http://archive.salon.com/mwt/col/dill/2002/12/12/adhd_study/ > > Parenting, not pills > > A new study casts serious doubt on our all-too-common practice of dosing > hyperactive kids with Ritalin. Dr. Lawrence Diller welcomes the news. > Editor's note: Parents, kids and other readers are invited to query Dr. > Lawrence Diller about behavioral issues related to young children. Dr. > Diller can be reached at drdiller@salon.com. > > Dec. 12, 2002 | > > Dear Dr. Diller, > I am the mother of a "spirited" 4-year-old boy whose behavior has become > almost too difficult for me, or his preschool teachers, to handle. [Fred A. Baughman Jr., MD:
> At > school, I'm told, he is unable to sit still, stay focused or get along well > with the other kids. He has been aggressive, and I'm not sure he's going to > be allowed to stay. At home, he is active, in fact he bounces off the walls, > but so far we haven't gone beyond basic attempts to control him. > His teachers, and a couple of parents, have hinted that he might have ADHD > and that we should look into medication. I am at wit's end, but I'm very, > very reluctant to start giving him pills. My impression is that this is the > accepted treatment, but I need to know: Is there an alternative that works? [Fred A. Baughman Jr., MD:
> -- Out of ideas > > The controversy over attention-deficit/hyperactivity disorder (ADHD) and its > main treatment, Ritalin, refuses to go away. Parents struggling with their > children's seemingly insurmountable behavioral issues -- at home and in the > classroom -- still face a bewildering array of passionate, conflicting > opinions about the diagnosis of ADHD and the safety and effectiveness of > stimulant drugs like Ritalin in treating it. [Fred A. Baughman Jr., MD:
> This confusion reigns despite > relative unanimity from mainstream medicine that ADHD is a brain disorder, > and its best treatment is Ritalin or one of the newer, long-acting drugs > like Adderall or Concerta. [Fred A. Baughman Jr., MD:
> > Now, however, there is heartening news from a major study of toddlers with > ADHD -- and the surprising outcome should please virtually everybody. > This multi-site study headed by Laurence Greenhill of Columbia University > involves several hundred children from ages 3 to 5 who have been thoroughly > screened and diagnosed with ADHD. That, in itself, is a remarkable feat. [Fred A. Baughman Jr., MD:
> The > government-funded project was the result of a national brouhaha that erupted > two years ago when an article in the Journal of the American Medical > Association (JAMA) revealed that the number of Ritalin prescriptions for > toddlers as young as 2 for alleged ADHD were soaring. > > ADHD in 2-year-olds? The news was astonishing, and raised many more > questions than it answered. Just how much activity, distractibility and > impulsivity distinguishes a "disorder" from some variation of normal in the > 5-and-under set? And should Ritalin be the treatment of choice for this very > young age group? The public's reaction to the JAMA article was vigorous and > skeptical. Political cartoons featured babies in cribs staring up at mobiles > dangling pills instead of cute bunnies. > > This new study's primary purpose was to determine the effectiveness and > safety of stimulants in very young children. [Fred A. Baughman Jr., MD:
> But extra thoughtfulness and > care went into the design of this study -- a reaction not just to public > anxieties about pills, but to worries about the ADHD diagnosis and efficacy > of treatment without medication. > > Unlike most drug studies, which are financed by the pharmaceutical industry, > this study required all families in the trial to participate in a behavioral > intervention component before their children could receive Ritalin or a > placebo. [Fred A. Baughman Jr., MD:
> Greenhill explained that researchers felt both morally and > medically obligated to offer support and strategies for therapy to parents > before trying out medication on their very difficult children. Indeed, no > one knew for certain just how well the behavioral interventions would work. > Amazingly, no one had looked until now. > > And a funny thing happened once they finally did look. Results are > preliminary and the percentage could still change somewhat, but nearly half > the families are opting out of the study after the three-month behavioral > intervention because they are satisfied with the changes in their kids. [Fred A. Baughman Jr., MD:
> Suddenly, a pleased but chagrined Greenhill doesn't have enough children to > participate in the medication arm of the study to satisfy statistical > certainties. It is likely that more money will be needed to recruit > additional children and pay their families to complete the research. > > The fact that brief, focused, short-term parent education and support work > (teaching the parents the need for immediacy of rewards and consequences -- > "less talk, more action") should please everyone, except, perhaps, the drug > companies. What Greenhill's group discovered is that, at the end of > behavioral intervention, the children didn't change as much as their > parents' attitudes. The parents came out of the therapy feeling much more in > control of their kids, and as a result, they wanted to see how things would > go without trying medication. > > Whether these children continue to demonstrate ADHD behavior as they grow is > important. Up until now, most researchers say that ADHD is biological and > basically fixed at birth (or even conception) and that parenting doesn't > make much difference. [Fred A. Baughman Jr., MD:
> I, along with many other doctors on the front lines, > have found otherwise -- especially if interventions in the family are made > before age 6. > > I'm not saying that Ritalin doesn't work at this age, though I will say that > it doesn't work as well and has more side effects than with older kids. But > even if Ritalin works, it is not a moral equivalent to helping parents > parent better. And it still is unclear, despite thousands of studies on > Ritalin, whether the drug makes a difference in the long term. For myself, > I'd bet on the effectiveness of healthy parent and family relationships over > a drug anytime. > > So where does this leave the parents of ADHD toddlers or even those of older > kids who are struggling at home or at school? Try to find someone who works > with families and knows children well but meets primarily with the parents > and school personnel. Unfortunately, finding that someone won't be easy for > most families. Access, availability, and costs for therapy are more daunting > than offering a pill. But news of these parenting successes should spur us > to provide these families with the kind of help that works, and the support > they apparently prefer. [Fred A. Baughman Jr., MD:
> > salon.com > > About the writer > Dr. Lawrence H. Diller practices behavioral pediatrics in Walnut Creek, > Calif. He is the author of "Running on Ritalin: A Physician Reflects on > Children, Society, and Performance in a Pill." > |
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