Why doctors are too quick to prescribe drugs for ADHD

Originally published in MedPage Today

by Kristina Fiore, MedPage Today Staff Writer

Physicians may be too quick to medicate children suspected of having attention deficit hyperactivity disorder (ADHD).

The etiology of the disease is not well understood, and while some cases may have neurological causes, children may respond to psychotherapy instead, Esther Fine, PhD, a psychoanalyst in private practice in Los Angeles, told attendees at the American Psychoanalytic Association meeting.

“Unfortunately, it is now a prevalent notion that it is no longer necessary or relevant to understand the unconscious meaning of psychological symptoms,” Fine cautioned during a scientific paper presentation. “It’s becoming a popular idea to consider psychoanalysis, and even psychotherapy, ‘dinosaurs’ in the treatment of mental disorders.”

Fine said that between 1990 and 1998, the number of children and adults diagnosed with ADHD rose from 900,000 to nearly 5 million.

The increase coincides with a broader trend toward prescribing stimulants for its treatment. Since 1990, prescriptions have risen by 700%, Fine said.

On the other hand, the proportion of children referred to psychotherapy for ADHD fell from 40% in 1989 to 25% in 1996, and Fine said that number is even lower today.

One reason is that teachers may be diagnosing children as having ADHD. Concerned parents then request medications from pediatricians, Fine said, and pediatricians may be too quick to comply.

“Teachers and parents are looking for a quick fix,” added Mark D. Smaller, PhD, a psychoanalyst in private practice in Chicago who was not involved in the paper. “They’re reluctant to look at what’s behind that behavior, at what’s going on at home.”

On the other hand, psychoanalytic psychotherapy may provide patients — even young ones — with an opportunity to understand how their minds work, and why it works the way it does.

For example, Fine said some disorders can have roots in abusive child-rearing patterns.

“Certainly, parental child abuse might well set the scene for an attention deficit disorder,” she said.

In a case report, Fine discussed working with a school-aged patient who had a troubled childhood. After a few sessions, she discovered the underlying reasons for the young patient’s anxiety and aggression, and how they affected his relationships and his ability to learn in school.

“Clearly it did not indicate that his problems were due to some form of brain impairment,” she wrote in the case report.

Smaller said that if the therapist does “a full evaluation of the child and the parents, you’ll get a much better sense of what’s going on,” and a better idea of disease etiology so it can be treated.

Fine said her patient began improving in school before his parents divorced, resulting in his mother moving away and not returning him to therapy sessions.

She added that there may be other reasons parents avoid psychotherapy for their children.

“Parents prefer to believe there is a neurological basis for their children’s behavior, as it relieves the guilt that the child’s difficulties may be related to their inadequate parenting skills,” she said. “This tends to mask the family entanglements that might contribute to an overstimulating environment.”

She said ADHD certainly has many different symptoms and causes, so she doesn’t mean “to suggest that there are no children who suffer from a neurologically-based ADHD, or that medication should never be used.”

She does, however, caution against “a rush to judgment.”

Other attendees stressed that, in some cases, medication may be the way to go.

“I work with children a lot and I always try to get at the underlying mechanism for their behaviors,” said Mirel Goldstein, MA, MS, of St. Mary’s Hospital in Passaic, N.J. “But you really need to look at it on a case-by-case basis. Sometimes medication will be the appropriate treatment.”

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