The birth season effect in ADHD is real, and important, but it doesn’t discredit the diagnosis

A recent paper in the Journal of Child Psychiatry and Psychology has provoked something of a media stir. It reviewed 17 papers from around the world which reviewed the relationship between the time of year that a child is born, and their chance of receiving medication for ADHD. Consistently, as shown below, the younger children in a school year will be treated more for ADHD. This finding is consistent, whatever month the school year starts, and does not seem to be confined to countries with high levels of diagnosis and treatment.

birth

The study authors interpret this effect as indicating that the ‘excess’ of young-for-year children being diagnosed are being over-diagnosed, with teachers and clinicians mistaking normal immaturity for neurological disorder. They advocate that children be allowed time to mature rather than receive diagnosis and treatment for ADHD.

Are they right? Well, yes and no, in my view. They are right that in that the effect is real, and demands careful consideration.  Whether its existence undermines diagnostic practice depends on your view of the nature of ADHD. I will present my own view and explain why a modest birth season effect does not worry me too much.

Evidence is converging on the hypothesis that ADHD is a spectrum disorder, with heterogenous biological contibutors, but high heritability and good construct validity as a diagnosis. So it makes sense to talk about degrees of ‘ADH-ness’. At some point of the spectrum this characteristic starts to become problematic, and ADHD is the impairment caused by the interaction between the child’s ADH-ness and the environment (including in this case certain aspects of the child themselves as ‘environment’ in relation to the ADH-ness).

And here’s the big point- the more adapted, understanding and supportive the environment is, the less problematic a certain degree of ADH-ness will tend to be. This is the whole foundation of non-pharmacological intervention, after all.

And as the authors of this paper helpfully point out, other factors such as poverty, previous abuse and sleeplessness are associated with increased diagnosis rates. In my model, each can amplify the effect of a given degree of ADH-ness, in effect ‘shifting the curve’ upwards, as shown below.

adhness

So to return to birth season effects- are they a surprise? Well, if you put a year 1 in and year 2 class, and ADH-ness will be amplified by being presented with greater expectations. This may push the child over diagnostic threshold for impairment.  In the same way, a young-for-year child is forever with older children who have an advantage in meeting classroom expectations, and for this reason it seems that some birth season effect is inevitable.

But shouldn’t classrooms be accommodating enough for all levels of maturity? Yes, and one implication of the existence of the birth season effect is that clinicians involved in ADHD diagnosis need to make one of their duties helping local schools to maximise inclusion in their classes, in order to keep the effect at a minimum. Those of us who work at a national policy level need to push for inclusion of those displaying ADH features (and, for that matter, all atypical neurodevelopment).

The birth season effect may give us pause before diagnosing and treating young-for-year children with ADHD- watchful waiting with support is in any case often a reasonable strategy in younger children. It challenges a simplistic view of ADHD as a purely neurological condition, which I know paediatricians don’t generally hold to anyway. In no ways does it invalidate a careful diagnosis made after thorough and holistic assessment… although it is yet another reasons why assessments need to be thorough and holistic!

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Some thoughts on ‘the Doctor who gave up drugs’

Chris Van Tullekan’s programmes about medication for children were compelling, raised some excellent points, but ultimately were too eager to score points to count as a balanced account.

The shows were formed of two episodes but essentially 4 stories.

  1. ADHD and methylphenidate
  2. Fever and calpol
  3. Cow’s milk allergy and hypoallergenic formula
  4. Depression and SSRIs

In each episode two stories were interweaved- this did not help clarity, because whether intentionally or not, this gives the impression that criticisms in one half apply in the other, when there are important differences between the issues. So, in descending order of how much I agree with Chris, I’ll try to explain:

Fever and Calpol

This is uncontroversial. We should not reach for the medicine bottle whenever a child is distressed or a bit hot, but the sweet taste and ritual of caring have a powerful placebo effect. As long as you stick to recommended dose, all you’re doing is wasting money, you’re not causing harm, so while Chris is right here, I’m not sure it’s an issue to get too excited about. We all waste money on keeping our kids happy, after all.

