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By Kevin T. Kalikow, MD
Recent articles about the alleged overuse of stimulant medicines, such as Ritalin and Adderall, neglect the core issue. As a child psychiatrist, I spend a good part of my day talking with parents who are considering a stimulant medicine for their child. I am by their side as they grapple with their hopes and fears and can shed light on their real struggles.
Medicines as a Tool:
Medicine, any medicine, is simply a tool to help us obtain what we value. We take statins to lower our cholesterol because we desire a long life. We take oxycodone after a dental procedure because we want to be pain-free. The most important question about the use of any medicine is, what does the user hope to achieve? What do they value?
So, why do parents seek a prescription for stimulant medicines used to treat Attention Deficit Hyperactivity Disorder (ADHD)? What do they hope to achieve?
Some parents want to prevent extreme hyperactivity/impulsivity (I’ve had one patient run into the street and end up in a near-full body cast and two patients who have literally burned the house down). Others want to improve extreme inattention. Because we value life, most of us wouldn’t argue with the use of a stimulant to potentially save a life…or a house.
And, because listening while another person speaks is a basic function, many would accept using medicine to help a child focus long enough to follow a one-step instruction or complete a simple task. So, why the fuss? Why has this issue become a lightning rod for people’s charged emotions?
Healthy Parental Concern:
ADHD has become a lightning rod because it evokes parental worry beyond that of their child’s physical safety and basic functioning. Every parent wants their child invited to the dance-whether it’s the seventh grade dance or the adult dance of finding your successful niche in the economy.
With parental involvement and concern at an all-time high, ever-vigilant parents want to assure their child’s success. Parents rarely try to get their undeserving child into Harvard. Most parents know their child’s capabilities. However, they desperately want them to reach their intellectual potential, to be socially accepted, to be happy with who they are, goals that frequently seem beyond the reach of the child with ADHD. And they want these goals achieved in a home relatively free of nightly screaming over schoolwork.
A mother who resists starting her bright, if disorganized and fairly inattentive, son on medicine sits in my office. What is your concern? I ask. She hesitates, then fighting back tears, responds, “I’m afraid he’ll get left behind, that he won’t realize his potential. He’s as smart as his friends, but he won’t be in the enrichment classes with them. He’ll feel like a failure and will never be seen as the smart kid he is.” I hear this sentiment frequently.
"Dysfunction" - A Complicated Term:
This concern is for neither physical safety nor basic functioning. It is the parental concern for psychological, social, and ultimately financial, well-being. In an age of increased control over bodily function, this use of stimulants has made them the poster child for the elective use of medicine to improve a child’s self esteem and chances for success.
As such, looking at the use of stimulants brings us to a discussion of what truly constitutes dysfunction, and when does dysfunction become a disorder and when does this disorder merit treatment?
So, what constitutes dysfunction? Is it not living up to what most people are capable of doing or what I am capable of doing? If I earn a B in math, I sound functional. However, if I have an IQ of 130 and am particularly talented in math and hope for a career in engineering, my B sounds arguably dysfunctional.
Dysfunction is difficult to define.
Childhood dysfunction also includes low self-esteem, a much-maligned form of function. Often heard as a feel-good term reflecting the over-concern of the over-indulgent modern parent, in fact, child mental health professionals often see the ravages of true low self-esteem, caused, in part, by chronic academic disappointment.
Many of these children grow up to be angry adolescents who see themselves as stupid and unsuccessful and who search for an alternate peer group in which they feel accepted. Every parent tries to avoid this dysfunctional outcome.
When does dysfunction become a disorder? For decades, ADHD has been seen as a categorical diagnosis (like pregnancy, you have it or you don’t).
However, a provocative study from the National Institute of Mental Health seemed to find biological evidence of something that many clinicians have known for some time, that ADHD is not a categorical diagnosis, but rather exists on a spectrum. Researchers followed four groups of children-those with ADHD, without ADHD but with many symptoms of ADHD, without ADHD but with only some symptoms of ADHD and, lastly, those without symptoms.
