Dave: A Family Medicine practitioner asked me if I had any thoughts about prescribing neurostimulants, such as Ritalin, for ADHD. She prescribes them, finds them helpful in some situations, in others they make no difference. She is uncertain where her uneasiness comes from.
I have many thoughts. I will include a few with a clinical illustration. There are so many factors behind the fact that little attention is paid to relational and contextual issues in the way we think about children’s behavior problems.
It is virtually routine to give kids medications for ADHD. There is an industry organized around ADD, well orchestrated, with abundant research to create what I consider to be an illusion of scientific certainty. Questionnaires are available to make assessment by pediatricians, family physicians, nurse practitioners easier.
It is important to say here that I am not opposed to the use of neurostimulants. What I am opposed to is too much single-mindedness. I am a skeptic about almost everything. I think it is important to use caution in the use of neurostimulants not because they are likely to be harmful physiologically, but because giving the medication may play a role in defining a child as mentally disordered. It neutralizes attention to interpersonal experiences that are partial explanations for the problem. The skeptical side of me is concerned that the diagnosis may be in the interest of serving agendas other than the health of the child. The agendas of concern come from managed care companies and pharmaceutical companies.
I assume that everything we include in the domain of Mental and Emotional Disorders (see DSM) is related to interpersonal experience, until proven otherwise. I apply this assumption to how I think about ADHD. It is related to the family and the family’s living and thinking patterns. Children’s identity is shaped in part by projective identification (how they are seen by their parents), by reaction to the microsocial behavior of family members (microsocial behavior is persistent and not likely to be described by family members even when the behavior is toxic). These are psychological ideas that I won’t define here. I will get back to them another time.
Case Illustration: Evan, a nine-year-old boy with ADD was referred by a colleague. Father was an energetic radiologist, mother a hypoactive, emotionally repressed nurse who came from a middle-eastern culture. Evan had been treated by a well-regarded Child Psychiatrist since age four with a variety of medications. I ushered the family into my office then went to talk to a colleague for two minutes. When I entered the office Evan was jumping around pawing at my book shelf and his dad was scolding, pleading, “Evan, don’t do that to Dr. Keith’s books. You have to ask him.”
Oh, you must be Evan.” I said astutely picking up the father’s cue. “I heard you are hyperactive. You better keep it up, otherwise I might start to think your parents are fibbing.” He looked at me quizzically, then did a crazy act, jumping and prancing on his toes, talking too fast, pawing the books in my book case. He slowed down. “Don’t stop yet. I am still not impressed.” He stopped, looked at me, then went and sat next to his mother on the sofa.
I did a fairly standard (low) stress first interview. By this I mean I focus the interview away from the identified patient and focus on the family’s operating systems, e.g., if Mother is crying because of Evan’s behavior, what does Father do? The interview is stressful in the sense that it forces them to talk about relationships that do not include Evan. The interview mildly disrupts their customary way of describing experiences. “How can I be helpful? What do you think you need?” “How does the family operate? I will pick on you first Dad.” Then I asked the eight-year-old sister, Annie, what the family is like, she tried being silly. I changed it to “When you worry about your family what do you think about?” Then I asked Evan similar questions. Then the mother. The stress comes from me attending to and sometimes questioning family living patterns, emphasizing what they ignore and ignoring what they take to be important.
The second interview was fairly active. Evan tested me, tried to figure me out by pushing limits. I did not take him seriously. I talked to the parents about him. In the conversation I nonchalantly referred to him as a “twerp.” I treated him with what might be called “pseudo-indifference.” He was not the center of the attention. He experienced a deficit of attention.
The third interview was quiet, not much had happened since the second session. When they came for the fourth session, all sat silently for five minutes or so. I was waiting for them to begin. The kids, Annie and Evan, were playing quietly with some of my toys. “Is this helpful?” I asked. “Do you feel you are getting anywhere?” The parents responded with energy, “Oh yes. We are surprised. He has not been a problem.” I was surprised. “What do you think happened? How do you explain the change?”
“Well we have seen Dr. Michaels for five years. But he never saw us with Evan. He always talked to us separately. We don’t think Evan really understood why we were upset with him. But he is a different boy in the last three weeks.”
They wanted to make another appointment and did. At the fifth interview something very curious happened. Ever-polite, well-behaved Annie went on a rampage. She was very silly and dancing around the office singing and being deliciously sassy. She was crazy throughout the session, throughout most of the hour. She might have been doing a burlesqued imitation of her brother. The parents were astounded. Evan wanted his sister to stop. He seemed embarrassed by her behavior and ultimately went off to the toy corner and ignored her.
She quieted down by the end of the session and that behavior was not seen again. It was her brief flight into madness or flight into ADHD. This phenomenon is not unusual when change happens and the problem child becomes less symptomatic, it is not unusual for someone else to transiently become a problem
The family decided after two more visits that they had what they needed and decided to stop coming. I never saw them again. The doctor who referred them told me six months later that the situation seemed stable.
So what does this prove? It suggests that some of what is diagnosed and treated as ADD may, in fact be related to interpersonal experiences. They boy’s behavior changed as a result of our therapeutic interactions. I have other clinical stories that are variations on this theme. I have stories where as a result of therapeutic action the medication was stopped. I am describing this case not to neutralize other views of ADHD, but in the interest of offering alternatives to how we think about ADHD.
I do believe that primary care practitioners are in a difficult position when parents insist on a diagnosis of ADHD based on what they read in a magazine, saw on the Internet, or were told by the school nurse. I think for primary care doctors, it is wise to develop some kind of protocol for getting some kind of evaluation before starting medications.
I am a Psychiatrist, but I don’t use medication. I do not simply withhold however, I offer an alternative—bring in the family. When the family becomes engaged, medications are less necessary.