Trees:
I believe that one of the main efforts of neurobiology and medicine should be directed at alleviating suffering.… But how to deal with the suffering that arises from personal and social conflicts outside the medical realm is a different and entirely unresolved matter. The current trend is to make no distinction at all and utilize the medical approach to eliminate any discomfort.
—ANTONIO DAMASIO, M.D., PH.D., Descartes’ Error
AS A PRACTICAL MATTER, THE USE of medications in treating attention deficit disorder is straightforward. It’s how they are currently employed and their status as first-line treatment that are complicated.
There is a legitimate perception that too often drugs have been prescribed with the intention of making a child more manageable from the adult point of view. I have seen a child put on Ritalin because the parents have been told that unless the child is medicated, he cannot come to school. It is not unusual to hear such stories. It has been estimated that in Quebec the number of children using Ritalin has almost quadrupled from 1990 to the present. According to a Globe and Mail report, Pierre Paradis, a professor of education at the University of Quebec, has said that this is in large part because schools ask parents to have their children use the drug.1 Professor Paradis points out that the increased use of Ritalin has paralleled reductions in the number of special education teachers, psychologists and social workers in the educational system—results of the cutbacks in funding that throughout North America are considered to be among the duties of “responsible” governments.
It is also true, however, that some of the opposition to the use of medications comes from people without the least knowledge of the subject. I was once sharply challenged by a radio host who demanded to know how I could justify prescribing to children a new and untried medication such as Ritalin—the reality being, of course, that this drug has been known and used for at least four decades. I find, too, that the people most closed-minded on the question of medications are also the ones least aware of what attention deficit disorder is. Not appreciating its complex physiological dimensions, they tend to imagine ADD to be a simple matter of authoritarian schools trying to control the spoiled or troubled children of negligent parents.
Only people who have not witnessed or personally experienced how helpful medications can be could maintain a categorical opposition to their use. The positive effects are often dramatic and immediate. One patient of mine, a fifty-four-year-old woman, came back excitedly after taking a low dose of the psychostimulant Dexedrine. “I never saw the trees,” she said. “We live across a park and have a beautiful view, but I never noticed before how green it was.” Almost three years later, she continues on the same low dose and reports the same effects, which to her still seem miraculous. One gets similar testimonials from other adults. “You know what I’m doing for the first time in my life?” asked a forty-year-old man, after three weeks on Ritalin. “I am asserting myself.” People report that they can get through the workday without losing track of what they’re doing every three minutes, or that they can complete pages of writing at a time. A university student found that her migraines had abated. I had worried about giving her Ritalin because of its potential to cause headaches; it turned out her migraines resulted from anxiety over her difficulties studying, which the medications resolved so well that she attained higher marks than she ever could before.
A teenager for whom I recently prescribed Ritalin, a fifteen-year-old with a cunning sense of humor, approached her parents a half hour after taking her first dose. “I feel like listening to a boring lecture from a geography teacher,” she said. What she did, in fact, was watch the educational channel, a first. That evening she also had the first calm and intimate talk with her mother in years. One could relate similar positive outcomes with elementary-grade children.
In many other cases, the results are not so impressive. The medications will not work or will cause unpleasant side effects, such as headaches, loss of appetite, listlessness, insomnia or anxiety,* or, simply, the positive changes will not be so dramatic. There is no way to predict how a given individual will react to a particular medication. I explain to everyone who chooses to try a psychostimulant that each human brain has its own chemistry; one cannot know just how it will be affected. Although as a class, stimulants have been used clinically since 1937 and are about as safe and well understood as any drugs used anywhere in medicine, each person taking them for the first time is being, in a sense, his own guinea pig. There is no reason to be afraid of them, however. More exactly, if we are to be reluctant to use them, it should be for the right reasons, not because of misinformation, such as that these drugs are addictive if used for ADD. While they are subject to abuse, as are other legitimate medications, their administration in medically prescribed doses does not induce addiction. A better case can be made that they may prevent addictions, by correcting some of the biochemistry that predisposes a person to substance abuse, as described in the previous chapter.
The main drugs in ADD treatment are the psychostimulants, the most familiar being methylphenidate, known by its trade name Ritalin, and dextroamphetamine sulfate, commonly referred to as Dexedrine. Although they have different modes of action, they both stimulate the activity of the cerebral cortex by balancing the levels of the neurotransmitters (chemical messengers) in the frontal lobe of the brain and in other centers concerned with arousal and attention. As we saw with the “sleeping cop” analogy in chapter 5, with the inhibiting power of the cortex enhanced, there is less chaos in the mind and a greater capacity to resist distraction. The person feels calmer, more focused and purposeful.
