DRUG HIM WHEN HE TEASES

Record numbers of British children, some as young as five, are being excluded from school for bad behaviour. Between 2,000 and 6,000 are popping psycho-active pills prescribed to calm them down. Are they all victims of a new mental disorder? Or have parents, teachers and other adults changed the social rules?
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The Independent Culture
DAVID STRATTON is an attractive little boy. He is nearly eight years old, with bright ginger hair and freckles, pale skin and a delicate frame. But soon after meeting him for the first time, you realise that his behaviour is somehow not right. He wanders aimlessly around. The room - in the home of educational therapist Jean Robb - is large and airy, and full of enticing toys, coloured pencils and crayons, building blocks, Lego, and books; but David dips into everything, without paying proper attention to anything. He picks things up and drops them, flicks through books without looking at the pages, turns over a heap of toys listlessly. He passes the picture window, with its spectacular view down the garden to the Dee estuary and the Welsh hills, without a glance.

This is David's first visit to Successful Learning, a scheme run by Jean Robb and her fellow therapist Hilary Letts to give extra help to children who are finding it difficult to cope with school. Robb's living-room - in West Kirby, Merseyside - has a friendly, homely feel. But David is nervous and fractious. Asked to sit down and write his name, he mixes up the letters and writes "Startton"; when the mistake is gently pointed out by Jean Robb, he is furious and refuses to believe he is wrong. "Go away, go away, go away!" he snaps. By now he is hunched up, his white T-shirt stretched over his knees, rubbing his eyes, occasionally grabbing for toys, a picture of distress and frustration that is painful to see. When he is encouraged to ask if he can go and play, instead of simply abandoning his writing and running off, he swears, and huddles close to his mother.

David is having a bad day. All seven-year-olds have bad days occasionally, for all sorts of reasons; in David's case, the cause is both specific and alarming. He usually relies on a powerful psycho-stimulant drug to modify his behaviour: half a small white tablet first thing in the morning, and another half at lunchtime. But his mother is hoping to wean him off the drug, and so today he has not had his usual dose. As a result, he is uncontrolled and even violent. As Sue, his exhausted mother, begins to detail his long, complicated medical history, David starts tossing foam blocks around the room. Sue looks for a moment as if she might cry.

Since she first took him to a psychiatrist, when he was three, David has, she says, been diagnosed with various problems: mild autism; Asperger's Syndrome; "emotional disturbance". He has been excluded from mainstream school, and shunted into various classes for "problem" children. This has not helped him; at his current school, for children with learning difficulties, his behaviour at first deteriorated still further. Not only did he make no academic progress, but he began to pick up bad habits - anti-social behaviour, bad language.

Recently, however, what seemed like a glimmer of hope appeared. David was diagnosed as suffering from Attention Deficit Disorder (ADD), a condition characterised by lack of concentration and, sometimes, hyperactivity; more importantly, Sue Stratton was told by David's current psychiatrist that ADD is treatable with a drug, Ritalin. David has been taking this since January. "He's more content, happier, and he has been getting badges for good behaviour at school," says Sue Stratton, who is divorced, with two other children, a daughter of 16 and a son of 11 (both of whom are sailing happily through their schooldays). "I was very worried about giving him this medication. I didn't want to give him a drug. I felt so guilty that I hadn't been able to cure him myself. But since he's been on Ritalin, he's only been excluded from school once or twice, and he has started to read. I can hardly imagine life without it now."

Nevertheless, she does not believe that Ritalin can be a long-term solution, and is keen that her son should learn to cope without the drug; hence today's visit to Successful Learning. Jean Robb and Hilary Letts specialise in helping children who are "difficult" - under-achieving, or socially maladroit, or intelligent but unable to settle in school. Sue Stratton hopes they might help David to do without Ritalin. She also hopes - desperately - that they will help her to get her son back into mainstream education. But while it is relatively easy to be shunted from mainstream education into schools for children with a whole range of "learning difficulties", it is much harder to make the return journey. "My child is not stupid," she says wearily, "but he is stuck in the wrong educational environment, one that is dragging him down - they have just passed the problem on to someone else. If I have to use medication as a crutch to get him out, I will do it - well, it is the only thing that's on offer from the local authorities. But I don't want to have him for ever on medication. I want him to be able to contain himself, to be all right in himself."

