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The "Right" Treatment for ADHD: Revealed

Posted by Dr. Sushrut Jangi  August 23, 2013 04:28 PM

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This is the conclusion to a case about a child diagnosed with ADHD I posted last week (http://www.boston.com/lifestyle/health/mysteries/2013/08/medicating_children_for_attention-deficit_hyperactivity_disorder_adhd.html).

The child's family and physician were making decisions about how to treat this disease. Many readers voted that starting an ADHD medication and behavioral therapy together might be a good way forward. Her doctor agrees with this approach.

"A lot of judgement happens the day I talk about starting medicines for young children," Dr. Chan says. Most parents have already tried numerous other routes, such as behavioral therapy which is frequently recommended first.  

But behavioral therapy alone is hard to implement. "It's hard to access and there's not too many families who can actually carry it out," Chan says. "If you're a single parent working multiple jobs, its really hard to fit the time to take your child regularly. It's a huge time investment." J's parents tried the behavioral therapy route and they worked hard at it. But he wasn't improving.

Dr. Chan is more than familiar with the culture of fear that surrounds ADHD medications, but she feels these fears are overinflated. Consequently, children who might benefit from being on medicine get delayed treatments, which can have harmful social effects. "Children in his class already know that he's different, so they react to him differently. Children with ADHD start getting negative feedback from their peers early on."

Dr. Chan feels that this is one potential justification for starting medications early.  "These medicines can help children get out of cycles of negative-feedback.  And we're not condemning children to medicine for the rest of their lives. They can be started as a trial, and then stopped down the line."

Frustrated, tired, and hoping for a solution, J's parents listened to Dr. Chan and made the choice to begin medication. Within weeks, J's teachers noticed a startling difference. His behavior reports at school, which used to be mostly reds and yellows - a sign of inadequate performance - suddenly transformed into greens. His parents were stunned. "The effects of these medicines are fairly immediate," Chan says. "You can pretty much tell within a day or two if they are going to work."

But the key, Dr. Chan says, is not just using medications. Once a child has proven to benefit from an ADHD medication, the child is more likely to work together with a parent or a teacher to learn strategies that will lead to longer-lasting behavioral changes. Then, when the child is off medication, he retains these useful behavioral patterns.

The diagnosis, Dr. Chan stresses, must be accurate before starting a child on ADHD medications. Sometimes, other conditions masquerade as ADHD, such as insomnia, anxiety, depression, autism, seizures, lead poisoning, or even child abuse.

 When I ask her if she feels that dramatic rise in ADHD rates is real, she pauses.

 "I think overdiagnosis of ADHD occurs but so does underdiagnosis. There are children out there getting medications who shouldn't be, and there are children who are not receiving medical therapy who should be."

 But despite this phenomenon, she agrees that its possible something else is going on in our society, something that is driving up ADHD rates in children. "We are requiring younger and younger kids to be in more structured academic environments. There's a lot of kids who are 3 or 4 or 5 years old who are just not ready to be quiet and do that kind of intensive work." Schools have curbed recess and made lunches 20 minutes long; at home, kids are exposed to high amounts of television, Ipads, and the internet providing continuous novel stimuli that might induce neurologic changes that foster shorter attention spans. "The jury is still out on this, but people are studying these kinds of environmental changes now," Chan says.

Not every child with ADHD will benefit from the medicine, or even the same kind of medicine. Every diagnosed child requires a unique combination of treatments, whether they are medications, behavioral therapy, school accomodation or special education services. And every medical decision is intensely personal, shaped by experiences of the child, parents, and the physician.

Recently, at a party, I met a couple raising their four year old daughter that made me realize how difficult diagnosis and treatment of ADHD in children must be, especially when childhood is a period of such intense activity, growth, and change.  The young girl, I noticed, had a lot of energy and was running around the room in circles. During dinner, she sat in the corner with an Ipad glowing, the screen throwing colorful lights and sounds across her face. "The Ipad keeps her quiet," her mother whispered. But I worry, she went on, that she can't keep quiet without it. What will we do when she starts school?

 Do you think she's normal?  she asks.  Or do you think she's developing a larger problem?

This blog is not written or edited by Boston.com or the Boston Globe.
The author is solely responsible for the content.

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About the author

Sushrut Jangi is an internist at Beth Israel Deaconess Medical Center and an editorial fellow at The New England Journal of Medicine. More »

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