ADHD and medication: a (mainly) personal view

This is my third post about my ADHD. You can read the first two here and here.

If you’ve read my ADHD stuff before you’ll know my penchant for starting with caveats about how my views, though informed by years as an ADHD specialist, are essentially personal. This one needs a conflict of interest statement as well, because I want to take on the thorny issue of medication.

This is a subject that provokes understandably strong feelings. One of the worries for people who feel that we use medication too much in ADHD is that drug companies have undue influence over the doctors who advocate and prescribe these medications. I suspect these worries are justified in many cases, after all doctors are as prone to influence and bias as anyone else, but I’m pretty confident I’m not in the pocket of ‘big pharma’.

I don’t attend events run by drug companies, I don’t meet their representatives, I don’t have so much as a pen with their branding on it. It doesn’t seem possible to entirely avoid their arms-length involvement, but I try.

Right, if that’s clear, I’ll begin.

As I said in my first post, I think ADHD as a condition is the product of the interaction between an insatiably hungry brain, and an environment that makes having such a brain challenging, for the person and those around them.

Of course, the more hungry the brain, the more challenge and impairment is created. I’ve illustrated this below: it seems to me that a s-shaped curve reflects the fact that milder degrees of brain-hunger are often well compensated for, then there’s a degree of brain-hunger where the person starts to decompensate, and then a part when the degree of impairment levels off, because even severely affected people can still do an awful lot.

adhd 1

The key, though, about this curve is that the gradient and position varies hugely according to the environment. A supportive, understanding and enriching environment will push the curve to the right. A harsh, punitive and isolating environment will push the curve to the left.

So for any given degree of brain-hunger, the amount of trouble caused depends hugely on the environment. Look at the rather shonky animation below.

via GIPHY

So the first task, when presented with a person with ADHD, whose brain isn’t suiting their environment, must be to see if the environment can get better.

By improving the environment, I mean access to exercise, sleep and positive relationships. I mean support from adults at home and school with an authoritative but empathic approach. I mean addressing emotional health, underlying special educational needs, and family dysfunction. I mean strategies and structures in the classroom that promote success. I mean giving the ADHD person a positive and realistic frame for understanding their struggles and harnessing their strengths.

I don’t, by the way, necessarily mean specific one to one therapies, such as CBT. The evidence that these help is very limited in most cases of ADHD.

There are limits to what can be achieved environmentally, however. Some of these barriers may be to do with resources, at school for instance, others to do with families being so overwhelmed that they just can’t change counter-productive patterns of relationships and behaviour. Sometimes things have got so bad that the person’s own behaviour is preventing effective support. Or everyone has tried really hard, and things are a bit better, and they’re all pretty exhausted.

Here’s where medication can, in my view, have a role. Nothing, as far as I can see, is as effective in taking the edge off brain-hunger, and addressing the traditional ‘core symptoms’ of ADHD than medication. In those terms, by moving the person (not the curve) to the left of my diagram, they can make a big difference to the right person at the right time.

via GIPHY

 

There are side-effects (which vary by drug, and are unpredictable). The first few weeks can be tough, as the brain gets used to a different setting, and emotions can run high, both anger and sadness, partly for neurochemical reasons and partly, I think, because people often become suddenly more aware of how difficult things are, as the storm in their heads subsides.

Headaches and bellyaches are common. Appetite is very commonly suppressed, especially by stimulant medications. Sleep can be affected of there is still stimulant around at the end of the day. There is an effect on the heart, which needs an eye keeping on it but for most people is harmless.

Sometimes these side effects lead to medication being stopped. At which point you are back where you started. But no worse off, because these effects go away when you stop.

But if you’ve come to terms with ADHD, either in yourself or your child, you’ve done what you can about the home/school/work environment, and you think meds might be worth a try, they probably are.

But, and here’s the important thing. No-one should be pressured to either take or not take meds. It’s for the ADHD person and, for children, their parents to decide. We as doctors can give the facts, and suggest when it might be worth thinking about it. But that’s it.

You may have strong feelings either way. That’s great, but if those feelings lead you to judge the decisions of ADHD people and those around them about this tricky area, then jog on, my friend.