Neither methylphenidate nor dextroamphetamine can be said to be better than the other; individual predisposition determines what works best. Alternative medications are available, including other psychostimulants, antidepressants in low doses and some different classes of drugs as well. I will not conduct here a technical discussion of which drug and in what doses; the subject is well outlined in a number of other books on ADD. Far more important are the principles that should guide drug treatment, and not least, the very question of whether medications should even be used in the case of any particular child or adult.
For adults, this is self-evident, but in the treatment of children, this principle is often not recognized. It is essential that the child not perceive that she is sick, that something is wrong with her. She does not have a disease and does not have to be cured. The medication may improve functioning, if that is her own chosen goal, but no one should impose on her the demands of the adult world. When you take a chemical substance, it alters how you feel internally and how you relate to the world. Even if these changes are positive, it is a major boundary violation for parents or schools to insist that an unwilling child subject herself to fluctuations in her internal chemical states.
One can understand the frustrations of the teacher facing a classroom full of children, of whom perhaps two to four may have ADD. Unless he ignores those children completely or coerces them into passivity, a good half of his energies will be taken up interacting with these few, to the detriment of the others. In most cases, he is not trained or equipped to teach such children. The awareness of what attention deficit means is as unpredictably variable from teacher to teacher as it is from doctor to doctor. What is outrageous is that cash-deprived educational systems should have to think in terms of chemical straitjackets. Children are being altered to fit the schools, rather than schools being organized to meet the needs of the children who, due to their life experience in this society, have needs and personality traits that call for greater flexibility and creativity than most institutions of learning are currently able to offer them.
The desperation of parents for some relief from what often seems like the impossible task of dealing with their ADD child is also understandable, as is their worry that without medication the child will do poorly in school. One couple I have seen have gone so far as to mix Ritalin into their son’s breakfast drink. He refuses to take it knowingly, and without it he is constantly in trouble in school. I urged them to stop this practice immediately.
Parents are sometimes upset that I insist so heavily on the child’s autonomy. “He will fail if I don’t make him take the medicine,” they argue. Apart from the principle involved, my reasons are quite practical, if we have in mind long-term rather than short-term objectives. It may well be that one can push a young child through the early grades by the enforced use of medication. But then what? Well before adolescence, all but the most intimidated children are capable of putting up a strong resistance. All their counterwill-driven oppositionality, hitherto suppressed, will erupt. They will have been driven into a position of obstinate refusal of medication, no matter how useful it could be to them. Along with that, pressuring the child and violating his boundaries will sabotage the long-term developmental goals that should really be the main aim of treatment. Far better for the parents to work on the attachment relationship with their child and on their own parenting approaches than to worry about his passing a grade. Children who feel good about themselves and secure in their bonding with their parents are unlikely to refuse the help of medications, if such help is truly needed.
The medications employed in attention deficit disorder cannot be prescribed according to the fixed recipes appropriate for most medical drugs. Doctors are familiar with the cookbook approach, which is how most medications are prescribed. The dosage of penicillin given for a bacterial throat infection, for example, does not vary between an eight-year-old and an eighty-year-old. Some other medications are dosed according to body weight. With the psychostimulants, neither is there a fixed dose nor can one judge by body size. A small child may need more than a large adult, or vice versa. The principle is to begin with a very small amount of the drug and to build it up gradually. If a child experiences unpleasant effects from psychostimulants taken over a long period of time, the problem is due to prescriber error, not to the medications. It is very simple to reduce the dose or to stop the medication altogether if problems are encountered.
The vast majority of preadolescents receiving Ritalin are boys, and even for the boy with attention deficit disorder there are reasons for rambunctious behavior other than his ADD. If a physician increases the dosage of the drug until classroom perfect behavior is achieved she may end up tranquilizing the child into an overly subdued state, with loss of the special vivacity and spark that characterize many ADD children. The end point should be the child’s experience of himself, not only observed behaviors. No child should have to take medications that give him side effects, any more than an adult would want to do so.
At an adult ADD conference I attended, the buzz of conversation between sessions was largely about which person was prescribed what medication, and about what other drugs they could be using instead, or along with it. There was a general sense of disappointment that despite the pharmacological treatment, people continued to experience significant difficulties in their lives. Drugs, of course, do not alter the major issues a person needs to struggle with. In some cases they can be of tremendous help, and in others their benefits are more limited. In no case do they resolve the basic problems of low self-esteem, fear of intimacy, driven lifestyles and lack of self-knowledge. The medications, if taken, should be used with the specific purpose of reducing distractibility and improving concentration and focusing, not of changing people’s lives.
Not infrequently, the ADD adult may be suffering from chronic low-grade depression or anxiety. If this is the case, the psychostimulants may not help, or in some cases may make matters worse. If depression or anxiety is present, it needs to be addressed first, or at least at the same time.
