Dave Traxson is sitting in
his Victorian house in
the West Midlands with his foot
in a cast and a pile of books next to him
on the sofa. He is currently off work
recovering from an operation and is using
the time to catch up on his reading. He
has just started Shyness: How Normal
Behavior Became a Sickness by Christopher
Lane (Yale University Press 2007), and
enthusiastically recommends it to me.
I can tell from the title alone that he and
Lane probably have a lot in common.
Traxson is a chartered educational
psychologist and has been for over 30
years. He has spent nearly all of this time
in the West Midlands working for a series
of local authorities and continues to be
a contributor to the training course for
educational psychologists at Birmingham
University. Before becoming an EP
himself he spent six years teaching. It
seems fair to say that if it wasn’t for a
conversation in a school corridor in spring
2009, few outside his current authority
would have heard of him. As it is, he’s
become something of a media celebrity
– even appearing on Woman’s Hour.
Rise of the prescription
I start by asking him about that significant
meeting. ‘I bumped into this head of year
and he just asked me the question,’ he
explains. ‘“Dave,” he said, “I have got six
young people that have been diagnosed
with bipolar disorder in my year group of
120 kids – do you think that’s normal?”
And I said no, I was very surprised.’ Prior
to this, Traxson says he had come across
about six children with bipolar disorder in
his entire career. ‘To get six as a cluster in
one year group I found very concerning.’
At the time he says he was already
aware of the exponential increase in the
number of methylphenidate prescriptions
being issued for children diagnosed with
conditions like ADHD. Methylphenidate
is the active component of a range of
psychostimulants better known by
their brand names; they include Ritalin,
Concerta, Daytrana, Methylin, Equasym
and Metadate. It wasn’t until later, he
says, that he realised the true scale of
what was happening. ‘When I started
researching it, the evidence was clear.
From 1994 to 2009 there had been
a 120-fold increase in prescriptions,
which is phenomenal in just 15 years.’
Traxson says an increasing number
of headteachers were also sharing their
concerns with him: ‘It was becoming
a more and more common topic of
conversation on my regular school
visits.’ One worry headteachers had was
that they were not being consulted by
medical practitioners, a practice Traxson
says was widespread at the time. The
psychology service in his own authority
carried out a comprehensive survey to
assess the experience of heads locally:
‘Questionnaires were sent out to schools
and the returns showed that in only
47% of cases did the prescribing doctor
send a checklist to the school, let alone
have a telephone conversation with
them, which was incredibly rare.’ This
meant doctors were not ‘triangulating
the data’, ie moderating their own
observations on the basis of those
of the child’s parents and school.
So are medical practitioners to blame?
Traxson says no one group is responsible.
As with most things it’s a combination
of factors. He points out that some
critics, like Professor Steven Rose of
the Open University, point to parental
bias.
‘Usually there is a genuine concern
about the child’s pattern of behaviour,
but sometimes parents might have been
influenced by information they have seen
on the internet or in the media. As a result
they might have a skewed perception of
what the normal range of behaviour is or
they may have too high an expectation of
their child.’ He says there’s also anecdotal
evidence from headteachers that some
parents are aware they can claim disabled
living allowance (DLA) if their child has a
firm diagnosis of ADHD. ‘I am not saying
that a majority are doing it for that reason
but there is a significant minority that is
very aware of that possibility,’ he adds.
Out of control
‘Out of control’ is a familiar description for badly behaved
children, but chartered educational psychologist Dave
Traxson thinks it’s the over-prescription of psychotropic
drugs that needs reining in.
Whatever the explanation, headteachers
were becoming uneasy because children
were being diagnosed with conditions
they hadn’t shown signs of in school.
Traxson even questions the view
that behaviour standards in schools
have declined. He says he witnessed
far more aggression and violence in
the Birmingham grammar school he
attended in the 60s than he sees in
most of the schools he visits now: ‘You
don’t see the widespread disruption,
rudeness or fighting that people seem
to think is happening in schools.’ In
the schools he visits, most discussions
focus on low-level disruptive behaviour,
not verbal or physical aggression.
Upping the dosage
When Traxson looked into the case of
children diagnosed with bipolar disorder,
other worrying trends began to emerge.
One was a cluster of children who were
on higher levels of medication than was
recommended by the manufacturers.
Another was children who were on a
cocktail of drugs: anti-psychotic drugs
and/or anti-depressants combined with
methylphenidate. Traxson wasn’t only
concerned with what was happening,
he was concerned about the language
being used to ‘normalise’ these practices.
‘When some children were on a high dose
of methylphenidate some doctors were
choosing to give them an extra dose in
the morning, which they referred to as a
“kickstart”. They would give them another
dose at lunchtime, which they would call a
“booster” or a “top-up”. I began to feel very
uncomfortable about the language being
used. It might have just been a way of
explaining it to the parents but it seemed
a way of minimising what was happening.’
Traxson’s concerns came to a head in
the summer of 2009 when he set about
investigating the use of methylphenidate.
He was shocked to find that in the USA,
12% of the school population is on
the stimulant at any one time and that
40% of school-age children (2-18) will
have been on it for at least two of their
school years. He also discovered that
professional tensions were running high
in the USA over the intention to widen the
net of mental health problems with the
introduction of new categories in DSM-V
– the revised version of the Diagnostic
and Statistical Manual of Mental Disorders,
which is due to be published in 2013.