Cow’s Milk Allergy and industry infomercials

Here there are some serious points made. The formula milk industry exist to shift product, and cow’s milk allergy has, like many conditions, criteria for testing that are pretty inclusive. The problem is that the (genuine) best test for CMA is to give hypoallergenic formula and see if the child gets better. There are a few ways in which this can lead to over-diagnosis. If the doctor gives into the temptation to be ‘the clever doc’ and gives a confident diagnosis of CMA prior to testing, if the child gets better during a trial of hypoallergenic formula, but for unrelated reasons, or if the child doesn’t get better but people persist in treatment rather than think again.

In such a delicate situation, needing critical thinking and sound handling of uncertainty, industry-funded and run education can be problematic both in presentation and practice. We may think that as doctors we are immune to marketing, but we’re really not. On the other hand, medical education would struggle to continue without any help at all from industry. There are differing views on this, but for me a robust ‘firewall’ between industry promotion and education is essential. People differ on how strong this needs to be, but for me any education done under a pharma banner, with pharma input into content or with access via pharma is beyond the pale. Chris rightly identifies that this line has become unhelpfully blurry, leading to the industry’s obvious interest in overdiagnosis and overtreatment to potentially influence diagnosis and practice in a worrying way. Involvement of industry in education is something we just get used to, and it’s important to challenge it as Chris has done.

Depression, ADHD and medication

The issues here are the most complex, and, I’m afraid, the worst handled. In both cases Chris makes a similar case and in both cases misleads, so I’ll combine these two.

The first part of his argument is that there has been a huge and ongoing surge in prescription

That is true to an extent, prescription has doubled for anti-depressants, but firstly that is from a very low baseline (at this point about 0.6% of the under 16 population take these meds), and secondly is not just treatment for depression- they are also use quite extensively at low dose in chronic pain.

For ADHD medication, there was a surge in the early 2000s, again from a very low base-line, but for the last 5 years of so prescription rates haven’t shifted.

So…. Kind of right. But misleading.

Secondly, Chris argues that doctors only want to prescribe meds.

This is just plain wrong. In depression, given the safety concerns, psychiatrists are in my experience desperate to avoid prescription, but often run out of other options. Likewise, in ADHD, there is no situation in which medication should be the only thing offered, even according to the NICE guidance that Chris is so critical of being ‘focused on medication’- but it happens, and the reason is the devastation of local CAMHS and other support services since 2010. This never gets mentioned across 2 hours of television. There simply isn’t enough resource even to run the evidence-based alternatives to medication that NICE suggest.

Thirdly, he argues that the drugs don’t work and are harmful

Establishing the effectiveness of psychiatric drugs is notoriously difficult. Within the field, ADHD medication methylphenidate is established as among the most effective. Chris appropriately discusses a Cochrane review that says the evidence for methylphenidate is weak, but omits the large amount of criticism from academics who felt that it discounted evidence by being too restrictive. For antidepressants he stretches things further- when a researcher says the fluoxetine has evidence of benefit on average, Chris insists on placing a question mark on it in felt tip, because it might not work in every patient. Like…. every drug ever. Chris scoots off to interview David Healy, who argues that he must be right that no antidepressants work for any child ever, because no-one has sued him- ignoring the fact that having a clinical opinion, however wrong, is not libellous. And David Healy is wrong about this.

The sections on side effects are odd.. in both cases Chris opens the medication leaflet and acts amazed at how many side effects there are and how alarming it all is, LIKE HE HAS NEVER SEEN ONE OF THESE BEFORE. For ADHD he suggests that 10% of children will experience personality change (they won’t). He talks to a woman who very sadly lost her daughter while on antidepressants, who says that if doctors knew the risks we wouldn’t prescribe these meds. Thing is, they do know the potential risks, that is why they try not to prescribe them unless they feel the benefits outstrip those risks, and spend so much time campaigning for alternatives to be available.

Finally, he claims there are effective, side-effect free alternatives that we are ignoring.

By now, you might think Chris was an evidence stickler, standing stern guard over the sanctity of the RCT… But what’s this? A whiff of pine or incense and Chris is all giddy like a schoolboy. For ADHD, having said that ‘couldn’t find anything in the UK’ (I’m guessing his copy of the NICE guidance was missing a few chapters) he turns to a mindfulness programme with ‘promising’ results. To be clear, promising means ‘not yet proven and quite possibly never proven’. But we need a story, so off he goes to group mindfulness for kids with ADHD. Now, hopefully this will be a useful approach, but so far, the better the quality of research, the worse the results for mindfulness. Even in the programme, he needed to compare the chaotic initial session with 6 children against a one-to-one session with 3 adults and one child, in order to give the impression of improvement.