The most serious problem with the widespread use of medications in the treatment of attention deficit disorder is that very often—probably in the vast majority of cases—they are the only form of intervention consistently pursued. Yet in themselves they do not promote long-term positive changes. When children or adults stop taking them, they find that none of their problems have gone away.
Attention deficit disorder is not primarily a medical problem. Neither its causes nor its manifestations are due to illness. The factors that maintain the ADD-related mental turmoil and behaviors are only in part biochemically internal to the individual, and have more to do with the circumstances in which an adult or child lives her life. The easy route of relying on a pill is tempting but leads in the wrong direction. Much more difficult, and much more essential, is to address the issues of psychological security, family relationships, lifestyle and self-esteem.
One of the many astute recommendations made by the psychologist Thomas Armstrong in his book The Myth of the ADD Child is that medications have no place as the first-line treatment for ADD. “Most importantly,” he writes, “medication can be used as a last resort, after a sincere attempt to employ a number of appropriate non-drug interventions has failed to produce significant results.”2 I might not put it as categorically as that, but despite my initial enthusiasm for medications when I first learned about ADD, and despite the clear benefits they can have, I do now tend toward that view.* There are some cases where early pharmacological intervention is sensible—if the child voluntarily accepts it—for example, the relentlessly hyperactive child whose family and school life are in crisis. The exclusive use of medications can never be endorsed and the development goals outlined throughout this book must always be foremost.
The fifteen-year-old who felt like “listening to a boring lecture by a geography teacher” after taking her first dose of Ritalin had, nevertheless, some mixed feelings about the medication. “It’s not the me that I’m used to,” she told me. “It’s kind of weird to see my mind working differently.” Before and all throughout their teenage years, children have the task of consolidating a sense of themselves, of who they are. Medications impose an artificial state, affecting the child’s moods and thoughts. Even if such changes are positive, they still may introduce further confusion into a process already teeming with changes and internal conflicts. They may, as Stanley Greenspan points out, “undermine the adolescent’s long-term goal of forming a united sense of self.”3
One of the main reasons not to pressure children into taking medications is that this integrated sense of self is far less likely to be disrupted if they themselves choose pharmacological treatment. When they are making a free choice, they are not simply electing to take a medication, but indicating that their sense of self is ready to accommodate an awareness that they may have problems in some areas of functioning, and that they will accept help. In supporting the young person’s freedom of choice, parents express their faith in his own processes and do not convey a belief that there is something wrong with him. They also do not reinforce the child’s anxiety that he is not accepted by his parents just the way he is.
It would be easy to come to the wrong conclusions from experiences like that of the same teenage girl who, having taken Ritalin, had a meaningful talk with her mother for the first time in years. The story may be seen as proof that the only thing wrong between mother and daughter had been the teenager’s ADD, now “cured.” Not so. Many problems remain in that family, which the parents are only now beginning to work on. The girl herself, despite the contact with her mother while on Ritalin, still spoke despondently of her relationship with her parents. “Why can’t they just accept me for who I am?” she said. “I don’t understand why they even want me at home.” That the medication worked to calm and focus her certainly indicates that she does have a neurophysiological problem, but the episode also highlights the mother’s problem: something in the mother tenses up when her daughter is tense. Her own anxieties are triggered so that she can not remain calm, loving and attentive. Unless her daughter is well controlled, she cannot be accepting toward her. There has not been enough individuation, or differentiation between them. In his own way, the father, too, has been involved in the triangle. It is the parents’ responsibility to recognize such dynamics and to move to change them, which this couple are keen to do.
Given the importance of nonpharmacological approaches, how to explain the huge imbalance in favor of medication use in the treatment of attention deficit disorder? There is, of course, the North American propensity for the quick fix and the hope of fast relief from a nagging and difficult problem. But it is not as spontaneous as all that.
“While until very recently the bedside usually determined what was done in the medical research laboratory,” the physician and author Sherwin Nuland has written, “the findings coming out of the laboratory nowadays are just as likely to tell the clinician what he can do at the bedside. The tail often wags the dog. In fact, the tail is becoming the dog.”4 The fact is, researchers and doctors find it much easier to raise funds for drug evaluation studies than for treatments that do not hold out the promise of huge profits for anyone. Pharmaceutical companies, the major source of research dollars, have no incentive to support alternative approaches that will do nothing for the size of their coffers. If, as Dr. Nuland suggests, the laboratory tail is wagging the clinical dog, it is largely because the poor dog is starving even as the tail becomes bigger and bigger.
*Who develops side effects and who doesn’t is unpredictable. Fear of side effects is no reason not to try medication, if otherwise doing so is advisable. They go away within hours of stopping the drug and cause no long-term damage. On the whole, the psychostimulants are tolerated quite well by the majority who try them.
*Unfortunately, in all but rejecting the very existence of ADD, Dr. Armstrong throws out the baby with the bathwater. For all that, his book is a most useful read for the parents of ADD children.