We Are Only Human

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The Art of ADHD

Can we free children from ‘chemical straitjackets’?

It’s now days later, and I’m still thinking about Alan Schwarz’s recent New York Times article about prescribing stimulants for children. I am quoted in the piece, but Schwarz also quotes another physician who doesn’t believe that attention deficit hyperactivity disorder—better known as ADHD— exists, and yet he willingly prescribes stimulants for children anyway. Why? He thinks they’re truly suffering from another ill: “Poor academic performance in inadequate schools,” Schwarz writes.

But despite well-meaning attempts to level the bar for children in mediocre or failing school districts, we can’t forget that ADHD is sadly all too real, with at least six percent of children and adolescents having the diagnosis in multiple epidemiological studies. Schwarz’s physician source (one of many out there, it’s safe to say) is knowingly contributing to the overmedicating of children who may not be struggling with ADHD—not because it doesn’t exist, but because these children could be suffering from another problem altogether.

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It’s all too easy to make a rapid diagnosis of ADHD and then swiftly fork over a prescription, but this is a quick-fix solution that doesn’t do a child justice. The child may have other problems—trauma, dyslexia, or mental illness—all of which can look like ADHD and all of which can, in turn, be missed entirely and go untreated.

So, what’s the differential?

Diagnosing ADHD takes more than a discerning eye. It takes effort to recognize the impact of other underlying problems. It takes persistence for the physician to work with parents, teachers, and the patient to figure out what’s really going on. Students with completely unrelated medical conditions (including lead poisoning and severe anemia) can have difficulty paying attention, a symptom that is consistent with ADHD.

It is also extremely difficult to tell the difference between a child who has experienced trauma and a child who has trouble focusing because of ADHD. The symptoms can look the same: the hyperactivity, the disorganized approach, the distraction, the frequent mood changes, the anger, the reactivity.  No stimulant is going to help that. When trauma is present, there’s often an overflow of adrenaline in the body, which primes the brain for hypervigilanceand initiates a fight-or-flight response. In such cases, stimulants can backfire and make the child even more irritable. Safety is paramount for children suffering from trauma. They need to learn strategies to comfort themselves and to recognize when they are in true danger and when they may have misinterpreted a situation. The child, school staff, and parents needs to understand why he responds the way he does in order to help him with the pain and confusion.

Children with an undiagnosed learning disorder can also be contenders for a false ADHD diagnosis. Some kids can’t grasp what a teacher is saying because their brains process information slowly. These students will certainly be distracted in the classroom if they’re flying under the radar and are not effectively engaged. These are the kids who can give up and act out. They may earn bad grades, and they might as well have a bull’s-eye on their backs. Stimulants such as Ritalin or Adderall may aid in sustained concentration in fifty percent of students with learning disorders, but these medications do not address the underlying learning problem. Appropriate educational services need to be mobilized to make a critical difference. When the learning disorder is not adequately addressed, children can display such behavioral disturbances as impulsivity, irritability, and difficulty focusing. When the learning difficulty is acknowledged and appropriate accommodations are put in place, these symptoms can abate.

Students who suffer from oppositional defiant disorder may also be improperly diagnosed with ADHD. These children may be annoying and explosive. They consistently break rules and have difficulty with peers. Of course, it’s important to address the oppositional behavior, but sometimes teachers conclude that the answer is ADHD medication. A patient once asked me to listen to an answering machine message in which a teacher (illegally, by the way) said, “Don’t come back to school until you have taken your medication.” While much evidence suggests that medication can curb impulsivity if the child really has ADHD, the same medications are not usually effective for treating oppositional behavior caused by other factors. Before sending a child off for an ADHD evaluation, parents and teachers need to understand how to avoid power struggles and how to encourage children to be more flexible.

When it comes to mental illness, especially bipolar disorder, there’s quite a bit of overlap with ADHD. Both illnesses can share the same symptoms: impulsivity, pressured speech, and difficulty concentrating. Contemporary psychiatry is fraught with much debate over how to diagnose someone with bipolar disorder and/or ADHD. Yes, they can look that similar. The bottom line is that physicians can’t be cavalier with stimulants, and we can’t make snap judgments about ADHD either. But with stimulants being prescribed to children so commonly now, and with the threshold so low, can we ever turn back?

The bottom line is that each child deserves a balanced, thorough evaluation that allows everyone involved to proceed in a thoughtful way. And even when ADHD medication is indicated, we need to remember that medication alone is never enough. Children with ADHD—or with some of the other conditions discussed here—also need help with problem-solving skills, organization, and communication. Diagnosing and treating kids with ADHD is an ongoing war, but it’s not a war without rules—and we owe it to our kids to fight fairly.

Nancy Rappaport is associate professor of psychiatry at Harvard Medical School.

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