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Is drug addict sister appropriate carer?

Case history

Eight-year-old Andrew has attention deficit hyperactivity disorder. He is educated in the behaviour support system after being excluded from several primary schools and is on maximal doses of methylphenidate under shared care with the child psychology unit.

Both his parents work overseas and he is often left in the care of Julia, his older sister, who dropped out of university to get over an eating disorder complicated by cocaine abuse.

It is Friday evening and Julia has come as an emergency to request more methylphenidate. You point out that he had a month's supply less than two weeks ago. Julia becomes hysterical and says Andrew flushed his tablets down the loo and that their parents will be out of the country for several days and she cannot cope if he doesn't have his medication.

Dr Leila Davis

'Is she overdosing Andrew in an attempt to calm him down?'

Oh dear, what a Friday evening heartsink! This family is suffering from parent deficit disorder to a grave degree. Between them the kids have got a job-lot of psychiatric disturbance ­ drug addiction, eating disorder and ADHD. The parents seem to place work well before their children. And Julia seems hardly a sterling choice of childminder for a confronting and difficult eight-year-old, which makes me concerned about their judgment.

I would feel very concerned regarding his safety in her care given her past history. What are the parents thinking of?

So he's flushed the tablets down the loo? Don't know how much I'd buy that story. (There needs to be clarity about who is taking prescribing responsibility if he's also seeing a child psychology unit.) The suspicion of course is that she's overdosing him in a bid to calm him down, and as he's already on maximal dose methylphenidate this could be very dangerous. I would be very wary of further prescribing at this stage.

Julia's becoming hysterical and ascertaining her mental state is fundamental. As primary carer the pressure is on her and it will be vital to establish with her whether she can in fact cope with Andrew. I would ask about her present drug use including alcohol and cigarettes. Also, any sign of reactivation of her eating disorder would signify that she is under significant strain and unable to cope.

Where is Andrew at this moment? Are there other family members or close friends who can help? If social services have previously been involved I would contact the case worker or the duty team to discuss options such as respite care. Julia needs help and Andrew needs to be safe. These are the prime concerns.

I would offer Julia a small quantity of methylphenidate to last over the weekend and arrange further review, for both of them on Saturday morning and again on Monday. We could discuss the option of asking the duty social worker to call over the weekend to give support and check the situation is not deteriorating. There are definitely issues to raise with the parents when they return and I would send them a letter expressing my concerns and inviting them to come and discuss the situation.

Dr Christine Maple

'Is she abusing drugs and using brother's medication?'

My immediate reaction is: at least Julia has come to the surgery. These requests often come through the repeat prescription system. A face-to-face encounter is always preferable.

First I would want to substantiate Julia's claim. Has she brought Andrew with her? Do their stories match? I would have to consider whether she is using excess medication to control Andrew and whether there is any risk to Andrew's health. I would need to know how well Julia has been recently. Has she consulted any of my colleagues? How is her mental state? Is it possible she's abusing drugs again and using her brother's medication? May she be dealing to feed her own habit?

I would initially be sympathetic to Julia. How is she coping with looking after her brother? Eight-year-olds can be a handful, let alone a hyperactive child when you are only a teenager yourself. Has she discussed her feelings with her parents? Is there anyone else to share the burden ­ a grandparent or close friend? I would encourage her to discuss things with her parents on their return and offer to speak to them myself about the inappropriateness of leaving Andrew with someone who is obviously struggling and not fully fit herself.

If I could reassure myself that Andrew is well and the story is true I would issue the prescription but consider weekly or even daily prescribing. I would also need to know that the parents' return was imminent.

If I am concerned for the well-being of Andrew I would want to contact the parents myself or if that was not possible I would need to contact the social work department. He may even need a place of safety.

Dr John Couch

'A meeting with the parents on their return is essential'

If this prescription request came from Andrew's parents or parents of another hyperactive child it is unlikely I would be suspicious unless the same had happened before. Although Julia's story may be truthful, the concern, given her hysteria and own history, is that she may not be coping and is either taking the medication herself or overdosing Andrew.

Although it is irksome to face this problem late on a Friday, it is important to give Julia time to calm down to get a clearer idea of how she is coping. If she is lying she is unlikely to open up if the consultation is rushed or accusatory. I would sympathise with her difficult role and ask about Andrew's behaviour. It would also be useful to explore whether her role is by mutual agreement or parental pressure. She is in a difficult position, psychologically vulnerable and probably financially dependent on her busy parents. I wonder how much support she actually gets from them.

My other concern must be for Andrew. Is he being cared for appropriately and could he be at risk?

If I am convinced by Julia I would prescribe for the weekend but insist she brings Andrew in on Monday. If not, I would discuss this with her, explaining I want to help both her and Andrew in what is clearly a difficult situation. A visit to the house after evening surgery would then be inevitable.

If my concerns were confirmed, I would attempt to contact the parents and arrange another responsible relative to take over. If this were not possible, an emergency social services visit with a place of safety order for Andrew is inevitable. Julia would also need support, probably initially via the crisis intervention team or duty CPN. Finally, a meeting with the parents on their return is essential to help revise the current arrangements and support both of their offspring.

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