And, to answer some questions that may have been in your mind:

Yes I am

Yes, it did help

No, I’m not telling you which one.

Bye!!

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What ADHD feels like

This is a follow up from my first hello-i-have-ADHD post. You can read that first, if you like.

All personal accounts are subjective. But in talking about my experience of ADHD I need a disclaimer ten feet high, in case anyone mistakes this for an authoritative account.

Firstly, ADHD is not defined by subjective experience but by outward behaviours. Sure, these behaviours cluster together sufficiently that there’s almost certainly something fundamentally similar about ADHD brains, especially if you factor in imaging and genetic studies, but even a cursory look at the lived experience literature in ADHD reveals a dizzying variety of experience. Partly this is ADHD folks being… ADHD, but there almost certainly is huge variation in how the condition feels. I can only describe mine.

Secondly, I’m not describing an episodic state that I tip into from normalcy, like a seizure or hallucination. It’s a state of being, and in some ways it’s no more possible to describe the experience of ADHD than it is describe the experience of the colour red to someone who sees in monochrome.

So why bother? I think it’s worth it, because on the face of it, ADHD people can be pretty annoying. Disruptive, impatient, alternately drifting off in conversation or ploughing on relentless with their own ideas. Our fun, inspiring, energising qualities can wear thin, especially in the context of task-focused work or school environments. Of course we can lecture about how it’s a condition, not our fault, and have you seen these brain scans? But no-one gains empathy from a lecture. Only an attempt to see ADHD from the inside can really do that.

So.

I’ve been looking after children with ADHD for over a decade now, in my day job as a paediatrician. It’s never satisfied me to just pat them on the head and say “you just have a special brain, that’s all”- kids are curious and want to know what’s different, especially as they’ve only ever lived in one brain, so how could they know any different?

I’ve used a few analogies over the years: I like the image of ADHD as a Ferrari brain with bicycle brakes, popularised by Edward Hallowell, but ADHD is not just about speed, it’s about chaos. Still, the Ferrari is a useful image for younger kids.

For a while I talked about a fizzy brain, with ideas, impulses and emotions popping up in an uncontrolled way, and pressure building if they are not released or if the fizzy drink/child is agitated. It’s a neat image, and useful for explaining the emotional pressure of ADHD, but too many kids got the impression that they had actual bubbles in their brain, and it still didn’t answer the question of what unites all these symptoms.

So here’s where I am right now. I think my brain, and the brains of people with ADHD, are hungry. Not for food necessarily (although impulsive eating is an under-researched area of the condition), but for experience, emotion, movement. The next thing. And not just hungry, but insatiable.

If you present a brain with a rewarding stimulus, you will get a response, which you can measure in various ways, including mapping the activation of various brain areas. If you present a typical brain with the same stimulus over and over, and it is relevant to a task, the brain will activate in roughly the same way for quite a while. For ADHD brains, however, this activation tails off markedly quicker, and when a different stimulus is presented, the fact that it is irrelevant to the task doesn’t matter- the hungry ADHD brain leaps upon the novelty. So any task that is repetitive or unstimulating quickly becomes deeply unrewarding at a neurological level.  The leap from that to a child who is  ‘easily bored’, (an almost constant refrain in ADHD parents) isn’t a big one.

But in linking this to an explanation of the destructive potential of ADHD for relationships, careers and lives,  it’s important to emphasise just how unpleasant boredom is to the ADHD brain. The brain-hunger induces an almost painful itch, that demands to be scratched, and is so aversive that any potentially boring situation can create considerable anxiety. Many seemingly irrational and destructive ADHD behaviours, especially in the classroom, have boredom aversion at their root. This is not to say that children with ADHD should be shielded from boredom, any more than someone who is scared of dogs needs to live in a dog free compound- it’s just more helpful to understand what’s happening and help the child learn to tolerate tedium where necessary, rather than just condemn then for ‘wrong choices’. But I digress (and, I suspect, start a topic for another day).

