Published: December 8, 2012
Parents, patients and care providers discuss treatment options.
To the Editor:
In the span of less than a year, The New York Times has published several news and opinion articles about the use of stimulants to treat attention deficit hyperactivity disorder that are simultaneously intriguing, disturbing and confounding.
On the Op-Ed page, in January, L. Alan Sroufe (“Ritalin Gone Wrong”) asserted that stimulants offer no lasting benefit because the causes of attention deficit disorder are better explained by environmental factors and experience. In August, Bronwen Hruska (“Raising the Ritalin Generation”) wrote about being pressured to medicate her son, despite her misgivings.
In your news pages, in June, “Risky Rise of the Good-Grade Pill” documented the misuse of stimulants by upper-middle-class suburban youths in an effort to gain an academic edge. In October, “Attention Disorder or Not, Pills to Help in School” described physicians who treat children in low-income regions with stimulants to help them to perform better academically and behaviorally.
The contradictory images of stimulant medication conferring either no benefit or major benefit must be truly dizzying for the reader not familiar with the proper diagnosis and treatment of A.D.H.D.
But those of us who work in the pediatric mental health field see every day that stimulant medication properly used can help improve achievement and behavior in children and adolescents with bona fide A.D.H.D. Stimulant medication helps them curb impulsivity and sustain attention so they can function better in both social and academic contexts.
Medication is but one part of a program that should include education about the condition, psychotherapy, tutoring and, most important, coordination among all significant players in the child’s life (family, school, doctors, academic tutors).
With all the challenges impinging on effective treatment of A.D.H.D., the task may seem next to impossible to accomplish, but despite these obstacles, we should not be dissuaded from finding creative ways to meet the needs of these children.
FRANCES C. SUTHERLAND
Bryn Mawr, Pa., Dec. 3, 2012
The writer is a psychologist who works with children and their families on attention deficit disorder and learning disabilities.
In my 17 years as a school social worker in the South Bronx, I saw many children medicated for A.D.H.D. It made them more docile and compliant. Often it made them into “zombies.”
Medication is one way to make rambunctious children fit in with the system, but it is not meeting the needs of these children. It is meeting the needs of the classroom. For that reason parents are often advised to give the medication only during the school year and not during the summer months.
The history of medicine is replete with medications that cause serious problems in the distant future. In other words, we may be harming the children both now and in the future.
Many good teachers have found creative ways to help children without medication. And if the schools would include more periods of gym every week, that might reduce the “need” for medication.
There are no blood tests, biopsies or X-rays to make a definitive diagnosis of A.D.H.D. What one doctor sees as A.D.H.D. another doctor may see as something else. The diagnosis itself has an element of subjectivity.
Scarsdale, N.Y., Dec. 6, 2012
I received a diagnosis of A.D.H.D. in second grade and was never medicated. As I reached middle school, the symptoms became more and more apparent. I was impulsive, rarely taking the time to consider the consequences of my actions. My grades slipped, and I began to get into serious trouble at school. By the time I was in ninth grade, I was using drugs and alcohol, and a year later I was kicked out of private school.
Despite all of this, our family therapist refused to consider stimulant medication as an option. She opted instead for antidepressants and antipsychotics.
A stimulant called Adderall turned my life around. At 18, I suddenly found myself able to focus and excel in all my classes. I graduated college cum laude and am now applying to medical school.
Stimulants are misused and abused like dozens of other prescription drugs. That fact does not negate their value in treating children with A.D.H.D.
Studies have found the incidence of A.D.H.D. in prison populations to be as high as 40 percent. When one looks at the symptoms of untreated A.D.H.D., those numbers shouldn’t be surprising.
I applaud Dr. Sutherland for addressing the inconsistencies, stereotypes and distortions that the media have too often brought to bear on the subject of A.D.H.D. I am a child psychiatrist and psychotherapist who uses medication in what I believe is a thoughtful and judicious manner.
When medication does appear to be a potential tool for treatment, I work closely with children and parents to examine the pharmacological options, potential risks and side effects. Like most of my colleagues, I use as little medication as possible and constantly re-evaluate my patients for the possibility of reducing or discontinuing medication. I work collaboratively with schools and other providers to look at additional treatment options and to offer a coordinated “net.”
There is much excellent neurological data to support a biological foundation for the true diagnosis of A.D.H.D. Like other diagnoses in the field of child (and adult) psychiatry, A.D.H.D. has passed in and out of fashion and been overapplied. This does not, however, negate the true and disabling nature of the disorder.
The judicious and supervised use of stimulant medication (along with proper and coordinated supports in other areas of the child’s life) can be truly lifesaving, as many of my patients — and their parents — would affirm.
Some of the conflicting opinions about A.D.H.D. are due to widespread lack of awareness about how research has changed our paradigm for understanding it. For decades this disorder has been seen as essentially a behavior problem of children who were hyperactive and had difficulty in listening. Over the past decade scientific research has demonstrated that A.D.H.D. is essentially a developmental impairment of the brain’s cognitive management system, its executive functions.
Many children and adults who suffer from A.D.H.D. are very bright and have never had any behavioral problems. They have chronic difficulty in focusing on many important tasks of daily life, yet they can focus very well on a few tasks that hold strong personal interest for them. This makes it appear that A.D.H.D. is simply a lack of willpower when, in fact, it has now been shown to be a complex inherited problem with the dynamics of the chemistry of the brain.
THOMAS E. BROWN
Associate Director, Yale Clinicfor Attention and Related Disorders
Hamden, Conn., Dec. 6, 2012
I am sure that there are many children for whom drugs are the only solution to facilitating a better life. But I am equally sure that there are millions of others, particularly young boys, for whom our current system is not working — and medicating them to make them fit in could have serious consequences for their future. After all, the truth is that doctors don’t know why Ritalin works.
