These days, I’m doing something in my pediatric practice that I didn’t plan on doing: I’m giving medications to children with attention problems.
When I started working in pediatrics more than fifteen years ago, I figured I wouldn’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 didn’t want to be part of something so controversial.
So why am I doing it?
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%. That’s a lot of kids.
The numbers have been increasing. It’s hard to say whether there are really more kids with ADHD, or whether doctors are simply diagnosing it more. There’s more awareness of the problem, too, so more families (and teachers) are asking for help. It’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.
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 what’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 life—and future—of a child.
This does not mean that I’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:
· It’s not so easy to diagnose. If only there were a blood test! As with most mental health problems, it’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:
o A significant number (not just one or two) of behaviors that demonstrate hyperactivity, impulsivity, and/or inattention
o Symptoms that started before age 7 and lasting for at least 6 months
o 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 don’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 doesn’t mean the diagnosis is correct.
· Lots of things can look like ADHD.
o 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.
o Hearing difficulties
o Learning disabilities
o Seizures
o Medical problems that affect the brain’s functioning, such as lead poisoning or thyroid disorders
o Substance abuse.
· 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 picture—and treatment. It’s also not uncommon to have a learning disability and ADHD. If only the ADHD is treated, the kid isn’t going to get better.
· 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 child’s family has a heart problem such as an irregular heartbeat, it’s crucial that the doctor know, in order to make the safest medication choice.
· 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.
· Medications don’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.
· But…there are risks to doing nothing, too. Studies have shown that untreated ADHD can lead to:
o School failure
o Poor self-esteem
o Strained relationships with family and peers
o A higher risk of accidents and injuries
o 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 won’t ask all the questions we need to ask. We won’t worry that we are missing something—and we will miss something. We won’t be thinking about all the risks—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 them—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? 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".
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Comments: 33
He has just started taking a new medication, Vyvanse, just before school started, and so far- we like this one. Previously he was on Concerta, then Adderall, then Adderall and Straterra, then Dexadrine. Concerta worked the best, but stopped working at all with him after a few months. The other ones didn't help him out much at all.
Thank you for writing this!
2) How do you address the drug addiction problem created by taking these ADHD medications?
Once the child is off the medication, what will he or she use to fill that lovely new chemical "socket" that has been created in the brain?
3) Most importantly, isn't it difficult to tell the difference between ADD, Bipolar Disorder, or a combination of both in children? Are you concerned about misdiagnosing the problem and giving the wrong medication, which studies are showing will exacerbate the real problem permanently?
A few years of annoyance and extra work as a parent is well worth avoiding the risk of making a case of mild Bipolar-Disorder into a lifelong struggle with severe Bipolar Disorder for my child - to me.
He's twenty, well employed, has never had any problems with the law, doesn't do drugs or drink, and has not been on ADHD drugs since a few months in the second grade. After I saw what Ritalin did to him, and began researching for myself, I took him off the drugs even with the school threatening me that he would not be allowed to attend if he were not medicated.
Boy, as soon as someone labels a condition the pharmaceutical companies lick their collective chops.
When I was a kid - NO ONE had ADD. I'm a boomer, and proud of what my generation accomplished. Imagine how much spark would have been doused with drugs if parents and doctors had just let popular culture lead them around by the nose.
We had nuclear families. We had discipline, and we had self-esteem.
A caveat to end my tirade - truly mentally ill children need help in any way we can administer it, but just because Johnny is a little pistol is not reason enough to give him drugs and turn him into a zombie.
Go out and research how families, like Frightening's, managed to avoid the trap of chemicals and produce fine, upstanding citizens.
And parents, just say NO!
If you have ever seen a child with sever ADHD whose family has a history of the disorder, and what medication does for them in the school setting, you would change your mind in a hurry! I did! I was against medicating all together, but seeing my child fail time after time, to see him fighting all the time, seeing him in trouble with all the teachers and neighbors, I soon realized after the medication, that I was wrong!
While I'm sure there are children who are medicated that it either doesn't work or they don't need it, there are still those children who do. Our child was medicated for 3 years...then after one great summer without the meds and my feeling that it depressed him, we went without and with the help of his dedicated pediatrician and a Special Education Department that is outstanding, we are seeing success.