The relief of doing something, feeling something, after a period suppressing my brain- hunger, say in a meeting or a serious conversation, is intense. And the longer such a period goes on, the more the brain-hunger and subsequent itchy agitation increases. At 45 years old  I can usually keep this internalised, or fiddle or fidget, or ‘micro-daydream’ during a sentence I’ve already got the gist of. For my young patients, the same ‘itch’ happens, but it gets scratched pretty quick, and often in ways that disrupt and challenge.

I mentioned emotions at the top, alongside movement and sensation, as something to relieve the brain hunger. Of course, you can’t choose to feel an emotion like you choose to move, or to induce a sensation in yourself. But what you can do is release control on your emotions. When I’m frustrated (and a major part of that feeling is boredom) losing my temper feels like a huge release- a rush of adrenaline that naturally I immediately regret, but a part of my brain is, however briefly, sated.

Much of what I’ve said about ADHD probably applies to many of us, especially when tired, hungry etc. And we all have a ‘window’ of stimulation in which we are comfortable. Equally, the size and position of each of our windows can vary according to mental and physical health. What I suspect is different about ADHD people is that the lower limit of our window ( the minimum amount of stimulation- most boredom- that we are comfortable with) lies at a higher level;, we need a constant ‘grazing’ diet of novelty and intensity to avoid the unpleasant itch of brain-hunger.

The psychological impact of straying outside this window seems steeper, and more unpleasant (or perhaps we just react to it more?). There’s no fundamental difference to the experience of typical people, it’s a matter of degree.

None of this is intended as an explanation of all of the challenges of ADHD, just of the ‘core symptoms’ of hyperactivity, impulsivity and inattention, plus arguably the unofficial fourth core symptom, emotional lability.  I’m not trying to explain anger, social isolation, aggression, delinquency, poor coordination, academic problems, substance misuse, or any of the other legion of difficulties than can either flow from this core, or come as part of a neurodevelopmental ‘bundle’ of strengths and difficulties, which is after all how most ADHD people are. Again, I’ll explore this another day.

I’ve swapped a bit between describing ADHD as a hunger and an itch. I considered dropping hungry brain in favour of the ‘itchy brain’, but itchy is only really good to describe the negative aspects of ADHD. Itchy does nothing to describe the curiosity, creativity and openness to new ideas and people that are so ubiquitous in ADHD, whereas a brain hungry for information, sensation, and positive (as well as negative) emotion is a brain that offers real joys, both to the owner, and those around them.

So yeah, I’m glad my brain is hungry. I’m just sorry about some of the mess I leave behind.

 

How I found my tribe

Now that I’m “some kind of expert or something”, I have met enough children and young people to realise that many spend their childhood and adolescence in an agony of self-reproach, fuelled by constantly measuring themselves against others.

In retrospect, I’m rather glad that I had an insulating layer of social obliviousness, that prevented me from concluding that my years of teasing and social exclusion were anything to do with something about me. I simply attributed it to an arbitrary quirk of fate.

But I was different, no question. I was less socially mature and more emotional; prone to outbursts of silliness, temper and tearful devastation more or less equally. I was friendly and funny (sometimes), but though I could be good company, I was never relaxing company.

I was an absolute ballache to teach, from primary school right up to the end of medical school. I lost focus constantly, and relied on my wits and an ability to hyperfocus to get through exams. I floundered horribly when continuous assessment required consistent effort. I routinely questioned and challenged the authority of teachers. This continued right up to my medical finals, when my fury at the unfair and derogatory tone of my psychiatric examiner very nearly ruined the whole thing.

Some of you will know where this is going, but to spell it out: I entered the NHS as a doctor carrying significant cognitive disadvantages. Had I ended up in pharmacy, or been somehow coerced into a career in surgery, I would not have lasted too long- I’m not meticulous enough, or respectful enough of hierarchy. But I’m energetic, creative, engaging, and able to take in a lot of information, whittle down what is important, and make decisions. So I did OK in paediatrics.

Mainstream medicine is ok, if you like that sort of thing, but what really started to grab me was child development. The process of a baby with, let’s face it, a pretty meagre skill set, becoming a fully fledged person still strikes me as the most complex and fascinating phenomenon we know of, and it’s still a privilege to work in this area.

