July 12, 2011

Mark Foster, DO
1
769

Dear Bob–

I want to share a case from this past week the reveals a disturbing misuse of stimulants in treating a poorly diagnosed case of ADHD.

I was filling in at a local urgent care on a Sunday when a mother brought in her six year old son for a refill of his Adderall XR. As I scanned the chart prior to entering the room, I thought, “This can’t be an emergency.” After introducing myself, I found out that they had missed an appointment with the boy’s regular physician last week, and his Adderall XR had run out on Thursday. Now off the meds for three days, his mother, who was very sincere and somewhat simple (I’m sorry, I don’t know how else to say this other than she had a low level of education and understanding–not a pejorative, merely a description), had noticed that he had been acting up more, and this worried her. She thought maybe it was dangerous to be off the meds. The boy was sitting politely on the exam table and fidgeting with a tissue paper.

Right away, I informed her that this urgent care’s policy was to not refill controlled substances like Adderall XR on weekends, that the refill should come from his regular doctor during regular hours. Attempting to refrain from getting too involved in the care of somebody that I would never see again, I informed her that there was no danger in him going another day or two without the drug. She was reassured by this. But then, my curiosity piqued, I asked why he was on the medicines on a weekend in the summer.

“His doctor told me he should just stay on them pills everyday,” she replied.

“Did he mention to you taking weekend or summer holidays from the pills?” I asked.

“No, he just said to keep taking them and to come in every month for refills.”

I didn’t know her family doctor, and I wanted to assume the best about his methods and motives, but this information upset me. At a minimum, the mom needed to know that drug holidays were important to limit overall exposure to the meds, and to help with normal growth and development, that the effectiveness and necessity of medication should be automatically re-evaluated at least every six months. Maybe the doctor had shared these things with mom, but if so, then the message hadn’t gotten through. Not divulging my bias against over-prescribing meds, I probed further. “How long has he been on these medicines?”

“Since January.”

“Why did you start them?”

“His kindergarten teacher was always calling me telling me how much trouble he was causing. She said I should take him the doctor’s ’cause he might have a disease.”

“So what happened at the doctor’s?”

“He said he had ADHD and wanted to start him on the pills.”

“Did he ask you any questions?”

“Yeah, he gave me these papers that I filled out and took to the teachers. When we went back to see him, he told me these showed he had ADHD and he gave him the Adderall.”

“Did he make any other recommendations, or talk about a plan to come off the pills?”

“No. When we went back the next month, he went up on the dose ’cause it wasn’t working too good.”

“Do you think the medicine is helping him?”

“Kinda. He don’t act up as much, and the teachers don’t call me near as much.”

“Have you noticed any side effects?”

“He’s got really skinny now and he don’t eat nothing. And he acts different. He just sits and watches TV.”

I looked at the boy, still sitting politely on the table. I asked, “You said he’s been acting up this weekend off the pills. He’s being very polite right now. What has he been doing at home?”

“He’s been running around the yard and getting in fights with his sister. And he was talking back to my boyfriend.”

Running around the yard and getting in fights with a sister sounded like pretty typical six-year old boy behavior to me. Talking back to her boyfriend sounded like a complex family dynamic issue. None of it sounded like brain pathology, or evidence of a chemical imbalance requiring treatment. I asked, “Do you think those behaviors are signs of a disease?”

“I guess not. He’s just acting like himself again now that he’s off his meds.”

I went on to share, in a way that I hope was not judgmental towards his other physician, my opinion that ADHD is over-diagnosed, and that the medicines have serious side effects that need to be weighed against any possible benefits. I told her that from what she described, I didn’t think her son was broken or had a disease that required chronic treatment. I said that having a lot of energy can be a sign of intelligence, that distractedness can be a sign of creativity, and that many behavior problems are a sign of internal family tensions. Mother was very receptive to these concerns and said she was going to bring them up to her regular physician the next week. Who knows how he will respond? I hope he won’t be dismissive. She simply doesn’t want her son to take any meds that might hurt him.

