ADHD Weekly 2017-11-02

There have been some claims in the popular press that ADHD medications, especially the stimulant medications, are over-prescribed. But those claims either have had to be retracted (such as the New York Times publishing three corrections to its 2013 article) or have been challenged by qualified professionals for failing to consider critical factors and scientific evidence. For example, this apparent bias from some journalists was challenged in an article by one professional, who says, “Some people in the media appear to already know the answer … [they] simply leave out any disagreeing viewpoints and data.”

What’s the real story?

The idea of over-prescribing has been based on anecdotal situations (such as possible side effects meaning that medications are harmful) rather than on data from controlled scientific evidence, says Max Wiznitzer, MD, a pediatric neurologist at Rainbow Babies and Children’s Hospital in Cleveland, and a member of CHADD’s professional advisory board.

Dr. Wiznitzer emphasizes that clinicians and parents must remember that all evidence shows that multimodal treatment for ADHD―which includes behavioral interventions for the patient (and/or caregivers when the patient is a young child) along with medication―provides the greatest likelihood of success.

“Medications can improve focus, but they don’t teach how to learn and behave,” he says.

So what explains the persistence of the idea of over-prescribing? Anecdotes versus scientific evidence is one issue. Dr. Wiznitzer offers several other reasons:

• There is a misconception that the “stimulants” prescribed for ADHD are in the same category as cocaine or other addictive drugs. But there is a big difference between these two classes of drugs, having to do with different rates of absorption and retention; the medications for ADHD have been shown not to be addictive.
• Some people harbor a suspicion of medical science and believe doctors are in collaboration with the pharmaceutical industry.
• Some people (such as some college students) seem to think that ADHD medications will make them smarter and they attempt to misuse their or their friends’ medications. Research has shown that ADHD medications don’t improve test performance. A good night’s sleep before an exam is more effective, and pulling an all-nighter to study without sleep degrades performance.
• Parents may sometimes see a problem behavior in their child that they can’t handle, and proactively seek a prescription to “fix” it, neglecting to also do the hard work of behavioral training to ensure a supportive environment. When the problem persists, the medication gets a bad rap.
• Both effectiveness and appropriateness of medication depends on an accurate diagnosis. There are sometimes issues of misdiagnosis, for several reasons.
• Some people may “self-diagnose” themselves or their child based on what they see on the internet, and ask their doctor to diagnose ADHD without going through the full rigorous diagnostic process.
• Some symptoms of ADHD are shared by other disorders, resulting in diagnosing the wrong disorder. In other cases, ADHD is only one of two or more co-occurring disorders, therefore requiring different medications.
• In some cases, clinicians are given unintentionally skewed information regarding behavioral symptoms from caregivers, or there can be ambiguity of symptom description and severity, making it hard to know which symptoms belong to which medical condition.

What can you do?

The right diagnosis will help ensure the right treatment.

• Don’t assume you know the answer before your doctor conducts the lengthy and rigorous evaluation. Take the time to be sure the diagnosis is right.
• Carefully monitor, log, and report to your doctor the response to treatment (side effects, behavioral changes) over time.
• Feel free to get a second opinion if necessary.
• There are a number of medication options for ADHD. If you or your child are experiencing intolerable side effects from one type medication, talk with your child’s doctor about other types of medication that may be helpful.
• When behavioral interventions are included with medication in a multimodal treatment plan, the dose of medication is often less than it would need to be when behavioral training or therapy is lacking.

Join the discussion: Has someone said to you that “medication is over-used” for ADHD? How have you responded?