UNRULY children - foul-mouthed, ignorant, violent - are currently a source of great national disquiet. It isn't just the media that create the impression that increasing numbers of children are not coping, academically or socially, with normal school life - children like the four-year-old who recently attacked a teacher so viciously that she is now seeking compensation; or the boy who caused teachers to strike when his exclusion was overruled. The statistics bear it out. Figures published by the Department for Education and Employment show that, since the start of the decade, the number of children expelled from primary schools has increased fourfold; children as young as six are regularly being excluded for bad behaviour. David Stratton, far from being an isolated case, could stand for a whole new infant underclass: excluded from mainstream education (at the age of five, in David's case); beyond the reach of parents, teachers, psychiatrists; untameable.

A number of medical professionals, including paediatricians at flagship hospitals such as the Maudsley, are suggesting that this seeming epidemic of bad behaviour is not the result of wilful naughtiness, social breakdown or poor parenting. Rather, it is down to a medical condition, a complex psychological syndrome that was first recognised in the Diagnostic and Statistical Manual of the American Psychiatric Association in 1980, and labelled attention deficit disorder. ADD (also known as AD/HD, attention deficit hyperactivity disorder, when hyperactivity is particularly severe) is difficult to pin down; there is no specific biological test for it, and diagnosis relies on observing the child's behaviour. In some quarters, its very existence is disputed. Symptoms are said by those who believe in the syndrome to include excessive forgetfulness, inability to finish tasks, often losing things, fidgeting, and excessive talking. Among American psychologists and their patients, the notion of adult ADD is also becoming fashionable; some, in a virtuoso display of retrospective diagnosis, are now claiming Einstein, Churchill, Leonardo da Vinci and Mozart as fellow- sufferers. (Paul Gascoigne also looks like a classic case, suggests one British expert.)

Unfortunately, like other fashionable, non-specific syndromes, ADD is not only hard to diagnose, but, since its cause is unknown, hard to treat. Gill Mead, president of the AD/HD Family Support Group UK, which offers free information and advice and has 17,800 members, talks of "caring parents seeking help for years, going backwards and forwards to psychiatrists and psychologists, being told that their parenting is somehow at fault - when they speak to me and they are finally listened to, they cry and cry." But there is one treatment that a growing number of parents and practitioners believe to be effective: a combination of therapy - that is, sessions with a psychiatrist or psychologist - and Ritalin. Ritalin can have a dramatic, if unpredictable, effect on an unruly child; on some children, there is no effect at all; on others, the calming effect can be close to instantaneous, turning a screaming, raving brat into a "normal", controlled child in the space of half an hour.

Ritalin is a schedule two controlled drug (the same category as barbiturates, methadone and heroin) related to amphetamines. For parents at the end of their tethers it can be a godsend - a quick panacea on a par with Prozac or Valium. Gill Mead believes that it is very much underprescribed. At the age of 16, her own daughter was sectioned (put in a mental hospital on the advice of doctors and social workers), before being diagnosed with ADD and treated with Ritalin; she then went back to college, took her GCSEs and Duke of Edinburgh awards, and got a job. "While paediatricians, psychiatrists and psychologists are arguing about Ritalin, parents are watching their children self-destruct," she says. "All we have is medication and ourselves, which is why parents are clamouring for Ritalin. I've got more faith in Ritalin and the common sense of mothers than in a bunch of professionals who haven't got a clue. In Britain we have a medication phobia, but Ritalin is available in Thailand, Chile, Malaysia, South Africa - a woman rang me from South Africa just the other day to say, `My five children are on Ritalin and I'm coming back to the UK, where on earth do I go for help?' There is so much ignorance about Ritalin that doctors are coming to support group meetings for information."

The Family Support Group exists mainly to provide the latest information on treatments, particularly details of the nearest NHS consultant who will diagnose and treat ADD. It also puts families with a child who is showing symptoms of ADD in touch with other families who live nearby and are dealing with similar difficulties. Local parents' meetings, which provide a chance for parents to swap notes and bring up specific worries or queries, take place, she says, across the whole country "from Cornwall to Aberdeen". Parents welcome the chance to share their woes; a raging six-year-old coming at you with a knife or a hammer, or even teeth and fists, is an unsettling experience.