The areas which drew me most were those related to relationships, communication, emotions and behaviour. So naturally as a paediatric trainee I started off working with autistic children, those inspiring and wonderful minds who try so hard to cope with a nonsensical, neurotypical world.

But then I was lucky enough to get a substantial CAMHS placement, and I was assigned to help in the ADHD clinic. I was hooked.

It was the energy of the kids. Their lack of filter, artifice or ceremony. You may say….”like all kids”, but these guys were turned up to 11. And they were often terribly, terribly misunderstood, as ‘impossible’ ‘unteachable’ pupils who ‘persisted in making wrong choices’. I threw myself into trying to help these children and families.

My inspirational supervisor, Dr Carsten Vogt, was an enthusiast for direct measurement of ADHD symptoms, using the QB test, essentially a highly repetitive computer game. He suggested I had a go. It was enormously tedious and created an unbearable itch at the back of my brain. My scores, of course, came out well into the ADHD range. When I told him, he was typically sanguine “well, I guess you can say to the kids that people like them can succeed”.

And that’s how I left it for 10 years.

The model of ADHD I have in my head is that really it’s the convergence of two things: firstly, a neuropsychological state of ‘brain-hunger’ whereby the brain constantly seeks out stimulation, be it tactile, emotional, visual, or proprioceptive. Secondly, there’s the impairment to the person’s life caused by their neuropsychology. So in my head there’s a graph, with brain hunger on one axis, and impairment on the other. I flattered myself that I was quite far along the former axis, but not far off the ground on the latter. I bumbled through fatherhood, training and, without really meaning to, setting up and running an ADHD service.

But then two things happened; I got a new PA- a very organised PA with no time for deference to consultants, or for my higgledy-piggledy approach to caseload management. A couple of stern looks and a comprehensive re-think, and she had me pointing in the right direction, but it made me realise how indulgent the team, and the families, had been of my forgetfulness and disorganisation.

I also, finally, after 15 years of marriage, realised what it must be like for my wife to be with me. Imagine living with someone who is constantly restless, always thinking of the next thing, who leaves dull tasks half done but has boundless energy for his own obsessive interests. Who snaps when criticised and can’t calm your equally restless children. This is not, whatever other qualities they may possess, an easy partner to have. My wife is patient and kind, and finally I began to see what she had to deal with, trying to keep loving me.

I was quite a bit higher up the impairment axis than I thought.

So I went to the GP, and after a surprisingly short wait, found myself having a delightful chat with a psychiatrist.

I told her pretty much the same story I’ve just told you, and after an hour or so we concluded that yes (and this is no-one’s idea of a big reveal) I do have ADHD.

Given that I have tried most things that we could think of short of medication (sleep, exercise, organisational props), would I like some tablets?

I must admit, as someone who has been prescribing meds for a decade, I hesitated for a few days with the prescription in my drawer. To make the transition from a person who is ‘a bit different’ to a treated patient is a big thing. I was grateful that, as far as I know, I’ve never pressured a family into making this decision, and often resisted external pressure for ADHD medications: families and young people must arrive at the decision themselves.

In the end I took the meds. This isn’t a post about how well they have worked, though. Another time.

Knowing that I’m ADHD has been… interesting. It’s made me think more deeply about what the condition actually is, and what it feels like (again, another time), and how fantastic and irritating and exhilarating and painful it can be. It’s given me insight into myself as a father, husband and colleague. And it’s made sense of the fact that for all the offers I’ve had as an ADHD specialist (talks, writing, meetings, charity trustee), the answer has always been yes. Because these are my people.

So, an ADHD specialist with ADHD, eh? Must be unique…. well, no, not really. So why am I sharing this? I think for a few reasons;

Firstly as someone with both lived experience and specialist knowledge, I hope I can make a unique contribution to the debate around ADHD, behaviour, support, medications and mental health.

Secondly, I want any potential conflict of interest to be open and transparent. I advocate for all children in my Royal College work, but I do feel that ADHD kids are one of the more neglected groups, and I want to be free to carry on making that argument. .

But most importantly, I want to young people growing up with ADHD to have an example of someone with the condition who is not unattainably cool, or famous, but has done…. pretty OK.

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!

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…..