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Treating ADHD with Medication: The Ongoing Debate

Doctor talks with a boy seated on examination tableWhen someone asks me what a developmental pediatrician does, I tell him or her that I treat children who have a variety of developmental problems, such as attention deficit hyperactivity disorder (ADHD). Without fail, that disclosure elicits some sort of an emotional reaction.

Many people have strong opinions about whether the disorder really exists. Parents are still being told, by family and so-called friends, that it’s “their fault,” and that all these children need is discipline, sometimes defined as “a swift kick in the you-know-what.”

The truth is that ADHD exists and often requires a multipronged approach to treatment. According to the CDC, 6.4 million children ages 4–17 have been diagnosed with ADHD in the U.S. This percentage has risen sharply over the past decade—from 7.8 percent in 2003 to 11 percent in 2011.

To Medicate or Not
Even more emotionally laden is the topic of medication. People tend to be either for or against stimulant medications, such as Ritalin and Adderall, with no middle ground. Earlier in my career, I had a charming but extremely hyperactive patient whose mother was a healthcare worker. After a variety of nondrug approaches failed to help her child, she finally resigned herself to starting a trial of medication, but just for when the child was in school. It worked well, but at a follow-up visit the mother, shamefaced, admitted that she had been giving her daughter the medication on weekends, as well as for school, after the girl tearfully asked “Can I please take my medication for soccer?” 

A pivotal research project changed the treatment landscape. In 1999, the MTA Cooperative group published the Multimodal Treatment Study for Children with ADHD. This landmark study proved that medication, with or without behavioral treatment, was superior to community treatment or behavioral treatment alone.

The findings took the country by storm. Pharmaceutical executives happily embraced these powerful, scientifically based results that would enhance company market share and increase profits and dividends. Insurance company executives were equally excited, with no more need to pay for time-consuming and expensive behavioral interventions. I was ambivalent. On one hand, these were beneficial data to help convince reluctant parents of children with such severe ADHD that they weren’t benefitting from behavioral and academic interventions simply to try the medication. On the other hand, I knew that ADHD is a complex disorder that generally coexists with a number of other problems, and that, despite the results of the study, quick fixes are rarely a total solution.

Fifteen Years Later: Questions Remain about the Value of ADHD Drugs
Fast forward to today: I am not surprised to read and hear that people, both healthcare professionals and others, question the validity of the MTA study and are reevaluating the impact it has had on the current generation of children with ADHD. People are blaming the study for the overuse of medication. However, now, instead of parents being told that they are responsible for their children’s problems, critics are suggesting that medication is being used to keep children quiet in the classrooms because teachers can’t control the children’s behavior.

I am still ambivalent. I believe that the questioning is good, because maybe it will cause more doctors to follow the revised and updated 2001 AAP guidelines for the multidisciplinary assessment and multimodal (medical, behavioral and educational) treatment of ADHD (AAP 2011; AAP 2001). Those guidelines emphasize the benefits of an integrated approach that combines drug and nondrug therapies. But I am concerned that media hype focusing on overuse rather than misuse of medication can lead to mass hysteria, like that seen with regard to autism and vaccinations. Given the nationwide prevalence of ADHD, ranging from 4.2 percent in Nevada to 14.8 percent in Kentucky (CDC, 2011), it is important that we not “throw the baby out with the bath water” by negating the value of medication as an integral part of a treatment plan. We cannot return to the dark ages.

ADHD Drugs: Tools, Not a Panacea
In my professional opinion—after treating hundreds of ADHD cases since the 1990s—medication is a tool that allows many children with ADHD to benefit from other educational, behavioral and psychological treatments and thus function better in their lives. It’s not for everyone, and is not a magic bullet, but for children who have been appropriately diagnosed, it can mean the difference between success and failure. 

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Iris K. Lesser, M.D.

Iris K. Lesser, M.D.

Iris K. Lesser, M.D., is assistant professor, department of pediatrics (child development) at Albert Einstein College of Medicine.

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  • Amelia February 14, 2014, 4:09 AM

    Very comprehensive post. I feel you are very sensitive to this topic . However I don’t think many doctors are. Most of the doctors I met just prescribe the drugs without any thorough examination of the child. I do believe that those medication can be helpful when properly used. But how can we know that our children are being properly diagnosed?

  • Fi February 27, 2014, 7:01 PM

    This is a really excellent, well balanced look at treatments for ADHD. I have an 11 old child with autism who is in remission from acute lymphoblastic leukaemia and is now has a very noticeablel attention deficit problem that she did not have when she was younger. Here in the UK there is a real reluctance to diagnose this as a comorbidity in spite of the changes in the current DSM V that allow this, and an added reluctance to prescribe any form of pharmacological intervention except in cases of self injury or aggression. Many other aspects of my daughter’s autism have worsened, but it seems such as shame that this particular problem, which could possibly be ameliorated by a mixture of interventions, is not being addressed. If she was a child without autism who had suffered a similar deterioration in her ability to give attention, the leukaemia late effects clinic would probably have helped her with a pharmacological intervention such as ritalin by now. Not having expertise in the area of autism, the haematologists handed her care to the clinical psychologists and so she has gone from an intensely physiological medical environment to one that is very, very different . I understand that the treatment of attention deficit in children with autism is more problematic than in the general population, but I really wish for my daughter’s sake that she could have the opportunity to meet with a doctor like you who has such an insightful, nuanced approach to all of this. I will keep trying, but our ‘pathway’ for treatment here is feeling a bit like a tramline

  • fi February 28, 2014, 9:12 AM

    Dear Dr Lesser,

    just a quick postscript to my previous comment – it interests me that the proportion of children with autism who have a comorbidity of ADHD is roughly the same as the proportion who find it easier to focus with a raised temperature. I only recently realized that this odd phenomenon also occurs with ADHD sufferers. Do you know whether the fever effect only happens in autistic patients with this comorbidity of ADHD? My daughter’s improvement when she has a fever has always been discernible, but has become much more pronounced since her ability to focus has deteriorated. Could it be the case that the degree of improvement due to the fever effect correlates directly to the degree of attention deficit that is normally present? I am fascinated by the research that Dr Hollander at the Albert Einstein is currently doing in this area.

  • Alicia March 3, 2014, 10:55 AM

    Great article. It’s not easy for us parents to figure this out and I know it’s not easy for the doctors either. I have a 14-year-old who has had reading issues her entire school career. We finally got her tested outside of school at age 14. She was diagnosed with ADHD of the Inattentive Type. She was prescribed Concerta and like the soccer playing child in the article was able to tell her parents how much it helped. I hate giving my child medication but I know it helps. I wonder how much more good it would have done if she had started the medication at a younger age when she was just learning to read. My point for writing to you is to say yes, you got it, and I hope that there will be a conclusive test at some point. Also, I would have liked to see an example of ADHD of the Inattentive type included in your article. Awareness needs to be built. It is so typical that my daughter was diagnosed as a young teen rather than as a small child. It is a parenting issue, a medical issue and a women’s issue.