The equivalent American support group, CHADD (Children and Adults with Attention Deficit Disorder), was widely criticised for accepting over $800,000 in sponsorship between 1987 and 1994 from the Swiss-owned drugs giant Ciba-Geigy, the maker of Ritalin.

Ciba-Geigy insists that it has had "little" involvement with British support groups, and only of an "educational nature". "We are squeaky-clean and we have nothing to do with the drugs companies," says Gill Mead. However, articles originally published by CHADD in the US, which give extensive advice on "medication", are among the material handed out by the Family Support Group.

THE seemingly miraculous way in which Ritalin works on children who have been diagnosed with ADD is not properly understood. Ritalin is the brand name of a drug called methylphenidate hydrochloride. It acts as a stimulant of the central nervous system. It is possible that it "tops up" stimulant chemicals in the brain to a level that makes "normal" behaviour possible. The latest thinking is that the brain chemical in question is dopamine, which facilitates communication between brain cells, and influences attention span. Reduced attention span is one of the crucial characteristics that are supposed to signal ADD; whether the child in question is hyperactive or lethargic, he or she is unable to concentrate on any subject for more than a moment or two, and typically short-term memory is also poor.

Quite what this all signifies is a matter of some controversy. Children have managed without Ritalin for thousands of years; in most parts of the world, they still do. Why are so many of them in developed countries apparently unable to function without it today? Has the chemical nature of their brains changed - perhaps for some reason relating to pollution of the environment? This is not inconceivable. Or are the causes social? Is it possible that the nature of modern childhood - confined in classrooms and cars or in front of computer screens, with outdoors increasingly a no-go area - places constraints on energetic children that make problems of overactivity and restlessness hardly surprising? Or that selfishness or overwork have caused a deficit in the attention that parents give to their children?

Alternatively, society's expectations may have changed: levels of antisocial behaviour or educational underachievement that were once thought inevitable for some children are now considered unacceptable. Or one might speculate that the very diagnosis is symptomatic of a growing social phenomenon: the medicalisation of normal behaviour. After all, many of the symptoms that are supposed to signal ADD will be recognised to some extent by all parents. Today, however, we expect every ill to have a cure, usually provided by medicine, and naughtiness has become a "disorder". Needless to say, those whose business it is to cure the disorder - from pharmaceutical companies to therapists - have done little to discourage this shift in attitude.

The pattern of increasing Ritalin-use certainly suggests that there are cultural forces at work as well as medical ones. At the beginning of the decade, Ritalin was virtually unknown in Britain. However, its use has increased steadily, and today, Ciba-Geigy says that around 2,000 British children are taking it. Other estimates put the figure as high as 6,000. But Britain's Ritalin children are as yet a tiny group compared to the numbers in America, Australia and Canada, where Ritalin has been in use for several decades, and hyperactivity has been a high-profile disorder for 30 years. In the US, estimates of how many children are taking Ritalin or a similar psycho-stimulant form of medication vary; the figure hovers somewhere between three and 10 per cent - that is, up to 2.5 million. Around half of the children who are being monitored by US social services are taking it.

Recently, though, the use of Ritalin has been causing controversy. In Canada - where prescriptions of Ritalin have tripled since 1991, to 486,000 per year - Vancouver child psychiatrist Dr Thomas Millar has criticised "promiscuous prescribing" and called the diagnosis of ADD a "myth". The Toronto Sun carried a story earlier this year about a mother who force- fed her four-year-old son huge doses of Ritalin simply to shut him up. In Australia, Dr Cyril Hellier, senior educational psychologist at Perth and Kinross council, who has lived and worked in Australia, and who worked on a recent paper prepared by a working party from the British Psychological Society, has talked of a "social epidemic". Dr Hellier explains: "In Australia, Ritalin is a quick fix - you can go in off the street, get a prescription, and have the child taking the pills in the car on the way home."

