Month: July 2012

Over the past few weeks we’ve looked at some alternative approaches to dealing with ADD/ADHD. (Alternative, that is, to the wild rush to medicate that seems to be so prevalent within the medical community at the moment) The ‘approach’ I want to focus on today may not seem like a formal approach at first, perhaps because it simply has to do with the rediscovery of something that previous generations would have seen as a foundational part of childhood.
I think it is fair to say that we are currently living through the biggest ever change in the way of childhood is experienced. If one asked every generation of children, before the present one, its members would have indicated that time spent outdoors was a very important part of daily life. This is simply no longer the case.  The world described by Mark Twain in Huckleberry Finn (or even that of the, much more recent, cartoon characters Calvin and Hobbes) where the majority of play time was spent out of doors must seem strange and unfamiliar to most modern children.
There are many reasons for this profound shift. A significant contributing factor is the perception that we are living in a world that is much more dangerous than the one encountered by our forebears. Many parents respond to this by keeping their kids indoors as far as possible. (Although to think that this will automatically keep your children safe is a fallacy, as the growing tide of Internet initiated abductions confirms) I do not think, however, that safety is the primary reason behind the current reconfiguration of childhood (previous generations of parents also experienced the world as a pretty scary place). The main reason, in my opinion (and this is confirmed by reams of research), is the rapid growth of home-based entertainment systems.
Most modern North American children have access to a vast array of gadgets and gizmos that can open up totally new worlds to them. They can, from the comfort of their own home, chat with friends halfway across the world, conquer virtual kingdoms and draw up musical playlists that reflect their personality. None of this is a bad thing as such, but the net effect is that fewer and fewer children feel the need or urge to explore their immediate surroundings. The results are, to say the least, depressing. The writer Michelle Howard wrote a poignant piece about a piece of land where generations of children from her hometown congregated to share their dreams and their lives. She noted sadly that the paths to this ‘place of meeting’ was overgrown and that the last hearts carved into the trees in order to signify eternal love and devotion dated from years and years ago.
It is easy, when one describes changes like this, to collapse into a kind of pointless nostalgia where the past is elevated to a mythical country where everything was perfect. This is obviously not my intention. I do think, however, that we as a society should be very worried about the experiment in social engineering that we have embarked upon. It would be simplistic to say that the rise in lifestyle related illnesses among young people (e.g. obesity, heart disease and even psychological disorders) is all due to lack of outdoor activity. It would, however, be equally simplistic to deny that any such link exists. This principle also applies when it comes to ADD/ADHD.
Recent studies about the effects of nature on ADD/ADHD symptoms have yielded surprising results. Consider the following:

• A wide-ranging survey asking parents about the effects of different settings on the ADHD symptoms of their children consistently showed that these symptoms were less severe in green settings than indoors.
• An even more surprising insight can be found in the results of an experiment where children with ADD/ADHD were taken for a walk in different outdoor settings (a downtown area, a neighbourhood and a park). The positive influence of this activity on the ADD/ADHD symptoms was directly proportional to the amount of interaction with nature! (With the downtown area scoring lowest and the park the highest)

Could it be that something in our natural make-up predisposes us to paying more attention and feeling more alive in natural settings? There are certainly many people who believe that this is exactly the case. One of them is Richard Loev author of a groundbreaking book called Last Child in the Woods: Saving our Children from Nature-Deficit Disorder. (It should be noted that the title could be a little misleading. Loev does not attribute all cases of ADD/ADHD to a lack of contact with nature, nor does he teach that contact with nature is the only thing that this required to overcome the condition). Loev’s work has led to the growth of a movement called ‘No Child Left Inside’. Although not exclusively focussed on the treatment of ADD/ADHD the principles and methods advocated by this movement could prove invaluable to those struggling with the condition. At its most basic the message is: Make sure that your child has sufficient ‘green time’! Please check back next week for a more detailed and practical summary.

