Friday, October 22, 2010

Medications for ADHD: newspaper headline

I have just looked at a front-page newspaper article by Carolyn Abraham in The Globe and Mail (Tuesday, October 19, 2010).

The article attempts to discuss the issue of whether medications are prescribed too often, for treating supposed attention deficit disorder, particularly in male children.

This is a very serious, important question.  It warrants careful analysis of the issues, and a balanced evaluation of evidence.

Unfortunately, the article bothered me greatly, because of its bias.  Here are some quotes from the article:

Boys: Fixing with a pill is easier than counselling  [this was a heading]

There's a desire for the quick fix...the idea that - 'oh, we'll fix this with a pill' - rather than spend a few months in counselling, is pretty appealing. [this was a quote attributed to Gordon Floyd, the CEO of Children's Mental Health Ontario]

What are we drugging?  Female teachers who don't understand boys like to run and jump and shout - that's what boys do. [this was a quote attributed to Jon Bradley, an education professor at McGill University]

Prescription rates for ADHD drugs, which like cocaine, are psycho-stimulants...

Mr. Floyd feels counselling stands a better chance of getting to the root of the problem with children, rather than using drugs for years to dull symptoms.  Research shows, he says, that talk therapy can be very successful for kids with ADHD.

stimulant drugs may be dangerous for those with underlying heart problems - and those who do not actually have ADHD.

I have often wondered why no real connection has been made between the over-medicalization of our children and the increasing prevalence of illicit drug use in our society.  When we give kids the message that they can be 'fixed' by popping a pill, it hardly seems surprising to me that they would later seek to solve their problems by using other available substances. [a quote attributed to Judy McGuire, a "Globe Catalyst"]

The article mentions important issues of concern, including the role of pharmaceutical marketing in changing medication prescription patterns.  The diagnosis of ADHD, and the use of medications, appears to vary substantially from one locale to the next.  The phenomenon of teachers coercing parents to seek medication treatment for their children is certainly problematic.

But the article did not give a balanced presentation of evidence.

It is more common, in my experience, to encounter young adults who have struggled with ADHD symptoms, without any medication treatment,  all their lives.   Often times, they, or their parents, have been strongly opposed to the idea of taking medications.  Many of these young adults are very intelligent, but often have been unable to sit through the intellectual tasks required to develop their intelligence.  Therefore, they have often not been able to achieve the goals which are reasonably available to them.  There is really no way around the fact that reading, for example, is necessary to develop one's mind in the modern world; reading requires one to sit still and focus for extended periods of time.  A great deal of the discipline required to develop one's intellect requires prolonged focus, often with tasks that are initially perceived to be uninteresting (with discipline, intelligence, and imagination, any so-called "boring" subject can become interesting--but if individuals are unable to focus during the initial "boring" introduction to a subject, this deep interest and engagement may never be found).

Treating ADHD with medication does not increase substance abuse.  Rates of substance use in an untreated ADHD population are substantially higher.  Here is a reference to a research article demonstrating this:  It is certainly my clinical experience, that subjects with untreated ADHD have much higher rates of substance use, including cigarettes, alcohol, cannabis, and harder drugs.  The belief that treating ADHD with medications somehow increases risk for substance abuse, is simply unfounded--the opposite effect has been clearly shown.  Exceptions exist, of course, in individual cases where adolescents may be abusing their medication, selling it, etc. Also, in many cases "ADHD" is not the only issue or problem; there may be antisocial behaviour, mood disorders, severe family or psychosocial problems, etc. which also obviously affect risks. 

In terms of dangers or risks, it is of course important to examine negative side-effects or toxicity from stimulants.  Such an analysis would fairly establish that risks are present, but of low incidence.  For example, the risk of stimulants causing heart problems.

But a fair assessment of risk must include consideration of the risks of non-treatment!  The obvious risks in an ADHD population are  higher risks of accidental injuries, car accidents, sequelae from substance abuse, and reckless interpersonal behaviour.  The risk pertains not only to those with untreated ADHD, but also to peers (for example, passengers in a vehicle).  Here are a few references evidence about this:

 It is also, of course, very important to consider whether counseling or other types of therapy could be helpful for ADHD symptoms.  The prevailing evidence shows that there can be small effects with existing therapy styles--this is certainly worth pursuing--but counseling often doesn't work very well.  In cases where there are multiple other problems going on (e.g. anxiety, mood, family conflicts, etc.) then of course some type of external counseling support would be preferable to simply obtaining a stimulant prescription. The notion that "a few months of counseling" would make much of a difference for most kids with ADHD symptoms is absurd, and entirely unsupported by any evidence. 

