Welcome to my blog, which speaks to parents, professionals who work with children, and policy makers. Through stories from my behavioral pediatrics practice (with details changed to protect privacy) I will show how contemporary research in child development can be applied to support parents in their efforts to facilitate their children’s healthy emotional development. I will address factors that converge to obstruct such support. These include limited access to quality mental health care, influences of a powerful health insurance industry and intensive marketing efforts by the pharmaceutical industry.

Tuesday, April 20, 2010

Standard of Care for ADHD Violates this Pediatrician's Professional Integrity

After giving the subject much careful thought, I have decided to leave my ADHD practice. In a previous post I described how I inherited a large practice of patients with a diagnosis of ADHD. While I have treated many children who have benefited from stimulant medication, I find the standard of care by which medication is prescribed to be significantly problematic.

Consider this one observation. Many clinicians prescribe medication for ADHD based upon a visit with only one parent. Once, a father called me to set up an appointment to discuss medication for ADHD. I learned that he was divorced and that the child split time between both parents homes. I told the father that I preferred to meet with both parents for the initial evaluation. He said he would call me back to set up a time, but never did. Often I will have one parent say, "His father is totally against medication." Imagine being a child in such a position. Your mother wants you to be on a drug that affects your brain. Your father is against it. Your doctor, without even discussing it with your father, prescribes it anyway. Yet this kind of situation happens all the time.

I also wonder what it does to a child's sense of self to sit in a room once every three to six months and listen to a conversation about his behavior and its relation to a pill he takes every day. Often things are said like, "He's just terrible when he misses his dose." These visits are usually thirty minutes long, and do not offer an opportunity to explore a child's life experience in any meaningful way. Yet this frequency and duration of visit, and line of questioning, is the standard of care for ADHD, and what parents expect.

Behavior management may be recommended in addition to medication. Again, the focus is on making a child behave, rather than exploring the meaning of behavior. Often, there are significant life events contributing to a child's inattention.

Recently I was interviewed by Kaitlin Bell for her upcoming book. She writes thoughtfully about the effects of being medicated since childhood on the current generation of young adults, and explores the complex issues such treatment has raised for them. I hope her writing will help us to think more carefully about the way in which these medications are prescribed.

In addition, while I observe on a regular basis the short term benefits of these medications, I do have nagging doubts about their safety over the long term. It is only with in the last ten to fifteen years that we have huge numbers of children taking stimulant medication for many years, often well into adulthood.

In the February issue of ADHD report Russell Barkley addresses a recent article from Scientific American Mind by Edmund S.Higgins that questions whether long term use of stimulants might take a toll on the brain. Higgins expresses concern that long term effects might include increased risk for anxiety, depression and disrupted cognition, among others. Barkley dismisses the article as "well-crafted propaganda," saying there is no evidence for these adverse effects. In his reply, Dr. Higgings writes,"The history of medicine is replete with examples of treatment interventions that appeared safe but ultimately revealed their adverse effects with long term-controlled studies."

The point is that we don't have good evidence either way. Add to that the fact that there is not good data demonstrating long term benefits, and I feel that I can no longer in good conscience prescribe stimulants year after year to large numbers of children.

I know that someone will prescribe these medications in my absence. In the mean time I will continue to write about my concerns. I am fortunately joined by many others, including Daniel Carlat, in his upcoming book Unhinged:The Trouble with Psychiatry and Robert Whitaker, in his book Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs and the Astonishing Rise of Mental Illness in America who are writing to call attention to the possibly very wrong direction we are headed in the way psychoactive medications are prescribed.

In my clinical practice I will work primarily with young children and their parents. My aim is facilitate healthy development at an age when children's brains are rapidly growing and thus most open to change.

My forthcoming book, to be published by Da Capo Press,
integrates the most contemporary research in child development with stories from my pediatric practice to support parent's efforts to think about their child's mind and the meaning of their behavior, which in turn facilitates the child’s healthy emotional development at the level of structure and chemistry of the brain.

Please stay tuned to my blog for more about both.

3 comments:

  1. There is a lot of evidence that stimulants are destructive to everybody. They stunt growth in children, for one. They deplete the brain pleasure centers of dopamine so that people can not enjoy things like food and sex as much. They can cause psychosis over the long term, as well as raise blood pressure and cause strokes and heart attacks.

    Their physiological effects are not all that different from cocaine and methamphetamine. Adderal contains dextroamphetamine; housewives in the 50's got strung out on these when they were hawked as "diet pills."

    At a medical conference I went to, a lecturer from NIDA was going on at great lengths about how amphatamines deplete dopamine in the brain's pleasure centers. When someone from the audience asked him if we were not doing that to our kids with stimulants, his unforgetable response was, "But the drugs work so well." Talk about sidestepping an issue.

    Back when I was at UC Berkeley in the Hippie days of 1967, they used to say "Speed Kills," and they were not talking about driving too fast. And this from people who were generally in favor of getting high on drugs!

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  2. This is an extremely poignant observation:

    "I also wonder what it does to a child's sense of self to sit in a room once every three to six months and listen to a conversation about his behavior and its relation to a pill he takes every day. Often things are said like, "He's just terrible when he misses his dose."

    That paragraphed tugged real hard on a heart string for me, it's truth too familiar, because I know exactly what it's like to be that kid sitting there -- mother and doctor exchanging information about my behavior in relation to all the medicine I was taking.

    Often my mother would pin some behavioral outburst on me refusing to take one dose of medicine, which isn't a drop in the bucket when your taking several mood stabilizers and several antipsychotic drugs.

    That was really the only difference for me -- I was taking the drugs for my alleged bipolar disorder. I was treated by an MGH guy.

    Lot of fighting in my home. My mom is like a child, she wanted me sick and this was Biederman et al's heyday (circa2001). The doctor was only too willing to go along.

    Now my mom's job in life is to present herself to the doctor as sick.

    I have no sense of self.

    I love your blog. Your ideas are refreshing and your attitude is bold. This is what's needed to protect children.

    Please help a lot of children in your practice. Don't let any more childrens lives be destroyed by this false pediatric bipolar epidemic.

    Let them know they are normal. Let them know they're lives will not be irreparably changed. Let them know that hard times and situations can be dealt with. Let them know their bodies are theirs -- not the doctor's, not the drug's. Let them grow physically, let them grow emotionally.

    Drugs don't let that happen.

    Prevent adolescent and young adult cases of "BPD" by helping these dysregulated kids before they become such.

    Write, teach, scream if you need to. People need to be practicing like you.

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  3. Thank you, JC, for your touching and inspiring comment.

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