I often have parents coming to me with behavioral or academic concerns about their child. Sometimes both. Some make it very clear to me, unabashedly, that they are looking for medication as an answer. Others make it clear to me that they are not exactly comfortable with the idea of putting their child on medication but are open to it if there is no other solution The last group are the parents who do not want “unnatural” medications as a solution, but are open to more holistic medications or methods to help their child’s problems.
Which is the right approach? Which is the better parent? There is no one-size-fits-all approach for every child, and the overwhelming majority of parents have their child’s best interests at heart. It is incumbent upon parents, though, to educate themselves about ADHD from reliable sources and to work with the pediatrician and educators to arrive at the best solutions for their child. I am quite sure that I am speaking for most pediatricians when I say that our goal is not to steamroll parents into stimulants for their child.
There are very good reasons to address and manage ADHD
Studies suggest that ADHD left unmanaged leads to a higher risk of dropping out of school, drug abuse, and other high risk behaviors. Think about that impulsive 8 year-old child who does wheelies down the middle of the street and shoots rubber bands in class. Imagine this child being scolded day and night because he doesn’t stay on task or he forgets what you tell him to do. Other kids may not like him much because he is always getting in their space, interrupting them, or messing up the group project. Imagine those D’s coming back despite the frustrating 3 hours you and he spent doing 45 minutes-worth of homework. He now hates school because he isn’t getting much time to play outside and the brain drain from reading even 2 paragraphs is unbearable. He is so used to not following what is going on in class that he thinks it is because he’s not smart enough to understand. His self-esteem is shot. Now here is the scary part; imagine this child 10 years later with access to cars and mind-altering substances.
This 8 year-old has combined-type ADHD with both inattention and hyperactivity. Some kids with predominantly inattentive type ADHD may not be as rowdy, but they can suffer the same fate as this 8 year-old in many ways.
Is ADHD a real disorder or just kids being kids?
ADHD is a real disorder with demonstrable differences in how the brain functions. Like most disorders, there is a mix of genetics and environment. Decades ago scientists used to argue over what is more important, nature or nurture. Some of you probably have heard of those studies of identical twins raised in different environments. We now know that nature and nurture are not mutually exclusive. Environment can actually cause changes in genetics. Some of the environmental factors most of you know well, like carcinogenic toxins. But did you know that our experiences can cause changes in our genetics? That’s right, our experiences. Genetics is not only about the genes we have when we are born, but also about which genes are active and how active they are. For example, paleontologists believe that dinosaur DNA is alive and well in today’s modern birds. Birds are not dinosaurs because the genes that would make them look and act like dinosaurs have been turned off over time; but they are still there. Our experiences can actually affect activity or expression of our genes.
So while there are clearly some ADHD-causing genes, as evidenced by a higher incidence within families, there are environmental factors that affect how these genes are expressed. What are some of these factors? Premature birth, maternal smoking during pregnancy, and alcohol exposure in the womb are a few well-known factors. However, these have existed for centuries, so why do we seem to be seeing more ADHD today than, say, 100 years ago? There are a lot of theories but nothing has been definitively proven. Food additives, refined sugars, and food allergies have all been theorized but remain unproven in studies. Screen activities like TV and video games seem to be associated with increased inattention, however it really isn’t clear from studies whether screen activities cause ADHD or if kids with ADHD just tend to want to watch TV more.
I have never met a child who didn’t have some inattentiveness or some degree of hyperactivity at times. In fact, I would guess that there are benefits to that in childhood development. If kids were so focused on one thing at a time, they might expose themselves to fewer activities or see fewer things that enrich their development. Without some degree of hyperactivity perhaps they wouldn’t get the exercise they need. What separates the child without ADHD from the child with ADHD is that the former’s inattentiveness and hyperactivity is not to such an extent that it causes significant academic and social problems.
A very common scenario I have encountered in my practice is as follows. Parents are separated and mother brings child in for an ADHD evaluation. Her son, Johnny, is missing recess at school on a pretty regular basis for disciplinary reasons, grades are poor, homework time is torture for both her and him, he has few to no friends, and he often tells her “I can’t do this” or “I’m stupid”. Mom has to constantly redirect his attention for the simplest of tasks like setting the table or picking up the clothes on his room floor, and admits that there is a lot of yelling involved. When Johnny goes to his father’s house on weekends they play video games together (he concentrates very well on that) and generally do a lot of fun activities where he can “just be a kid”. Mother has come to the realization that he needs to be on medication, while father thinks that is hogwash and Johnny is a normal kid.
Johnny clearly experiences academic and social dysfunction as well as poor self-esteem. Whether he has ADHD as the root cause or not, there is a problem here that needs to be addressed. Getting into constant trouble at school, poor social relations, and being unable to play outside much after school because he and his mother are glued for hours to the kitchen table doing 30 minutes-worth of homework is not “a kid being a kid”.
I typically explain to Johnny’s father that my goal is not to turn Johnny into a model child. I don’t want to take away his free-spiritedness and I don’t want to turn him into an unhappy zombie. In fact, in the beginning I don’t even know whether ADHD is the diagnosis. He may have an entirely different problem, or he may have ADHD and other disorders combined. There are parental and teacher screenings I need to review. I need to look into other possible diagnoses like learning disabilities, cognitive disabilities, autistic spectrum disorder, depression, and anxiety. Is Johnny having quality sleep (sleep disorders can definitely mimic or worsen ADHD symptoms)? I am not a pawn for a pharmaceutical company, but I will recommend whatever therapeutic modality I believe will suit Johnny’s best interests for quality of life now and 30 years down the road. If it is truly ADHD, then medication and behavioral modification together are effective. If there are clues that Johnny has more than just ADHD, psychoeducational evaluations, sleep studies, or even psychiatry referrals may be needed.