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Programme 4. - ADHD
RADIO 4
THURSDAY 23/08/07 1500-1530
PRESENTER:
BARBARA MYERS
CONTRIBUTOR: PETER HILL
PRODUCER:
PAMELA RUTHERFORD
NOT CHECKED AS BROADCAST
MYERS
Hello. One in every 200 schoolchildren has a medical diagnosis of ADHD, that's attention deficit hyperactivity disorder. But it's estimated that 10 times as many actually have the condition and may be missing out on treatment. With the right treatment children who are impulsive and inattentive calm down enough to learn and to make friends at school. But without treatment their disruptive behaviour can continue into adolescence and adulthood, where they may end up with relationship difficulties and mental health problems.
Well if you're concerned about your child's behaviour and have questions about ADHD we're here to help. Professor Peter Hill is our expert today, he's child and adolescent psychiatrist at Great Ormond Street Hospital and he's here to take your calls and your e-mails to checkup@bbc.co.uk.
It's a call that we have first. Val Tindale-Briscoe is in Suffolk and is concerned about her grandson who I believe has been diagnosed with ADHD. What's your worry about this, tell us a little bit about your grandson and his behaviour Val.
TINDALE-BRISCOE
Yes indeed. Well his reading is behind, he does read but he's about three quarters of the year behind with his reading and writing and maths. And so he's being kept back for a year to go through the same thing again.
MYERS
And does he have behavioural problems that are obvious?
TINDALE-BRISCOE
Yes he does get frustrated about things and can be really quite awkward, shall we say, and takes a lot of calming down. At school he does tend - he's not badly behaved at school but he does sort of interrupt the other children when they're doing things and so the teacher's got a little area where she puts him so that he can work on his own.
MYERS
And I believe he's been offered drugs but your daughter's a bit concerned.
TINDALE-BRISCOE
Yes she wasn't sure yet. I've tried to contact her but I can't get hold of her at the moment. But she's due to see someone I think in October because when I heard that the right treatment can be beneficial. I think the diagnosis was just by her doctor, it's his thoughts about it, but he's a very sociable child and he does make friends and he loves being with other children and he's excellent at games.
MYERS
Well let's put your concerns to our expert today Professor Peter Hill. I mean is this obviously - it's been diagnosed as ADHD, it may not be as severe of some of the cases I know that you see in your own clinic but what about treatment if that has been offered, would that be the right thing to use drugs at this point?
HILL
Well quite possibly but not necessarily, not all children with ADHD need medicines. But for those that do the medicines are terrific because they're not a chemical cosh, as is sometimes said, what they do is they stimulate the parts of the brain that really aren't working adequately to help a child concentrate or indeed help them to function academically in the classroom. So I'd have every optimism that medicines might be helpful but on the other hand there are other measures that always need to be taken, that are special educational or supportive or psychological. So I don't know whether he needs medicines but if he does then I think your daughter should go for them.
MYERS
I mean there are a lot of concerns about giving children as young as seven or in some cases even younger medication that may have to continue right through into adolescence and you can understand that concern I imagine.
HILL
Yes of course I can. On the other hand we know quite a lot about the medicines that are used in ADHD, I mean some of them - the ritalin group if you like - have been around for 50 years or so now. We actually know very much more than many people think, we know quite a lot about the long term outcomes which are super, they're very favourable. And we know all about the everyday side effects, which can be fairly readily managed, so long as one gets the dose right. So I think that although it's perfectly reasonable to be cautious about giving medicines to children then one has to bear in mind that the medicines we do have we know quite a lot about.
MYERS
Thank you for that. Val I hope that's been helpful, please do stay with the rest of the programme because there are other callers. Adam, who's next, who's in North London, has experienced ADHD himself as a youngster and continues to have problems now - I think you're about - what are you in your early twenties Adam?
ADAM
Yeah I'm 22.
MYERS
And what were your problems and what are they now, very briefly obviously, but what are the highlights?
ADAM
Well essentially I was diagnosed quite late at age 13, very disruptive, very hyperactive, living basically one minute to the next, loving that but also found it very depressing. Didn't get any work done though get by anyway. And nowadays after all the warnings at school that I'd be an unemployable adult - [indistinct words] I feel - I just don't seem to have an attention span and don't get places on time and many simple tasks that only require sustained attention I can't do consistently - when I can do them I do them very well but that's no good. So I'm kind of a bit stuck as a recent graduate trying to get a job because I got fired from my last four for being late and I kept trying not to and obviously - but yeah that's essentially it and I'm wondering what help there is.