In the depression story, a young person gets wilderness therapy, which Chris informs us is ‘established in the USA’, which rather suggests that it’s only our obsession with drugs that stops NHS doctors from donning Gore-tex and embracing the call of the wild, rather than a total lack of robust evidence. When the young person (who was really great, by the way) got better, the fact that she got better while taking an increased dose of her medication is glossed over, and the wilderness therapy is praised as making all the difference. Again, I would love to be able to prescribe a day in the woods, but we need evidence.

So Chris wants us to abandon medication, which has its significant problems but a much better evidence base than he is willing to give credit for, for unproven therapies that would suck resources from an already collapsing system. All the while, he is happy to ignore the many non-drug interventions which are recommended by NICE but are not available due to cuts.

The double standards are stunning, the science is junk, and the wilful ignorance of why the system is under such strain is unforgivable.

Conclusion

There is an interesting, thoughtful and provocative programme to be made about the collapse of the public sector in children’s mental health and public health, the consequences in terms of over-reliance on medication, and commercial interests being increasingly unopposed in education. This is not that programme, and on this evidence, I very much doubt that ‘Dr Chris’ is the right person to make it.

The government’s green paper on CYP mental health looks a lot like a white wash.

At this point, everyone agrees that children and young people’s (CYP) mental health services are in crisis. So we all gave a wary cheer when a green paper was announced last year. Just before Christmas it emerged and…. well.

The challenge facing the government is, admittedly, immense. Only 25% of CYP with a mental health problem receive treatment from specialist services, suicide is the 2nd biggest killer of adolescents, and the mental health problems in adulthood that represent our single biggest health problem (more than cancer, heart disease et al) mainly start in these years.

There are two ways it could have gone. The DH could faced up to the crisis, and the fact that you’re not going to quadruple the size of specialist services (even if you had the money, you don’t have the people). They could have looked beyond a simplistic, linear view of mental health as a line from ‘OK’ to ‘a bit sad’ to ‘really sad’ to ‘ill’, and realised that mental health is complex in ways that cuts across organisational boundaries, that usually doesn’t fit into neat treatment categories, and is more likely to present with anger and disruption that sadness or worry.

They could have paid proper attention to the various reports over the last decade which have pointed out the fragmentation of the system (CQC 2017) the need for meaningful collaboration between agencies locally and nationally (Lenehan 2017, Future in Mind 2015), and that CYP mental health needs to be actually, properly, everyone’s business (Basically every report ever).  They could have injected resources into the system while creating the legislative structure to pull agencies together into the kind of collaboration we need.

But they took the other approach, that of the PR professional, who asks ‘who are the loudest voices, and how can we get them onside?’. From this point of view, the fact that the linear view of mental health as ‘sadness and worry’ is so wrong doesn’t matter, because it’s the media view. The fact that the most common condition in mental health, conduct disorder, is barely discussed is quite convenient because it’s complicated to treat and mainly happens to poor people. And the fact that schools are loudly banging the mental health drum becomes an opportunity.

What the DH need is to be seen to do something- they need a headline, and they need visible services that will please schools. So they will embed mental health workers in schools who will pick up the low-level sad/worried pupils, and give them a brief psychological intervention. No matter that we don’t know if this model works, how many of these cases would be self-limiting anyway, how on earth schools will ensure quality or governance, or how it will connect to the wider system. It will allow the government to claim huge figures of young people ‘treated’ and allow everyone to feel better about themselves.

But I’m being slightly unfair. These teams will also, it seems, run parenting course. I’m all for that, but it doesn’t really help unless you also have a service that can assess children’s behaviour and see what underlies it. And there are no extra resources for this, so what happens if the parenting course doesn’t help? “The parents aren’t doing it right”.

This is a disappointingly narrow, shallow, and headline-chasing response. There is no mention of wider child health services which provide support for autistic children, those with ADHD, children with special needs, looked after children etc, there is scant reference to wider vulnerable groups, and the connections between physical and mental health are ignored. Above all, there is zero attention to reversing the fragmentation of local systems. It’s not even as if the model suggested it that cheap- estimates are circulating that they will need to employ 8000 people, more than currently work in specialist CYP mental health services now!

