First a few disclaimers: 1) I’m not rabidly anti-medication; it certainly has it’s uses and I’ve worked with clients to start medications as often as I’ve worked with them to discontinue them. 2) I am neither trained in prescribing medication nor do I want to be; I’m much happier collaborating with other providers who have that expertise. 3) My experience providing behavioral health services to children under 12 is limited.
According to this article, up to 90% of physicians specializing in ADHD are disregarding established American Academy of Pediatrics treatment guidelines for treating very young children (4-6 years old) suspected to have ADHD. The author indicated that AAP guidelines specify behavioral treatments (e.g., therapy) should be tried first, followed by a trial of methylphenidate (e.g., Ritalin) if behavioral treatments are not working. The researchers found that many specialists prescribed medication to preschool-age children before trying behavioral treatments, and many chose medications other than Ritalin (which reportedly has a stronger research base supporting use in younger children) for initial trials.
Of course, the AAP guidelines are just that – guidelines – and physicians are free to practice according to their own policies and professional discretion. I can imagine a number of reasons specialists might choose to disregard the the guidelines. Like many physicians, they might have limited time to collect data and thus miss crucial information. They may be facing demands from patients or parents for medication. Some may be dealing with limited access to and/or collaboration with appropriate behavioral health providers.
Regardless of explanations however, I find this alarming for a number of reasons, including that reliably diagnosing ADHD can be difficult; that behavioral treatments can be extremely helpful for many people and have distinct advantages over medication; and that medications can have significant side-effects and long-term risks.
Let’s start with a question: How do you reliably differentiate between your average 4-year-old, a 4-year-old with behavior problems, and a 4-year-old with ADHD? The DSM-IV-TR criteria for ADHD include signs and symptoms such as doesn’t seem to listen, loses things, is easily distracted, has difficulty waiting her/his turn, and interrupts people (full criteria can be found at behavenet.com). All of these are easily within the range of normal behaviors for this age. Additionally, acting out behaviorally is something that many kids do when stressed out or anxious (e.g., following a divorce), and behavioral issues may arise from parents’ difficulties setting boundaries, maintaining consistent rules and routines, or other family-related situations. My experience and training has been that severe ADHD is fairly recognizable, but anything less requires very careful assessment and efforts to differentiate between possible diagnoses.
Further, even if the issue really is ADHD, many people benefit from behavioral treatments including therapy and parent training courses. Children and parents can learn behavioral strategies to compensate for the challenges ADHD introduces into children’s (and families’) lives. Unlike medications, which work only as long as they are taken, these techniques will be available as coping skills throughout the children’s lives. For some, learning such skills eliminates the need for medication; others may find increasing their skills allows them to work with a physician to lower their medication dose.
Additionally, attempting behavioral treatments first may help aid diagnostic clarity. For instance, a therapist working with a family may find out diagnostically important information that the family either neglected to disclose to a physician or the physician neglected to collect. This might include recent significant stressors in the child’s life or the family that may be causing the child to act out or otherwise display ADHD-like behaviors. Alternatively, it may become clear that parental expectations for the child are skewed. I once worked with family who was convinced their child had ADHD in part because he often refused to complete the extra homework they assigned after he had dutifully completed all homework assigned at school. Finally, some parents simply find their current parenting skills overwhelmed by an active, headstrong child and can benefit from parent training to learn new skills for setting and enforcing limits, and so on.
Conversely a therapist working with a child and family can be extremely helpful in gathering confirmatory evidence for an ADHD diagnosis, including important details about what settings or times of day are most challenging for the child, and whether the child has most difficulty with attention, hyperactivity, or both. Sharing this information with the prescribing physician can be helpful in determining type of medication, dose, and timing of doses. Therapists can also help a family secure accommodations in schools, and assist parents and teachers to develop behavioral management plans when appropriate.
In contrast using medication as the first line of treatment, which the study reported 20% of specialists frequently did, can have significant drawbacks. The first I’ve already mentioned: ADHD medications – like other psychoactive drugs – have no continuing effect once you stop taking them. ADHD symptoms and challenges will likely recur soon after discontinuing the medication. If the child and/or family are not given the opportunity and encouragement to pursue behavioral treatments, they may essentially become dependent on the medication to engage in daily life.
Second, the medications come with risks for short- and long-term side effects. As I mentioned at the outset, I’m not in any way qualified to speak about these risks in depth. However, I write from my experiences with clients and note common reference material. In the short term, I’ve worked with adolescent and adult clients who complained of difficulty falling asleep or negative behavior changes (e.g., increased aggressiveness) after starting ADHD medication. Others have noted a disconcerting and difficult-to-describe sense of feeling “muted,” “muddled,” or mentally “stuffed with cotton.” With longer use, other concerns appear including growth impairment and physiological dependence. Additionally, recent media coverage of people abusing and/or becoming addicted to ADHD stimulant medications may be somewhat sensationalized, but also reflects a real risk. Just as stimulants like cocaine and methamphetamine can result in tolerance and addiction, so, apparently, can stimulant medications prescribed for ADHD. A quick search through Epocrates, a reference tool used by many medical professionals I know, lists myriad other side-effects (e.g., reactions to methylphenidate).
Third, based again on my professional experience and available references, misdiagnosing ADHD and prescribing medication can elicit or exacerbate other mental health issues including increased anxiety and agitation, psychosis, or mania. Imagine being chronically anxious and being handed a quadruple espresso. Now imagine being 4 years old without the vocabulary to describe what’s going on inside you.
Of course, when properly prescribed and monitored, ADHD medications can be extremely helpful. People often experience symptom relief much faster from medications than from behavioral treatments. Indeed, reducing the symptoms – and the personal and interpersonal stress they often produce – may be necessary for behavioral treatments to be effective. Physicians I’ve worked with have mitigated side-effects and long-term risks through carefully adjusting doses and prescribing “medication vacations” (e.g., during summer break).
In all cases, individualized, collaborative treatment plans tailored to clients’ and families’ needs, resources, and presenting problems is essential. At their best, such treatment plans involve the child, parents, physicians, medication providers, teachers and school staff, behavioral health providers, and other caregivers (e.g., daycare) as appropriate. What is clear from the study mentioned at the start of this post, is that well meaning specialists may not be following best practices for working with kids with ADHD. Parents need to be prepared to educate themselves and advocate for their children if they are going to get the best care and outcomes for their children.
