In an interesting article on 25th June, Chris Smyth reveals some of the perverse incentives in the combined education/health areas affecting children.
Middle-class parents and teachers are pressing doctors to label children as mentally ill in a worrying “medicalisation of normality”, the new leader of Britain’s psychiatrists has declared.
Drugs such as Ritalin and Prozac have been massively abused because of the desire to label problems as medical disorders, said Professor Sir Simon Wessely, who takes over as president of the Royal College of Psychiatrists next week.
Huge rises in the use of antidepressants and drugs to treat attention deficit hyperactivity disorder (ADHD) show that they are being given too freely in response to social pressure and not to those who could really benefit, he said.
Professor Wessely also criticised the prejudice against mental health among other doctors, adding: “You could not have designed a health service less able to join up mind and body, physical and mental, than the health service that we’ve had in the past 20 or 30 years.”
The use of ADHD drugs has tripled in a decade and the use of antidepressants has doubled. Professor Wessely said that this was unlikely to be explained purely by more disease or better detection.
“Medicalisation is not often done by doctors. In areas that are more accessible to public debate it’s almost the other way around. Now we see a huge rise in support groups, we see pressure brought to bear to bring in labels,” he said.
“Certain behaviours carry stigma and there’s less stigma if it’s associated with a disorder. Often it’s about the avoidance of guilt. You get obvious pressure from parents: we’ve all been to middle-class dinner parties where so many parents seem to say their kids are mildly autistic and yet they’ve just got into Oxford. And you think, ‘I don’t really buy that one’ . . . It’s interesting that many of these disorders are more common in the private sector of education.”
He added: “When did you last hear a kid called bookish or shy? At what point do those normal traits become social phobia or Asperger’s, or when does a naughty kid become ADHD? Now those are socially defined, and where psychiatry sits on those is often not where the public think.
“We are the most conservative in those areas because we know how awful autism is, we’re the ones who don’t want to extend the boundaries to include every shy, bookish, odd child. It’s psychiatry which is against the medicalisation of normality.”
Arguing that there are “perverse incentives” in the system, he said: “The more children that are labelled ‘special needs’, the more resources a school gets. If you just have a difficult kid in your classroom, you’ve just got to cope. But if you have a kid with ADHD you might get a classroom assistant. So you get pressure from teachers.”
Justine Roberts, from Mumsnet, disagreed. “Getting a diagnosis or educational statement for your child is fantastically difficult and the stigma associated with behavioural disorders can be a powerful disincentive, so it seems unlikely that [parents] are driving any significant increase in diagnosis rates,” she said. “Disparaging parents and teachers who are seeking support for children in their care seems misplaced.”
Professor Wessely said that ADHD and other conditions were real disorders, for which drugs did work. “It’s likely that stimulants [such as Ritalin] have been massively abused, but we know for children who have ADHD the evidence that stimulants are good, effective treatments is overwhelming. Therefore what we’re trying to do is ensure that the right treatment goes to the right person,” he said.
“We should be concerned about it, just as we should be concerned with the rise of antidepressant prescribing for the same reason. We know that many people who should be on antidepressants aren’t, we also know that people are getting antidepressants because of the lack of any other available alternative.”
While some critics suggest that psychiatric drugs do more harm than good, Professor Wessely said it was nonsense to say that antidepressants did not work. “It’s the same with Ritalin. It’s probably over-prescribed, but it’s also under-prescribed because we don’t have good enough [child and adolescence mental health] services,” he said.
Professor Wessely also said other doctors looked down on psychiatry because “we don’t have very big machines that buzz”, but it could teach the rest of medicine about the importance of communication with patients.