You need to understand that there is a tremendous difference between little Johnny being a pistol and actually having ADHD. A little pistol I could deal with...a true brain dysfunction requires the support and help of your pediatrician and despite your inference to drug companies, these children need these drugs too.
A dedicated pediatrician like the writer of this article will actually spend time getting the diagnosis and not base it on a few incidents. Our child was diagnosed after 8 sessions with a Psychiatrist and numerous testing with both the pediatrician and the psychiatrist. He also visited our child's school and spoke with all of his teachers. It was not a diagnosis made willy nilly! There was also test to rule out all other disorders!
When she was 7, I went to a therapist for parenting skills to better handle her behavior, and they suggested bringing her in for ADHD evaluation. Again, because she is smart and had already developed good people and coping skills, she did not receive the proper diagnosis. Our family background is that her father and I have been married for 23 years, she is the oldest of two teenage girls, I've been a stay at home mom since she was born, and her sister doesn't have these problems. In fact, her sister has helped her with responsibility since she was five. I've often said that if my youngest was born first, I would have had my 17 year old back to the doctor as a baby asking what was wrong. However, I didn't know any better. I thought parenting was supposed to be this hard.
ADHD, especially the inattentive type, presents differently in girls. My daughter convinced herself she was stupid because the easy things caused her so much trouble. She couldn't figure out why she caught on so easily to complicated drum rhythms while the easy ones were hard. It could be the hard rhythms were varied and complicated enough to hold her concentration. She is now on medication and holding her own. She still isn't 100% reliable, but 70% is a lot better than 40%. I look for progress, not perfection. Her self confidence has improved, too. She was afraid to get her driver's permit because she felt something was wrong with her. Now that she is on medicine, she's ready. Her problem isn't that she can't pay attention, but that she can't always pay attention to what she is told she should. It isn't that she doesn't notice things, but that she notices so much she can't always pick out what other people consider important.
I am not happy that she is on medicine, but I am happy that she is happier with herself. The best thing is that she feels confident in her abilities to make it on her own.
I would never medicate a child because he was a pistol. I celebrate spunk and energy in my patients whenever I find it. The kids I worry about are the ones like those mentioned above, who are having a terrible time in school and at home, especially those who feel terrible about themselves because of it. And rather than dampening accomplishment, I've seen medications help kids accomplish.
If only it were as simple as a cup of coffee, or a just some effort on the part of the kids and parents! But as people are pointing out, helping kids with attention problems is far from simple. I don't like medicating kids—and I've yet to meet the parent of a medicated child who wouldn't rather their child weren't taking meds. C.A. is right, there needs to be more research, and more help available. Lots (and I mean lots) of structure and support can make a difference in kids with ADHD, but my experience is that it's not always possible to build enough structure and support to help every child—not every school, or every family, can manage. Which is probably why the current research shows that the best results in treating ADHD come with a combination of behavioral treatment and meds. If we could provide all families and schools with the resources they need when they need them, I bet fewer kids would need meds.
Dr. McCarthy sees the issue, that's why she wrote the article. I do take exception, though, with the notion that more money will help solve the problem (i.e. providing schools and families with resources). It hasn't helped so far.
I am now, and have always been, a fearsome advocate for children. They have no voice, and they have no choice. We must protect them...even from the well-meaning.
And, lest you think I'm talking sans experience - I spent years working with these kids, first as a volunteer, and then later as a (very) low-paid teacher's aide. It was fascinating, exasperating, and rewarding. The kids who did best were the ones whose parents were very involved, and who had structure, boundaries, and rewards in their lives.
Yes, ADHD is complex! I'm a boomer too. Sadly, Cynthia's story about her daughter could have been my own story. I wasn't a quiet little girl, but I was likeable and a teacher's daughter. All my teachers knew my parents were involved and we had a pretty good home life. I was a good student when I remembered to do my work. I loved learning. I was often frustrated with myself because I would often miss instructions. Or not understand them. My drifting mind only heard bits and pieces.
Years later as a mother myself of two children, my psychiatrist spoke with my parents and concluded that it was a shame I wasn't diagnosed with ADHD and received help as a child. But he had his doubts too whether it was truly ADHD I was experiencing. I am presently diagnosed with bipolar, a condition similar to ADHD.
