ADHD: To medicate or not

When someone asks me what a developmental pediatrician does, I tell him or her that I treat children who have a variety of developmental problems, such as attention deficit hyperactivity disorder (ADHD). Without fail, that disclosure elicits some sort of an emotional reaction.

Many people have strong opinions about whether the disorder really exists. Parents are still being told, by family and so-called friends, that it’s “their fault,” and that all these children need is discipline, sometimes defined as “a swift kick in the you-know-what.”

The truth is that ADHD exists and often requires a multipronged approach to treatment. According to the CDC, 6.4 million children ages 4–17 have been diagnosed with ADHD in the U.S. This percentage has risen sharply over the past decade — from 7.8 percent in 2003 to 11 percent in 2011.

To medicate or not

Even more emotionally laden is the topic of medication. People tend to be either for or against stimulant medications, such as Ritalin and Adderall, with no middle ground. Earlier in my career, I had a charming but extremely hyperactive patient whose mother was a healthcare worker. After a variety of nondrug approaches failed to help her child, she finally resigned herself to starting a trial of medication, but just for when the child was in school. It worked well, but at a follow-up visit the mother, shamefaced, admitted that she had been giving her daughter the medication on weekends, as well as for school, after the girl tearfully asked “Can I please take my medication for soccer?”

A pivotal research project changed the treatment landscape. In 1999, the MTA Cooperative group published the Multimodal Treatment Study for Children with ADHD. This landmark study proved that medication, with or without behavioral treatment, was superior to community treatment or behavioral treatment alone.

The findings took the country by storm. Pharmaceutical executives happily embraced these powerful, scientifically based results that would enhance company market share and increase profits and dividends. Insurance company executives were equally excited, with no more need to pay for time-consuming and expensive behavioral interventions. I was ambivalent. On one hand, these were beneficial data to help convince reluctant parents of children with such severe ADHD that they weren’t benefitting from behavioral and academic interventions simply to try the medication. On the other hand, I knew that ADHD is a complex disorder that generally coexists with a number of other problems, and that, despite the results of the study, quick fixes are rarely a total solution.

Fifteen years later: Questions remain about the value of ADHD drugs

Fast forward to today: I am not surprised to read and hear that people, both healthcare professionals and others, question the validity of the MTA study and are reevaluating the impact it has had on the current generation of children with ADHD. People are blaming the study for the overuse of medication. However, now, instead of parents being told that they are responsible for their children’s problems, critics are suggesting that medication is being used to keep children quiet in the classrooms because teachers can’t control the children’s behavior.

I am still ambivalent. I believe that the questioning is good, because maybe it will cause more doctors to follow the revised and updated 2001 AAP guidelines for the multidisciplinary assessment and multimodal (medical, behavioral and educational) treatment of ADHD (AAP 2011; AAP 2001). Those guidelines emphasize the benefits of an integrated approach that combines drug and nondrug therapies. But I am concerned that media hype focusing on overuse rather than misuse of medication can lead to mass hysteria, like that seen with regard to autism and vaccinations. Given the nationwide prevalence of ADHD, ranging from 4.2 percent in Nevada to 14.8 percent in Kentucky (CDC, 2011), it is important that we not “throw the baby out with the bath water” by negating the value of medication as an integral part of a treatment plan. We cannot return to the dark ages.

ADHD drugs: Tools, not a panacea

In my professional opinion — after treating hundreds of ADHD cases since the 1990s — medication is a tool that allows many children with ADHD to benefit from other educational, behavioral and psychological treatments and thus function better in their lives. It’s not for everyone, and is not a magic bullet, but for children who have been appropriately diagnosed, it can mean the difference between success and failure.

Iris K. Lesser is an assistant professor, department of pediatrics (child development), Albert Einstein College of Medicine.  She blogs at The Doctor’s Tablet.

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  • http://www.ronsmithmd.com/ Ron Smith

    Hi, Iris.

    Very good article.

    I’ve been treating children with ADD now for the whole of my thirty years. The struggles of parents to consider medication is sometimes monumental. I’ve seen my share of scams to cure these children up to the tune of even $6,000 for 6 weeks of biofeedback.

    What does amaze me is how easily it is for some it seems to prescribe medication without really much time listening to parents. I wonder if some aren’t taking as little as five minutes in the exam and consultation before parents walk out with a prescription in hand? I take time to explain the neurological nature of the problem and usually my long-windedness causes me to run past the appointed times.

    My experience has been that the medications do work of course, but I’m always concerned about other issues like learning disabilities which cannot be treated with ADD meds.

    Given that we like to see psychoeducational testing in these kids, at $1600 to $1800 its expensive and not covered by insurance mostly. The schools are required to do testing, but not with any speed, and the testing is almost never comparable to the 15 to 17 page reports that I get from private testing.

    I probably have some five hundred children I take care of. I don’t need another prescription to have to sign every month. I want my kids to be successful in school and life and so that time is worth it.

    I see four sequential peaks in ages of first presentation for evaluation. The largest is at 1st and 2nd grand, then 3rd or 4th, 7th and 8th, and finally there is a small blip at 10th grade. What I wonder is if the children are treated earlier rather than later get beyond their illness and can eventually stop medications? I have only a handful who continued to require treatment into college.

    Warmest regards,

    Ron Smith, MD
    www (adot) ronsmithmd (adot) com

    • PedsDad

      In reference to the psychoeducational testing… when my son’s school psychologist referred to her concern that he was autistic three times in the pre-interview process, we knew we weren’t going to get a good evaluation (he had already seen a developmental pediatrician who laughed when I asked her if this was a possible diagnosis and I was just in denial). We called the school and told them we would be requesting our federally allowable (under IDEA or ADA, can’t remember which) second opinion from the psychologist of our choice and they would need to pay for it as required by law. We recommended they skip the first evaluation and just pay for our psychologist. They did. She agreed with the ADHD visit and found that the crunchy granola Montessori school he was going to was having him sit in the corner looking out the window all day and was allowing other students to make fun of him. No wonder he was way behind in reading. We changed schools, got real services and started medication and he’s a classroom star (still bouncy but able to focus).
      It has amazed me how many of my patients have gone in alone and been given horrible evaluations and garbage diagnoses, but when I give them a few laws to quote suddenly things are done right.

  • http://www.ronsmithmd.com/ Ron Smith

    Hi, RenegadeRN.

    All the studies (and there have been more than a few) that have tried to reproduce prior claims that ADD was caused by food, food additives, dyes, sugar etc. have repeatedly been unable to verify any connection since I started thirty years ago.

    In my experience, I have seen many, many parents who’ve ended up coming in for evaluations after trying dietary restrictions only to have them fail. They were absolutely convinced in their heart there was a connection prior to the failure also.

    I just don’t believe these dietary restrictions prove out in my practice.

    Warmest regards,

    Ron Smith, MD
    www (adot) ronsmithmd (adot) com

    • RenegadeRN

      Thanks Ron!