Autumn 2004, Vol 8 No 1
The debate about using stimulant medications such as Ritalin to manage a child’s difficult behaviour has been raging across North America for 30 years. Why is inattention such a big issue? Is it because increased class sizes create inevitable distractions for students? Is it because children with special needs are being included in regular classrooms without the necessary supports? Or is it because children have more difficulty attending to classroom routines than spending hours enthralled with fast-moving cartoons or computer games?
As more children with inattention without hyperactivity and impulsivity are prescribed stimulants, the question is whether we are seeking quick fixes for unrecognized learning disabilities, anxiety or other social-emotional problems. It may be easier for parents striving for academic success for their children to accept inattention as the problem rather than pursue more complex and long-term solutions. As for teachers, they are under pressure to have their classes do well in provincial achievement testing. Parents fear for the future if standards are not met. Children begin, as early as grade 3, to experience fear of failure.
Caught in the crossfire are children who have very serious problems. Varying combinations of inattention, hyperactivity and impulsivity are part of a disorder that may not be recognized by people unfamiliar with it. Children for short periods can look so normal, so bright, perhaps just not trying, preferring instead to be the class clown. But attention-deficit hyperactivity disorder (ADHD) carries a huge cost for the child and family, as well as to society, in the form of the economic impact of parents’ time away from work and the strain on mental health services and the education system.
There is clearly a scarcity of resources to train front-line personnel about ADHD. A Health Canada survey found that many physicians feel so frustrated that resources are not available when an ADHD diagnosis is made that they quickly turn to prescribing medication. Physicians get little help in refining the diagnosis, as school boards have fewer psychologists to sort out the differential diagnosis and comorbidities.
Inattention can be a final common pathway for many problems affecting many parts of the brain. Inattention may indicate boredom, anxiety, avoidance, fatigue, obsessions and other levels of meaningful distractions, such as thinking about the bully on the playground. Before a firm diagnosis of ADHD is made, and certainly before treatment starts, these options should be explored; but frequently the resources for these assessments are not available.
The beneficial effects of stimulants for children with ADHD can be magnificent. When someone has experienced the frustration of trying to interact with a child with ADHD and then meets the same child when focussed and able to carry on a conversation, it is easy to hope that other children could receive stimulants. Parents have told me, “For the first time, I have been able to have a meaningful conversation with my son after eight years of living with him on the move.” Children receive a major boost to their self-confidence when they can make a friend for the first time, succeed academically and, above all, don’t anger their parents or teachers. Teacher pressure is greatly reduced when a previously disruptive student can focus. It’s natural that the teacher would then look with similar hopes for improvement at another problem student who hasn’t tried medication. Achievements, at least in the short term, can improve; everyone can feel happier. The result has been that every year, more of our children are receiving medications for attention.
When medication does not work (for about 20% of children) or is used inappropriately because ADHD isn’t the problem, it is a big frustration that frequently leads to searching for another medication. Particularly worrisome is the tendency to try much more powerful drugs, particularly neuroleptics such as Risperdal. The much more serious side-effects that accompany these medications are not always considered, side-effects that apart from significant weight gain can include cognitive dulling, sedation, decreased energy, involuntary movements and hepatic and cardiac complications.
When children do experience success with medication, they may be told, “You’re having a great day. I’m glad you remembered to take your pill.” So credit for the improvement goes to the medication rather than to the child’s hard work. Instead of putting the pill into the context of the many forms of stimulants that adults use regularly such as coffee, we give children the feeling that they have a problem requiring medication. Does caffeine change our potential? Does it compensate for less than optimal work habits, lifestyles or time management?
But research has shown that children with ADHD are more likely to succeed academically and socially with stimulant medication than with only behavioural interventions. Medication accompanied by behavioural and educational management is believed to offer the best chance for real long-term success. Society owes children who have difficulties with inattention a learning environment that can support them and their families, facilitate their learning to focus, protect them from bullies and give them the required remedial assistance. Stimulants can be extremely useful when used the right way. But we must not forget the other educational and social resources that are critical for all children with inattention, whether they respond to medication or not.
We need to remember how difficult it is to live inside the brain of someone with major inattention, unable to focus and complete tasks as easily or successfully as others do. We need to advocate for the necessary resources. We need to continue to gather information on safe and effective medication, which can be combined with other resources, for those children who can really benefit.
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