The rise in cases of children diagnosed as 'hyperactive' and the use of drugs to treat them may reveal some flaws in today's expectations of the youngest children, says Ruth Thomson
Lewis, aged three-and-a-half, is restless, impulsive and inattentive. His approach to life seems to be: why speak when you can shout, why walk when you can run and why hold something when you can hurl it instead.
Sitting still is, of course, out of the question. Last seen and without warning, Lewis trampolined off the footstool, somersaulted over the back of the sofa and landed head-first in a heap among the cushions. His mother smiles bravely in the face of his ceaseless exuberance and mutterings from relatives that such overactive behaviour surely can't be 'normal' and that the child must be 'hyperactive'.
The dividing line between 'normal' relentless energy and 'hyperactivity', or Attention Deficit Hyperactivity Disorder (ADHD), in a young child is a fine one, but one that more and more early years practitioners are grappling with.
Publication of a Mental Health Foundation leaflet, All about ADHD, prompted almost 200 calls from practitioners and parents in one week.
Early years consultant Marian Whitehead fears, however, that some practitioners are too ready to 'diagnose' children when they are quite simply unqualified to do so. She says, 'Some practitioners are influenced by media stories about behavioural problems in young children and they are glibly telling parents that there is something wrong with their child.'
Sharp rises in the prescription of psychotropic drugs to children have triggered fears that the doctors too may be rushing to judgement about children's behavioural problems and providing quick pharmacological fixes to children who need structured help for their behaviour and learning.
Recent figures showed a 20-fold increase in the prescription of Ritalin, a stimulant often used in the treatment of ADHD, to children in Scotland in the five years to 1999. England has seen prescriptions rise from 2,000 to 92,000 in the five years to 1997. The prescription to under-fives is very rare indeed but it has increased threefold in the US, according to research by the University of Maryland (see Nursery World, 27 April 2000).
In fact, diagnosis of ADHD can be problematic whatever the age of the child and external pressures, because of the complexity of the condition. It is a syndrome - a package, covering a wide spectrum of behavioural problems.
At one end of the spectrum, explains Dr Hessel Willemsen, a clinical psychologist at the Tavistock Clinic in London, ADHD is caused by neuro-
developmental problems which have been with the child since birth. The condition is characterised by impulsive behaviour and an almost continuous inability to concentrate, and is often treated effectively with medication.
Supportive family therapy often helps the family to live with it.
At the other end of the spectrum, ADHD is caused by emotional and developmental problems, stemming from and exacerbated by social and environmental circumstances. Here, the child with impulsive and non-attentive behaviour is more likely to be withdrawn as well, and is treated through psychotherapy and family work.
'In between,' says Dr Willemsen, 'there is the grey area, which is a mixture of both. The clinician needs to be sensitive to the child's life history in order to come to the right formulation of the child's behaviour. Often it seems the symptoms are the same but the aetiology - that is, the development of the symptoms - can be very different. Therefore, the aetiology should be included in the formulation of the problem behaviour. The child might need psychotherapy and/or family therapy rather than medical intervention, or sometimes a combination of both.'
Reaching a diagnosis has been made all the more problematic because of doctors' ever-changing understanding of the condition. There is now greater unity of opinion among the medical professions that the condition exists and a greater understanding of the condition (which may in part account for the rise in prescriptions). But new research can still challenge current thinking and methods of diagnosis.
Reading concentration is a standard test used by doctors to diagnose ADHD, but now new research suggests that some ADHD children may have defective vision may be misleading doctors in their diagnosis. In the research, a team of US paediatric eye specialists has reviewed 1,700 children diagnosed with ADHD and found that they were three times more likely than other children to have 'convergence insufficiency', which makes close focusing hard.
But the real problem with diagnosing ADHD in under-fives is that symptoms can equally be seen as 'normal' behaviour, says Professor Peter Hill, consultant child psychiatrist at Great Ormond Street Hospital in London.
'You need to very careful in diagnosing under-fives because quite a number of them will be impulsive, inattentive and boisterous by nature,' says Professor Hill. 'And many of them will grow out of it, given the time, space and an ordinary life.
'It is probable that social and environmental factors have been overlooked when the causes of ADHD have been studied. It seems likely that high levels of criticism from siblings and parents can maintain the condition in some children instead of allowing it to settle with development.'
Concerns that the chances of securing a reliable diagnosis are being compromised by financial and sociological factors are continuing to grow. And there are fears that pressures on an overstretched NHS within its child and mental health services are putting ever greater pressure on the medical profession to resort to quick fixes.
Steve Baldwin, Professor of Psychology at the University of Teesside and author of new research into the prescription of methylphenidate (the generic name for Ritalin) to children, believes the culture within the NHS has always been to prescribe drugs rather than provide therapy.
He adds, 'There is a very strong social and economic need from parents, teachers, educational psychologists and the medical profession to label and prescribe, mainly because of the need for social control.'
Child psychologist Jennie Lindon believes that adults' changing expectations of 'normal' childhood behaviour have contributed to the pressure on doctors to diagnose and medicate.
She says, 'There is no reason to suppose that children have changed that dramatically in their behaviour in the past generation and logic says that these dramatic rises in the prescription of psychotropic drugs to children are much more about adults being intolerant of normal levels of activity in young children and having unrealistic expectations of what is normal behaviour.'
Professor Hill urges the greatest caution in diagnosing behavioural conditions in the under-fives. 'You need to be very, very careful in making a diagnosis of ADHD because the diagnostic criteria are really designed for six- to 12-year-old boys and it's very difficult to translate them to pre-school children,' he says.
'Diagnosis should be the province of very specialist services, as only with an extensive knowledge of child behaviour will you know whether it is pathological, and the cases where the picture indicates underlying pathology is relatively small.'
Yet despite all its complexities, early years staff can play an important part in diagnosing ADHD. 'Early years practitioners are incredibly valuable, not in diagnosing per se, but in flagging up problems, as they have wide knowledge of child behaviour. If they are concerned, it's usually a good pointer for a parent or a health visitor to take notice,' says Juliet Buckley, manager of the parent information service at mental health charity Young Minds.
Early years practitioners can lend valuable support to children with ADHD and their parents. But they have a responsibility to ensure that the supposedly 'hyperactive' children in their care are not simply responding to social and environmental pressures, including a misguided approach to early years education and unrealistic expectations of children so young.
'You cannot take the adult expectations of an eight-year-old and apply them to three-, four- and five-year-olds,' says Professor Hill. 'It's not fair.'
Marian Whitehead adds, 'Unless we're prepared to get back to planning and implementing an appropriate curriculum for early years education, we'll have increasing behavioural problems and when it all ends in tears, they'll say it's the child's fault instead of asking: is there something wrong with the setting? Is there something wrong with the practitioner? Is there something wrong with the approach?'
The Government is reviewing the prescription of Ritalin to under-fives, but the challenge remains for Government, for practitioners and doctors to ensure that children with ADHD are properly diagnosed, treated and supported, while the Lewises of the world are given the freedom to express their 'normal' exuberance - without wrecking the furniture.