The frustrating thing is that the green paper could be much better with just a bit more attention to the system as a whole– better guidance for commissioners, money in the system as a whole and a duty for all local agencies to spell out their contribution to a ‘local offer’ for mental health, which the local population can interrogate and influence, will do so much more than the sticking plaster on offer.

But it’s still just a green paper. It can change, right? Well, yes, but so far the DH have been amazingly bad at engaging with the sector about this, and time is running out. Pressure is required to get them out in the open- more pressure is needed to see that a good headline and some happy headteachers isn’t going to make the problem go away.

 

Doin’ it for the kids

Single issue voting had a bad press, perhaps because people find it odd that someone would align themselves politically according to whose policy on local parking is most to their liking, or whatever. But I’ve realised in this campaign that I’m a single issue voter, more or less, but my issue is children.

Partly this is professional. I’m a paediatrician, and so very aware of the impact of social and economic factors on children’s well-being. I know, for instance, that child poverty is a huge driver of ill health, both physical and mental, and that the removal of much of the early intervention safety net (such as health visiting and sure start) has been a disaster for families who are already struggling.

But the issue is also about schools, who are simultaneously squeezed financially, and pushed into being dour exam factories, making them rapidly less healthy places to be.

And it’s about families- most people have found the last few years tougher and tougher, with merciless cuts to working age support and stagnating wages, and all this stress and disruption will eventually find its way to kids.

Of course, as we are constantly reminded, support for the vulnerable relies on a strong economy, and there are genuine disagreements about the balance between balancing the books by restricting funding, and investing for growth (although the last 10 years gives a pretty convincing case for the latter).

Wherever you stand on this, though, presumably you don’t feel we can afford the £66bn cost of Brexit... oh, you think we can?  Then presumably a few quid for better child services might not be beyond us? After all, either you want to pay down the debt, or you don’t.

Finally, there’s no point supporting children through the early years to hand them a world ravaged by the climatic, political and humanitarian catastrophe that climate change will turn into unless we act now.

So, we need politicians willing to swallow pride over Brexit, reduce child poverty, ensure decent services, release pressure on schools, genuinely support those ‘just about managing’, and stand up to the troglodytes opposing climate change.
Which party? Well, that’s up to you, but I can think of a couple that this checklist really counts out…..

Who speaks for the bad boys (and girls)?

In a way, we are in a golden age for attitudes to young people’s mental health. Just this week, no less a figure than Prince Harry talked about his own help-seeking, both he and his brother and sister-in-law have campaigned for better services and more positive societal attitudes. Theresa May has discussed the issue in a not-entirely-bad speech.

But what if I was to ask you what the most common mental health condition is in the UK? Most people guess at anxiety, or depression. If pushed they might go for eating disorders. But it’s none of these. By a considerable distance, it’s conduct disorder.

Conduct disorder is, roughly, an established and disruptive pattern of anti-social behaviour, which impairs the young person’s life. The commonest objection is that this is not really  a mental health disorder, but that in itself betrays quite a restrictive attitude to what emotions and thoughts we regard as worthy of help, and which we reject and condemn.

Imagine two girls of 14.

One, Amelia, is lonely and sad a lot of the time, she doesn’t think her friends like her, and self-harms by cutting her forearms.

The other, Charlie, is angry and alienated. She thinks her mum hates her and they row a lot, and she self-harms by drinking in the park and getting into fights.

Which girl is more worthy of our concern and care? I would argue that they are both, equally worthy of our compassion and to receive the help that they need.

However, the narrative around mental health is exclusively about the type of problems that Amelia has, and puts Charlie in the ‘broken Britain’ bin of delinquents and ‘problem families’. And it isn’t just the media- I’ve been to discussions of young people’s mental health at the Department of Health, NHS England, the Royal College of Psychiatry and innumerable charities, think tanks and parliamentary groupings. I have never seen a young person with conduct problems attending, and no-one (other than me) has ever, ever mentioned this condition which, just to remind you, is the most common mental health condition in young people. When I do mention it, everyone nods, mumbles, and goes back to what they were talking about. Usually mindfulness, or apps.

Why is this? It’s not because people in the field are stupid, or uncaring.