I hope that she seeks alternatives and that the boy is able to stay off of meds and do well in school and in life. I think the first step is always a shift in perspective, away from “broken brain” and towards a tolerance to behaviors that deviate from societal norms, towards an integration of symptoms, changing a patient’s (or parent’s) focus from a futile quest for elusive happiness, docility, conformity, and normalcy, and towards a quest for meaning and purpose in a unique and tumultuous life.

I’m not going to comment too much on this case, because I think it is pretty self-explanatory and disturbing as it is: a teacher requesting the diagnosis overtly because of classroom management concerns; the doctor’s clear bias towards diagnosing and treating ADHD (I have to wonder if he was recently visited by an Adderall rep); the lack of full disclosure (or comprehension by the mother) of side effects of the meds; the lack of planned drug holidays and a termination plan. All of these are very disturbing.

But the most disturbing thing is that there is no safety net to catch patients who are poorly treated like this, no medium in which to identify and challenge doctors who recklessly prescribe psychotropics. The mom and the boy were started down this destructive path merely because they earnestly engaged our health system to help them solve a complex problem, pointed there by an exasperated teacher. They put their trust in the system, and system, instead of helping them, appears to merely be serving its own interests.

It was by pure random chance that I was able to inform them about the potential brain- and life-altering effects of these stimulants. Maybe my effort will make a difference, maybe not. Maybe they will become fully informed from both viewpoints and decide in the end that brain-altering medication is the best way to control the boy’s rowdy behavior. But at least I provided a counter-message. It seems unlikely it would get through an any other way.

Sometimes it feels like we’re pushing against a tidal wave of societal belief and drug money, like we’re screaming into a void and only hearing our own echoes. Let’s hope that the system is in the process of a slow and painful self-correction, that we can help right the ship before an entire generation is drugged into submission, just so they can be more easily controlled in the classroom and at home.

“He’s just acting like himself again now that he’s off his meds.” Parents, isn’t this what we want, for our children to be appreciated for who they are, for them to act like their exquisitely unique selves, warts and all? Not zombies.

Mark

1 COMMENT

  1. I read your article about a parent requesting an Adderall refill at an urgent care. May I just say that you have no idea what it is like to be the parent of a child with severe ADD and how difficult it can be to keep the prescriptions that they NEED filled.

    Case in point, my son needed a refill and when I contacted his pediatrician who usually fills it I come to find out that she is on leave. So I ask if another provider in the practice can write the prescription and I was told that the pediatricians don’t want to do things with patients that are the patients of other primary care providers without seeing them and they don’t like to fool with psychoactive medications of other provider’s patients. I was told that until his primary gets back, my only option was basically to make an appointment with one of the other providers. Because he is not their patient , you don’t get priority in scheduling so the next available was like a month away.

    My son is “twice excpetional” basically, where he has severe ADD and is gifted. He CAN’T function in his advanced classes without Adderall not to mention the trouble he gets into without the impulse control Adderall provides. Without it he fights with his sister, breaks things, makes huge messes, does random ridiculous things. etc. With Adderall he is well behaved. He goes to a private school where behavioral issues can and will get you expelled.

    Next time you see a patient in an urgent care seeking Adderall , think about if it were your child facing what my son faces without his medication and then decide wether that might me an emergent situation. If his chronic condition were asthma or diabetes, one call to pretty much any pharmacy and I could easily get any medication he needs.

    No controlled substance can be phoned into a pharmacy, his pediatrician’s office is on the other end of town from our house so every refill is a trek. The office closes at 5 of course and is not open weekends, good luck fighting traffic after picking up kids from school to get there before the office closes. Not to mention , God forbid the parent doesn’t have their picture ID – good luck getting any medication for your child with ADD.

    Before you judge, put yourself in the shoes of a parent of a child with ADD. I am trying to help my son become a productive citizen so he isn’t a drain on society. Keeping Adderall filled is not as easy as you might think.

    Parent of a child with ADD

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