Meds for ADHD: They Work, But Is That the Right Question?

Recently my teenage daughter presented me with a moral dilemma. Up to one third of the kids in her high school are prescribed some kind of psychiatric drug, most of them stimulants like Ritalin. Many of the others students buy drugs from those who are getting them by prescription. If a person who has not been prescribed the drug takes it for the SAT's, is that cheating?

My reflexive response was "yes," but on further thought I wondered: If it has become so much the norm to be on stimulants, are the kids who are not taking them at a disadvantage? As my daughter wisely observed, anyone has trouble paying attention when sitting for a 5 hour test.

The point of this story is that there are serious long-term consequences to prescribing stimulant medication to large numbers of children. In addition to the above dilemma, by controlling symptoms with medication, the motivation to provide more comprehensive treatment is lost.

To the statement that they "work" I answer that yes, the drugs, at least in the short term, reduce symptoms of inattention and hyperactivity. They make a child conform to society's expectations. If medication helps a child to learn, then in our current educational and social system prescribing may be necessary. But is it right?

Bruce Perry, a psychiatrist who has developed a comprehensive treatment approach based on brain development captures this dilemma well when he writes:

Human beings are biological creatures. Of the 250,000 years or so that our species has been on the planet, we spent 245,000 years living in small transgenerational hunter-gatherer bands. The human brain has evolved specific capabilities that are hominid and pre-hominid adaptations to the millions of years of living in the natural world in groups of 40-50 individuals in these transgenerational groups.

The relationally-enriched, developmentally heterogeneous environment of our past is what our brain "prefers." Our brain is not well-designed for the artificial light, pervasive visual over­ stimulation from television, the distracting sounds, images, anonymous social interactions and host
of other phenomenon related to life in the modern Western world. The impact of the changes in the way we live, work and raise our children has not been completely examined. While well­ intended, many of our current lifestyle choices are likely contributing to the emotional, social, cognitive and physical health problems in our children. The most alarming is the relational poverty that many of our children are experiencing. This is most disturbing because humans are fundamentally relational creatures.

Relationship-rich interventions include such things as martial arts, music, and team sports (Michael Phelps had severe ADHD), activities that foster relationships and also promote self-regulation. Family systems are often severely strained when a child is struggling, and interventions aimed at supporting the family as a whole are very important. Careful examination of the school setting and accommodations to decrease over-stimulation are similarly necessary. But if the drug makes the symptom go away, there is no motivation to devote effort and resources to make these kinds of changes.

Obama's health care reform takes a small step in the right direction. ACO's (accountable care organizations), if they work the way they are intended to work, will encourage primary care clinicians to take the time to carefully listen to patients stories. In building relationships with parents, these clinician have the opportunity to support healthy development of the next generation in a preventive model.

Last week there was a little noticed news item about reports of the possible association between suicidal ideation and Focalin, a stimulant medication used for ADHD.

The FDA said it received eight reports of suicidal thoughts for children or adolescents who took the drug over the past six years, and four of the cases appeared to be linked to the medicine. The link for the remaining cases was less clear.

Kaitlin Bell Barnett, a journalist who writes very intelligently about psychiatric medication, asks on her facebook page "Based on 8 cases of suicidal thoughts ever reported?" I'm not sure what she meant by this question. But it seems to me that even 4 cases is enough to make us seriously rethink this path we are on to medicate away symptoms rather than address "relational poverty" in a meaningful way.