ADHD needs more than drugs to appropriately treat

I consider my most successful cases to be the ones that do not seem me any more. Not that they are “better”, but they and their families have come to realize the full complexity of the problems they are struggling with, and are getting appropriate help.

I inherited my “ADHD practice” from another pediatrician. He was wonderful man, a larger than life, toss babies in the air pediatrician with a hearty laugh. He never had an unkind word to say about anyone. He had retired from general pediatrics and was only seeing “ADHD patients,” when he died suddenly in a tragic accident. His patients were devastated. I had recently started my own behavioral pediatrics practice, and his practice, where I had worked previously, asked if I would return and take over his “ADHD patients.” Out of loyalty to him, I agreed.

I learned that he was seeing his 170 or so patients once every three to six months for a 30 minute visit. This was pretty much the standard of care in pediatrics. But I felt that if I were going to prescribe a mind altering drug to these children, I wanted to learn what was going on in their lives. I particularly tried to open things up when kids were doing poorly. I didn’t focus on adjusting the dose of medication when they were failing in school, but explored other possible reasons for their academic struggles. This meant uncovering some pretty difficult problems, including complex family conflict. Some families got angry and left. “We thought you just weighed and measured Johnny and then refilled the prescription.”

But a few families welcomed this chance to talk. I encouraged one mother (details have been changed to protect privacy) to meet with me alone because at our visits with her 12 year old daughter, Kaitlin, she would speak so harshly and critically that it made me uncomfortable. “She’s just lazy, ” she would say. “She’s always been impossible.” When we met alone, she described a deeply troubled relationship with Kaitlyn since she was an infant. Kaitlin had been on medication for ADHD since she was 9, but her mother revealed to me that she had always questioned the diagnosis, saying, “its more complicated than that.”

We worked together for a year. I met with them for a 60 minute visit every three months. I would ask about the medication, while also talking about other aspects of Kaitlin’s life. I started to meet for half the visit with Kaitlin alone. It each visit I suggested that talking with someone on a more regular basis would probably be helpful, but they did not follow through. Finally, at the end of one session Mom said to me, “Kaitlyn feels that she would like to talk with a therapist.” I referred them to a wonderful colleague who fortunately took their insurance and had time.

It proved to be a great match. Kaitlin has now been in therapy for 2 years. Recently my colleague and I met for lunch. She filled me in. Kaitlin is off her medication. While she does need extra help, she is doing well in school. She is developing a strong sense of herself. She has many friends and interests. Perhaps most importantly, her mother, who also meets regularly with my colleague, is happy and very proud of her daughter.

Some of my patients have what I refer to as “straightforward ADHD.” They likely have a neurobiologically based difficulty with focusing and attention. Stimulant medication allows them to learn. There are no other issues. If I can get all of my patients to receive the help they need, as I did with Kaitlin, my practice would consist of only these children. It would be a fraction of the size it is now.

Claudia M. Gold is a pediatrician who blogs at Child in Mind and is the author of Keeping Your Child in Mind.

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  • http://www.myadhdsite.com Bruce Ziebarth

    This article leads me with several questions. Initially, this doctor sounds like a pediatrician. You would expect a “medical” doctor to treat the problem and send the patient home.

    Since I live with ADHD, I would say that it does take follow up visits. ADHD may be accompanied by many accompanying issues. Once, one symptom is learned to be dealt with there may be more.

    The doctor eludes to the fact that patients do better with therapy. In my experience, this is the best treatment. If for no other reason then to provide another point of view. My doctor would not prescribe me stimulant medications. He stated that should come from a psychiatrist.

    As I said, this article left me with more questions than answers.

  • http://www.silvercensus.com/ Steffan Lozinak

    As a person diagnosed with ADHD, I can honestly say I do not feel medication is the answer. In fact, I think medication is a bad thing to give to a person with this “disorder”. I feel ADHD, Aspergers, and Autism are all essentially just varying levels of the same mindset, and I don’t think actually thing there is anything “wrong” with people like this. I feel it’s a disorder as it removes order from things, but I feel society should be malleable enough to work well with people like this. It shouldn’t be the goal of society to make them fit in, so much as it should be the goal of society to work with everyone.

    • http://www.myadhdsite.com Bruce Ziebarth

      Steffan,
      I whole heartily agree. As ADHD subtypes go, I have what they call “Ring of Fire” ADHD. Stimulant medications are necessary in my case to begin slowing my mind down. However, medication alone does not cover all symptoms. Non-medication strategies are necessary to alleviate all symptoms.

  • Bruce

    As a patient with ADHD, I enjoyed this post. However, I really think that… Oh, look! An airplane!!

    • http://www.myadhdsite.com Bruce Ziebarth

      That was intelligent.

  • http://bizsavvytherapist.com Susan

    As a psychologist who works exclusively with children with ADHD and autism and their families I want to thank Dr. Gold for this article. It would be terrific if more pediatric practices could bring in developmental psychologists into the practice to work with families such as the one she describes. We could help children and families so much more quickly and easily if all it required was a walk down the hall and a passing of the medical record, rather than needing to offer referrals and hope the family follows up and the therapist is available and takes insurance.

  • Lisa

    I also have adhd and I see both a psychiatrist and a psyhcologist. I made the choice to take medication and I believe it goes hand in hand with therapy. The medication helps me in so many ways, not just simply helping me concentrate better. Seeing a psychologist is a necessary part of treating adhd because there are adhd-related issues that only a psychologist can address. If a person with adhd just takes a medication, they’re missing out on part of their treatment.

  • Truce T. Ordona, M.D.

    I am an Adult and Child Psychiatrist working in a mental health center with a catchment area of about one million people. We just received a fouryear research grant by the NIMH to study and treat early onset psychosis.
    One of the issues that distressess me is the issue of longterm outcomes of children misdiagnosed as “simple ADHD” as I see them in our center with serious and, often tragic outcomes.
    There are 3 tiers of symptom and behavioral complexes associated with Bipolar Affective Disorders from childhood upwards The most common tier has 23, the less common has 19, and the least common has 4. In the first tier, one of the most common–and beguiling as well as misleading is the symptom cluster called ADHD. If the practitioner does not carefully solicit input from the school and the whole family, one can fall into the trap of treating the smoke (ADHD) and aggravating the fire: Cognitive, affective, and behavior disorders that can, in fact, be aggravated by CNS stimulants which, some practitioners treat with anxiolytics or atypical antipsychotics.
    We all need to be more impeccable about our diagnostic formulations heeding the caution written by Ludwig Wittgenstein who said:
    “The limits of my language mean the limits of my world.”