‘Piecing all this anecdotal information
together with what I was discovering
myself I started to think, “We have got to
raise the public profile of this issue,”’ he
says. ‘I think sometimes in your career
you have got to go back to fundamentals
and I think one of the fundamentals for
me is that the over-prescription of drugs
is a potential danger to children. More
fundamentally than that, I think it’s
basically wrong to be giving broad swathes
of children psychotropic medication
when their brains haven’t yet fully formed
and these toxic substances could have a
negative impact on their development.’
Raising awareness
To raise the level of public debate about
over-prescription Traxson started his own
awareness-raising campaign. Using the
slogan ‘Pastoral care, have a duty of care
to be aware’ he set out to raise the issue
with staff in schools. He says he did so
after consulting hundreds of headteachers,
70% of whom felt that pastoral care staff
did have a duty to monitor the number
of children in their school who were
taking prescribed psychotropic drugs.
His next step was to formulate a set of
20 questions that pastoral staff should ask
themselves. The full list can be found on
his blog (http://cope-yp.blogspot.com),
but among the issues they raise is whether
there is a link between the early use of
prescribed drugs like methylphenidate
and later illegal drug use among young
people. Traxson says that when he raises
this with medical professionals it often
stops them in their tracks and they ask
him whether there is any evidence of
such a link. After a lengthy pause, one
senior medical colleague suggested
that his own professional group should
do more research into the issue.
Evidence of such a link exists, he
says, giving the example a longitudinal
study carried out in 1999 by the late
Berkeley psychology professor Nadine
Lambert. Lambert followed 492 San
Francisco Bay Area children, half of whom
suffered from some degree of ADHD
and half of whom did not have ADHD.
The study found that children treated
with stimulant drugs such as Ritalin to
control attention deficit/hyperactivity
disorder (ADHD) take up cigarette
smoking earlier, smoke more heavily and
are much more likely to abuse cocaine
and other stimulants as adults (http://
gse.berkeley.edu/admin/publications/
termpaper/fall99/ritalin.html).
Traxson also trialled another of his
20 questions in one of the two schools
where he is a governor. ‘At one governors’
meeting, under “any other business” I
just asked if the headteacher and the
pastoral staff were aware of how many
children in the school are on psychotropic
medication for their behaviour. The
head had no problem with me asking
the question but said he couldn’t answer
it. He said he felt slightly embarrassed
he couldn’t answer it here and now but
promised he would look into it and report
back. At the next meeting he reported
that there were 13 and he, as a science
teacher, was quite alarmed by that.’
Having formulated the questions,
Traxson set about publicising them far
and wide, first through articles, then
through his blog and eventually on radio
and as a guest speaker at two major
national conferences, one organised by the
Association of Educational Psychologists
(AEP) and the other by the British
Psychological Society (BPS). In terms of
day-to-day practice, he says his first big
breakthrough came in September 2009
when the paediatricians in the local
authority he works for agreed a new
protocol to the effect that any concerned
professional – an educational psychologist
or a teacher, for example – can ring
the prescribing doctor to share their
concerns. Hundreds of telephone calls
or face-to-face meetings later he says the
most common response from medical
professionals is actually, ‘Thank you for
taking the time to share your concerns.’
Professionals working together
It’s clear from Traxson’s accounts of
this episode that he doesn’t see medical
professionals as adversaries. On the
contrary, he believes everyone has the
best interests of the children they deal
with at heart. What distinguishes the
different approaches he suggests is that
medical practitioners and paediatricians
will pursue a medical model and look for
an explanation for the problem within
the child whereas a psychologist will
look for a broader explanation, including
social factors. Time pressures on medical
practitioners and lack of access to ‘talking
therapies’ can also result in medication
being seen as the first and only option.
This is despite guidelines from the
National Institute for Health and Clinical
Excellence (NICE) stating this shouldn’t
be the case with children with ADHD.
As it is, Traxson’s practice of asking
simple but powerful questions has
sparked something bigger.
His own
professional association, the BPS, has
now given its support to a call for a
national review into the use of medication
to help treat children’s behavioural
issues. With a major reorganisation of
the NHS under way, Traxson agrees.
‘While all budgets are under scrutiny
I would argue that a good percentage of
the £32m that we spent last year just on
psychostimulants could be redirected to
better uses, such as talking therapies,’ he
says. ‘There’s also the tens of millions of
pounds being spent on disabled living
allowance that could possibly be used
more efficiently and more appropriately
for school-based interventions. There
are many, many good practices such as
nurture groups that schools can explore.
The time is ripe with all these changes
to put this issue under the microscope
and to have a proper national review.’
He was shocked to find that in the USA,
12% of the school population is on
methylphenidate at any one time and that
40% of school-age children (2-18) will have
been on it for at least two of their school
years.
As it is, Traxson’s practice of asking
simple but powerful questions has
sparked something bigger.
His own
professional association, the BPS, has
now given its support to a call for a
national review into the use of medication
to help treat children’s behavioural
issues. With a major reorganisation of
the NHS under way, Traxson agrees.
‘While all budgets are under scrutiny
I would argue that a good percentage of
the £32m that we spent last year just on
psychostimulants could be redirected to
better uses, such as talking therapies,’ he
says. ‘There’s also the tens of millions of
pounds being spent on disabled living
allowance that could possibly be used
more efficiently and more appropriately
for school-based interventions. There
are many, many good practices such as
nurture groups that schools can explore.
The time is ripe with all these changes
to put this issue under the microscope
and to have a proper national review.’
Find the full B.P.S. statement calling for a National review on separate Post.
for more information and BBC radio programme commentaries.
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