They found that the rate at which children prune their brain’s nerve cells (a normal process) is on a continuum from fastest for kids without ADHD to slowest for kids who meet full criteria for ADHD.
In other words, some symptomatic children, though short of a full-fledged diagnosis of ADHD, have slower brain maturation than their peers. This spectrum concept of diagnosis is perhaps more biologically valid than the categorical model, but puts us on an even steeper and more slippery slope of who merits treatment.
Function & Diagnosis:
Without a clear diagnostic boundary, function tells the tale. So, when does dysfunction merit treatment? And, more importantly, who decides and on what basis?
Today, parents see school as a crucial arena for function.
Academic dysfunction, often as measured by grades, can reflect underlying neurological symptoms, such as disorganization and time management problems. Thus, in the competitive academic environment in which the child lives, school dysfunction becomes symptomatic of a medical disorder and, as such, raises the possibility of treatment. Worried parents see grades below their child’s intellectual potential as reflecting underlying neurological weakness and leading to future vulnerability. And they want relief of the disorder or at least the symptom.
Although these parents are accused of gaming the system, seeking the edge, that is simply an easy to blame, largely fictitious stereotype, rarely seen in the real world.
The Office Visit:
Here’s what often happens. A parent calls about their child who is educationally symptomatic: disorganized (yes, more than his peers), forgetful (yes, more than his peers), fooling around in class (yes, more than his peers) and whose grades indicate that he is not living up to his intellectual potential.
Every night the house is in turmoil over homework never written down, never completed or never handed in. This begins with the child lying about homework and concludes with the parent screaming about homework. I evaluate the child. The child falls short of the research criteria necessary for a diagnosis of ADHD. But, he’s somewhere on that spectrum of ADHD symptoms. His concerned parents, searching for a reassuring “yes” or “no,” though unsure what they will do after their question is answered, inquire, “So, does he have it?”
I answer with a certainty that brings little relief. “Well, he’s on a spectrum.” The parents and I are then left with the philosophical conundrum: Where do you draw the line on a spectrum? Who do you treat?
Usually the parents have tried environmental solutions, such as increasing academic support, but they can’t change the school’s (or college admission committee’s) academic expectations. And so they struggle with the dilemma of medicine, weighing potential benefits and feared risks. Will medicine bring the hoped for relief? Sometimes. The stimulants help a child focus, whether he has ADHD or not. Even those on the ADHD spectrum might have symptomatic relief.
Notwithstanding the alarmist concerns of many parents, the stimulants have few serious side effects when used responsibly. And the stimulants help many raise their grades in the short-run and arguably in the long-run. Given that grades are, in fact, the proxy most used by colleges for who you are and what you know, the reasoning of these parents is understandable.
Can parents be impatient, misinterpreting normal child development for ADHD? Sure. Does the life of a 21st century child offer sufficient distractions, social, electronic and otherwise, to distract the most focused of children? Absolutely. Do some parents lack the confidence that with maturity their child’s other assets will eventually win the day? Of course.
Hard Choices – Hard Parenting:
The physician’s responsibility is to help parents understand these complicating factors. However, parents set their own values. These include a peaceful home, reasonable self esteem, and educational and ultimately financial success. All of these are sometimes more easily attained by stimulants.
We can and should examine our definition of and parameters for success. We should ask how our system of education makes certain children educationally symptomatic and some homes war zones. We should adapt our teaching to assure the success of all children. However, we should not blame the parents for trying to attain what they value, namely their child’s best interests in the world in which we have set before them.
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Kevin T. Kalikow, MD is a child psychiatrist and author of "Your Child in the Balance: Solving the Psychiatric Medicine Dilemma" and "Kids on Meds: Up-to-Date Information About the Most Commonly Prescribed Psychiatric Medications"
For more from Dr. Kalikow see: http://kevinkalikow.com/
Your Child in the Balance (2006)
Kids on Meds (2011)
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