children themselves. The report also says “better integration of paediatric, child and adolescent mental health services (Camhs) and adult mental health services” will benefit those with ADHD.
But ADHD is complex – symptoms include hyperactivity, impulsivity and inattention which may co-exist with other conditions – and requires significant improvements in the availability of these alternative interventions to meet the needs of the estimated 100,000 children receiving drug therapies at any one time.
So what are the options? Jan Assheton, a children’s nurse and specialist ADHD and Asperger’s syndrome trainer for children’s mental health charity YoungMinds, has seen the benefits of educating ADHD sufferers, their families and the professionals working with them in treating the condition. “It is about giving people strategies to help young people with ADHD achieve and be happy because many of them are so unhappy. They are being excluded from school because of their behaviour,” she says.
Medication as a prop
Assheton emphasises that she does not oppose the use of medication but advocates its use in tandem with suitable training. “You need to have medication and training at the same time because it’s easier to help someone with ADHD make behavioural changes if they have the prop of medication, unless the medication outweighs the benefits.”
Another person who supports educating people is Andrea Bilbow, chief executive of the Attention Deficit Disorder Information and Support Service and parent of a son with the condition. She trains children and young people with ADHD using a cognitive behavioural therapy programme called Why Try. She says the 10-week training programme uses multi-sensory techniques because children with ADHD are visual learners. “It uses pictures, visual analogies and music, such as hip hop, to explain key concepts to help them learn emotional and social skills.”
Bilbow runs a two-day version of Why Try for teachers, youth workers, police, counsellors, social workers and youth offending teams so they are better prepared to engage with young people with ADHD. She also favours training parents and carers to adapt how they parent a child or young person with the ADHD. “You need to educate parents about the condition so they can understand their child and not put more pressure on them because there is only so much information that child can have in their brain.”
To ensure the Nice and NCCMH guidance is adhered to, Assheton says awareness of the condition needs to be raised among medical professionals. “There is still so much ignorance about ADHD and some GPs know next to nothing about it.” She adds that, although specialist ADHD nurses are attached to Camhs, they are under-resourced and over-stretched.
Ann Baxter, chair of the Association of Directors of Children’s Services health care and additional needs committee, believes social workers can play an active role alongside specialist professionals in addressing these clients’ needs. “This is an area at the heart of integrated services and what new legislation, like the Children Act 2004, covers. It’s about people working together in a joined-up way. ADHD is not just a symptom and a child takes a pill and gets better.” She adds this is also where the common assessment framework comes into its own.
Many will be relieved that GPs are now required to issue medication to young people with ADHD only in the most severe cases. As Bilbow says: “The non-medical intervention deals with the whole person. Medication deals only with the mechanics of the condition.”
“It’s very difficult to work with people on the drug”
lastair Gardiner has spent 19 years working in residential care, often with those with ADHD. He is evangelical in his belief that professionals need to change how they work with children and young people with ADHD.
Gardiner, director of practice for Lancashire independent care provider Perpetual Care , is the UK’s first qualified trainer in the Nurtured Heart approach of working with children with the condition. The approach focuses on emphasising a young person’s successes – not their mistakes – to boost their self-esteem and confidence, and change their challenging behaviour.
Gardiner says the approach works particularly well for those with ADHD because they are used to being told off about their behaviour. “We create successes for young people in whatever they do,” he says. “We’ve moved away from pep talks, lectures and focusing on the negatives because young people don’t feel recognised enough for keeping to the rules.”
Energy and commitment
The approach is used by staff in the company’s two residential care homes, where some young people have ADHD diagnoses. Gardiner plans to train the company’s foster carers in the approach because of its success.
He says changing the way staff work with children who often exhibit disruptive and antisocial behaviour takes energy and commitment. It can also be a different experience for the young people.
“They say to me ‘why are you talking to me like this?’ I reply ‘because I’m tired of talking to you negatively and whenever I see you I’m going to say positive things to remind you of your worth’.”
Although he agrees with the use of medication in severe ADHD cases, he has found that some young people become emotionally dependent on taking it.
He says: “When I work with young people I have to work with their presenting behaviour and I’m not looking for a chemical response to their behaviour. It’s very difficult to work with young people on Ritalin because it doesn’t allow me to work on the underlying issues regarding their behaviour.”
This article is published in the 16 October edition of Community Care under the headline “Ritalin: There is an alternative”