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NYC Child, Adolescent and Adult Psychiatrist Diary: ADHD, the Parent, and the School

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In a previous article, we discussed the fact that kids with ADHD are increasingly prescribed not only Ritalin and Adderall (which are FDA approved for ADHD), but also antipsychotic medications (which are not).

Why?  Here’s the typical story:

A parent comes to see me saying, “The school is really concerned about Johnnie’s behavior. The teachers and school psychologist are calling me every day about how aggressive and disruptive he is. They want me to speak to you about his medications. They feel that being on Ritalin is not enough and that he may need something like Risperdal. The school staff told me that this is a safe and effective treatment for ADHD and that other kids in his class are taking it.”

They said WHAT? No,  no, no!  Risperdal is NOT a treatment for ADHD. It is an antipsychotic medication FDA approved to treat Bipolar disorder, Schizophrenia, and irritability in children with Autism.

Risperdal is by no means a benign medication. It is in the category of major tranquilizers and carries with it the risk of weight gain, as well as elevated blood sugar and cholesterol.

I don’t   want to sound like I am placing blame on our parents, teachers and schools. Many of our schools are  inundated with too many students and have too few resources. I have the utmost respect and admiration for them, and I’m truly inspired by the work they do.

But we need to educate our parents, teachers and schools about psychotropic medications,  their indications for use, and their side effects.  Many parents and  educators have unrealistic expectations about these medications and misunderstand their role in treatment.   Too many  in the mental health field are either quick to start or to  advocate for the use of these powerful medications before more beneficial alternatives are utilized.

I often have to explain to parents that psychotropic medications are only a piece of the overall treatment. Behavioral interventions, programs, and other school activities are in my opinion a much larger and effective piece of the puzzle.

Applied Behavioral Analysis (also known as ABA) is  a scientifically validated approach to modify problem behaviors. ABA is nationally recognized as safe and effective and is endorsed by many state and federal agencies including the U.S Surgeon General and the New York State Department of Health.

ABA therapy has demonstrated improvements in learning, reasoning, communication and adaptability in children with Autism. Many of these same principles are also being applied to help treat kids with other behavioral disorders including ADHD.

I would love to receive phone calls from teachers and parents asking me about ABA therapy rather than pushing for the use of powerful medications like Risperdal.

As I  discussed in a previous article commenting on Dr. Richard Friedman’s New York Times article, often all that  is needed is a reassessment of the child’s individual education plan, classroom setting and size.

Let’s not forget the power of talk therapy. Kids need to have someone to talk and share their feelings with.  They may be depressed or anxious over conflicts in the house, parents separating and divorcing,  or perhaps even domestic violence.

Sometimes aggression in school is due to a child’s feelings of inadequacy about having learning difficulties and not being able to comprehend the material like the other children.

So please let’s not be so trigger-happy with psychotropic medication. Save the Big Guns for when there are no other alternatives.

And let’s not forget  the various scientifically validated behavioral therapies that we have at our disposal.  As far as I know, ABA therapy has yet to be associated with weight gain or diabetes.

©Roey Pasternak, MD
New York City
www.parkavenuepsychiatry.com

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NYC Child Psychiatrist Responds to “A Natural Fix For ADHD” by Dr. Richard Friedman in the New York Times

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The New York Times and ADHD — Deja Vu All Over Again

For reasons known only to its editors, The New York Times has for years championed non-medication approaches to ADHD.  For the most recent example of this, see Dr. Richard Friedman’s article “A Natural Fix For ADHD.”  The title alone gives you a pretty good of idea of The Times’ slant on the matter.

Dr Friedman, a distinguished psychiatrist and psychopharmacologist at Weill Cornell School of Medicine, describes a patient with ADHD who struggles at a routine desk job. When this individual quits his job and joins a start-up company, he thrives in the more active stimulating environment and his ADHD symptoms no longer cause much of a problem.

There’s certainly some science behind this. It is thought that a specific genetic variant of the dopamine receptor DRD4 is associated with yearning for novelty and with being less able to tolerate routine.  In addition, research conducted at the National Institute on Drug Abuse (NIDA) shows that people suffering from ADHD have fewer dopamine receptors in the reward circuits of their brains compared to non-ADHD controls.

The fewer the dopamine receptors, the greater the symptoms of inattention reported.  The upshot? People with ADHD may be walking around with less sensitive reward centers. Less sensitive reward centers don’t make interesting activities boring. They simply make boring activities horribly boring— or even intolerable.

But let’s get back to Dr Friedman’s main idea:

What’s the best way to treat ADHD?

I think Dr. Friedman and The New York Times does people with ADHD a disservice by suggesting that the “natural fix” of switching to a less routine job “cures” ADHD.

The truth is that all jobs involve some tasks that are more interesting than others. As a child, adolescent, and adult psychiatrist who treats many people with this condition, I’ve heard too many stories of creative individuals who falter in their careers due to not being able to get their billing or other paperwork done.

In fact, one wonderful thing about medications for ADHD is that unlike many other psychotropics, they can be taken as-needed. The analogy might be made to reading glasses. Most immediate-release preparations of methylphenidate (Ritalin), for example, give about 2-3 hours of effective help.

What if we just medicate ADHD in some situations, but not in others? I’ve had patients report that they only needed a short burst of Ritalin to get started in the library, and after that their natural interest in whatever they were working on kicks in.

One patient,  a surgeon,  has no need for ADHD medications when he’s operating. It’s exciting, and there’s enough risk to keep his brain awash in dopamine. But during office hours, it’s a different matter. A little Adderall helps both him and his patients.

I’m not going to tell that many of my ADHD clients that they should consider a career in party planning or professional hockey. There’s creativity and boredom in almost every job. To paraphrase Ecclesiastes, there’s a time for medical treatment and a time for career counseling.

A good psychiatrist should be able to do both.

©Roey Pasternak, MD
New York City
www.parkavenuepsychiatry.com

 

See related articles:

Is Stimulant Medication for ADHD Addictive?   We all hear stories about people abusing ADHD medications.  Yes, this does happen. But stimulant medication for ADHD is far and away still the best treatment for this very common and often debilitating condition.  The best solution is to make sure stimulants for ADHD are being prescribed by a careful and experienced child, adolescent, and adult psychiatrist who does a thorough evaluation and spends enough time with patients to make sure they’re on the right track.

Does Medication for ADHD Lead to Drug Abuse? An ADHD Specialist Child Psychiatrist Speaks Out.   The link between ADHD and chemical dependency is an association with the ADHD itself, not with the medications we use to treat the condition. There is a common misperception that stimulant medications make people into addicts.  In fact, research shows the opposite:  Adolescents with ADHD treated with medication show less incidence of problematic substance use.

NYC Child Psychiatrist Speaks Out on the “Myth of ADHD.”   Psychotherapy helped Rebecca in many ways, but it did nothing for her ability to concentrate.  Finally when she became the mother of two young children, she was overwhelmed with the stress caused by forgetting and losing things she and her children needed.   Finding out she had ADHD was by itself helpful.  Just knowing that there was an explanation for why she had such a hard time getting organized (you mean I’m not just lazy?) helped her immensely.  She chose to try a stimulant medication, and it took a few tries before we found the right one for her.  In the end, the combination of psychotherapy and medication was particularly helpful.  Her daily life has markedly improved.  So has her marriage.

 

 

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