UK: Children suffering multiple behaviour problems ASD and ADHD

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http://www.timesonline.co.uk/tol/life_and_style/health/article5727101.ece

February 16, 2009

Children suffering multiple behaviour problems ASD and ADHD

Does having a clutch of acronyms after their names help or hinder children

with multiple behaviour problems?

Naish

When Jordan's son began experiencing social problems at play

group, a specialist concluded that the boy was suffering from an autistic

spectrum disorder (ASD). At 7, his behavioural difficulties led him to a

paediatrician, who diagnosed attention deficit hyperactivity disorder (ADHD)

Now 10, s suffers long, wakeful nights and serious tantrums. Health

professionals have suggested that he also has sleep disorder (SD) and

oppositional defiant disorder (ODD). is an “alphabet kid”, one of a

growing population of British children with a trail of diagnostic letters

after their names. But does a clutch of acronyms help or hinder?

No central figures are held on the number of children in Britain with mixed

behavioural diagnoses, but Colin Troy, a Lancashire-based educationalist who

has worked with children with special needs for 30 years, says: “They have

been around for some time and are definitely on the increase. It used to be

thought that you could not have a student with conditions such as Asperger's

and ADHD overlapping, but that belief has completely changed.” Indeed, a

recent report in the Journal of Autism and Developmental Disorders found

that half of the children with autism studied also had hyperactivity

symptoms.

Research in the Journal of the American Academy of Child and Adolescent

Psychiatry found that ADHD often occurs alongside disorders such as ODD and

conduct disorder. Another study, led by Simon Baron Cohen, a professor of

developmental psychopathology at the University of Cambridge, found that

children with autism have a raised risk of Tourette's syndrome.

Robbie Woliver, the American author of the recently published book Alphabet

Kids: From ADD to Zellweger Syndrome, claims that millions of children in

the US (including two of his own) are “plagued by clusters of disorders”.

The numbers are rising, he says, “because of growing awareness, ongoing

strides in research and improved diagnosis techniques. And because so many

alphabet kids are just beginning to be included in published studies, the

rates will rise even more dramatically.”

In Britain, the Department of Health cites 2004 research indicating that one

child in ten has at least one clinically diagnosable mental disorder. But

the figures seem to be rising fast. For example, a report last July produced

by Wandsworth Primary Health Care Trust in Southwest London revealed that

cases of autism in its area had risen from 161 in 2001 to 448 in 2007.

Countless others are on the fringes of the diagnosis, according to a study

last month by the UK's Institute of Child Health in the Journal of the

American Academy of Child and Adolescent Psychiatry. Professor Skuse,

one of the researchers involved, says that many children exhibit elevated

levels of autistic traits, and that “our research suggests that these

children are at slightly greater risk of developing behavioural and

emotional problems”.

Jordan, who lives in Southeast London and cares full time for her son,

hopes that growing awareness of multiple behavioural conditions could help

to reduce some of the stigma that she feels is associated with her situation

“A lot of professionals are supportive and interested, but I definitely get

the impression that others think I've been out shopping for 's

diagnoses because I'm either needy or neurotic.”

But Colin Troy, who has worked as a head teacher at two special schools,

says that there can be pitfalls in multiple diagnoses: “The difficulty for

the parents is that it can be very confusing. They may see one professional

who has a bee in his or her bonnet at the time about a certain condition,

and will say that's what the child has got. Then the parents will see

another specialist and are given another diagnosis, and so on.

“As more and more children develop these overlapping conditions, new

spectrum disorders are turning up, such as ‘sensory interpretation

dysfunction' and ‘pathological avoidance dysfunction'.

“The argument against multiple labels is that we are offering lots of

medical excuses for children's behaviour, because they have 16 letters

behind their names. I work with parents, health professionals and teachers.

“I tell them, ‘Never mind the labels'. These children are people first, then

they are these characteristics. Sometimes when talking to groups, I

literally cover myself with sticky labels to reinforce the point.”

But why are such disparate diagnoses growing exponentially? One possible

explanation is that we notice maladies more readily. Before the advent of

the NHS in 1948, many families were reluctant to pay for medical help for

anything other than serious contagions such as typhoid and tuberculosis.

