Defusing the Explosive Child and the Demise of Discipline

Along with death and taxes there have always been problem children and experts who have offered advice to concerned, suffering parents and teachers. A visit these days to any large bookstore will reveal rack upon rack of parenting advice books covering virtually any problem or angle of child rearing imaginable, a testament to an enduring and insatiable belief in self-improvement/help especially true of the American parent. The majority of these books focus in one way or another on the behavior of children, especially over limit setting and discipline. The range of books and answers strongly suggest there is no single approach that works for all children and all families.

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A Misuser’s Guide to Adderall

(first appeared in the Harvard Crimson, April 28,2009)

The history of amphetamines shows that the use of Adderall to study or to get high at college campuses has exploded. While drugs like Adderall, Ritalin, and Concerta are prescribed primarily to treat ADHD/ADD, multiple surveys reveal rampant use—as great as 35 percent of students on some campuses—of students who admit to the illegal use of a prescription stimulant.

Everyone on campus knows about illegal Adderall or Concerta usage and knows where these drugs can be obtained quickly—in order to study, to cram, to pull an all-nighter, or to get high. Technically, while selling and distributing prescription stimulants is a federal crime, the Drug Enforcement Agency rarely takes action against students.

There is much urban legend at college and high-school scenes about the effects and side effects of Adderall. Having prescribed stimulants like Adderall to patients for over 30 years, I offer the following as a misuser’s guide to Adderall.

Adderall does improve performance in normal, learning-disabled, and ADHD/ADD students, as measured by short-term improvements in tests and grades. The improvement comes as a result of more efficient test-taking and studying, in the form of more focus, deliberation, efficient methodology, and decreased fatigue.

However, Adderall does not improve complex thinking tasks. For example, Adderall will not improve reading comprehension but will allow the user to go over the paragraph multiple times to obtain the answer. Without the drug, fatigue, boredom, or distractibility might occur. It is also not clear whether Adderall “works” by actually improving performance or by simply improving motivation. It decreases procrastination but will not turn the “no” of a defiant child into a “yes” for getting homework done.

Adderall’s most consistent effect is to give users the sense that they are doing better in their tasks. This positive sense, which can become grandiose and manic, may be the strongest contribution to the real improved performance. Under the influence of the drug, people feel better about their performance. Therefore, they perform at least a little better in reality, yet not as well as they think.

Despite the short-term academic gains, there is no evidence that Adderall improves learning overall or that short-term gains in learning persist without the continued use of the drug. What a user produces on an exam will not necessarily translate to long-term knowledge or improved performance without the continued use of the drug.

Common side effects of Adderall are loss of appetite and trouble falling asleep—for some, desired effects. While highly publicized, psychotic reactions to occasional oral doses of Adderall are rare. Serious misjudgment can occur, such as writing an hour’s worth of essay in microscopic print. More gravely, snorting crushed Adderall increases the very small risk of a cardiac arrhythmia that can be fatal.

Government data from surveys conducted in 2002 suggest that about one in 10 casual college-age users of illegally obtained Adderall reports his use as consistent with clinical levels of abuse and addiction. If you’re using Adderall illegally, the risk of becoming addicted to it or another stimulant drug (like cocaine or methamphetamine) is about 10 percent.

So, if you use Adderall illegally or legally, it’s worth asking why you are in college and whether the path you’ve chosen best fits your personality and talents. It may be that many of you are in school because the other option is to live at home with your parents, playing video games and working at a restaurant. Or the academic work may be too hard. Your skills and interests lie elsewhere or are still to be determined. If you regularly require Adderall to cope or do well, you are likely still trying to squeeze yourself into that old, rigid educational hole your parents tried to shove you into before you were “on your own.”

If you’re doing Adderall on a regular basis to cope, you may soon also need another drug. Perhaps it will be Xanax—to deal with the anxiety of having gotten to a place where you really don’t belong based upon your own chemical makeup. If you don’t want to go to an MD for anti-anxiety medication, just smoke more weed. If you’re using Adderall to get high, you are running the same risks of getting truly caught up with one of the worst drug addictions possible (they weren’t kidding in the 1960s when “Speed Kills” first appeared as wall graffiti in the Haight-Ashbury district of San Francisco).

