The Side Effects of Doing Nothing

“Well, I’m not giving my baby any more dangerous drugs. From now on, it’s nothing but fresh air, lots of hugs, and good old-fashioned Ritalin.”      –    Marge Simpson         

To medicate or not to medicate, that is the question. It is, at any rate, for scores of parents of kids and adolescents with ADHD. Paraphrasing the old commercial, at Academy MetroWest, we’re not doctors (and we don’t even play one on TV), but we often serve as sounding boards for parents when they want to discuss this issue.

Conventional wisdom has it that, as a society, we are overmedicating our children. This line of thinking suggests that we have opted to throw pills at kids for behavioral issues that could be better addressed by a return to stricter discipline. In my experience, this problem is vastly overstated. If I wracked my brain, I could probably come up with one or two families I’ve worked with over the years who might plausibly fit that description. But I’ve met many more families in which the kids might benefit from a medication trial but the parents, for one reason or another, have ruled it out.

There are plenty of reasons for parents to be wary about placing their children on medication. My personal bias is that, for the right reasons and under the guidance of a qualified physician, medication can be an effective way of managing the symptoms of ADHD. Medication can help reduce impulsiveness, distractibility, and hyperactivity, and it can help many people with ADHD learn, succeed, and thrive to a much greater extent than they could without it. When I talk to parents about meds, I try to be upfront about this bias but I also acknowledge that it’s a complicated issue. The decision to place a child on stimulant medication is not an easy one. My role is to present parents with the information I have at my disposal, discuss their concerns, and then respect their final decision. While stimulant medications, the most commonly prescribed class of medication for ADHD, are often easier to manage and come with milder and less frequent side effects than other classes of psychotropic medications, the side effects do need to be considered and are often the reason that parents look for other options. At its core, the decision whether or not to medicate a child comes down to a risk/benefit analysis. Potential therapeutic gains must be weighed against potential side effects. The most frequent side effects center on difficulty with sleep and appetite. Often, the effects are pretty mild and most parents find a way to work around them if the medication has been otherwise helpful. Less frequently, parents report that stimulants can lead to changes in mood and personality in their kids. Mood and personality changes are more problematic and are usually deal-breakers for parents. However, like the other side effects, they tend to go away once the medication has been discontinued.

Recently, I’ve heard more concerns than I used to from parents about the paucity of research on physiological effects of long-term stimulant use. It’s a valid concern. For a number of reasons, the research into the long-term effects of these drugs has been frustratingly scanty. Even though, according to the Child Mind Institute, “a number of studies have followed children with ADHD for longer periods, and none has turned up any negative effects in kids whose parents reported that they were taking medication,” it’s not necessarily the case that future studies won’t find contradictory results. With much of the funding for medication research coming from the pharmaceutical industry, an industry known for their tendency to push the marketing envelope, some caution and skepticism about the research they fund are understandable.

I agree that more research needs to be conducted on the long-term use of stimulants. Parents are right to be concerned about the issue. However, for me, those concerns are, at the very least, balanced out by a more thoroughly researched phenomenon: the side effects of doing nothing. Kids with ADHD face behavioral, academic, social, and family struggles that leave them susceptible to all kinds of negative outcomes. According to the Centers for Disease Control,  parents of children with ADHD report significantly greater levels of problems with peers, as well as greater levels of injuries, inpatient, outpatient, and emergency room admissions,  and greater risks of drunk driving, traffic violations, and motor vehicle accidents. They are more likely to get in trouble with the law, develop problems with substance abuse, underemployment, and have trouble in school. Clinically, the most common dynamic I see resulting from a struggle with ADHD is the development of a very tenuous self-image, owing to the frustration that stems from struggles with peers, parents, and school. After being in a cycle of failure for an extended period of time, kids with ADHD may come to see themselves as being incapable of making friends, succeeding academically, or having a positive relationship with their parents. So they do what they see as the logical thing: They stop trying. If you combine impulsiveness with the sense that it’s pointless to try to manage it, the results can be ugly as well as tragic.

Of course, medication is not the magic bullet. Finding the right dosage of the right medication still comes down to advanced trial and error and it doesn’t always work. But with accurate diagnosis, studies strongly suggest that it’s likely to be helpful.

Again, I’m not a doctor so I’m not in a position to make authoritative statements about whether or not medication is the right option for anyone. I am suggesting that, if and when you start to analyze the risks and benefits of placing your child on medication, you should do the same thing for the prospect of not putting your child on medication. It’s important to note that there are alternatives to medication, with perhaps the most promising one being neurofeedback. This alternative was nicely covered in the excellent blog Climbing the Cinder Cone earlier this week. The research on alternative treatments has not been as thorough as the research on medication and if you’re looking for insurance coverage, you’re not likely to find it for neurofeedback, which can be expensive. This usually leaves  medication as the first line treatment for managing ADHD symptoms. If you have questions about it, find a competent, qualified physician and ask a lot of questions. Do some reading. Join your local CHADD chapter. Examine the risks and benefits and decide what’s right for you and your child.