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"THE McDONALDISATION OF  MENTAL HEALTH TREATMENT" FOR CHILDHOOD BEHAVIOUR DISORDERS.Prof Sami Timimi

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"FAST FOOD THERAPY" -
 
Guidelines for the treatment of ADHD say drugs should only be turned to
as a last resort, so why is their use so prevalent? Amy Taylor hears from
experts who liken the over prescribing of drugs as the “McDonaldisation”
of treatment and symptomatic of our ‘quick fix’ nation  and it represents the Coca Colinisation of our children's brains.

A mother and her son go into a
pharmacy and hand over a new
prescription for a serotonine
reuptake inhibitor antidepressant.
When he checks his records the
pharmacist finds the boy has
previously been diagnosed with
ADHD and is already on a much
higher than maximum daily dose
of Ritalin (a psychostimulant) and
a very high dose of Risperdal (an
anti-psychotic drug). So he tells
the mother that he can’t issue the
prescription as to do so would be
“life threatening” for her child
and that she needs to request a
review of his medications by the
prescribing psychiatrist.
This is a real life scenario
that, according to Dave Traxson,
an educational psychologist
working in the West Midlands
and who has set up a blog
on the over prescribing of
psychotropic drugs for children,
illustrates the lack of ‘duty of
care’ and readiness with which
some doctors and psychiatrists
are giving out psychotropic
drugs for ADHD and other
psychological conditions without
fully considering other options
available. “I don’t think it is the
only case in the UK of this level of
risk,” he says.

There are a range of views on
the causes of ADHD: some argue
that it is a brain condition, others
put it down to poor parenting
and environmental factors, most
think it a combination of these.
The differences of opinion in turn
lead to a range of views on how
it should be treated. Under the
National Institute for Health and
Clinical Excellence guidelines
children with ADHD and their
families are supposed to be
thoroughly assessed by a multiagency
group of professionals
and given psychological
based interventions, such
as psychotherapy, cognitive
behavioural therapy or parenting
programmes, rather than drugs
in the first instance. Drugs can
then be issued at a later date if
required and for many children
a combination of the two is
often the best option. NICE
also recommend that children
under six should never be given
psychostimulant drugs except
in exceptional circumstances.
While the guidelines are greatly
respected Traxson and a number
of other psychologists argue that
on the ground they are often not
followed.
“Under the NICE guidelines
drugs should be used as very much
a last resort not a first resort. The
problem for psychologists is we
know that all over the country
they are being used as a first
resort based often on incomplete
assessments,” he says.
In November 2010, views
were split even further by the
publication of research by
scientists at Cardiff University
claiming to have found the first
direct evidence of a genetic link to
ADHD. The research suggested
that ADHD was not purely the
result of social factors. At the time,
some psychologists expressed
concerns that the findings could
lead to the condition being seen
solely as biological, thus fuelling
prescribing rates.

 
Sami Timimi, consultant child
and adolescent psychiatrist at
Lincolnshire Partnership NHS
Trust and one of the leading voices
on ADHD, is dismissive of the
Cardiff research. He argues that
ADHD is a “cultural construct”
demonstrated by the difference in
prescribing rates across the UK
and internationally.
“We have these patterns going
on all over the world that reflect
different beliefs and different
priorities,” he says. By way of
example Timimi describes how
the highest rates of prescribing
in America take place in middle
class white areas where boys are
achieving less academically than
girls, revolving around a concern
that without a diagnosis and
prescription boys will fail to get
into college. Conversely, in Britain
most diagnoses are in white
working class areas.
In Timimi’s view rather than
looking at the complexities that
children and their families exist in
and the impact they have on their
mental health, certain societies
choose to create disorders such as
ADHD and blame them on a range
of other factors. “On one side of
the coin [people say] it’s a health
problem and a psychological
disorder, while on the other side of
the same coin it’s bad parenting.”
Timimi says that such
environments tend to lead to
parents coming under intense
scrutiny. He explains that once
a diagnosis of ADHD has been
made the discussion can move
from being about bad parenting
to one about a parent struggling
with a demanding child, making
it understandable why a diagnosis
can become attractive.
Timimi argues that psychiatric
drugs work by creating abnormal
mental states in people, which may
prove helpful in managing their
emotional distress rather than
correcting chemical imbalances.
He says that this means they
can be useful as a short term
treatment to bring about such
states. On this basis he will
prescribe “once or twice a year”
stimulants for ADHD, for a
maximum of one year.
While backing Timimi’s
arguments on prescribing rates as
proving ADHD to be a cultural
construct, Traxson feels that there
could be a genetic predisposition to
the condition but that this may not
lead to its development. He says
that the NICE guidelines should be
followed and that when extreme
behaviour is involved drugs may
be appropriate once therapeutic
treatment has been tried.
Traxson, who observes
hundreds of children as a part of his
work, says that it is the intensity of
the impulsive behaviour that singles
out children with the condition for
whom drugs may be appropriate.
He explains how a child getting up
in the middle of a lesson to snatch
a pen from a desk could be doing
so because they are keen to carry
on doing their work and that this is
a totally different action to a child
that’s playing with a piece of string
in their hand thinking about how
that piece of string could go round
a person’s neck and then acting on
that impulse.
The Cardiff research covered
366 children with ADHD and
1,047 controls and found large
rare chromosomal deletions and
duplications, known as copy
number variants (CNVs), were
significantly higher in children
with ADHD (15.6%) than children
without the condition (7.4%).
Despite this finding, Professor
Anita Thapar, who helped to carry
out the research, sees ADHD
as caused by a combination of
genetic and social factors. She
says that just because a person
has a high number of the CNVs
does not mean they will develop
the condition. She argues if we
lived in a vacuum the condition
may not come into existence and
that its impact is only felt when
it interacts with social factors.
“If you had a society where there
were no schools and no social
constructs we might not be unduly
concerned,” she explains.
However, Thapar dismisses
the idea that differences in
prescribing rates is proof the
condition is simply a social
construct. She says that such
rates are a “completely different
issue”, and highlights the need
to disentangle causes of the
condition and referral numbers.
She also feels the NICE
guidelines approach is the correct
one for treatment but stresses
that it should be remembered
that drugs are beneficial for some
children. “With ADHD you have
got a spectrum of severity and
it’s important to me that I can
discuss in detail all the things
that are likely to be effective (with
parents). So I need to be able to
discuss psychotic intervention
and medical interventions
because children are likely to need
a combination of them dependent
on the strength of the condition,”
she says.
Working out the reasons
behind a child’s behaviour can be
a slow process and not one that fits
well with our fast paced culture.
Traxson says that it’s the quick
fix and relatively cheap nature
of drugs that lie behind their
popularity. Both he and Timimi
agree that the main responsibility
for the situation lies at the
pharmaceutical companies’ doors.
Timimi refers to a “McDonaldsisation”
of children’s mental health
with a marketplace for companies
to exploit.
“Because we are in a money
driven culture what you get is
that these different diagnoses
start to function like brands with
industries that are created around
them. The most obvious one is
drugs because there’s lots of money
to be made,” he adds. !
 
Amy Taylor is a freelance journalist.