MYERS
And what about medication, I think you have used medication as a youngster when you were given your diagnosis originally but it didn't suit you totally?
ADAM
Yes that's right. I took ritalin, starting on half a pill and ending up on five pills a day, so I think 20 - I can't remember how many milligrams they are each, might be five actually. And it made me murderous actually, it didn't help me, maybe because I didn't have the will or something but I found myself concentrating instead on scratching my head or something so I'd diligently scratch my head for two hours at a time or something. It made me very unhappy and I realised later that every fight I got into between - when I was on it, shortly after a ritalin pill.
MYERS
Okay well let's put your question to Peter. I mean first perhaps Peter you would pick up on that - it doesn't sound great if - I think in Adam's own words he felt murderous after taking his medication - ritalin - which is one of the - it's one of the drugs that is prescribed quite widely. So didn't suit him?
HILL
Could be. Thanks Adam, thanks for calling in because you make two points I'd really like to pick up on. One is my guess is that the dose of ritalin you were given wasn't necessarily the best for you. Different people need different doses. The other thing is that nowadays of course it isn't just ritalin, there's a host of medicines that can be used for people with an ADHD problem. The situation now I think would be really very different from what I guess was eight or nine years ago. But if you give somebody too much methylphenidate, which is the active component, you can make them rather flat and you can make them really not enjoy life, as you put it. And that's really a question of getting the dose right and getting the medicine right. The other point I'd like to pick up on if I may is that you point out that when you're younger you were hyperactive and the rest of the things that go with that but you're now, as you're older, left with an attention problem, a problem with self-organisation. And that I would regard as a classic story for somebody with mainstream ADHD as they mature into their twenties. So the problems are still there in the attention sphere and the self-organisational sphere and those you can do something about. There are medicines that can be used for that and not just ritalin. But there is also a technique known as cognitive or sometimes cognitive behavioural therapy where you can learn the principles of organising yourself and perhaps managing things like distractability or maintaining what I would call on task behaviours. So cognitive therapy, delivered by a clinical psychologist, is a resource to think about as well as the medicines.
MYERS
And if we may we'll bring Julie into this, Julie Harris from Ispwich, who is particularly interested I think about behavioural approaches to support people with ADHD, which is of course what you've just recommended, Peter, as an option for Adam. Is this something you've had experience with Julie?
HARRIS
Yes thank you. I've got a 14 year old daughter who was diagnosed with ADHD when she was 11, originally taking Concerta XL, recently started on Atomoxetine. But what we struggle with is her behaviour and the impact on family life and on her siblings. And it's very difficult to source behavioural support for her, I mean the psychiatrist said to me only a few weeks ago - let's try these new tablets but otherwise you know you're on your own. I got six weeks of support for her from the local EBD school after trying very hard for a long time. So we were just trying to think about what other - if he has any other strategies and resources that we could access for an adolescent, knowing that this problem isn't going to go away for her?
MYERS
Peter.
HILL
Well treatment for ADHD at whatever age ought to be a combination of things, so it shouldn't just be medicines, it should - in fact official recommendations from people like NICE - say that it must involve a psychological approach and a local service ought to be able to provide a clinical psychologist with the skills that are required to advise you as to what would make a sensible behaviour programme in the home. Many people have learned through books and so forth the simple techniques, like One, Two, Three, Magic as a way of managing disruptive behaviour in the home ...
MYERS
Sorry what is One, Two, Three, Magic?
HILL
One, Two, Three, Magic ...
MYERS
Sounds great.
HILL
Yeah, well it's the title of a book, which I didn't write, by a man called Phelan - p h e l a n - which you can buy quite widely. And it's a very straightforward technique, he didn't invent it, if anything the people in Northern Ireland, child mental health clinics, purified it as a technique 20-25 years ago. But it's internationally used, it's simply a way of giving precise sharp instructions - when I say sharp I don't mean fierce but I mean crisp - clear cut instructions to a child about what should or should not happen and then implementing the use of time out, which is actually removing the child from your own social attention. And it's a very simple structure and you can read about that in books or there's a video and that's great. And if that's in place for children under the age of 14 then parents can find ways of doing that over 14. The usual problem with teenagers is discovering what authority parents have, it often centres round money and access to computers and televisions, that they can use as disciplinary measures within the home.
