The growing problem called 'ADHD'

Few would deny that Attention Deficit Hyperactivity Disorder has, in a short period of about 15 years, moved from an issue of relative obscurity to one well known to Australians. For this reason, among others, a diagnosis of “ADHD” and even the existence of the disorder itself tends to be regarded with suspicion.

While pediatricians may play down diagnostic and stimulant medication rates for ADHD, from the early ’90s Australian statistics show a 2,400 per cent increase in the prescription of dexamphetamine sulfate and a 620 per cent rise in methylphenidate. Since then, defined daily doses - the amount individual children are consuming a day - have also risen steadily.

While there has been mention of a slowdown in prescription rates and greater caution on the part of pediatricians, recent figures show that since the inclusion of Ritalin in the PBS, prescriptions for Ritalin rose from 523 a month in August 2005 to 5,800 a month in January 2006.

Some might argue that this increase is the result of a switch between Ritalin and Dexamphetamine use because some children may respond better and experience less side effects from Ritalin than they do dexamphetamine sulfate. If this were the case, one would expect a corresponding downwards shift in prescriptions in dexamphetamine. To date statistics to support this have not surfaced.

What we don’t know is how many children are being prescribed anti-depressants, anti-convulsants and anti-psychotics on top of stimulants. But we should. Not only that, given that these drugs lack federal approval for use in children due to issues with side effects such as suicide ideation, there should be stricter protocols to stop this from happening.

The stumbling block towards a better solution for these children is that the ADHD debate has been characterised by the need to find a bad guy. Conveniently for some, parents usually top the list - even when the suspected villain is bad food, bad television or bad video games. The road inevitably leads back to the parent, who is seen as either failing to discipline their children, feed them “healthy” food or spend quality time expanding their minds.

The hypocrisy underlying this debate is obvious.

Most contemporary parents attend antenatal and settling classes. Fathers now learn to bath their newborns, change nappies and drive screaming babies around at night. Mothers are exhorted to attend to their baby’s every cry to produce a secure, attached infant - until bedtime when they must switch to “controlled crying”. Without the support of the extended family or cohesive community networks, mothers and fathers, to greater and lesser degrees of success, struggle to achieve the exacting standards set by others.

It has to be said, unpopular though it may be, that it is those others who stand to benefit when parents fail to reach the bar. Somehow the dubious PR practices of psychologists who target their local area pre-schools and daycare centres with flyers offering parenting programs, “aimed at the prevention and treatment of behavioural and emotional problems in children between 2 and 12 years”, seem to fly under the media radar.

Speaking of which, why has no one asked how parents end up in a pediatrician’s office? In the short storm following the blow-out in Western Australia stimulant prescription rates, why was it that the focus narrowed on six pediatricians? While pediatricians are responsible for the bulk of stimulant prescriptions, to effectively deal with the problem we call “ADHD” we have to ask how parents come to believe their child might have ADHD in the first place.

Ultimately pediatricians and psychiatrists are responsible for writing prescriptions for stimulant medication. That doctors play a large part in the problem is not in dispute. But if we take a step back from the scene of the doctor’s office and begin to question how parents arrive there and, even more pointedly, what guides the conversation they have, then we can begin to unravel this very complex problem and work out ways to reduce it.

Research shows that teachers are often the first to suggest that challenging behaviour may indicate Attention Deficit Hyperactivity Disorder. Research also indicates, however, that teacher perceptions of child behaviour are influenced by factors such as class size. In the US, this has prompted several states to introduce legislation to prevent teachers recommending that children be medicated.

So, are teachers responsible for the increase in ADHD diagnosis? Let’s exercise the same caution that we did in the doctor’s office and take another step back to look more closely at the scene of the school.

Teachers are currently being asked to teach to diversity with one hand tied behind their backs. Over the same 15-year period that “hyperactivity” has become part of our common lexicon, education systems have recognised the need for schools to become more inclusive institutions.

Our teachers are now teaching children who would never previously have entered the gates of the local school. For this, they should be commended. Instead, they are insulted with talk of “performance pay”.

Note however that in those same 15 years, public schooling in Australia has also experienced the effects of harsh neo-liberal reforms. Public services such as education and health have been asked to do much more with much less.

Here in Queensland, we have seen what happens when you strip hospital systems of funding. The increase in ADHD diagnosis in Australia is one telling symptom of what happens when you abandon public education: a growing number of children lose out as under-resourced schools and teachers are forced into a funding play-off.

While schools offer learning support services, many children miss out because of the way their difficulties in school are described. In Queensland, a child whose difficulties are described in ADHD diagnostic nomenclature does not qualify for meaningful support. For these children, systems rely on teachers to plug a widening gap. The load is lessened when difficult children are diagnosed with something that qualifies for support funding or when parents oblige the school by shifting the problem to their local pediatrician. Often, the result is a prescription for stimulant medication.

This is a band-aid solution. But … a cheap one!

When Health Minister Tony Abbott announced the inclusion of Ritalin on the PBS, it was described as a “choice” initiative. Parents could now “choose” between brands of stimulant medication for their hyperactive, distractive, impulsive children.

What Abbott neglected to consider is what little choice parents actually have. In reality, parents cannot influence their child’s behaviour beyond the school gate in any other way. Nor can they influence what is happening in the classroom. If teachers are struggling with a range of diverse learning styles and abilities in a class of 30 seven-year-olds, yet being judged by the performance of their students in benchmark tests, then they are forced to seek support by other means.

Support, however, is tied to disability categories. On the ground, this means that teachers are being forced to seek diagnoses for children on the margins. Some children have difficulties that qualify for meaningful support. Many fall out of those neat little boxes - bright, intelligent, forgetful, inquisitive, disruptive children who require more redirection, more explanation, more repetition, more time, more energy, more help.

These are the children who end up in pediatrician’s offices. These are the children whose parents will learn to speak the lexicon of ADHD.

In this way, an ADHD diagnosis functions as an “escape clause”, so society can keep pretending traditional schooling methods and structures are working. Through such a narrow lens, the problem is the child and never the system.

The challenge to state and federal governments is to fund public schools and teachers in proper accordance with the value of education instead of spending yet more money on subsidising Ritalin - or on rolling-out policy that fosters a user-pays system along with a now flourishing private tuition market that few can afford.

Given that stimulant medication operates mainly during school hours, the million-dollar question becomes: how many parents would still medicate their kids if schools were better able to engage and support them? Most parents simply want to get their child through school to lead happy and successful lives. We must find other, better ways of making this happen.

Substantially reducing class sizes to allow for creative teaching, increasing the number of teacher aides, reintroducing space in the curriculum for art and physical education, and having subject-specialist teachers on rotation to prevent boredom and teacher burn-out are all responsible ways to help avoid behaviour problems in schools.

Problem is: this costs much more than the $1.5 million or so a year that Tony Abbott reckons Ritalin will cost Australian taxpayers.

It means we can’t have our cake and tax cuts too. It means that it’s time for politicians to act responsibly and stop buying votes. And it’s time for the rest of us to make them.