In the US, Ritalin has become so widely used that the US Drug Enforcement Administration prepared a report on it last year, and found evidence of abuse - enterprising ADD-diagnosed children selling the drug to their classmates (crushed and snorted, or dissolved and injected, it can reportedly have a euphoric effect similar to cocaine). At least one teenager has died after abusing Ritalin; a teenage student who collapsed with cardiac arrest after snorting the drug at a party in Roanoke, Virginia, last year. "Ritalin is an addictive drug that's getting easier to get, relatively inexpensively," according to a USDEA spokesman. "We've seen a great increase in abuse."

American psychiatrists, doctors and teachers reacted with alarm, and Ciba-Geigy earlier this year even sent letters to 100,000 pharmacies and 110,000 doctors across the US, warning them about the dangers of over- use and misdiagnosis. The company fiercely disputes the claim that Ritalin is addictive, and also rejects allegations that it has promoted the drug with excessive enthusiasm.

Medical and educational professionals talk about Britain as being - in child medication as in everything else - 10, 20 or 30 years behind the US (depending on who you speak to). In the next few decades, therefore, we can probably expect ADD to be routinely diagnosed in this country - and routinely treated with Ritalin. Problems of over-enthusiastic diagnosis and prescription - and possibly abuse - may well follow.

Professor Peter Hill, who runs an Overactivity and Attention Disorder Clinic at St George's Hospital in Tooting, south London, hopes that more restrained British attitudes to diagnosis will guard against the worst excesses. "With the American diagnostic scheme it was easy for all sorts of people who weren't properly trained to recognise bucketloads of kids who could be ADD, and give them Ritalin. There is definitely a trait or series of traits distributed in the population and some children are devastated by them, some don't have them at all. But there are cut-offs, and in Britain they are at the serious end of the disorder - around one per cent of children. The American cut-off diagnoses three to five per cent of children as ADD, though 10 per cent of primary school children in the US show some symptoms of it."

At the moment, Professor Hill's clinic is bursting at the seams; a GP's referral now, he says, would mean an appointment in the spring. Not long ago, he had a two-year waiting list (partly because parents used to be allowed to refer children themselves). Of the children he diagnoses with ADD, he would expect to prescribe Ritalin for between a half and two-thirds. But he says that in this country he is aware of a "small handful of people who are prescribing Ritalin very freely indeed, all operating from private clinics. Within the mainstream, people are quite responsible - the most important thing is that the treatment is multi-modal. Ritalin is great stuff, but it is not a cure. It provides a window of opportunity, a period of normalised behaviour where there is a chance to teach the child."

He is not alone in endorsing Ritalin. Other distinguished British doctors - including Professor Eric Taylor at London's Maudsley Hospital, one of the leading British authorities on hyperactivity in children - believe that it is extremely effective, as long as it is used in combination with other therapeutic options. Even the BMJ has tentatively expressed a positive opinion. "Careful monitoring is needed," it observed in an editorial last year, "but if this is done the treatment is usually well tolerated" - although it also warns against using drug therapy in isolation.

Some, though, would go considerably further in their endorsement of Ritalin. Dr Geoff Kewley, an Australian who has spent the past seven years practising in Britain, is one of the pioneers of the diagnosis of ADD here. He works from the Learning Assessment Centre in Horsham, West Sussex, where he sees patients both privately and on the NHS. He is somewhat reluctant to be interviewed, having already been portrayed with some gusto in the press as a wicked, white-coated shrink, doling out hard drugs to stoned kiddies; though he dismisses such hostility as the reaction of people "coping with changing attitudes".

Dr Kewley has specialised in treating ADD disorders for 20 years. "I realised a lot of children were not being helped by the conventional services being offered. I was overwhelmed by cases of AD/HD and eventually moved out of the NHS because I couldn't get the recognition that it existed. It is still engrained in myth, and seen as having a psycho-social basis rather than a biological one." He believes an accurate physical diagnosis of ADD may not be far away. "Scans are available on a research basis that are 92 per cent accurate in a neurometrics clinic in Sydney - they are like an EEG, a computerised pattern of the brain, and they show a clearly recognisable pattern of brain waves."

