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Monday, 4 November 2013
Special Children Article - "Out of Control" - the industrialisation of prescribed psychotropic medication for children for massive profits.
- is a familiar descriptor for badly behaved children and drug firms states chartered educational psychologist Dave Traxson, who thinks it’s the over-prescription of psychotropic drugs for vulnerable children that needs reigning in. IT IS A SAFEGUARDING ISSUE -in his professional opinion.
Dave Traxson is sitting in his Victorian house in Wolverhampton with his foot in a cast and a pile of books next to him on the sofa. He is currently off work recovering from an operation and is using the time to catch up on his reading. He has just started Shyness: How Normal Behavior Became a Sickness by Christopher Lane and enthusiastically recommends it to me. I can tell from the title alone that he and Lane probably have a lot in common.
Traxson is a chartered educational psychologist and has been for over 30 years. He has spent nearly all of this time in the West Midlands working for a series of local authorities and continues to be a contributor to the Educational Psychology training course at Birmingham University. Before becoming an educational psychologist he spent six years teaching. It seems fair to say that if it wasn’t for a conversation in a school corridor in Spring 2009 few outside his current authority would have heard of him. As it is, he’s become something of a media celebrity – even appearing on Woman’s Hour.
I start by asking him about that fatal meeting. ‘I bumped into this head of year and he just asked me the question,‘ he explains. ‘ “Dave,” he said, “I have got six young people that have been diagnosed with bipolar disorder in my year group of 120 kids – do you think that’s normal?” And I said no, I was very surprised.’ Prior to this Traxson says he had come across about six children with bipolar disorder in his entire career. ‘To get six as a cluster in one year group I found very concerning.’
At the time he says he was already aware of the exponential increase in the number of methylphenidate prescriptions being issued for children with A.D.H.D. Methylphenidate is the active component of a range of psychostimulants better known by their brand names; they include Ritalin, Concerta, Daytrana, Methylin and Metadate. It wasn’t until later, he says, that he realised the true scale of what was happening. ‘When I started researching into it the evidence was clear. From 1994 to 2009 there has been a 120-fold increase in prescriptions, which is phenomenal in just 15 years.’
Traxson says an increasing number of headteachers were also sharing their concerns with him: ‘It was becoming a more and more common topic of conversation on my regular school visits.’ One worry headteachers had was that they weren’t being consulted by medical practitioners, a practice Traxson says was widespread at the time. The psychology service in his own authority carried out a comprehensive survey to assess the experience of heads locally: ‘Questionnaires were sent out to schools and the returns showed that in only 47% of cases did the prescribing doctor send a checklist to the school, let alone have a telephone conversation with them, which was incredibly rare.’ This meant doctors weren’t ‘triangulating the data’, i.e. moderating their own observations on the basis of those of the child’s parents and school.
So are medical practitionerss to blame? Traxson says no one group is responsible. As with most things it’s a combination of factors. He points out that some critics, like Professor Steven Rose of the Open University, point to parental pressure. ‘Usually there is a genuine concern about the child’s pattern of behaviour but sometimes parents might have been influenced by information they have seen on the internet or in the media. As a result they might have a skewed perception of what the normal range of behaviour is or they may have too high an expectation of their child.’ He says there’s also anecdotal evidence from headteachers that some parents are aware they can claim disabled living allowance (DLA) if their child has a firm diagnosis of ADHD. ‘I am not saying that a majority are doing it for that reason but there is a significant minority that is very aware of that possibility,’ he adds. Whatever the explanation headteachers were becoming uneasy because children were being diagnosed with conditions they hadn’t shown signs of in school.
Traxson even questions the view that behaviour standards in schools have declined. He says he witnessed far more aggression and violence in the Birmingham grammar school he attended in the 60s than he sees in most of the schools he visits now: ‘You don’t see the widespread disruption, rudeness or fighting that people seem to think is happening in schools.’ In the schools he visits most discussions focus on low level disruptive behaviours not verbal or physical aggression.
When Traxson looked into the case of children diagnosed with bipolar disorder other worrying trends began to emerge. One was a cluster of children than were on higher levels of medication than was recommended by the manufacturers. Another was children who were on a cocktail of drugs: anti-psychotic drugs and/or anti-depressants combined with methylphenidate. Traxson wasn’t only concerned with what was happening he was concerned about the language being used to ‘normalise’ these practices. ‘When some children were on a high dose of methylphenidate some doctors were choosing to give them an extra dose in the morning, which they referred to as a ‘kickstart’. They they would give them another dose at lunchtime which they would call a ‘booster’ or a ‘top-up’. I began to feel very uncomfortable about the language being used. It might have just been a way of explaining it to the parents but it seemed a way of minimising what was happening.’
