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REFLECTING ON THE
STANDARDS FOR USING MEDICATION TO TREAT CHILDREN WITH ADHD
Sam Goldstein, Ph.D.
I recently had the privilege to speak to parents and professionals
in
In the
Prior to 1994, the
diagnostic protocol for ADHD did not require that the level of impairment or
severity be assessed prior to making the diagnosis. Thus, an individual could
be provided with a diagnosis of ADHD based upon symptom report, yet experience
mild impairment and few, if any, problems in every day life. However, the
authors of the diagnostic manual (DSM-IV) recognized the risk of over-diagnosis
with this model. Since 1994, level of impairment must be considered prior to
providing a diagnosis. An individual must not only experience the symptoms of
ADHD, but significant impairment in at least two major life domains. For
children, this includes school, on the playground, and at home.
In the thousands of
parents I have worked with, I have yet to meet a parent who responded
positively when a diagnosis of ADHD was made and a discussion of medical
treatment followed. I don't believe any parent in their right mind would
respond, "I've been waiting for you to make this diagnosis and suggest
that my child be placed on this regulated, controversial medication." Yet,
medicine is effective for ADHD. In this case, effectiveness is defined as a
reduction of symptoms leading to relief of impairment. That is, when children
with significant problems stemming from ADHD respond positively to medication,
the pattern of impulsive, inattentive, and hyperactive symptoms reduces in
severity, leading to improved functioning at home, school, and on the
playground. Yet, it also appears to be the case that symptom relief does not
equate to changing long-term outcome. While symptom relief is an important
reason for treating children with ADHD, it does not appear that children with
ADHD who take medicine grow up to be more functional, happier or healthier than
children with ADHD who do not take medication. The medicine is primarily a
treatment to relieve symptoms. As I have written, however, in previous monthly
columns, symptom relief "evens the playing field." It allows children
with ADHD to enter school, go out on the playground, and interact with their
family members in normal ways. The benefits of medication should be assessed
relative to the immediate relief of symptoms. As such, the determination for
medication usage in children with ADHD, I believe, should be based on level of
presenting impairment.
At present, there are
few, if any, objective measures to evaluate impairment. I have increasingly
begun using a subjective, one to ten scale, with ten equating to significant
impairment. Once I've made a diagnosis of ADHD, I consider the child's level of
impairment along this scale. Keep in mind that a very low score doesn't equate
with normal functioning, since if a child didn't experience some degree of
significant impairment, I wouldn't provide a diagnosis of ADHD according to
current diagnostic criteria. In making my determination, I focus upon the
child's level of social interaction, academic functioning at school, in
particular if the child has a learning disability, comorbid or cooccurring
problems, such as depression, anxiety, and oppositional defiance, the child's
ability to participate in organized social activities such as sports, and
finally, the child's relationship with parents and siblings. When children
receive a rating of seven to ten, I strongly urge parents to speak to their
physician about including a trial of medication as the treatment plan is set in
place. When I provide a rating of four to six, we discuss medication as a
likely option, but not necessarily a first step. In my experience, however,
children with this mid-level of impairment will be tried on medication at some
point, and usually benefit. Finally, if a child receives an impairment rating of
3 or less, we begin with psychosocial intervention, including setting up a
behavior management program at home, and advocating for interventions within
the classroom. Children with this lower level of impairment usually are not
experiencing significant social problems. I also explain to parents that ADHD
as an impairing condition is catalytic. That is, if children experience other
problems, such as learning disability, mood or anxiety disorders, it is likely
that untreated ADHD will act to worsen those conditions. Thus, if ADHD is
present, impairment secondary to the condition should be evaluated and the
condition should be treated immediately. It has been my experience with
children experiencing significant cooccurring problems, that treatment of ADHD usually
lessens the severity of these other conditions. For example, research has
demonstrated that children with ADHD who are good medicine responders and also
experience a learning disability, make significantly more progress from the
special help they receive than those children who are poor responders. It is
not the medicine improving their learning, but rather their increased capacity
to sustain effort and focus in the face of frustration leading to accelerated
progress.
I remind parents that I am
the consultant and they are the case managers. To be good case managers, they
must understand their child and see the world through his or her eyes. I
believe it is important for professionals to possess and be capable of
articulating a reasoned and reasonable system to determine when medication
should be considered as a first line intervention for children with ADHD. I
also utilize this system for children experiencing significant comorbid
problems whose response to stimulants may be good, but because of additional
impairments may, in fact, be candidates for consideration of a second
medication. I try to help parents separate science from non-science, and
ultimately from nonsense. I try to assist them to be confident consumers of the
essential information necessary for them to make good choices for their
children.
When parents are interested in learning more
about the medications used to treat the emotional and behavioural problems in
children, I have been referring them to Dr. Tim Wilen's text, Straight Talk
About Psychiatric Medications for Kids, (Guilford; 1998). I recently finished
reading Dr. Larry Diller's new book, Should I Medicate My Child, (Basic Books;
2002). This text provides parents with an excellent set of guidelines to make
decisions about psychiatric medications for their children and an up to date
overview of the medications currently being used.
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