He believes that the current diagnoses of ADD children in this country are just the tip of a substantial iceberg, and that, rather than Professor Hill's one per cent, as many as three per cent of British children have ADD - similar to levels in America or Australia. "Ninety per cent of them will be helped by Ritalin, " he says. "It's really important that the doctors who are diagnosing are experienced. GPs must not prescribe Ritalin without a proper assessment. It's very much a clinical diagnosis, based on dealing with what is a progressive neurological disorder." And he reiterates that Ritalin alone is not sufficient. "The medication gives a window of opportunity for other strategies to work better - it makes the child available for teaching, able to pay attention."

THIS educational "window of opportunity" is a term much favoured by those who deal with Ritalin; but there are also financial windows of opportunity for those who work in the field. One psychiatrist, asked to pay pounds 15 to attend a conference set up to pool information about ADD, forked out gladly, saying, "That's nothing compared to the millions we'll be making from AD/HD." Parents who can afford to pay for their child's treatment can end up paying out far more than the price of a few packs of Ritalin. (Ciba- Geigy's current basic NHS price is pounds 5.06 for a pack of 30 tablets.) There are also the costs of private medical consultations with sympathetic practitioners, which can be as much as pounds 500 for diagnosis and initial treatment; and a minority of worried parents with deep pockets can send their troubled children to be educated privately, outside what they see as the rough- and-tumble of the state school.

The Center Academy in Battersea, south London, is described by its director of education, Fintan O'Regan, as "an ADD-friendly school" for pupils aged six to 18 with a variety of learning problems - around 25 per cent of them have been diagnosed with ADD, and about half of those are currently taking Ritalin. O'Regan, a kindly man in his mid-thirties, is open and friendly and happy to show off the Academy (which has parent schools in the US - hence its spelling). The school is the epitome of old-fashioned educational virtue. Desks are arranged in traditional rows. There are abacuses and globes in the classroom, as well as videos, televisions and computers. The essential teaching difference between this and any other school, says Fintan O'Regan, is the lack of "chalk and talk" - the pupils can't concentrate for long lectures, and they work at their own pace, supervised by a teacher who can give individual help.For 54 pupils, the school employs seven full-time teachers, four part-time teachers and three other helpers; class size is between one and 10, and larger classes are managed by two teachers at once.

Visitors tend to expect a bear-garden, but Ritalin in action is actually low-key and un-scary - much less so than an unmedicated child in a rage. "They think the kids will be leaping around, but that is not conducive to task completion," says O'Regan. "People are surprised by how controlled it is." His approach is practical and results-oriented, and this extends to the use of Ritalin. "I am not a doctor, I'm a teacher, and while we do not actively recommend medication, some of the children who come here are already taking it. The short-term damage caused by ADD - low self- esteem, poor performance - is major. The long-term effects of Ritalin are being researched now in the US, and can you imagine the lawsuits these guys would be facing down the line if they weren't sure it was safe? It helps people to have the term ADD - a label - but I don't really care what you call it. Call it pink pyjama syndrome if you like. Whatever diagnosis you attach doesn't matter. What is important is remedial action."

The Academy, which is a charitable trust, has various non-drug-related techniques for managing children with short attention spans: little boxes with liquid crystal displays that sit on desks and click if the child isn't working ("a way of managing the classroom without yelling"); rationing talkative children to 10 questions a day; keeping work groups small ("Never put an ADD child in a group of more than two - three is too many"); a short classroom day (lessons finish at 1pm).

In an upstairs classroom, a middle school maths group is working. At first glance everything seems normal. However, some pupils are sitting so that they are screened from seeing round the classroom, and will not be distracted; others wear headphones that play soothing white noise. One boy, sitting by the window, is fiddling intently with the string of the Venetian blind rather than working. There are nine pupils, and three teachers. The atmosphere is calm; even when confronted with unexpected visitors, the children - after an initial flurry of interest - keep working.

They wear uniform, and call O'Regan "Sir". They seem to like him, and they look happy. They are working towards GCSEs and American High School diplomas. Is it possible that those who are on Ritalin (quite indistinguishable from the rest) are being helped as much by the high-quality teaching as by the drug? "Bad teaching does not cause ADD," says O'Regan firmly.