Traxson’s concerns came to a head in the summer of 2009 when he set about investigating the use of methylphenidate. He was shocked to find that in the USA 12% of the school population is on the stimulant at any one time and that 40% of school-age children (2-18) will have been on it for at least two of their school years. He also discovered that professional tensions were running high in the USA over the intention to widen the net of mental health problems with the introduction of new categories in DSM-V – the revised version of the Diagnostic and Statistical Manual of Mental Disorders, which is due to be published in 2013. ‘Piecing all this anecdotal information together with what I was discovering myself I started to think, “This is something that we have got of raise the public profile of”,’ he says. ‘I think sometimes in your career you have got to go back to fundamentals and I think one of the fundamentals for me is that the over-prescription of drugs is a potential danger to children. More fundamentally than that, I think it’s basically wrong to be giving broad swathes of children psychotropic medication when their brains haven’t yet fully formed and these toxic substances could have a negative impact on their development.’
To raise the level of public debate about over-prescription Traxson started his own awareness raising campaign. Under the slogan ‘Pastoral care have a duty of care to be aware’ he set out to raise the issue with staff in schools. He says he did so after consulting hundreds of headteachers, 70% of whom felt that pastoral care staff did have a duty to monitor the number of children in their school who were taking prescribed psychotropic drugs.
His next step was to formulate a set of 20 questions pastoral staff should ask themselves. The full list can be found on his blog (http://cope-yp.blogspot.com) but among the issues they raise is whether there is a link between the early use of prescribed drugs like methylphenidate and later illegal drug use among young people. Traxson says that when he raises this with medical professionals it often stops them in their tracks and they ask him whether there is any evidence of such a link. After consideration one senior medical colleague agreed that this issue warranted further research by his own professional group.
Evidence of such a link exists, he says, giving the example a longitudinal study carried out by the now deceased Berkeley psychology professor Nadine Lambert. Lambert followed 492 San Francisco Bay area children, half of whom suffered from some degree of ADHD and half of whom did not have ADHD. The study found that, children treated with stimulant drugs such as Ritalin to control attention deficit/hyperactivity disorder (ADHD) take up cigarette smoking earlier, smoke more heavily and are more likely to abuse cocaine and other stimulants as adults (http://gse.berkeley.edu/admin/publications/termpaper/fall99/ritalin.html).
Traxson also trialled another of his 20 questions in one of the two schools where he is a governor. ‘At one governors meeting under Any Other Business I just asked if the headteacher and the pastoral staff were aware of how many children in the school are on psychotropic medication for their behaviour. The head had no problem with me asking the question but said he couldn’t answer it. He said he felt slightly embarrassed he couldn’t answer it here and now but promised he would look into it and report back. At the next meeting he reported that there were 13 and he as a science teacher was quite alarmed by that.’
Having formulated the questions Traxson more recently set about publicising them far and wide, first through articles, then through his blog and eventually on radio and as a guest speaker at two major national conferences, one organised by the Association of Educational Psychologists (AEP) and the other by The British Psychological Society (BPS). In terms of day-to-day practice he says his first big breakthrough came in September 2009 when the paediatricians in the local authority he works for agreed a new protocol to the effect that any concerned professional – an educational psychologist or a teacher, for example – can ring the prescribing doctor to share their concerns. Hundreds of telephone calls or face-to-face meetings later he says the most common response from medical professionals is actually, ‘Thank you for taking the time to share your concerns.’
It’s clear from Traxson’s accounts of this episode that he doesn’t see medical professionals as adversaries. On the contrary, he believes everyone has the best interests of the children they deal with at heart. What distinguishes the different approaches he suggests is that GPs and paediatricians will pursue a medical model and look for an explanation for the problem within the child whereas a psychologist will look for a broader explanation, including social factors. Time pressures on GPs – the average length of surgery consultations was 11.7 minutes in 2006/7 – and lack of access to ‘talking therapies’ can also result in medication being seen as the first and only option. This is despite guidelines from the National Institute for Health and Clinical Excellence (NICE) stating this shouldn’t be the case with children with ADHD.
As it is Traxson’s practice of asking simple but powerful questions has sparked something bigger. His own professional association, the BPS, has now given its support to a call for a national review into the use of medication to help treat children’s behavioural issues. With a major reorganisation of the NHS underway Traxson agrees.
‘While all budgets are under scrutiny I would argue that a good percentage of the £32 million that we spent last year just on psychostimulants could be redirected to better uses, such as ‘talking therapies’,’ he says. ‘There’s also the tens of million of pounds being spent on disabled living allowance that could possibly be used more efficiently and more appropriately for school-based interventions. There are many, many good practices such as nurture groups that schools can explore. The time is ripe with all these changes to put this issue under the microscope and to have a proper national review.’