BAD BEHAVIOUR

Drugs can work wonders for children who are mentally ill; but treat
them as a universal quick fix and they do more harm than good, says
Sandra Scott

Imagine the scenario: your son is disruptive at home and at school,
doesn't keep still or concentrate for more than a few minutes, speaks
out of turn in class and is learning next to nothing. Is this just
naughtiness, you ask yourself, or is it a symptom of mental illness?
Do 1 let it pass and hope he grows out of it, or should I send him on
a course of therapy with a child psychiatrist? Should 1, perhaps,
allow a doctor to prescribe him drugs to calm him down?

As a child psychiatrist, 1 deal with questions like these every day.
Deciding what is normal behaviour and what is excessive and requires
treatment is one of our greatest challenges. The trouble is that most
childhood psychiatric disorders differ from normal naughty behaviour
only in degree. So diagnosing the cause of a particular child's
problem can be difficult.

In the US, two million children who have been diagnosed as having
attention deficit hyperactivity disorder (ADHD) are being treated with
the drug Ritalin (methylphenidate hydrochloride). In Britain,
medication is used less often, but it's on the increase. It's a trend
1 find worrying, especially as the government is proposing to revise
the Mental Health Act in a way that is likely to encourage it.

The existing act gives police and health services powers to detain
people with a mental disorder who display "abnormally aggressive or
seriously irresponsible conduct". The proposed revision to the act
extends those powers by redefining a mental disorder as "any
disability or disorder of mind or brain, whether permanent or
temporary, which results in an impairment or disturbance of mental
functioning". This change could lead to many more people facing
detention-including children who show disruptive behaviour.

More than ever, the onus will be on doctors to "improve'' disruptive
behaviour by the quickest means possible. This can only encourage the
use of drugs to prevent a child from being detained or to hasten their
release.

One particularly worrying possibility is that the authorities may want
to detain children who are not mentally ill, but are suffering from
behavioural problems. Such conditions respond best to psychotherapy,
and for them drugs should not be the first option. An obvious case is
what is known as "conduct disorder": this involves excessively and
persistently disruptive and antisocial behaviour, often combined with
reading difficulties. Conduct disorder is naughtiness taken to an
extreme. In most cases, it happens in boys, and it does not respond
effectively to medication.

Contrary to what some parents presume, drugs do not treat bad
behaviour directly. Using drugs to treat conduct disorder exposes the
child to unnecessary side effects and makes it harder to apply more
effective methods such as cognitive behavioural therapy-getting the
child to understand why he behaves in the way he does-or therapy
involving the child's family.

Unlike conduct disorder, ADHD is a psychiatric condition. But many of
its symptoms, such as aggressiveness and impulsiveness, are shared
with conduct disorder, making it hard to tell the two apart. Children
with ADHD have genuine difficulty in concentrating and keeping still.
In class they are often out of their seats, wandering the room and
disturbing others. Their impulsiveness can lead them to shout things
out and speak out of turn.

The majority of children with genuine ADHD will improve if they take a
stimulant such as Ritalin or Dexidrine (dexamphetamine). They will
concentrate better and become less hyperactive, and be less verbally
and physically impulsive. But I am convinced that even for ADHD,
medication is only part of the solution. Psychotherapy is an essential
part of managing any disorder involving disruptive behaviour.

So when a child is behaving disruptively in class, is this simple
defiance, a lack of interest, or a symptom of ADHD? Herein lies the
danger: if a child is behaving so badly at school that he is
threatened with exclusion, and his behaviour is drawn to the attention
of the mental health services, there will be considerable pressure to
improve behaviour by the quickest means available. Stimulants act more
quickly than psychotherapy, and in cases where a firm diagnosis is not
possible a doctor might feel inclined to prescribe them.

Many parents are reluctant to allow their children to be prescribed
medication. In some cases, however, they can find themselves under
huge pressure to do so, even in cases where it is not appropriate.
Disruptive children are difficult to cope with, and put families under
great strain. Some parents are desperate for a quick solution.
"Wouldn't it be great if we could just give something to little Johnny
to calm him down and stop him hitting his sister?" they ask.

But treating a child with drugs when psychotherapy would be more
appropriate can do real harm. Medication might calm a child down, but
unless he is genuinely suffering from ADHD it will not address the
underlying reasons for his inattention, disruptive tendencies or
reading problems. In addition, stimulants can have serious side effects.

When I worked in a specialist ADHD clinic one of my patients was a boy
who had been diagnosed as having ADHD, and was prescribed stimulants.
The drugs were stunting his growth, so we stopped them for a while so
that he could catch up. During this time we concluded that he had been
misdiagnosed, and did not have ADHD at all.

If this child had not been reassessed, he might have continued on the
medication without a break until it was too late for him to catch up
on his growth. He would have been affected for the rest of his life.

Therapy is often not the easy option, but given a chance it can be
very successful. I hope that the widespread use of medication in the
US, combined with changes in British law, will not undermine the use
of therapy for treating disruptive children. Drugs can help some
children, but used inappropriately they can do more harm than good.

Sandra Scott is a child psychiatrist at the Maudsley Hospital in
London and with Kids Company, a charity for deprived children