None the less, good teaching of this kind does not come cheap. "It costs a lot of money to run specialised programmes," says Fintan O'Regan. Fees at Center Academy are between pounds 3,500 and pounds 4,000 per term. Around 15 of the 54 pupils are "statemented": that is, their fees are paid by local authorities. Left in mainstream education, they might, like David Stratton, have ended up in state-run special schools. "Students are ending up there that shouldn't be," says O'Regan (who has to turn away parents insisting their child has ADD when he or she is actually suffering from mental problems that need much more specialised help). "But if you raise awareness of ADD, you end up with four times as many statemented children. Special schools are not the answer. And grant-maintained schools will turn ADD kids away. At the end of the day, it's all down to money." Certainly, any child whose parents could afford the fees would flourish in the atmosphere at Center Academy. Half the school's pupils who have been diagnosed with ADD are managing very well without medication.

This raises the question, of course, of just how necessary medication is. Teachers in schools where money and resources are in much shorter supply - and Ritalin is thus much more likely to be seen as the only solution to behavioural problems - have expressed their concern about this very forcefully. After all, Ritalin is a powerful psycho-stimulant drug, being administered over years to small children - some as young as four. Head teachers in West Sussex claimed last year that children had been taking Ritalin without their teachers being aware of it - and that side-effects included hallucinations and "zombie-like" behaviour; a widely-reported scrap about this resulted in threats of legal action from the Learning Assessment Centre, the diagnosis centre in the area.

Such reports were among the factors that aroused the concern of the British Psychological Society (BPS), which set up a working party on ADD and Ritalin. After a year's research, a report was published last month which strongly advises caution. While it acknowledges the existence of ADD, Ritalin, it says, should be the very last line of attack. "We are in a situation increasingly influenced by transatlantic phenomena," says Dr Cyril Hellier, who worked on the report. "There is increasing pressure on professionals to think hard and objectively about this subject. It's a very emotive debate. We are evolving our understanding of ADD, but no one wants to go to the extreme lengths of over-diagnosis - it is questionable on moral and ethical grounds."

SADLY, by the time most parents get to the stage of hearing about Ritalin, finding a doctor to diagnose their child as suffering from ADD and having the drug prescribed, they are desperate; already in disaster management mode, frantic for help and ready to grasp at any possible solution. Many have already run an exhaustive gamut of family therapy, psychiatry and psychology. Suggesting to them that their child is not ill, but that they are somehow not coming up to scratch as parents, does not go down well. A few will openly agree that their home background is to blame. "When our oldest child was growing up, we were setting up our own business and we just weren't there for him enough," says one (remarkably candid) Merseyside father, whose teenage son has been excluded from several schools. Nevertheless, he has refused to consider Ritalin for his son. "It's like putting a plaster over a splinter: the splinter is still in there. You have to try to address the root problem of whatever is stopping the child from learning." He is doing this with Successful Learning, and he says his son is responding well.

There are, in other words, alternatives to Ritalin, though the effects may be less immediate. "The most effective way of helping a child with severe difficulties is positive management behaviour to promote the behaviour you want to see," says Dr Cyril Hellier. "It sounds so simple, so commonsense, but it's crystal clear from many studies. Many children don't need to go any further, especially if you add in parent training. Many children with some of the characteristics of AD/HD can be helped if they are put back in a position where they are able to choose to pay attention. It's not therapy, but a practical problem-solving exercise. For example, if it always goes wrong when you try to play with other children, perhaps you don't know how to play, because you haven't been in contact with other children or you don't know the rules. So sometimes teaching you to play can be enough."

This is precisely the kind of approach taken by educational therapists Jean Robb and Hilary Letts in their Successful Learning classes in Liverpool. Among their current crop of pupils, David Stratton is trying to learn to do without drugs; others are simply trying to keep up at school, or are making up educational ground lost through illness or poor behaviour. Robb and Letts, whose ideas are set out in their book Creating Kids Who Can, believe that behavioural problems go far beyond a simple medical diagnosis followed by treatment - that there is a whole range of social factors putting so much pressure on modern children that the less confident and more sensitive go under.