Behavioural disorders featured far less on the diagnostic radar. A related

argument says that our increasingly made-over society is less tolerant of

difference and more keen to diagnose and medicalise “unnormality”. This may

lead to parents seeking a multiplicity of different conditions to explain

their children's aberrant conduct, says Troy. “Some parents don't want their

children to have conditions associated with learning disorders or extreme

behaviour problems diagnosed.They are looking for more medical labels, so

that they can say, ‘It's not just autism'. They are looking for more

specific reasons.”

Aggressive marketing by drug companies “is absolutely a contributing factor”

to the rise in behavioural problems, according to a report published last

May by researchers at Brown University, in Rhode Island. They say that their

evidence indicates that fewer than half of the patients who had bipolar

disorder diagnosed actually suffered from the condition. The lead researcher

Mark Zimmerman, told the British Medical Journal: “You cannot go to a

meeting on bipolar disorder that doesn't have a big discussion right at the

start about how underdiagnosed this illness is and how doctors need to

ensure that patients are treated. These meetings are usually sponsored by

drug companies, and I think that they must be having an effect on doctors.”

Clinical updating meetings for doctors in the UK are likewise sponsored by

drugs brands.

Ellen Leibenluft, who runs the paediatric bipolar research programme at the

National Institute of Mental Health (NIMH) in land, also believes that

overdiagnosis and misdiagnosis are becoming rife. In her studies at the NIMH

only 20 per cent of children identified with bipolar disorder were found to

meet the strict criteria for the condition.

Woliver acknowledges that many alphabet disorders can be so blurringly

amorphous that they can blend into a kind of diagnostic soup. They “have

similar symptoms, some are even interchangeable and most interconnect”, he

says. But he adds that each mix creates a child with unique problems and

biological causes. And these causes, he claims, often originate in allergic

reactions.

“There needs to be some sort of predisposition in the child for factors such

as toxins or vaccines to have their ill effects. We must continue supporting

research studies that determine why these disorders are so prevalent and

growing exponentially, how they are related and how to cure or treat them.”

Another contributing factor to the proliferation of alphabet behavioural

diagnoses may be 21st-century lifestyles. Professor Jim Horne, of the Sleep

Research Centre at Loughborough University, says that children aged 5 to 8

are particularly vulnerable to sleep problems as a result of “electronic

distractions” such as computers and mobile phones in bedrooms. “Children who

persistently go to bed late get into hyperactive states and learning becomes

a problem at school the next day,” he says. Research indicates that up to 20

per cent of children who have midle ADHD diagnosed may in fact be suffering

from a regular shortage of sleep.

One worry, though, is that drug treatment for one psychiatric condition may

set off another problem. For example, a study in the journal Bipolar

Disorders in 2005 reported that children given antidepressants go on to

develop a bipolar disorder at an earlier age (at 10, on average, rather than

14), and with greater severity, than those not prescribed such drugs. The

physical side-effects of treatment may cause long-term problems, too: a book

published last month, The Metabolic Effects of Psychotropic Drugs, says that

antipsychotics and antidepressants can cause weight gain and possible type 2

diabetes.

Although multiple diagnoses can prove problematic, Troy stresses that we

should also acknowledge that they can be helpful: “There is a balance to be

struck. All of these different associated conditions are real and they are

specific, and from a parental point of view they may be helpful signposts to

specific interventions. If a child has a kind of Asperger's that also

involves semantic pragmatic difficulties, then the way in which we work with

that should be in terms of language and communications because it's more

precise.”

But Troy, who runs his own consultancy, CT Training, believes that the best

support for alphabet parents such as Jordan often lies in diverting some of

their attention away from the world of health professionals, drug companies

and multiple medical labels. “I'm keen to help these parents to form their

own self-help groups.,” he says. “The sort of ‘I've been through that'

advice that they can offer each other is often the best of all.”

Robbie Woliver's Alphabet Kids: From ADD to Zellweger Syndrome, is published by

Kingsley, £18.99. Case study names have been changed.