MYERS
Can I bring in a message we've just had from George Talbot and I don't know if it helps or hinders what you're saying Peter here but he says that parenting skills have a lot to do with this business of hyperactivity. He says - and these children need discipline, he says look at Supernanny - Supernanny's a television nanny who makes children sit on the naughty step. In a way that does fit with what you're saying - that you need to be very clear in your discipline but that's not to say, is it surely, that these children are out of control simply because parents can't control them, there's a lot more going on isn't there.
HILL
Well the trouble for ADHD children is they need a lot of discipline because they are extremely difficult children to parent. So you don't just have to be an ordinary parent, you have to be a super parent and therefore presumably employ a super nanny. But you need extra skills, both to build a child's concentration and the ability to do what they're asked to do as well as to try and control over excessive, over excitable, behaviours. So George is absolutely right - you do need discipline - but it's highly, highly, highly unlikely to be sufficient for most of these children.
MYERS
And there's no suggestion that it would be what causes the problem in the children - that the parents are not able to discipline and be good parents?
HILL
No quite. My - well a very frequent experience I have is talking to parents who have one child with ADHD and two who do not and the two who do not may well be older, so they've demonstrated their ability to be entirely competent parents but there is one child who for his own reasons, usually it's him, tests them to the limits and the child with ADHD can undermine the confidence of any competent parent who then has to employ extraordinary measures to build that child's confidence, to manage their behaviour, to encourage their academic work. It's quite an issue.
MYERS
What is it that's different about the brain of a child with ADHD, is there something that you can see on scans or are there tests that can clearly differentiate these youngsters from perhaps say the average range of children's brains?
HILL
Right at the moment ordinary brain scans won't tell us very much, they just look at the shape of the brain and they do that pretty well. But if you do research scans which look at blood flow or oxygen use or metabolic rate in parts of the brain something very striking emerges in ADHD, which is that children and young adults, both have been studied, with ADHD are not able to use the front part of their brain, their pre-frontal cortex, the frontal lobes and this is a dramatic site on a research active brain scan - something like functional MRI, which isn't routinely available and we can't use it as a diagnostic tool in the health service for example. But in the research world these pictures are absolutely stunning, something which should be let us say lighting up because there's adequate blood flow but the front of the brain just isn't and it's the front of the brain that controls measured behaviour, controls concentration and controls social judgement. So these are the things that are not happening.
MYERS
So we can see it but can we know what causes it?
HILL
Well yes we can and the causes of the ADHD pattern are various. The one that comes through most strongly is a genetic influence which can happen in several ways, though for most children it's going to be the interplay of several genes, rather than just one, that's occasionally true. But there are other factors as well, such as the foetus being exposed to high levels of alcohol, nicotine in pregnancy then that becomes a child with ADHD. Children who've been reared in very unsatisfactory surroundings, like some of the Balkan orphanages that used to be around, have very high rates of ADHD. So there's a combination of both genetic and environmental factors.
MYERS
We go to Manchester for our next caller, David Powell is waiting to speak to us, a man in his 40s diagnosed only last year with ADHD. What symptoms - what circumstances David are you experiencing?
POWELL
Well it's - on the continuous fronts, it's mainly manifested within myself as a depressive illness. I have combined types, so although I am hyperactive at times, I am also very disorganised and show the deficit side enormously. For instance in school, since I was in a large class and fairly clever, left to my own devices to stare out of the window for long periods.
MYERS
How come you got a diagnosis at this stage and you were missed completely in terms of diagnosis as a child?
POWELL
Well because I wasn't causing any trouble, because the hyperactivity side was fairly low. I was ignored because I wasn't that troublesome.
MYERS
And now what made you go forward for a diagnosis - the depression?
POWELL
Yes it was - it's really bad, if you've spent a lifetime being depressed it's pretty debilitating. So - I'm also having problems socially, I was causing absolute mayhem all over the place by being inappropriate, extreme behaviours, causing - not huge trouble - but always pushing against the boundaries trying to get into that adrenaline zone.
MYERS
So for you life's been quite tough and you feel somewhat compromised clearly by the difficulties that you're experiencing.
POWELL
Yeah I feel it's a disability like anything - any other disability.
MYERS
Let's ask Professor Hill what thoughts he's got, what recommendations perhaps for David going forward.