When my son was 3 he started displaying symptoms of severe ADHD. I was so torn about what to do about it. I was a certified teacher myself with Special Education emphasis, so I made a major decision. We homeschooled him and had him take Ritalin for his first 4-5 years. Most people are not able to choose the route we decided on. I felt it was more beneficial for him to be medicated for enough years for him to learn to learn. Once he knew how to read and enjoyed his schoolwork, we took him off medications. From then on, we learned together how to cope. We used a lot of different techniques, some of them looking very strange. But the most important thing we did was persist. He was intelligent and I wouldn't allow him to do anything that wasn't his best.
Today he's 18. Just graduated from our own High School. He's respectful, kind, thoughtful of others, a little shy, never has abused drugs, never gotten into trouble with the law, loves to read, wants to be involved in libraries some day.
He demonstrates some characteristics of Aspergers's but we've dealt with it. We tried the best of both worlds. He knows it was important for him to take medication. He knows he has trouble with attention. But he understands how to cope too. (Ever see what Vault does for the ADHD kid?) We've even suggested that he may want to see a doctor for some assistance if he runs into trouble with college classes. Temporarily of course.
I can see the issue on most of the sides discussed here. Part of our problem is the cookie cutter approach to education that doesn't allow different children to find their own way in life. As a former public school and private school educator, I can attest to the frustration of not being able to reach all the children with their individual learning styles. The bell curve still rules.
And maybe part of the problem is with the impatience we demonstrate today to treat everything in sight with a quick fix, AKA medication. Sure, we're going overboard. I agree that we are trying to medicate everything that looks like a problem.
There really is no simple answer. As parents we sweated our decision out and then went through decades of wondering if we made the right decision. The jury's still out, but I have a good gut feeling that Mark is going to do just fine.
Pouring more money into the educational system isn't really the answer either. Because I stayed home and didn't draw an income for about 15 years (I had two children with special needs), we lived in near poverty all that time. We often despaired of getting the educational materials we needed from year to year to homeschool. Thank God for libraries! If we ever reach the utopia-like Star Trekish society where money doesn't matter anymore, we might actually see some progress. But that's not going to happen.
More money could hire more psychologists, and create more programs to educate and support parents and families. It could create more after-school programs, too, that could help a child who needs structure as well as a place to get homework help and blow off steam. The money would have to be spent wisely, obviously, but it could truly help.
When I wrote the word "resources", though, I was speaking more broadly. Resources could be a neighbor who cooks a casserole so that a parent can sit for two hours with a child to do a worksheet that should have taken half an hour. It could be support groups. It could be an understanding teacher, or doctor, or school nurse. Resources could simply be help.
For those of you who have lived through this, what made the biggest difference for you?
CA...working with these children as a job, while being a wonderful rewarding experience for you, does not in anyway make you an expert on whether to medicate a child or not! My knickers tend to get in a twist when people like you decide I have been "doping" my child as an easy fix! Having a child with this diagnosis can essentially change your entire perspective on the issue of whether to medicate or not!
If you truly worked with children suffering with this you would understand the need to medicate some and not others. You would have also seen the difference that medication can make for some of these kids. You would also KNOW that the correct dose of medication does NOT make them zombies!
Until you have walked a mile in the shoes of parents who must deal with this...then you need to keep your thoughts off of my knickers!
To Cynthia, Beverly, PJ, Frightening, Kathleen, Amy, and Heather(I hope I got everybody!): my heart goes out to you and all parents of kids with ADHD. All we can ever do is fight for our kids, and do all that's possible to help them. Each of you is doing that in your own way, and I honor that: each child, each family, each situation is different. I hope that you don't get too discouraged—and I hope that you can get the help you need.
The main thing parents can do is to NOT rule out any treatment, until your sure that it does not benefit your child. The ability to learn to read as well as other skills may very well depend upon administering meds for at least a while. I don't advocate it for long term use, but find it has had tremendous benefits for our little guy!
Dr. McCarthy,
You are talking about medicating kids that can't pay attention, for what, may I ask, so they can grow up to be efficient soldiers and kill people. What does a child have to look forward to these days knowing what adults will expect of him or her once they are grown up. Maybe the kids with ADHD are healthy. Maybe it's the other kids, and me and you and the rest of the "so called" healthy individuals in this society who need to be drugged.
My son is homeschooled because he fell far short once he netered public school. He demonstrated a high degree of learning in his younnger years, and was in a Montessori program. Yet, the public school would say he did not show the typical characteristics of a gifted child. Add to that the slumping performance and poor social interaction, he was labeled as a problem.
