Avoiding over-medication in ADHD: babies and bathwater

In this blog, Allen Frances, whom I greatly admire for his stance on DSM 5, veers from sensible limiting of medication for child mental health problems to somewhere close to ruling it out altogether. The language is extremely emotive (zombies, legal speed etc), and there is a 12 point plan to avoid over-medication. It’s by Dave Traxton who campaigns against any medication for child mental health problems. What struck me about the list was how sensible most of it was. I’ve tweaked it a bit, to remove some of the insinuation about what decision parents ought to take, and adapt it back to uk practice. I hope Dave would forgive me if, in the spirit of compromise and consensus, I present my version.

1.) If the ADHD behavior is not severe and does not occur in all settings, then medication may well be inappropriate. Try ‘watchful waiting’ instead — i.e. see if improvements occur naturally or with changes in environment, exercise, expectations, diet, schedules, routines, and parenting.

2.)Increasing physical activity can help fidgety kids. Enroll them in a team sport, swimming, martial arts, dance– anything to let the kid blow off steam and acquire discipline.

3.) Realize that there is a wide range of normal when it comes to activity and focus. Not every difference is a sign of disease.

4.) Kids also differ in the pace of their development. Only a very significant degree of difference would count as a disorder

5.) ADHD medication is licensed from 6 years, and should only be used before then with great caution

6.) Children on psychotropic pills for longer than two years should have a ‘drug holiday’ to see if they still need them.

7.) If you are worried about the cumulative toxicity of multiple drugs ask the ADHD team looking after your child, or your pharmacist. The more opinions the better.

8.) Schools or parents noticing possible side effects should inform the ADHD team locally

9.) If your child has high levels of anxiety, psycho-stimulants can raise agitation levels.

10.) Do you regularly worry about giving your child medication? This is very common. Please talk to people around you, but also to the ADHD team, before stopping the medication.

11.) When your school is pressing for your child to be medicated, first, don’t be railroaded. Schools are trying to balance your child’s interests against the rest of the class, but you only need to worry about your own child.

12.) If you make a decision to withdraw your child from a medication due to concerns about side effects etc. always do it under medical supervision and based on information provided by reliable sources. Medicine should always be started carefully, but should also always be withdrawn carefully.

If we follow these hints, we should ensure that the right children get medication, and those who would benefit more from something else are directed in that direction. That, I hope, is something we can all agree on.

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