When experts discuss the rates of medication for ADD/ADHD most do so with a resigned air, as they believe that these rates will simply continue to rise indefinitely. This may seem, at first glance, like a defeatist attitude that there is no denying that the trend is upward and has been so for a long time. It need not be the case however! There is an excellent example, on the other side of the world, of a jurisdiction that effectively engineered a massive turnaround in ADHD prescription rates.
The state of Western Australia covers the entire Western third of the Australian continent, yet contains only about 10% of the Australian population. Its capital, Perth, could at one stage stake a credible claim as the ‘Ritalin capital of the world’ with prescription rates much higher than the US average. It is estimated that by 2003 about 20,000 West Australian children (out of a population of 2.2 million) were taking stimulants to ‘treat’ ADHD. A recent report by the West Australian Health Department puts the figure for 2008 at 5666! This means that the prescription rate was brought down by almost three quarters in the space of five years.
The West Australian experience proves that prescription rates need not be a one-way street, but that they can indeed be turned around leading to better outcomes for children and for society at large. (For example, the reduction in stimulant prescription rates coincided with a significant reduction in amphetamine abuse!) So what can we learn from Western Australia when it comes to tackling the sky-high prescription rates in most North American jurisdictions?
Here are a few factors that contributed significantly to the turnaround:
Citizen activism: The West Australian population is fairly small (only about 2.2 million people). Perth is also a very isolated city, about four hours flying time from the other major Australian population centres. The drugging of 20,000 children in such a relatively small and isolated population attracted widespread attention. The drug companies tried their usual tactics in trying to reassure people that their products were perfectly safe, but there were many people who refused to stop asking questions. The main question that they kept asking was why Western Australia had perhaps the highest stimulant prescription rate in the Western world. This led in 2004 to a full parliamentary enquiry into the issue. This enquiry conducted by the West Australian Parliament was the beginning of the end of high prescription rates in the state. The lesson is clear: In a democracy we have the privilege of bringing issues to the attention of our political leaders and doing so thoughtfully and persistently can sometimes result in radical changes.
Tightening up prescription rules: The enquiry by the West Australian Parliament yielded some surprising and disturbing results. It seemed that only a handful of paediatricians were behind the massive spike in prescription rates. These paediatricians wrote prescriptions under a system called ‘Block Authorisations’ under which: “…a practitioner was able to apply to the (West Australian) Department of Health and be granted blanket approval to treat any number of patients with stimulant medication, without further notifying of changes to individual patient details or dosage.” The rationale behind the system was that people who often worked with a specific kind of medication would be more familiar with it and that it would therefore not be necessary to check the reasons for every prescription. The unintended consequence was that it handed certain doctors (whom the state thought could be trusted) a blank check to write as many stimulant prescriptions as they wanted without being accountable for them. The enquiry made it clear that this trust placed on doctors was abused on a massive scale by some of them. One of the major recommendations of the enquiry was that physicians should be able to account for every single stimulant prescription that they write. Paediatricians would in future have to: “…apply to the (West Australian) Department of Health and obtain a unique Stimulant Prescriber Number (SPN) to initiate stimulant treatment in any patient. The practitioner must provide individual patient details, including age, gender and dose required, thus enabling the collection of data for future analysis of stimulant use in Western Australia.”
Emphasis on a multi-disciplinary approach: The Parliamentary enquiry was very critical of the way in which ADHD was diagnosed and treated. It pointed out that many paediatricians did not bother to look for other possible causes or at alternative methods of treatment. In many cases diagnoses were rushed, leading to only one possible outcome: Medication. As a result of the enquiry physicians will now have to be able to indicate how they went about eliminating other possible causes of inattention before deciding on an ADHD diagnosis. The state is also in the process of setting up two multidisciplinary centres for the treatment of ADHD where alternative treatment methods will be used under the direction of people from several different health-related disciplines. The purpose of the centres will be to reduce the rate of medication even further by first exhausting alternative treatment options before medication is recommended.
The West Australian example clearly shows that rising medication rates need not be a one-way street but that it can be successfully turned around where there is sufficient popular concern and resultant political will. It is true that Western Australia is a unique place with a relatively small and isolated population, but there is no reason why these stunning results cannot be replicated on a larger scale in other jurisdictions.
Click here for more information about the way in which medication rates in Western Australia was lowered.

In a recent report we focussed on the effects of blood sugar spikes on the human body (and especially the brain). I likened this to a rollercoaster that goes up and down at frightening speeds. The effects of this rollercoaster can be devastating when it comes to attention and other aspects of brain function. This is because the brain is by far the largest consumer of energy in the human body. Any fluctuation in available energy is therefore very likely to have a disproportionate effect on the brain. This fact should send the warning lights flashing for people who battle the effects of ADD/ADHD as they are perhaps least able to afford any hint of sub-optimal brain performance. Continue reading “The Rollercoaster that Keeps on Going!”