For him, tailoring lessons to his speed of thought has helped tremendously. The one on one has shown me where he is having problems and why he doesn't stay focused. I prefer not to medicate him, if that is even what he needs. But I also have the benefit of being able to give the attention to his learning. I felt I was spending so much time managing his education anyway, I might as well do it myself.
I do not have insurance, so going through a series of test to diagnose the true problem is not an option. After all, the bottom line for me is if I am able to address the problem without meds, that would be my ultimate choice with or without a doctor invovlement.
I guess I point this out because the comments here show that there is not one approach or one answer. What is working for my child may not work for another. I have dealt with some children where the meds have been a godsend.
If I just wanted him to be a soldier, I would leave him alone and let him do as he pleases!
I do agree that perhaps you need medicating before you start commenting on articles that you know absolutely nothing about.
As for letting kids be kids, my daughter pushed for drum lessons, pushed for a drum kit for middle school jazz band (and won several awards), pushed to be in the marching band percussion battery, and decided to stop it all her senior year. Her fellow band members gave her a hard time about this. I told her the decision was up to her, and I encouraged her to do what was right for her.
My daughter is far from a soldier. She is respectfully opinionated and outspoken. She has her own style and a great sense of who she is. She is one of the few people in school who is liked by almost everyone and truely enjoys and accepts them all for who they are.
So good bye, PJ, Dr. McCarthy. You can suject other human beings to your programming. To the extent that I don't have to be sujected to it, I won't. I'm not comming back to this article and it's probably only a matter of time before I log off this site entirely. I don't like to feel sick and that's the way you make me feel. I'm sure even human beings who are determined to direct their the path of their own evolution by willing themselves into unthinking robots who know nothing but how to program and reprogam themselves and to carry out any program that they dicide upon, will always have a vestige of humanity left in them, but that vestige is so tiny that it is worthless for me to try to connect to it. I'll go somewhere where people want to be human, where people love life because that's all they know, where people who make up their own minds about what constitutes their mental health, and finally where people who feel good about themselves "are" mentally healthy.
Bye
Can you say narcissistic with delusions of grandeur? Or perhaps are you having a medication induced psychotic episode?
I also have concerns about parents who would go "shopping" for physicians who would medicate a child that did not truly have ADHD. Our child is 12 and has the same pediatrician his entire life, plus we consulted him before our child was born....knowing that the father also had ADHD. While I'm sure there are parents out there who would do this kind of thing, I myself can't fathom changing Dr.s solely because he would not medicate my child for ADHD.
I'm not sure how your school district operates, but in the small town I live in there are educators who teach gifted classes, those who teach average classes, those who teach slower learners and then there are those that teach to the problem children. If your not seeing any children with attention or behavior problems, it might be because your not teaching that particular group of children.
I am of the notion that perhaps there are more children with this disorder today due to environmental conditions. We have much more pollution today than at any other time in our history. It will be years to come, but I believe that pollution will be the root cause of many many disorders, not only in children but in adults as well. Nor will the disorders be limited to behavior or mental problems.
I also believe that a child who has been thoroughly tested and found to have ADHD, should at least try medication for one month during a school session. I know it opened my eyes to the benefits of medication. If it helps your child, what a blessing, if it doesn't, one month on the meds won't make any difference. We medicate for colds, sinus and infections without any regard to how they affect our children, why would you do any less for this disorder?
I don't know what the answer is. More continuing education for teachers on behavioral problems and learning styles in children? More education for parents? More education for doctors? Probably all are necessary.
I also have questions about the American gene pool. The people who willingly came to this country either had big dreams and ambitions, a restless nature, or couldn't get along in their own society. Could the majority of the people who settled the west have had some form of ADHD?
We are also a very creative country. Creativity is usually very high in people affected with ADHD because, I think, they don't see the "normal" boundaries (thinking outside the box).
I guess I'm saying that ADHD has probably been here all along and helped our country grow, but our lifestyle changes have made it a disorder.
As I said before, ADHD exists. I've had friends in high school who had it, but they were taken to behavioral therapy and learned how to manage their illness. Their parents didn't sedate them with drugs.
I agree with Cynthia B. when she said that "ADHD has probably been here all along and helped our country grow, but our lifestyle changes have made it a disorder."