Nancy Rappaport: Stimulants: The Art of Diagnosis

I am a child psychiatrist who has spent the last 20 years working with the public schools. If you read "Risky Rise of the Good-Grade Pill," Alan Schwarz' alarmist recent article in the New York Times, you might think I spend my days cavalierly prescribing medications for children who don't need them. You might think I am duped daily by entitled kids who want medications to get better grades. As one girl bragged to Schwarz, "If you keep playing the angsty-teen role, you'll get something good."

Give me a break. Most seasoned child psychiatrists know when kids are trying to play them. I take pride in helping kids who need medication and would not otherwise have ready access to a thorough evaluation. I invest the time to help parents understand their child's struggle in school, and I work to galvanize resources to help the student progress. Articles like the recent Times piece paint the wrong picture for children and parents who are nervous about medication -- even when the medication can help.

Certainly, no rational person would endorse the rampant abuse of stimulants described in the article. But the piece seems to ignore the fact that there is a population of children who need these medications not just to succeed, but also to survive. The teachers I have heard from over the years do not describe "the angsty-teen role,'' but rather speak to much more troubling symptoms in their students. They tell me about attentional difficulties, swearing, impulsivity, sexualized comments, constant redirection, and sometimes even physical and verbal aggression with peers. These are not "angsty" teens at elite private schools. And they may be suffering from more than simple attention deficit hyperactivity disorder. They may be in foster care because of neglect or abuse. They may have a parent in jail, which adds another layer of complexity to their condition.

By the time these children get to me, the parents are often frustrated because the school keeps "writing their kid up" or suspending him when other kids seem to get away with the same behavior. The student may hate the school and his teacher because he is failing. The whole family may be suspicious of both the medical establishment and school authorities. They may cringe at the recommendation that their child needs therapeutic support and medication because it suggests that he or she is "psycho" or "not normal."

It is key is to take the time to assure parents that I am not getting a kickback from the drug companies but am simply trying to help them make an informed decision. There is a common perception that physicians are over-prescribing drugs to children, but according to the most recent National Health and Nutrition Examination Survey, only half of the sample of children (age 8 to 15) with ADHD received any mental health care over the past 12 months. Certainly, not every child with ADHD needs medication. But many do, and in some cultures, there is a stigma against taking medication for mental illness. And when children who need medication don't get it, they can end up in a "substantially separate classroom," where they feel alienated with no easy way out.

It's my job to help parents know when medication can actually help. Some parents may be wary of medication because they fear their child will become "addicted" and abuse stimulants. This is understandable if there is a family history of abuse, and it is always important to strategize with families about how to keep the medication safe and not have it diverted to other family members. Stimulant abuse can occur, but responsible clinicians prescribe doses that rarely lead to abuse.

At the same time, research has shown that if kids with ADHD are not treated, they are twice as likely as the general population to have other substance abuse problems, such as marijuana and alcohol. That's why treatment is so critical, especially for kids with a diagnosis of ADHD with impulsivity and risk-taking symptoms.

Stimulants are not a magic pill. I would never be so na?ve to say that. But in my 20 years of practice, I have seen dramatic changes in students. Given caring teachers, necessary therapeutic support, and, at times, medication, a child on a downward spiral can stabilize and even thrive. Every child in crisis demands enormous effort from the school, parents, and clinicians. Again, I never would endorse rampant misuse of stimulants on campus. I would not let myself get hoodwinked by a student who wants medication to do better on tests -- or to make money by selling them to other kids. But I have seen the value of a balanced approach, and I only wish the Times piece had been balanced as well.

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