ADHD Part II
Let’s assume I’ve had my conference with young Johnny’s parents and we’ve agreed on a trial of treatment with medication. Now come the adverbs: why, when, how.
Why treat? Because children must go to school, and their success is important to them, their families, teachers, and society as a whole. A child who is distracted, inattentive and disruptive makes learning difficult for himself and classmates. Such a child may get by in the early years of school but decompensate in later grades as expectations heighten. Treatment may be instituted in kindergarten or any time thereafter. Questionnaires are helpful and both parents and teachers give their input before we commit to treatment, but there is more art than science in this process. Behavioral methods may be tried first but seldom help by themselves; the same is true for herbal remedies.
There are several options for medication, all once-a-day and even including a patch. This improves compliance and side effects as well as avoiding embarrassing trips to the nurse’s office. The choice of brand may depend on age and aims of therapy. Dosage is started at a low level and carefully advanced as needed. Around puberty it is common for hyperactivity to diminish, which may allow reduction in dosage. However, ADHD seldom disappears completely. Many affected adolescents and adults are most impaired by lack of what is referred to as “executive function”, the ability to organize one’s daily life. Impulsivity is most dangerous in teenagers, especially those who have not done well in school or in relationships with peers. Recently I lost a patient who at 19 took himself off the Rx he had been taking successfully for twelve years without discussing it with me. Six weeks later he was street-racing and hit a parked car at 100 mph.
I believe most ADHD kids benefit from daily treatment because learning opportunities abound on weekends too. Everything from reading a book to a visit to a park to athletic activities can enrich the child’s life if he is paying attention, following the rules and waiting his turn. Some families prefer to withhold the medication on weekends and holidays to allow appetite to increase, although I don’t find any less obesity in ADHD kids than in their peers. It also seems important to me that the child knows what to expect from himself in all kinds of situations and that he receive as much positive feedback as possible at those times. Sooner or later, children who have clashed with parents, teachers and peers over and over will become depressed and ashamed. It is not just a better report card we’re after but an internal assurance that comes from doing well and being praised.
What about the long term? The research is confusing but mostly reassuring. As mentioned in Part I, prisons are full of people with ADHD, many with drug abuse, but they represent the huge group of young people (mostly male) who were never diagnosed or treated for lack of opportunity. Entering the world of drugs and crime usually starts with marijuana, which unfortunately amounts to self-medication but is accompanied by loss of motivation and impairment of memory and judgment.
Lack of compliance with treatment also accounts for many bad outcomes. If a child with ADHD has a parent or two with same, plus a high likelihood of failed marriages and lost jobs, the doctor’s influence may be fleeting. I remember my successes and see them frequently, but so many kids with ADHD drift away for lack of insurance, unstable home life, and occasionally because they’ve been scared off by an internitwit (I just made that up!)
ADHD is a chronic condition, not curable but manageable. Patients need to be seen regularly for checkups and tests, and communication among parents, teachers and other professionals is essential. Many older kids will need therapy for depression or other mood disorders as they arise. Successful people with ADHD are all around us, especially in L.A. where I practice. They often marry well-organized women or make enough money to have managers. They tend to choose careers that reward energy and initiative and allow for “thinking outside the box”. The world of Dilbert probably wouldn’t work for ADHD folks unless the cubicles were soundproof.