Pre-school children and Ritalin (Part 2)
The data were reassuring: although, compared to its use in older children, side effects occurred more often and it was effective in fewer kids, the majority of children appeared to benefit and only a minority (11%) stopped the medication due to significant side effects (which resolved when the medication was discontinued). Best of all, no really bad events occurred.
This is an important and legitimate question. Few trends have provoked more heated controversy and passionate opinions than has the surge in the use of psychiatric medications in children, and especially in those who are less than 6 years old.
As a developmental pediatrician getting long in the tooth, I have prescribed stimulant medications to lots of children. While I have seen their clear benefit, I too wonder and worry if starting such a medication in a young child whose brain is still actively shaping itself could have a long term effect - bad or good - on the final architecture and chemistry of that brain. Since this phenomenon is relatively recent, we simply don't know if this could happen and, frankly, we are unlikely to for another decade or two, when these kids grow up and are studied.
Given this unresolved concern, why then do I continue to prescribe stimulant medications to young children? It has evolved out of my clinical work.
I had been trained not to use medications (this, of course, when dinosaurs roamed the earth). It took me many years and many failures of recommending improved limit-setting and time-out and other environmental interventions which seemed to have no effect before I finally screwed up my courage and prescribed a stimulant for ADHD.
Kids with ADHD who need and benefit from medications are those who had been having serious problems in their lives: abysmal school performance, no friends, disrupted family relationships, poor self-esteem...the list is always long and heartbreaking. And I saw stimulant medications in many cases providing benefits that were so far superior to what I had been previously recommending, so gratifying for the child and parents, that it seemed like malpractice not to offer the child and family this way to relieve the child's suffering.
So, despite the unknown potential for long term side effects, the short term benefits are so undeniable and the side effects, when they occur, so manageable, that I recommend these medications without apology.
But, of course, some beg to differ. I have followed the objections to using stimulants for ADHD with interest. Generally they boil down to the following:
- It's a conspiracy by psychiatry and other nefarious elements (I suppose like me) to control and shape the minds of children, and/or it's an abominable practice fostered by unscrupulous physicians on the payroll of the drug companies. This is a time-honored ad hominen objection: if you have no coherent argument or evidence on your side, criticize the motives and honesty of the clinicians.
- It somehow just doesn't sit right. The implicit prejudice is that behavior problems must be managed by environmental engineering, not by tinkering with brain chemistry (even if it's clear that a difference in brain chemistry and not an inappropriate environment causes ADHD in most kids).
- These meds are a crutch, used by lazy, ineffective parents (and professionals) who want to chemically restrain their normal, active kids. In fact, they often argue, ADHD doesn't even really exist.
(Of the three, I find this last the most egregious. It unfairly damns parents of kids with ADHD as the cause of the problem, as maliciously using medications for their own selfish interests and not to benefit their child, and as not knowing or caring what is best for their kid. Aside from the fact that I've never met such a parent, it is a boneheaded and mean-spirited trifecta: self-righteous insensitivity to the real suffering experienced by kids with ADHD; the unconscionable accusation that parents are lazy and selfish and incompetent (with the self-righteous implication that "if I were this child's parent I would cure it beautifully without the need for medications. Why can't you?" This inevitably comes from someone who never raised a child with ADHD themselves.); and a stunning lack of insight into the complicated forces of both nature and nurture that guide human development and behavior.
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OK, that's my rant and I'm sticking to it. What about the use of stimulants in pre-school kids? Here's my take:
- By age 4 - but not before - good clinicians can be reasonably accurate in making a diagnosis of ADHD. If a child is experiencing signficant problems in the important aspects of his life (learning, relationships, self-esteem, etc.) then medications can be incredibly helpful - just as they often are in older kids - and should be considered.
- The diagnosis of ADHD can't really be made (although sometimes suspected) in two-year-olds. Let's face it, all two-year-olds have ADHD (and a touch of psychosis while we're at it). Stimulant medications at this age are a no-no.
- The same goes for three-year-olds. Although, occasionally a child is in such trouble (e.g., the child I saw who was being expelled from his 3rd child care site, who had all the hallmarks of ADHD, and whose mom was going to have to leave her much-needed job to care for him) that, in desperation, I have tried stimulants - with variable success.
Bottom line: If you are parent of a child 4 years or older whom you and the professionals are convinced really has ADHD and who is having a real hard time in his life, don't be afraid to engage in a 'therapeutic trial' of stimulant medications. Trust yourself. You'll know if it is helping your child or not. You'll recognize side effects that might warrant discontinuation. You'll know if the stimulants are a boon or bust for your child. Don't let the self-serving, self-righteous sneeries make you feel like a bad parent for doing so.
Related Topics: ADHD: An Update on Diagnosis and Treatment for Kids, ADHD: Boys Vs Girls
Technorati Tags: ADHD, Ritalin, preschool, child development
3 Comments:
Kids with ADHD who need and benefit from medications are those who had been having serious problems in their lives: abysmal school performance, no friends, disrupted family relationships, poor self-esteem...the list is always long and heartbreaking. And I saw stimulant medications in many cases providing benefits that were so far superior to what I had been previously recommending, so gratifying for the child and parents, that it seemed like malpractice not to offer the child and family this way to relieve the child's suffering.