One problem is that these kids do not have socially acceptable mental health problems. They are routinely rude, they often undermine attempts to help them (mainly because they don’t believe they are worth helping). They are not eloquent, typically, and are often ashamed of their feelings in a way that we encourage with our condemnation.

One big focus in mental health has been the role of schools in supporting pupils with mental health problems, but hand in hand with moves to train every teacher to deal with anxiety and depression is a hardening of attitudes to anything remotely anti-social, and the return of the disciplinary culture of the 1950s will do far more damage to mental health than any amount of amateur CBT can compensate for.

Anxiety and depression are, demonstrably, no respecters of social class. Conduct disorder, on the other hand, very much is- it is vastly more common in poorer families, and so society’s attitudes to poor families are transferred to their troubled offspring.

The help they require is complex, and requires co-ordination across multiple agencies, support for the whole family, and above all, patience. They can be helped, and there is a lot of evidence of effective interventions, but ultimately they are too difficult, and give too little political reward, to be the priority.

Conduct disorder is associated with every kind of negative outcome you can think of. It is a major, treatable, public health problem. Why are we not talking about it?

Does Theresa May actually care about the CAMHS crisis? If so, here’s what she needs to do

 

On the 9th January, Theresa May made a good(ish) speech. She talked about injustice, and about how peoples’ opportunities are too conditioned by their position in life. She then turned to children’s mental health and talked about the train-wreck that is current provision.

What did she suggest?:

  • A review by the CQC
  • Teachers to be trained in mental health first aid.
  • An end to out of area transfers (but only for ‘general mental health’ so won’t mean anything)

Now, for the issue to get prime ministerial attention is a good thing, no doubt. But how much difference will it make, really?

Let’s look at the situation. 850,000 children have a diagnosable mental health problem in the UK, of which only 25% receive a service from specialist CAMHS. The plan from NHS England is for the recent cash injection to increase this figure to…. 33% by 2020. This assumes that the money is getting through, which it pretty clearly is not. It also raises the question- even if you do manage this increase, what about the other 67%?

This is where Mental Health First Aid comes in. The idea is that teachers pick up the early signs of emotional distress and put in place simple measures, thus stemming the flow of referrals to specialist services. There are two problems with this: one is that there is no evidence that it does any such thing, and the second is that it’s only dealing with what I call socially acceptable mental health.

What is the most common mental health problem among the 850,000? Anxiety? Depression? No, it’s conduct disorder, broadly, a pattern of disruptive behaviour leading to significant impairment. These kids often have complex social, biological, psychological and educational aspects to their stories, and need complex, multi-agency intervention to get better. But the point is they CAN, but they are too tricky, and not good at advocating for themselves, and are much easier to shunt into the youth justice system. And they are HALF of the 850,000 with diagnosable problems. People talk about universal parenting course access, but anyone who works on the front-line knows that these are no panacea.

The rest of the 67% will be kids who don’t have straightforward mental health presentations- those with autism, ADHD, learning disability, or traumatised children who are too angry and fearful to look sad.

So what is needed? What should we say when CQC comes to call? Apart from handing them copies of the other three CAMHS reviews completed in the last 2 years?

You’re never going to get 100% of eligible children into specialist care, and actually you may not want to- what a lot of them need is broader, more complex and more long-lasting than a block of therapy with CAMHS. So firstly, we need to expand what we mean by mental health help, and embed it into local systems.

This will require:

  • clear commissioning of a ‘local offer’ for mental health
  • Support from local specialists for the rest of the sector, in terms of consultation, training and joint work.
  • A children’s workforce who understand mental health and the many ways of helping.
  • Inspection of what the local area provides for children’s mental health and wellbeing.
  • Training and guidance in best practice across the sector.

Second, we need to ‘shift the curve’ on mental health- by improving overall mental health we can decrease the number of children requiring care. The government are still, officially, committed to a ‘life chances’ strategy, and that sounds a lot like what Theresa May was talking about- the problem is that she was talking about adult employment, and income, rather than what really matters, which is  getting the best start by:

  • ensuring adequate incomes
  • improving early education and care
  • improving homes and environments
  • creating a truly inclusive education system that cares about more than exam results.

Is this ambitious? Sure. Is it possible? With the right political will, both nationally and locally, and engagement from professionals, yes, at least in part.

And the alternative is just leaving the 67% to fester into the next decade’s ‘problem families’.