There are times when I have to pinch myself to make sure I am awake and living in the twenty first century. Why do we spend so much children’s services, yet value children so little? This 9 year old boy has long standing behavioural problems, admittedly it is a family with problems. Other children are affected by mental health conditions, his mother has bipolar disorder and his father is long gone. So perhaps no one was surprised by the arrival of this boisterous toddler or that his behaviour was so far from ideal.
He was seen at two years old, found to be “normal” but boisterous, at 4 years old to be verging on ADHD and diagnosed formally at 6yrs. His final diagnosis was delayed because a questionnaire from his school was returned late. Since when did a medical diagnosis depend on a school form? because if it does, that is not a diagnosis, it’s a label.
By the time he was six years old, everyone agreed this child had ADHD and he was started on methylphenidate, which sometimes helps to control his symptoms, I am not sure that it did. In the meantime he has totally disrupted the already fragile household, scuppered the school chances of his older brother and sister who had to leave the house between 7pm and 9pm so that their mother could settle him for bed. An older brother had moved out of home completely. It is difficult to believe that any of the family had a great start in life. Mother was housebound because she couldn’t take him anyway, especially during the recent pandemic. The whole household had spent most days cooped up together, piling more damage on already fractured relationships. If any of them had any chances in life, five months of Lockdown had finally scuppered them.
It seems that child psychiatry is trapped in the Dark Ages. The only proven intervention for ADHD, and that only proven by the snake oil salesmen (Big Pharma), are the stimulants that include Ritalin, most of which is probably taken by desperate parents attempting to stave off the suicidal exhaustion induced by living with these children. By the time the diagnosis is made, usually around the age of eight years, there is all but no hope of a successful intervention.
HOW COULD IT HAVE BEEN DONE DIFFERENTLY?
This child was known to be at risk since birth. Already a vulnerable family, genetically (bipolar) and socially (absent father), the baby is born at 38 weeks with a meconium aspiration pneumonia.
Meconium is “Foetal Poo”. Occasionally before birth, the baby opens its bowels into the amniotic fluid that surrounds the baby in the womb. In the womb, amniotic fluid circulates freely into lungs and helps them develop normally. If however, before birth the baby “poos” into the amniotic fluid, (perhaps because it is distressed), the “meconium” or baby poo gets into the lungs and causes a pneumonia. This baby boy was in the intensive care unit for a month before being discharged home.
A month is a long time for a baby to be in “SCBU” (Special Care Baby Unit) as we used to call the neonatal intensive care. That period of low oxygen and respiratory damage may have damaged the babies brain, at the very least it would have been emotionally traumatic for such a young infant to be separated from his mother and human contact for so long. This puts him at risk of problems later in life. If there were to be any constructive interventions that would improve his life chances, they needed to start on day 1. These might have been giving mother a day or two a week of childcare with an experienced nursery nurse, to help with a demanding baby, extra money so as to make it easier to manage her other children,
Medically an early diagnosis might have been helpful. ADHD is a label given to children displaying a set of behaviours. It tells you nothing about the cause of the condition or its likely outcome. Paediatricians are reluctant to do too many investigations in children. Blood tests are traumatic, and the little people won’t lie still long enough to be scanned or cooperate with psychological testing. Even getting a child to be quiet long enough to listen to their chest can be a challenge! However that should not be a reason to stay in the Dark Ages.
This child has reached the age of 9 labelled with ADHD, and no one has the faintest idea of what is going on between his ears. There are no records of any blood tests, scans or even an EEG. No one has observed the child’s behaviour at night or for more than a half an hour in a medical consultation (hence the importance of school reports – where the child has been independently observed)
If Paediatrics and Paediatric Mental Health services are to reach out of the Dark Ages they have to use technology to find out what is going on in these children’s brains. Blood tests to exclude vitamin and mineral deficiencies, EEGs to find out about brain activity and exclude epilepsy and encephalitis, CT Scans and MRI scans to find out whether there is structural brain damage, fMRI and PET Scans to find out whether there is functional damage, sleep studies to find out what happens at night.
This child has already disrupted five lives to the brink of collapse, it costs several times the average to educate a special needs child. At the very least we owe to ourselves to find out what is going on and whether he is likely to get better or worse with time. He is likely be vulnerable for the rest of his life, so should we not already be planning a simpler life for him with a few rewarding and useful activities built in?
Educational assessment is the visible tip of this iceberg, but by the time a child has reached school age, any hopes of meaningful interventions have left the building. In other words, by the time the Titanic saw the iceberg, it was already too late because the ship was already on a course that led to the death of 1517 passengers. The carnage wreaked by failing these young children is far greater than it needs to be because we wait until they are educationally assessed at six or eight years old instead of using looking out for the icebergs and charting a different course.