My Dear colleague, these are not the kids your critics are referring to. No clinician worth his credentials disagrees with you. If only these were the only children treated with stimulants, I'd shut up.
But does 8% (I'm being kind here) of the poplulation fit this description? Clearly not.
Finally, accurate diagnosis is essential. Most of us in private practice cannot make an accurate diagnosis with a Connors or a Vanderbilt alone.
I will continue to refer before I prescribe.
best,
Flea
my son has had an adhd diagnosis for 8 years, which was made by Kaiser, and supervised by my ex-wife, a non-specialist MD.
For years I trusted Kaiser, and put up with dismissive and conclusory responses to my questions. Most of those answers eventually came down to "trust me, I'm a doctor".
But the results were dubious, and neither the ex nor Kaiser were happy with the results they were getting; it was not at all clear that the cure was better than the disease. I realized that my questions were not being answered, so I started to do my own research, including looking at the diagnostic standards themselves, and questioning many MDs about the diagnostic practices generally, and specfically in my son's case.
Initially, i was told insistently that ADHD was known to be the result of a neurological chemical imbalance. Gradually, doctors admitted they knew this was not true, and in fact they had known contradictory information, eg the conclusions of the 1998 NIH ADHD consensus conference (that there was no independent test, and no evidence of brain malfunction in ADHD). The current Kaiser position is that "nobody knows what ADHD is, you should have never believed that it was a chemical imbalance, and we never told you that; we only medicate because we don't know what else to do, and even if we are still telling other parents this is a disease caused by a chemcial imbalance, we are speaking in metaphors."
So I have asked specific questions, in writing, that they ignore. Of course this destroys their credibility in my eyes. Incidentally, I have a graduate degree and have done legal investigations for a living, over 20 years, so I have a fair idea of how to handle evidence, and a fair amount of experience in judging logic and credibility.
More academic discussions of ADHD call it a "spectrum disorder" (ie, you can have any amouont of it) that has no single etitology, and is a "complex of symptoms and associations". Nobody says, that is entirely consistent with the hypothesis that ADHD researchers are using a faulty model, and are barking up the wrong tree.
So I asked myself, if nobody knows what ADHD is, how do kids get diagnosed ADHD? Can we deny that ADHD is the diagnosis? That seems like a mathematical identity to me, and undeniable. If somebody wants to deny that, then they can try to explain that resulting bag of worms in another thread.
SO - let's look at the diagnostic standards, and how kids are diagnosed ADHD. You have to exhibit 12 of 18 DSM standards citing a vareity of instances of inattention. How do thay know the child does that? They get the consensus of the teachers and parents. Usually, a child has some sort of trouble in school, the teacher suggests a learning problem related to hyperactivity and/or inattantion, and the parents are cooperative.
(Because ADHD is thought of as a disease, ie a status, kids are generally not re-evaluated; Kaiser told me for many years that once diagnosed, the child would stay on meds throughout their school career, because it could not be cured, only treated.)
So do they confirm the evaluation of these laymen? No, they don't. They're not equipped to. Some MDs pay more attention than others, but the standards don't require extra effort, and it's not malpractice if you don't put in extra effort.
Do they ask the layment to adhere to a standard? Like, is this kid in the top or bottom half of inattention? No, they don't. They ask (and I have seen forms asking) is the child "more" or "less"?
Now, I do legal investigations. I don't know what "more" or "less" means, and no MD has been able to tell me. The point is, they could easily make it clearer and more objective if they wanted, but they don't.
So the ADHD children are "more" inattentive in 12 of 18 behaviors. So a simple beat cop would ask, how did you come to this conclusion? Did you sit your class down for 4 hours straight and lock them to the blackboard? Have you gotten ADHD diagnoses for more than half your class? Are you the world's most boring person? These things DO happen.
The point here is that the diagnostic standards are defined in realtionship to the environment, and yet the environment is NEVER investigated. As a result, some teachers have NO ADHD cases, and others have the majority of their students on Ritalin.
Why would an MD ignore half the evidence that creates the diagnosis? Surely he is not that illogical. Why would he trust a layman's subjective word and medicate a child based on that diagnosis?
I can only think of one explanation: ADHD does not depend on what the child does; it depends on the teacher's view of the child's reaction. The doctor cannot know objective reality, and he isn't diagnosing that. He's diagnosing the relationship between the teacher and the child.
That is exactly what Kaiser told me in saying "we don't know what else to do".
Well, if you don't know what else to do, why don't you let go for a minute and let other people try their luck? You know, maybe some teachers who relate better to their students?
That is a very embarrassing question, and I haven't got an answer to it yet.
Nor do I have answers to, how you can know a child has a disease by observing his behavior, without also investigating what he is reacting to?
The more people I talk to and read (including the last edition of the well known book Psychiatric Ethics) the more I realize these issues are typical and well-recognized.
Can anybody here answeer why people treat ADHD as a disease, when it's logically clear that no objective condition can be identified without looking at both sides of the DSM standards, ie, the child's environment?
In medicine, no diagnosis is perfect or set in stone. If I diagnose a child with ADD or ADHD, and the paretns agree to a tiral of medication, we start, no matter what the age. If we do not see a clear improvement immediately on stimulant medicantion, either the child does not have ADD/ ADHD, or he has important co- morbiditites. In that case, we stop the medication, and refer to a child psychiatrist. If we can find one.
CEK, pediatrician, California.
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