Clara Pirani

January 29, 2005

CAROLE-ANN was stunned when teachers said her seven-year-old son had attention deficit hyperactivity disorder.

"They recommended that we have him assessed for a possible learning disorder, which involved an IQ test. He produced outstanding results in puzzle-solving, well above average, but performed badly in tests that involved reading.

"The motor skills assessment showed he had trouble standing and hopping on one foot. So they said he had ADHD."

Carole-Ann was horrified that nobody bothered to ask if there were any problems in her son's life at the time that might be causing the changes to his behaviour, or if he had any physical problems. "They didn't know that he was born with club feet that required surgery - and they were asking him to stand on one foot and balance, which was impossible."

 Carole-Ann had also just separated from her husband and was suffering depression after the death of her brother and mother. She was incorrectly diagnosed with bipolar disorder and ADHD, and admitted to hospital.

She fought the diagnosis, and was released after a magistrate ruled she had probably suffered a drug-induced psychosis from the range of medications she had been prescribed, which included Prozac and dexamphetamine.

Carole-Ann has no doubt Stephen was reacting in part to the turmoil at home.

A week after teachers demanded to know why Stephen was not taking Ritalin, she moved him to another school.

Two years later, neither Carole-Ann nor her son takes any form of medication.

"He has had no problems at his new school and is very happy and doing well."

Experiences like Carole-Ann's are not uncommon.

Doctors are increasingly prescribing drugs to treat an ever-widening array of conditions, from ADHD to depression.

Last month a British Medical Journal article (2004;329:1394-6) warned that unhappiness among children seemed to be rising, but labelling it as depression and prescribing antidepressants was ineffective and possibly harmful.

Author Sami Timimi, a UK-based consultant child and adolescent psychiatrist, wrote that the boundaries between adulthood and childhood have become blurred and children were being viewed as miniature adults.

"One effect of these changing expectations of childhood and parenting is that more childhood behaviours previously considered normal are now seen as problematic, and problematic behaviours are more likely to be medicalised.

"These days we are as likely to use medicalised terminology to describe children's feelings (such as depressed) as we are less pathological descriptions (such as unhappy)," Timimi wrote.

Federal government figures released in April 2004 revealed 250,000 antidepressant scripts were issued to Australian children and adolescents in 2003, 30,000 more than in 2002.

The head of psychological medicine at the Adelaide Women and Children's Hospital, Jon Jureidini, says doctors are increasingly looking for medical explanations for childhood and adolescent problems.

"We're more likely to conceptualise suffering as being something that needs to be treated, or medicalised, than we used to be. So stress is more likely to be construed as an illness," Jureidini says.

"There is this notion that unhappiness needs to be treated. And it can be dangerous both from the point of view that the drugs can sometimes be dangerous, but also because sometimes significant, bad things in kids' lives get missed because it's seen as a medical problem, rather than recognising that they are just responding to bad things happening in their lives."

 Jureidini believes doctors are not spending enough time investigating the reasons why children are depressed. He says the situation is compounded by other problems including patients' desire for a quick-fix, and a lack of mental health services.

"A lot of people think medication is quick and easy and any doctor can give it, whereas therapy is very complicated and difficult, and you have to go to a specialised mental health service. And there aren't many of those around."

In 2002 a NSW parliamentary inquiry into the use of prescription and over-the-counter medication by children and teenagers found some parents actively seek out doctors who will prescribe drugs.

It revealed a Commonwealth Department of Health and Aged Care report found 16 per cent of mothers surveyed admitted to shopping around until they found a GP willing to prescribe medication, even when their own GP had refused.

Jureidini believes parents feel enormous pressure to make sure their child is "normal". "Parents are unsure when their child is showing typical teenager angst or whether they are experiencing a more serious mental illness that may require treatment.

"What makes that worse is the idea that is pushed around that if your kid's depressed, they might kill themselves. A lot of parents are very frightened by that. But antidepressants haven't been shown to be helpful in those instances."

Louise Newman, chairwoman of the faculty of adolescent and child psychiatry at the Royal Australian and New Zealand College of Psychiatrists, disagrees and says a better understanding of mental illnesses, combined with prescription medication, may be responsible for the fall in teen suicides.

"The adolescent suicide rate has plateaued and is now going down, so we're obviously doing something right. Maybe GPs are getting better at picking up severe depression in adolescents and are treating it early."

Newman argues medication should rarely be used for mild or moderate depression, and only when other treatments had failed. "Our position is that for the majority of mild to moderate depression cases in children and early adolescents, antidepressants and drugs are not the first-line treatment.

We need to keep advocating for a broad range of treatments for young people. And part of the problem for GPs is that there is not easy access to alternatives."

 However both Newman and Jureidini believe doctors need to be more proactive at finding alternatives to medication.

"We have to put the child's concerns into some kind of family, school and social context. Instead of saying 'what illness do these symptoms represent', we should say, 'what do these symptoms mean, and what does this tell us about the predicament this child is in and what can we do to alter that predicament'," Jureidini says.

It's perhaps not surprising that the diagnosis and treatment of mental illnesses, particularly depression, is often controversial. Unlike a broken arm or leg, the physical signs are difficult to identify and symptoms are open to interpretation.

Despite ongoing education campaigns and research into ADHD, debate about the prevalence and treatment of the condition continues.

 In November a bi-partisan report of a lower house West Australian parliamentary committee estimated 11,500 children in that state - some as young as two - were prescribed psychostimulant drugs, mainly dexamphetamines, for ADHD.

 It called for an urgent overhaul of the state's model for treating the condition and recommended the federal Government investigate and address the dispro portionate use of dexamphetamines across the states and territories.

In 2000 a federal Government report, the National Survey of Mental Health and Wellbeing, surveyed 4000 people in Australia and found 11 per cent of parents thought their child was suffering symptoms of ADHD.

Prescriptions for dexamphetamine - the top-selling drug to treat ADHD - have skyrocketed during the past decade. In 1994 about 46,000 prescriptions were issued for dexamphetamine, compared to 246,000 in 2004.