The idea of accepting that "that's what boys do," etc. is important to consider.  But imagine, as an adult reader, that you are transported to elementary school again.  Would it be a pleasant and rewarding situation for you to be in a classroom where the attitude "that's what boys do" prevails?    Similar philosophies, in the adult world, have been used to justify various types of antisocial behaviour.  The issue is not just about the individuals with so-called ADHD, but also about peers and community.  Rambunctiousness need not be pathologized, but a desire for sustained attentiveness need not be pathologized either.  Most people with ADHD histories have had serious difficulties not just in classroom settings, but in all spheres of life:  home, friendships, community, work, etc.  This issue is not just about artificially forcing people into the constraints of a boring, quiet classroom, although admittedly a sedate classroom environment could be a very unhelpful factor for some. 

The article seems to suggest that male teachers would be preferable.  What does this have to do with anything?  Where is the evidence?! Is this claim not an insult to female teachers?  And, in my memory, I don't remember male teachers being any better at managing a classroom of rambunctious kids, compared to female teachers.  In fact, I can think of counterexamples, in which female teachers could have a gentle, maternal effect on hyperactive kids helping them to enjoy their day, so that their experience of a classroom could be more positive.  

I do agree that there are learning or educational styles which could suit some individuals much better.  And I agree that having opportunities to be physically active is extremely important--for everyone, not just for "ADHD kids."  One of the authors in this article suggests that the decline of opportunities such as "wood shop" (the implication is, that these are mainly for boys) is part of the problem.   But, imagine as a wood shop teacher -- where you are in charge of a band saw, a lathe,  and a few power nail guns -- that you have a few kids who are easily bored, highly rambunctious, and have difficulty paying attention.  Band saw + ADHD!   Do you see any problems there? 

Some "alternative learning styles" could already begin to produce an unnecessary tier, sending kids with more ADHD symptoms away from a more scholarly focus, towards developing a more physical trade.  I don't think there's anything wrong with this per se, unless the child with ADHD symptoms actually wants to develop scholarly pursuits, and/or has an undeveloped talent for the type of scholarship which requires intense focus, and doesn't really want to be "tiered" in this way.

I recognize that this is an important issue, and everyone's point of view needs to be considered to work out the best solutions for health policy and for helping individuals.  But this article, in one of Canada's leading newspapers, was disturbingly one-sided, and in my opinion could contribute to many individuals feeling stigmatized or rejecting the possibility of medication therapy without a balanced understanding of the evidence. 

One of the main issues to contemplate, and really the main helpful theme in this article, in my opinion, has to do with degree or magnitude:  ADHD symptoms exist on a continuum, with everyone in the population having some measurable quantity of attentional capacity, physical restlessness, or impulsivity.  These could be considered traits, and each of these traits could be considered useful, positive, and "normal"  in some ways, as well as negative or deleterious in others.  Medications or other therapies have the capacity to change the degree of symptoms or traits somewhat, for anyone (it is a myth that stimulants improve attention only in those with ADHD).  The degree of environmental change required to help an individual escalates rapidly as the degree of symptoms increases.  So, there will always be a gray area, of individuals who have more "ADHD symptoms" than the population average, but fewer than those with extreme and highly disabling symptoms.   Determining how to help these individuals may be highly influenced by the whims of the local educational or medical culture, combined with the attitudes of the individuals and their families.  There may be no absolute, fixed standard possible, to determine exactly when to use a particular form of therapy.  

I believe that such decisions should be influenced by the following factors:
1) clear informed consent on the part of individuals and families considering medications or other therapies.   This involves having a balanced understanding of evidence, of the risks and benefits of treating and of not treating. 
2) thorough assessment with careful attendance to family and psychosocial stresses--never an impulsive prescription of stimulants after a single 5-minute appointment!
3) Follow-up in all cases, with opportunities for talking therapies and behavioural therapy if desired.
4) A reasonable set of nationalized, standardized guidelines for assessment and treatment, to reduce the possibility that a person's geographic location, or the whims of teachers, doctors, journalists, etc. would be strong determinants of whether or not treatment of any kind is offered.

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