These days, Iâ€™m doing something in my pediatric practice that I didnâ€™t plan on doing: Iâ€™m giving medications to children with attention problems.
When I started working in pediatrics more than fifteen years ago, I figured I wouldnâ€™t prescribe stimulant medication to children. I thought that treating mental health problems was something only a psychiatrist did. I worried about side effects of the medications, and about how children taking them might be labeled by their teachers and their peers. I thought that there had to be a different way to help children with attention problems than giving them a pill. I didnâ€™t want to be part of something so controversial.
So why am I doing it? Â
Being a primary care pediatrician these days means dealing with Attention Deficit Hyperactivity Disorder, or ADHD. Data from 2005 show that 6.5% of US children have been diagnosed with ADHD. Among boys, the number is 9.2%. Thatâ€™s a lot of kids.
The numbers have been increasing. Itâ€™s hard to say whether there are really more kids with ADHD, or whether doctors are simply diagnosing it more. Thereâ€™s more awareness of the problem, too, so more families (and teachers) are asking for help. Itâ€™s becoming heartbreakingly common in my practice for parents to come in saying that their child is very distractible, always in motion, and having lots of trouble in school.Â
I do send kids to psychiatrists, especially whey they seem depressed, anxious, or their behavior is really worrisome. But for most kids, the primary care doctor is in the best position to work closely with the family and the school to understand whatâ€™s going on and find the best treatment plan. Sending every kid with a behavior problem to a psychiatrist would be ducking my responsibilities as a doctor.
The other reason I give medications is, quite simply, because they work. Research shows that 70% to 80% of kids with ADHD respond to medication. I can tell story after story of children in my practice who, once on medication, paid attention, got their work done, participated in class, and made friends. These are not small things. These are crucial things for the lifeâ€”and futureâ€”of a child.
This does not mean that Iâ€™m happily tossing out stimulant medication like candy. Far from it. There is much to keep in mind and worry about when it comes to diagnosing and treating ADHD, whether one is a doctor or a parent. For example:Â
Â·Â Â Â Â Â Â Â Â Itâ€™s not so easy to diagnose. If only there were a blood test! As with most mental health problems, itâ€™s not that straightforward. Doctors generally rely on information the parents give them, and on questionnaires filled out by parents and teachers. Some administer tests in the office to measure attention and look for other neurologic or learning problems. In order to be diagnosed with ADHD, a child should have:
oÂ Â Â Â Â Â Â A significant number (not just one or two) of behaviors that demonstrate hyperactivity, impulsivity, and/or inattention
oÂ Â Â Â Â Â Â Symptoms that started before age 7 and lasting for at least 6 months
oÂ Â Â Â Â Â Â A real handicap. If a child is active and distractible but is doing well in school, has friends, and is otherwise doing fine, well, they donâ€™t have a problem.
Ultimately, the diagnosis of ADHD is subjective. And since stimulant medication can make kids without ADHD less active and more attentive, responding to medication doesnâ€™t mean the diagnosis is correct.
Â·Â Â Â Â Â Â Â Â Lots of things can look like ADHD.
oÂ Â Â Â Â Â Â Depression, anxiety, bipolar disorder, and other mental health problems. Sometimes a significant life change, such as a death in the family, divorce, or major move, can cause a child to be distractible as well.
oÂ Â Â Â Â Â Â Hearing difficulties
oÂ Â Â Â Â Â Â Learning disabilities
oÂ Â Â Â Â Â Â Seizures
oÂ Â Â Â Â Â Â Medical problems that affect the brainâ€™s functioning, such as lead poisoning or thyroid disorders
oÂ Â Â Â Â Â Â Substance abuse.
Â·Â Â Â Â Â Â Â Â Lots of things can be going on in addition to ADHD. Depression, anxiety, oppositional or compulsive behavior, and other mental health problems that are present along with ADHD can complicate the pictureâ€”and treatment. Itâ€™s also not uncommon to have a learning disability and ADHD. If only the ADHD is treated, the kid isnâ€™t going to get better.
Â·Â Â Â Â Â Â Â Â ADHD medications have side effects. The most common are loss of appetite, trouble sleeping, stomachaches, and headaches. Children who take stimulant medications should also be watched for tics (which may be a side effect, or part of the ADHD picture) and growth problems (which usually improve with better nutrition and/or a lowered dose of medication).
Stimulants can also have effects on the heart and blood vessels. Serious problems are rare, but a thorough checkup is important before starting any medication. If the child or anyone in the childâ€™s family has a heart problem such as an irregular heartbeat, itâ€™s crucial that the doctor know, in order to make the safest medication choice.
Â·Â Â Â Â Â Â Â Â Finding the right medication can take time and patience. Every child is different and it can take a while to find the medication and dose that works well with the fewest side effects. Parents, doctors, and teachers need to be committed and have good communication.
Â·Â Â Â Â Â Â Â Â Medications donâ€™t cure ADHD. We know that they help in the short-term, but the long-term picture is murkier. And even in the short term, the best results come when kids get behavioral help (learning strategies to help them concentrate and control their impulses) as well as medication.
Â·Â Â Â Â Â Â Â Â Butâ€¦there are risks to doing nothing, too. Studies have shown that untreated ADHD can lead to:
oÂ Â Â Â Â Â Â School failure
oÂ Â Â Â Â Â Â Poor self-esteem
oÂ Â Â Â Â Â Â Strained relationships with family and peers
oÂ Â Â Â Â Â Â A higher risk of accidents and injuries
oÂ Â Â Â Â Â Â Substance abuse
Giving psychiatric medications to children should be controversial. It should make doctors and parents uncomfortable, all the time and with each child. If we get comfortable, we wonâ€™t ask all the questions we need to ask. We wonâ€™t worry that we are missing somethingâ€”and we will miss something. We wonâ€™t be thinking about all the risksâ€”and something bad will happen.
Right now, medication is one of the best treatments available for ADHD. But I hope all of us stay uncomfortable with using themâ€”so that we keep looking for the causes of ADHD, for how to prevent it, and for better solutions.
Have any of you had experience with children with ADHD?Â Did they take medications? Does anyone have thoughts or questions about this difficult issue?
Claire McCarthy, M.D., is a senior medical editor for Harvard Health Publications. She is an instructor in pediatrics at Harvard Medical School, an attending physician at Children's Hospital of Boston, and co-director of the pediatrics department at Martha Eliot Health Center, a neighborhood health service of Children's Hospital. The author of two books, "Learning How the Heart Beats" and "Everyone's Children", Dr. McCarthy was a regular columnist for "Sesame Street Parents Magazine" from 1995 to 1998 and is currently a contributing editor for "Parenting Magazine".