Managing Managed Care

Our inequitable, inefficient, oftentimes uncaring health care "system," revealed. -- Jeffrey G. Kaplan, M.D., M.S.

Med. Newsletter / eBook

Be informed on reform; Newsletter and, if requested, a relevant eBook: "Mgd Care 101 in 2016" (No obligation)

Subscribe to Managing Managed Care newsletter feed

SSL Certificate

Attention Deficit, Sans Medicine

Is drug therapy an or the answer in ADD/ADHD?

Some would say to medicate is a remedy for kids or adults whose minds wander.  I’d say it is also part of the problem. Medications cannot treat everything and worse, it does not replace making the learning material relevant or the teaching method effective.  Often, it's quite the opposite in fact--'Give him medicine and then we can on with the boring subject matter.' 

What about that learning experience?  Is the child tuned in, seemingly distracted when he or she is actually quite bored or having real trouble at home?  Is the patient-student is at a stage of development where he or she cannot prioritize and then focus? What has the teacher done to raise the interest level in the subject matter being taught?  How is that subject matter made relevant? Are the mind, body and spirit in sync or, better, synergistic?  In some cases there's a physiological reason for learning difficulties; in others a basic skill is missing.  Sometimes there's an actual learning disability–visual, auditory weaknesses (or strengths), for instance. Sometimes (like the child in the photo who, it turns out is actually gifted), the student learns extraordinarily well, in their own way, but with their own sense of priorities, not seeming to pay attention or appearing distracted to the frustration of their rigid, if not inept instructor.

If this sounds confusing, it is, a situation made worse by the lack of standards of diagnosis or care.

Despite the official publication of the American Academy of Pediatrics' (AAP) recommendations the use of evidence-based standards for diagnosing and treating ADHD remains elusive.  For example, 

  • Less than "half of children had contact with the pediatrician during the first month after medication was prescribed;
  • Few pediatricians (about 10%) used parent and teacher rating scales to monitor treatment response or adverse effects as recommended by the AAP."  
  • "Only 70.4% of diagnostic evaluations documented ADHD criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), and only about half included parent and teacher rating scales.
  • Most children with ADHD were on medication—93.4%—whereas only 13% received psychosocial intervention (a combination of the 2 is considered most effective)." 

Furthermore, departure from said recommendations falls into "2 categories: behaviors at the pediatrician or practice level and behaviors attributable mostly to patients. Improving care .... will probably depend on system-wide changes at both the practice and policy levels."

And, not finally, many children including toddlers are being medicated because they can't sit still. This is unacceptable.

Bardossi, Karen. "First national study of ADHD therapy in kids." Contemporary Pediatrics, April 14, 2014

Thus, one can legitimately ask: Is attention deficit with or without hyperactivity (ADHD/ADD) a true disorder with demonstrable pathology? Is there a genetic predisposition (a "nature" verses "nurture" issue)? Is something wrong with the brain, a chemical disturbance?  Unfortunately, we still do not know.

Because the afflicted are easily distracted, inattentive or even disruptive, they can be treated differently, left out and they are usually labeled (meaning they are castigated).  In our society, however, that is the price one has to pay to avail themselves of scarce resources–clinical or educational–to help the patient and their family.

Note: often in a more tolerant settings, such as the religiously orthodox community in which I work, patients with ADHD/ADD can be mainstreamed, they can learn and they can succeed, meaning they can perform well, test well enough, stay at task, and retain, surprising us all the time; and, they can accomplish these things, often without heavy, mind-altering drugs.  In other words, not all children or adults diagnosed with ADD/ADHD “need” medication.  [Also see natural remedies, below.]

Should the main criterion for drug therapy be the typical threat, born out of frustration—‘Without medication he cannot attend this or that class/job/activity?"  In many cases, I suggest we prescribe more structure, make reasonable expectations, design, implement and shepherd behavioral interventions, and these patients frequent opportunities to ‘burn’ calories. [See "Raising Cain"–a documentary that probes issues facing boys (and, increasingly, girls) potential solutions for their dilemmas.]  

I say a new paradigm is needed in scholastics. Let's seek caring teachers who can deal with those having difficulties in self-control (weakness in 'disinhibiting' certain disruptive or distracting behaviors), and then, and only then, in my opinion should one consider using pharmacology as a supplement or aid.

Clinically, the decision to use meds also depends on the “severity of symptoms, the coping abilities of the child, and the availability of other treatment interventions. Although medication seems effective in managing behavior problems, considerable improvements might be achieved also through properly implemented alternative interventions. Currently, parents, teachers, and doctors make decisions about drug therapy—being the same ones who appear to receive the greatest benefit from it. In the future, these decision-makers should consider selecting therapies less on the needs of adults and more on the long-term needs and benefits of children.”

Given the risk for adverse outcomes, effective treatment of ADHD is both an art and a science. The efficacy of the various interventions that have been available focus on three general approaches:

  1. Drug (pharmacological) therapy;
  2. Behavioral/psycho-social; or
  3. A combination of the aforementioned approaches.

Doggett, A. Mark. “ADHD and drug therapy: is it still a valid treatment” J. Child Health Care (2004):8(1):69-81, esp. 76-77 (Sage Pub.) pdf

Sterman, M.B. ‘EEG Markers for Attention Deficit Disorder: Pharmacological and Neurofeedback Applications’, Child Study.2000; J.30(1):1–24

Other important references or resources:

See Drs. Mark L Wolraich and Steven Pliszka "Jumping In: "The ADHD Guidelines in Practice" [CME via the Annenberg Center for Health Sciences at Eisenhower], especially using a community-based collaborative approach (under HIPAA rules), which emphasizes discovery (standardized testing and monitoring tools) and information exchange, i.e., communication between all interested parties–psychologists, social workers, teachers, guardians and specialists, for example. [last accessed 8/20/14]

The American Academy of Pediatrics (AAP) has developed a resource kit to help with this process. Caring for Children With ADHD: A Resource Toolkit for Clinicians, 2nd Edition, provides more than 40 practice tools. including evaluation forms, assessment scales, teacher report forms, coding information, etc. You can order it online at the AAP bookstore.

Neurodevelopmental disorder or classification–"The new criteria require an age of onset before age 12, rather than age 7, given research showing no difference in outcome

Natural Remedies or Treating ADHD Without (sans) Drugs

Free fatty acids diet supplementation has shown positive effects in analysis of blinded assessments, after controlling for differences in medication use.

Medication can help alleviate or lesson the symptoms of attention-deficit/hyperactivity disorder (ADHD) among children having this diagnosis however, longitudinal outcomes in marital, employment, and legal areas of interest are still quite discouraging, even among individuals without histories of conduct disorder   (JW Psychiatry Nov 5 2012).

Study: industry-supported analysis of randomized, controlled trials

Subjects: 3–18 year old children who carried an ADHD diagnoses. 

Method: meta-analysis

Findings:  free fatty acid supplementation is found to be helpful, but food elimination, cognitive/behavioral therapy and neurofeedback were not beneficial.

Sonuga-Barke EJS et al. Nonpharmacological interventions for ADHD: Systematic review and meta-analyses of randomized controlled trials of dietary and psychological treatments. Am J Psychiatry 2013 Jan 30; [As reported by Geller B. in Journal Watch Psychiatry Feb. 15, 2013]


See also, "Honor Code" by David Brooks where he says:

"The basic problem is that schools praise diversity but have become culturally homogeneous. The education world has become a distinct subculture, with a distinct ethos and attracting a distinct sort of employee. Students who don’t fit the ethos get left out."

NY Times, pub. July 5, 2012

This article is posted in: