If you’ve read my ADHD stuff before you’ll know my penchant for starting with caveats about how my views, though informed by years as an ADHD specialist, are essentially personal. This one needs a conflict of interest statement as well, because I want to take on the thorny issue of medication.
This is a subject that provokes understandably strong feelings. One of the worries for people who feel that we use medication too much in ADHD is that drug companies have undue influence over the doctors who advocate and prescribe these medications. I suspect these worries are justified in many cases, after all doctors are as prone to influence and bias as anyone else, but I’m pretty confident I’m not in the pocket of ‘big pharma’.
I don’t attend events run by drug companies, I don’t meet their representatives, I don’t have so much as a pen with their branding on it. It doesn’t seem possible to entirely avoid their arms-length involvement, but I try.
Right, if that’s clear, I’ll begin.
As I said in my first post, I think ADHD as a condition is the product of the interaction between an insatiably hungry brain, and an environment that makes having such a brain challenging, for the person and those around them.
Of course, the more hungry the brain, the more challenge and impairment is created. I’ve illustrated this below: it seems to me that a s-shaped curve reflects the fact that milder degrees of brain-hunger are often well compensated for, then there’s a degree of brain-hunger where the person starts to decompensate, and then a part when the degree of impairment levels off, because even severely affected people can still do an awful lot.
The key, though, about this curve is that the gradient and position varies hugely according to the environment. A supportive, understanding and enriching environment will push the curve to the right. A harsh, punitive and isolating environment will push the curve to the left.
So for any given degree of brain-hunger, the amount of trouble caused depends hugely on the environment. Look at the rather shonky animation below.
So the first task, when presented with a person with ADHD, whose brain isn’t suiting their environment, must be to see if the environment can get better.
By improving the environment, I mean access to exercise, sleep and positive relationships. I mean support from adults at home and school with an authoritative but empathic approach. I mean addressing emotional health, underlying special educational needs, and family dysfunction. I mean strategies and structures in the classroom that promote success. I mean giving the ADHD person a positive and realistic frame for understanding their struggles and harnessing their strengths.
I don’t, by the way, necessarily mean specific one to one therapies, such as CBT. The evidence that these help is very limited in most cases of ADHD.
There are limits to what can be achieved environmentally, however. Some of these barriers may be to do with resources, at school for instance, others to do with families being so overwhelmed that they just can’t change counter-productive patterns of relationships and behaviour. Sometimes things have got so bad that the person’s own behaviour is preventing effective support. Or everyone has tried really hard, and things are a bit better, and they’re all pretty exhausted.
Here’s where medication can, in my view, have a role. Nothing, as far as I can see, is as effective in taking the edge off brain-hunger, and addressing the traditional ‘core symptoms’ of ADHD than medication. In those terms, by moving the person (not the curve) to the left of my diagram, they can make a big difference to the right person at the right time.
There are side-effects (which vary by drug, and are unpredictable). The first few weeks can be tough, as the brain gets used to a different setting, and emotions can run high, both anger and sadness, partly for neurochemical reasons and partly, I think, because people often become suddenly more aware of how difficult things are, as the storm in their heads subsides.
Headaches and bellyaches are common. Appetite is very commonly suppressed, especially by stimulant medications. Sleep can be affected of there is still stimulant around at the end of the day. There is an effect on the heart, which needs an eye keeping on it but for most people is harmless.
Sometimes these side effects lead to medication being stopped. At which point you are back where you started. But no worse off, because these effects go away when you stop.
But if you’ve come to terms with ADHD, either in yourself or your child, you’ve done what you can about the home/school/work environment, and you think meds might be worth a try, they probably are.
But, and here’s the important thing. No-one should be pressured to either take or not take meds. It’s for the ADHD person and, for children, their parents to decide. We as doctors can give the facts, and suggest when it might be worth thinking about it. But that’s it.
You may have strong feelings either way. That’s great, but if those feelings lead you to judge the decisions of ADHD people and those around them about this tricky area, then jog on, my friend.
And, to answer some questions that may have been in your mind:
Yes I am
Yes, it did help
No, I’m not telling you which one.