HILL
Well I'm glad you rang in David because depression is one of the things that doesn't get talked about when we talk about ADHD in children because it's something that can happen to people with ADHD as they grow up. People with ADHD as adults have a substantially higher rate of depression than they should have though we don't see that particularly in children. The reasons for that are I think not well understood but one very obvious thing to say is that if you've got ADHD you live your life to a soundtrack of negative criticism and you experience more than your appropriate ration of failure. So it's not surprising that your morale gets buffeted and your self-esteem can waver and then your mood goes down. So yes there's a higher rate of depression and in many ways it's easy to understand why there's a particular problem in adult life, especially if the ADHD symptoms persist from childhood and sometimes they do and sometimes they don't. But as you rightly say although children with ADHD, and some young adults with ADHD, like the adrenaline rush, like the bounce - this is called stimulus seeking behaviour and it's associated with the similar sort of pattern of genes that ADHD is - ultimately the life as an ADHD sufferer is not fun, it's not a joke at all.
MYERS
And you'd concur with that David?
POWELL
Absolutely. It has its excitements but the downsides outweigh I reckon.
MYERS
I wonder if - thanks very much for that call. I'd like to move to Cheltenham where Michael would also like to join the conversation. Michael's, I think, son has ADHD but he's doing alright, what's happened, what are your circumstances Michael?
MICHAEL
Harry - oh dear I shouldn't have mentioned his name sorry - he was excluded from kindergarten at the age of three for violence. When he went to infant school it was less than five weeks before they were talking about his permanent exclusion. And at the time I heard Dr Cosgrove of Bristol on Woman's Hour talking about ADHD. So we went to see Dr Cosgrove who diagnosed Harry with ADHD and he was put on ritalin which we had to really fight hard to get for him. It never had any of the effects that we were told it might have - he didn't become zombie like. He is now 17, last year he got nine good GCSEs, he's studying hard at college, he's an intelligent, bright and very articulate young man and hasn't had a ritalin tablet for 18 months.
MYERS
That's a really good news story. And is that what you find working with these children Peter, that having had a diagnosis and treatment they can actually do very well. I mean is there something about the treatment that is in that sense, if it works, it's curing their problem or is that stretching the point?
HILL
Well I don't think it is. I mean if I - if I were behaving properly I'd say that I treat these children because I feel sorry for them and that is undoubtedly true, I think they have miserable lives often. But there is a bit in me that is less appropriate and which is actually it's great to treat children who get better. And the medicines we have for ADHD are some of the most - well they are the most effective for any mental health problem in children or adults. When they work and when they're carefully and properly chosen and employed alongside other measures they are fantastic. And the treatment for ADHD, when it works, is an immensely satisfying experience for any doctor, any health professional and the results are terrific. The point about cure is a fascinating one. If you go to the States people often talk about drugs for life if you've got ADHD, that's not my experience and I don't think that's the experience of my colleagues in Europe. What we do see in recent work, over the last 12 months or so, in published papers, scientific journals, is that methylphenidate, in particular, which is the active component of the ritalins and concertas that have been mentioned and the Equasyms and [indistinct word] that haven't. That actually can produce a change in brain growth, a change in brain architecture, and a change in brain blood flow that persists in the right direction, I mean this is restoring normality, that persists even after the medicine is stopped. And now that's fantastic and you don't read about that in the papers, you heard it here first.
MYERS
Can we take very quickly a final call from Ann, Ann is desperate, Ann's son has this problem and I believe you really are struggling. Ever so briefly, how can we help you?
ANN
Yes my son's 11, he's got complex needs, one of which is ADHD. He's been on Atomextine and Ritalin and had bad side effects to those. What's left?
MYERS
What's left?
HILL
He could - I don't know exactly what the problems are, it would help enormously, but he could have, for example, Modafinil, he could have Nortryptiline, he might be benefit from Dexamfetamine, if he hasn't had that. Those are probably the three most widely used alternative medicines - alternative in the sense of other choice medicines - at the moment. There is a long list which I can't possibly go through that a specialist centre would know about and it may be the right thing to ask for a referral from your local service - whether it's paediatric or child and adolescent mental health - to one of the specialist centres.
MYERS
So is the bottom line there - there's always something that can be done and certainly don't give up hope, there is a way forward if you find the right service and it's worth pressing for that Peter?
HILL
Never give up.
MYERS
Okay, thank you very much. That said we will have to give up because our time is up but thank you very much indeed to my guest today Professor Peter Hill. And thank you to everyone who's phoned or e-mailed, I'm so sorry that we haven't been able to get more of you on air. But if you've missed any of the programme then you can listen again, just go to bbc.co.uk/radio4. And if you want more information then you can call the Radio 4 action line that's free and confidential and the number is 0800 044 044. And join me again if you will at the same time next week when I'll be taking your questions on another condition known by its initials IBS - irritable bowel syndrome.
ENDS
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