October 13, 2012

Give Me My Adderall!

(First appeared in the Huffington Post on October 10, 2012)

"Give me my Adderall!" Matthew, a 15-year-old patient of mine, recently demanded of his parents. When they refused, Matthew slashed his left wrist with a box cutter. His parents called the police and he was taken to the county hospital emergency room for evaluation and possible admission to the psychiatric ward. His parents had withheld the medication for Matt's purported attention deficit disorder (ADD) because they hadn't liked the side effects of irritability and anger they had associated with their son's use of the medication.


Matthew was enraged. His parents had taken away his cell phone and all access to the Internet because they felt he was making no effort at all early in his sophomore year in high school, either in class or in doing homework. Matthew felt he "couldn't" do his work without the medication and didn't think his mood on the medicine was a major problem. He and his parents had been arguing about his restrictions when, in essence, Matthew had a temper tantrum, threatening to cut himself. When his parents held firm, he injured himself with a dramatic act but fortunately made only superficial lacerations to his wrist.

I've witnessed many other dramas in my 34 years as a behavioral pediatrician and family therapist, but Matthew's recent episode epitomized for me a tectonic shift in the way adolescents view psychiatric drugs, especially the performance-enhancing stimulants (Adderall, Ritalin, Concerta, etc.). As recently as 15 years ago, I had a difficult time convincing young to mid-adolescents to try any psychiatric drug: Prozac, Adderall, whatever. I used to share my frustration with parents that their child was refusing my medications but was quite ready to self-medicate with marijuana, alcohol or other illegally-obtained substances. But with teenagers now insisting on pharmaceuticals as solutions to their problems, I wonder if that's really making progress.

While there could be multiple reasons for their problems, these days I've noticed teenagers regularly telling their parents they "can't" concentrate on school or homework and asking for medication. Ironically, it's their parents who have become more uneasy or reluctant to immediately give their children stimulants (amphetamines or some variation of them) to improve their school performance or behavior at home.

Some parents are understandably worried about side effects or the risks of addiction and abuse. Actually, most children (and people) can tolerate the side effects (if any) to the stimulants. Used properly (in my practice parents are entirely in charge of these drugs), the risk of physical addiction is close to if not zero. But many parents are also concerned about Adderall's "quick fix" nature of the teens' solution to their problems.

Adderall improves anyone's performance on boring and repetitive tasks. It will not make someone smarter. Indeed, despite decades of use, evidence that long-term learning or grades improve is absent to scant. Most consistently, it does give someone the sense that they are doing better and therefore often improves motivation. The work gets done. However, inconsistently or unmotivated naturally-distracted teenagers learn nothing about how to make themselves do the uninteresting or challenging tasks necessary to grow to be mature adults.

Undoubtedly some will say "Well that's exactly what teenage ADD is -- difficulty making yourself do something you're not interesting in!" Indeed, it's impossible to distinguish the behavioral symptoms of ADD from those of an inconsistently or unmotivated adolescent. There is no blood test or brain scan for ADD or for any psychiatric disorder for that matter. Nevertheless, doctors do seem more ready to offer these drugs to all people. What have changed are the teens' attitudes toward these meds. They want them and ask for them.

While not worrying about physical addiction, I've seen psychological addiction and dependency in teenagers for Adderall. Also, teens in high school and college students are increasingly obtaining the drug illegally (mostly from friends who've gotten prescriptions from their doctors). Some colleges report 35 percent of the students have tried Adderall-type drugs for studying or getting high (remember, it is amphetamine). For subgroups, like fraternity or sorority seniors, rates have been estimated as high as 80 percent. Used improperly or unsupervised, serious abuse and addiction can occur. Additionally, these drugs can be a pathway to the misuse and abuse of other prescription medications like Oxycontin and street drugs like methamphetamine.

There's certainly a place for these medications in the treatment of ADD. But I think we've done too good a job of "selling" ADD and Adderall as the answer to many teenagers who are in a normative struggle toward maturity. Unfortunately, there are few cultural influences strong enough to the counter the power of the medical-pharmaceutical industry that successfully brought our country's attention to the problems of attention. "Just say 'No'" didn't work with street drugs. Sadly, it's unlikely to work with ADD drugs like Adderall as well.

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