You've got questions . . .

We don't necessarily have answers. A reader asks about prescribing stimulants to children diagnosed with ADHD. This is another one of those issues where there isn't a bumper sticker. It begins with the basic question of the reality of Attention Deficit Hyperactivity Disorder as a "disease." This disease was only discovered after children were universally required to spend their days sitting quietly in rows, focusing for long periods on sedentary tasks assigned to them by adults. Very few children actually like doing this, and most of them squirm, whisper to each other, pass notes, and find their attention wandering.

Some children just won't, or can't do it, to the point where their teachers don't want them in the classroom. They talk when they aren't supposed to, won't sit still, engage in activities other than those assigned. Of course this is harmful to their prospects in life because they don't get their book learning and they find themselves in opposition to authority figures. Eventually this pattern of behavior was given a disease label and, based on the hypothesis that the children's brains weren't making the right chemicals, doctors tried giving them psychoactive drugs. They found that amphetamines and an amphetamine-like drug called Ritalin™ caused at least some of these children to sit more quietly and focus better on the assigned tasks. As with all psychoactive drugs, it is difficult to sort out placebo effects -- perhaps in this case operating as much through parents' and teachers' expectations as through the children's -- from the biological action of the drug.

These drugs happen to be controlled substances which are addictive and very commonly abused. Their mechanism of action is the same as that of Methamphetamine, against which the U.S. government is currently on a major crusade. They are weaker, to be sure, but amphetamine addicts do purchase them on the black market. They have the potential for severe adverse effects.

The U.S. government, through the National Institute of Mental Health and the National Institute on Drug Abuse, maintains that ADHD is a real, specfic, biological disease; that these drugs are effective for treating it; and that children with ADHD who receive the drugs do better in later life than children who don't. Some psychiatrists and parent activists dissent quite radically from this position. The radical dissent is that drugging children who don't behave he way we would like them to represents a failure to engage them respectfully as human beings, that counseling, negotiation, skill building, and changing the school environment to be more accomodative of normal childhood behavior are all better alternatives which get pushed aside in favor of the quick fix of drugging. Many of these people also point to what they consider harmful effects and dangers of the drugs.

The middle position is that the drugs are overprescribed and do represent an easy way out in many cases, but that there are some children who really do have a brain dysfunction which is ameliorated by these drugs. The challenge is to discriminate more accurately, and to come up with the resources to address the problems of children who don't fit in well at school without resorting to drugs.

I find this debate important and illuminating, but I haven't made up my own mind fully between the radical critique and the moderate position. For those who wish to pursue this further, you can get started with the NIDA position, which links to NIMH and other federal agencies. Then you can visit a psychiatrist who is a leading critic of the practice of drugging children. Information about the side effects of Ritalin and other stimulant drugs is here.

Let me know what you think!