I raised a stepson who received a diagnosis of a learning disability and A.D.H.D. in second grade. Medication was recommended before other therapies were even tried. We never got help with how to teach him to cope with his differences — what to do when he got frustrated or needed to take a break to clear his head. I also found it frustrating that school did not provide more outlets for an active mind. Our public schools put too much emphasis on making kids conform.
Drugs can be helpful but are not the answer. Kids come in all shapes, sizes and abilities. We need a more flexible system to help them.
Cameron, Ontario, Dec. 5, 2012
It is important to remember that A.D.H.D. is not a “real” disease in the way that diabetes and asthma are. A.D.H.D. is a constellation of symptoms of dysregulation of attention, emotion and behavior.
Stimulant medication may, at least in the short term, relieve these symptoms. But we need to be asking: What is the cause of these symptoms? In other words, what is the experience of this particular child and family?
In the fast-paced world of pediatric primary care, where these medications are commonly prescribed, this question receives minimal attention. There may be immediate symptom relief. The motivation to address the more complex issues is often lost. But if the underlying cause is not addressed, within a few months symptoms often recur. The exclusive focus becomes adjustment of medication dose.
Borrowing a phrase of the pediatrician and psychoanalyst D. W. Winnicott, the child’s “true self” may be lost.
CLAUDIA M. GOLD
Newton, Mass., Dec. 5, 2012
The writer is a pediatrician.
Growing up, I had nothing but problems focusing in school. I simply could not sit in a chair for an hour and focus on a given task. With all the problems, all the trips to the principal’s office and to therapists, psychiatrists and child behavior experts, I never received an A.D.H.D. diagnosis.
That may be a good thing. I’m a working artist now and always wonder where my creativity would be if I had taken Ritalin every day as many of my friends were back in grade school and junior high.
I still have a hard time focusing, and I have always wondered what amphetamines really do to help. So I took 5 milligrams of Adderall from a friend and noticed the effects quickly. For once in my life, I could focus on a task and not look around the room and find other distractions. It was amazing. But I still worry that taking these types of stimulants on a regular basis is harmful to the brain.
Los Angeles, Dec. 5, 2012
I had the pleasure and challenge of raising two A.D.H.D. children, who are now wonderful adults. It was a total left turn in my life, and I would happily do it all over again.
I learned to see that the problem is not lack of attention, but rather not being able to choose to attend to one thing, to the exclusion of the smorgasbord of everything else that is competing for one’s attention. What medication does is to reduce the noise of competing distractions so that the child can focus on the task at hand. Once focused, it is possible to learn.
Hardest for me, as a parent, was knowing that there would be no quick fix. This wasn’t a scraped knee; as soon as relief sank in that my child’s worrisome behaviors had a name, I quickly discovered that I would be partnering with my child to overcome A.D.H.D. for years.
A.D.H.D. children, by the very nature of what makes them fit poorly into our industrial education system, can be incredibly creative, courageous, generous people. These children must always be considered as assets to our society.
A parent’s task is to keep them out of jail (a very real risk for impulsive young people) and to give them tools to be able to live a good life. The commitment may be tiring, but the reward is sweet: a child who becomes an adult who can walk tall and follow through on dreams, making choices without fear.
Bel Air, Md., Dec. 5, 2012
The Writer Responds
Readers brought varied and strong views to the task of thinking about effective treatment of A.D.H.D. and the place of stimulant medication in that effort. Not surprisingly, the roles they assume with respect to the condition exert a powerful influence in shaping their perspectives.
As a mother of two children with A.D.H.D., Ms. Blum learned that “what medication does is to reduce the noise of competing distractions so that the child can focus on the task at hand.” As a stepmother of a child with A.D.H.D., Ms. Barr lamented, “We never got help with how to teach him to cope with his differences — what to do when he got frustrated or needed to take a break to clear his head.”
Two mental health professionals (Ms. Steinman, Dr. Cohen) provided contrasting pictures of stimulant medication in the treatment of A.D.H.D. As a pediatrician, Dr. Gold urged us to consider what the experiential causes of A.D.H.D. might be. And as a college student, Mr. Busko experienced dramatic improvements in academic achievement following treatment with stimulant medication.
By drawing on current neuroscience, which emphasizes that A.D.H.D. is a developmental impairment in the brain’s cognitive management system, Dr. Brown clarifies how common explanations for the condition (such as “lack of willpower” ) contribute to the continuing misunderstanding and mismanagement of A.D.H.D.
Implicit in each of these perspectives is the discovery that going beyond simplistic, cursory approaches to understanding and treating A.D.H.D. is essential if true lasting improvements are to be had. In Mr. Busko’s case, stimulant medication made a world of difference, but I suspect that the difficulties he experienced over the course of his life were instructive and galvanized him to excel once he was able to sustain focus.
As mothers, Ms. Blum and Ms. Barr had to hash out how best to define the condition and how to provide supports for their children even as they were recognizing the benefits and limitations of what medication provided. In their attitudes toward stimulants as mental health professionals, Ms. Steinman’s misgivings and Dr. Cohen’s vigilance underscore the need to scrutinize their efficacy, while Dr. Brown invokes insights from neuroscience to refine our understanding of A.D.H.D.
And finally, Dr. Gold challenges us to look beyond the immediate, observable symptoms a child shows in order to make sure that any treatment protocol is inclusive: of the child, the family and the dynamics affecting both.
The range of viewpoints and experiences expressed make it abundantly clear just how daunting yet worthwhile it is to grapple with the complexities of treating A.D.H.D. effectively.
FRANCES C. SUTHERLAND
Bryn Mawr, Pa., Dec. 7, 2012