"Where there is a problem of concentration, it's a nurture issue, not a nature issue," says Hilary Letts. "Today things move so fast and are so immediate, children have no time to focus. They are taken into school earlier and earlier, they are doing the national curriculum and studying history and geography at six. They need to be playing, meeting other children, listening to stories, being with a caring adult who has time for them. They have little opportunity to learn about interacting with others. And now we live in such big communities and go everywhere by car, everything is unknown - they aren't able to explore and form a picture of the world around them, find their own boundaries. Children have no idea that there are any boundaries, and when they meet them at school they find it really shocking."

Media emphasis on extreme cases, she says, only serves to panic worried parents. "Television shows shock-horror cases of children who are banging their heads on walls and damaging themselves. But the list of criteria for ADD takes in far less extreme behaviour. If you are six and you lose your cardigan, you are diagnosed as having poor organisational skills - not just that you have lost your cardigan because everyone loses their cardigan occasionally when they are six."

At Successful Learning, Ritalin is strongly disapproved of. "If the child's bad behaviour is in response to an external problem, drugging them to make them passive is not fair," says Jean Robb, who also has reservations about the usefulness of the ADD label. "It masks the problem, and puts the blame on the child. And whatever the situation, telling the child they are `different', that they have a `problem', means the child is absolved of all responsibility for his or her behaviour. We have children who take a long time to teach, and we are very patient - but we do not excuse them because of their `condition'. We say, `Well done - but there's still a long way to go.' If you give a child a label such as ADD, they can slip away behind it, use it as a smokescreen - and once a child has such a label, it is very, very hard to discard."

Succesful Learning takes children who need it back to basics and teaches them how to learn; right down to habits such as listening to the teacher and waiting their turn in class, which are often assumed to exist without explicit training. Parents with children here are eager to praise the method - and the extent to which behaviour can be improved, without resorting to Ritalin.

For example: Anna, aged seven, has been coming to Successful Learning sessions for two months. "Her teachers were suggesting a school for badly behaved children," says her mother, who would not consider drug therapy for her daughter. "We're trying to stop that before it happens." Anna is well known to her neighbours at home. "People in the streets were saying `Why don't they control her?' " says her mother. "It was really getting me down. The other kids wouldn't play with her, they would turn on her, she was always shouting and wandering off and disappearing - and so unhappy. She'd start swearing - language I'd never come across. I'd be saying, `What does that mean?' She just couldn't control herself. She killed our rabbit, but she didn't mean to - she just didn't realise what would happen if she hit it. At school she would disrupt the class by fiddling and messing and being silly - she wouldn't learn."

Anna has improved almost beyond recognition, says her mother. "She is calmer, better behaved, she has started reading. We used to dread the weekends, but now we don't. She's still learning things like tidying up, but now she can get herself ready for school, do her hair and teeth. I don't have to push her all the time. She's shocked her dad and me because her learning abilities were overclouded by the naughtiness. And when she came in and started showing us her spelling, it was so emotional, we both sat there and cried." But what if they had not found Successful Learning? In that case, the temptation to resort to a short-term fix - that is, to use Ritalin - might have proved harder to resist.

EARLIER this month, Sue Stratton went to the first of a series of meetings that will determine whether David will start on the road back into mainstream school. It went well; the local authorities have agreed to give David an initial trial, with a view to re-integrating him in January (a year after he began taking Ritalin). He will continue to take Ritalin, at least in the short term, and to receive the support of Successful Learning. David Stratton, say Jean Robb and Hilary Letts, is in fact a very bright little boy. "He is philosophical, and his range of references is unexpectedly wide," says Hilary. "Over the summer we were doing a craft project, making a stuffed whale, and he said `I think I'll call mine Ishmael.' He was reading Great Expectations - he actually reads very well - and there was a phrase he latched on to, where Pip says, `I didn't know that I knew.' Like Pip, he actually knows more than he thinks, and just needs the confidence to realise it."

So far so good. But even though his mother is trying to wean him off Ritalin, her feelings about it remain ambiguous. "Life was unbearable. I knew Ritalin wouldn't be a miracle cure, but without it we wouldn't even have reached this stage. I know some parents say they would never use it, but when you're desperate you'll try anything." !

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