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The "Right" Treatment for Attention-Deficit Hyperactivity Disorder (ADHD)

Posted by Dr. Sushrut Jangi  August 20, 2013 09:23 AM

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This month, we investigate the challenges of treatment, rather than diagnosis.  

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J was only 6 years old, but his parents came to their pediatrician with a difficult question: should we start J on medications for possible attention-deficit hyperactivity disorder? 

Dr. Eugenia Chan sees families struggling with this question all the time. She's a pediatrician at Boston Children's Hospital who directs the attention deficit hyperactivity disorder (ADHD) program in the Development Medicine Center. Many parents come to her afraid of ADHD medications - after all, we frequently hear stories that validate these fears. 

For instance, a recent report from the Substance Abuse and Mental Health Services Administration (SAMHSA) reported that ADHD medications sent 23,000 young adults to the emergency room last year in drug-related emergencies: that's a four-fold increase compared to 2005. ADHD medications have been linked to anxiety, addiction, and rarely, psychosis. A popular story in the New York Times a few months ago reported on the
suicide of the college student Richard Fee, who hanged himself after prescriptions for his ADHD medication expired. While such tragedies are rare, abuse of ADHD medications in the college setting are not uncommon: almost 35 percent of students have been estimated to use these medications to provide short-term bursts of energy to get them through rounds of finals. Colleges have begun cracking down on ADHD prescriptions to unmask abusers. Furthermore, with sales of stimulants reaching $9 billion last year compared to $4 billion in 2007, and almost 14,000 new prescriptions written monthly (a three-fold increase compared to five years ago), ADHD medications have become stigmatized, their use surrounded by a culture of fear and abuse, a culture parents are largely aware of and consequently do not want their children to enter at a young age. 

The option of medicating children for psychiatric or neurologic conditions force parents to face a difficult choice. 

For some parents, the decision takes a long time, especially when the diagnosis may not be clear. Dr. Chan met J when he was six, but his parents and teachers had noticed problems far earlier. "Even when he was 2 years old, he was restless and easily worked up," Chan says. By the time he started kindergarten, J's teachers raised red flags. They called home and told the parents they were concerned about his impulsivity and occasional aggression. His parents had heard similar complaints from others before. A year earlier, when J was first enrolled in preschool, the teachers had asked his parents to pull J out of class because of his disruptive behavior, a "solution" that is unfortunately not uncommon. 

Frustrated, J's parents took him to behavioral therapy, where a psychologist recommended they try a program of regular, consistent activities (keeping a daily schedule, limiting choices, using time-outs) to ensure that J got the direction he needed to move past his impulsiveness. But by the time he was almost 7, nothing had changed. J's parents were exhausted. Every few months, they got calls from teachers describing a litany of his difficulties: trouble following directions, inability to sit still, and trouble focusing his attention. 

"I met with this family several times," Dr. Chan describes, "and very quickly realized he met criteria for ADHD." She introduced the idea of starting a medicine to supplement his behavioral interventions. The drug she would use - called methylphenidate - has been approved as a first-line agent for the treatment of ADHD for children as young as 6 years old. Swallowed or chewed, the medicine prolongs the effect of the neurotransmitters dopamine and norepinephrine on the nerve cells in the brain, providing a stimulating effect that can foster renewed focus. But since the brain is still evolving during childhood, many parents fear that stimulants may disrupt normal neurologic development and create dependency. 

Consequently, J's father was against starting medication for J. "His father told me that when he was his son's age, he couldn't focus either," Chan says. It was only with time and sustained effort, J's father said, that he learned to grow out of it. "Many parents want to find an answer other than medication. Because when parents make a choice to start one of these medicines for their child, there isn't a single day they don't second-guess that decision. Will this affect my child's appetite, his sleep, will it change his personality? Will it make him a zombie?" Dr Chan says.  Most often, she goes on, parents feel they are condemning their child to a lifelong drug. "I've only had a handful of parents walk in who say, 'I want to medicate my child.'"

The conclusion to this case will be posted Friday. 

This blog is not written or edited by or the Boston Globe.
The author is solely responsible for the content.

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About the author

Sushrut Jangi is an internist at Beth Israel Deaconess Medical Center and an editorial fellow at The New England Journal of Medicine. More »

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