Ask the Experts

Is Your Child’s Treatment the Total Package?

Medication only treats the neurochemical deficiencies of attention deficit — we have to treat the psychological and social problems, too.

A handful of ADHD medications, some of which have potential side effects
A handful of ADHD medications, some of which have potential side effects

I completed my training in General Psychiatry, followed by training in Child and Adolescent Psychiatry, in the mid-1960s. My medical specialty was a relatively new sub-specialty of psychiatry. At that time, the theory for understanding and treating children was centered in psycho-analytic theory and psychoanalytically-oriented psychotherapy. All of my training and clinical supervision was based on this model. I was fascinated by the psychology of the mind. But I was equally interested in understanding brain function, and the relationship between the brain and the mind.

With the permission of the director of my training program, I attended case conferences for the residents in another new medical sub-specialty, Child Neurology. One boy there had something called “Hyperkinetic Reaction of Childhood.” It’s now called Attention Deficit Hyperactivity Disorder, or ADHD. The child was hyperactive and doing poorly in school. He was placed on medication (dextro-amphetamine), and his symptoms improved.

I was working with a child with similar symptoms in therapy. He showed all of the characteristics of Hyperkinetic Reaction of Childhood. I discussed my idea of comparing the results of therapy vs. medication. My supervisor was not happy with the idea of using medication instead of psychotherapy, and encouraged me to concentrate on “the psycho-dynamics of the case.” I was frustrated with the lack of progress, so I took the risk of getting into trouble. In collaboration with my patient’s pediatrician, I arranged for him to start taking dextro-amphetamine. His parents, his teacher, and my patient noted a dramatic improvement. He was able to sit in class and to concentrate on his work. His disruptive behaviors stopped. I could not explain to my supervisor that I had ignored his directions and arranged for medication to be used. So, I had to stress how the psychotherapy and parent guidance resulted in the improved behaviors. My supervisor praised my work.

How Things Changed

Child and Adolescent Psychiatry has come a long way since then. We use a bio-psycho-social model that takes into account brain function, as well as psychological and social function — all in the context of the child’s life within the family, at school, and with peers. Studies of children with ADHD taught us about the relationship between brain function, or dysfunction, and the observed clinical behaviors.

Many believe that ADHD was the first disorder shown to be the result of a deficiency in the production of a specific neurotransmitter in specific areas of the brain. The discovery that a group of medications — called “stimulants” because they stimulated specific nerve cells to produce more of this deficient neurotransmitter — caused a decrease in, or stopped, the observed hyperactivity, inattention, and/or impulsivity opened up the field of child psycho-pharmacology.

Today, we know of other disorders that are the result of a deficiency of specific neurotransmitters in specific areas of the brain. (To date, we have not found a disorder that appears to be the result of too much of a specific neurotransmitter being produced in specific areas of the brain.) For each of these disorders, we have medications that increase the production of the neurotransmitter, leading to improvement. It was studies of individuals with ADHD that expanded our knowledge of neuroscience and the treatment for neurologically based disorders.

Let me return to my own story. After my training years, I joined the faculty of a university-based medical school/medical center. Twelve years later, I moved to the National Institute of Mental Health. Later, I returned to a university medical center. Over those 40-plus years, my primary areas of research, clinical writing, and clinical work have focused on ADHD and on Learning Disabilities. During these years, the pendulum gradually swung from psychological to biological models for understanding normal behavior and psychopathology. Today the pendulum has shifted to the center, with equal attention on brain dysfunction and on psychological and social challenges.

Today, we know that a deficiency of a specific neurotransmitter in specific areas of the brain explains the difficulties found in a child or an adult who has ADHD. We know that certain medications correct the neurotransmitter deficiency, resulting in a reduction or elimination of these difficulties. We have also learned that medication alone is not enough. A person diagnosed with ADHD lives within a family and must function in the real world, with all of its expectations and demands. We cannot treat only the neurochemical deficiency.

There are still physicians, including some child and adolescent psychiatrists, who appear to have swung to one end of the arc. Their focus is too much on medication and too little on exploring the possible psycho-social and family challenges.

Let me give an example. A parent takes his or her child to the family doctor. The parent says: “His teacher says that he can’t sit still and that he is not paying attention in class. I see the same things at home.” The doctor hears hyperactivity and inattention, concludes that it is ADHD, and writes a prescription for a stimulant. What could the physician have missed? The restlessness and inattention may be the result of difficulties with academic tasks, possibly due to a Learning Disability. Or the difficulties might reflect stresses in the family because of problems between the parents. The hyperactivity could be the result of anxiety, not ADHD.

Doctors and parents must remember: Not all individuals who are hyperactive, inattentive, and/or impulsive have ADHD. The behaviors seen in children, adolescents, or adults who have ADHD might also be seen in individuals who have other disorders — mood disorder, anxiety, and obsessive-compulsive disorder, to name a few. It is also possible that such behaviors are the result of a student’s frustration at school because of LD, another brain-based disorder.

Takeaways for All of Us

It is important to determine whether the behaviors are neurologically based or psychologically based. We have clinical guidelines in our Diagnostic and Statistical Manual of Mental Disorders (DSM-V) to help distinguish between the two. If restlessness, inattention, organization difficulties, or impulsivity start at a certain time or occur only in certain situations, it is probably a psychological problem. If the behaviors are chronic (you have noticed them since early childhood) and pervasive (they occur at home, school/work, with peers), it is probably a brain-based problem, such as ADHD.

For your physician to make an ADHD diagnosis, he or she must show that the behaviors observed are the result of brain-based problems, not psychological, family, or social stresses. How is this done? 1) Document which behaviors a child or adult has. 2) Show that these behaviors are chronic. 3) Show that these behaviors are pervasive. If the identified behaviors started at a certain stage of life or occur only in certain situations, ADHD should not be considered.

It has been a wonderful 40 years for me, being part of the transition from a psychological model for understanding behavior to a model involving biological, psychological, and social factors. In large part, the study of ADHD led the way.

Leave a Reply