If you’re a regular misuser of Adderall, maybe this is a good time to reexamine your immediate goals and career path. These are tough economic times for everyone, with or without a college degree. Take a close look at your talents and what actually interests you. While you only run a one in 10 chance of becoming addicted to Adderall, the chances are much higher that, if you don’t figure out what you want and what you can do well, you will not only need Adderall, but also a few other psychiatric drugs, for the rest of your life.

Advice on Anti-Depressant Use in Children and Teens

The FDA will now require the manufacturers of antidepressant drugs to include a new black box warning about the risks of suicide. This is important information for physicians and patients but bound to cause a lot of confusion and worry.

A pediatric panel strongly recommended the FDA take this action after reviewing studies on the medications' use in children which demonstrated their lack of effectiveness in childhood depression and a doubling of the rate of suicide on the drug compared to placebo treatment.

I was at the FDA meetings in February and September. I'm sure the panel was also affected as I was by the dramatic tragic testimony of family after family whose children died while taking the drugs. But many psychiatrists are concerned that this group of medications, they still consider quite effective, will be refused by a multitude of children who could potentially benefit from the drug. What should a parent believe and should they allow their child to be medicated?

The first thing parents should know is that psychiatric drug prescription for children's depression is much more "art" than "science." Therefore, knowing the biases of the doctor whose advice you're following is quite important. Most child psychiatrists these days are primarily prescribing medication so there will be a tilt towards their recommending those kinds of interventions. Virtually all the psychiatric researchers who are quoted in the newspaper or television have studies funded by the drug companies or are paid consultants.

I prescribe psychiatric medication to children on virtually a daily basis but because I publicly challenge the use and overuse of these drugs to children in our country I have never accepted drug money. While it means I fly to professional meetings in coach instead of business class, I can't afford the risk to my credibility by accepting money from the drug companies, if I also suggest that medication can be effectively and safely used in children.

The anti-depressants and here I'm referring primarily to Prozac and her sisters, the SSRIs, which include Zoloft, Paxil, Celexa, Lexapro, and Luvox, have never impressed me as being particularly effective in treating childhood depression, say compared to the effects Ritalin has on ADHD. This is borne out by the drug company studies of 4600 kids reviewed at the FDA meeting of which only three of fifteen showed the active drug (it was Prozac) more effective than the placebo.

But not so fast. It isn't easy demonstrating a positive effect on childhood depression because the placebo cure is sixty to seventy percent in most studies. Any drug would have to be superior to that already high rate in order to prove its effectiveness. Just last week, this point came back to me in my own practice. A twelve year old girl was remarkably improved two weeks after I prescribed her Prozac for what appeared to be a depression with hallucinations (she was hearing voices). She attributed her better mood and elimination of the voices to her taking the medication. I was very impressed. But then later her parents called to remind me that I'd forgotten they had decided to give her a vitamin pill instead of the medication because they were nervous about the Prozac. One more cure for placebo.

So if a psychiatrist is convinced anti-depressants work, the science for the moment doesn't support that position. However, the drug could still be used in children. Evidence for Prozac's effectiveness in treating childhood anxiety is much stronger. And even using the drug for depression could still be justified but expectations should be realistic.

I would still consider using these medications for teenagers who are actively suicidal or have tried to kill themselves recently. Teens who self mutilate would also seem sufficiently impaired so as to risk the possibility that medication could be helpful. These children should be followed closely with visits and phone check ups in the first weeks of treatment and any time there is a increase in the dosage.

The most important take home message though is about the side effects. Prior to the FDA warning, if a child started an anti-depressant and complained of feeling worse, anxious, agitated, extremely restless, thinking thoughts never thought before (like killing himself or his parents), the doctor was likely to reassure the patient and his parents. "Hang in there. It's your depression. The medication takes two to four weeks to work. You'll feel better soon." Sometimes the doctor would increase the dose or even add a second medication.

STOP! That's the message from the FDA. If in the first days or weeks of treatment the patient is doing worse stop the medication -- there is a small group (about three percent) of kids who seem worse off on the medication. It may be necessary to hospitalize the child (on no medication) until the drug effects wear off. One could try another medication then but only under very tight supervision and perhaps treating the child without any medication may be the best course for that child.

Oh, if your kid is already taking the medication and is "doing better" you don't have to stop (though it may only be the placebo effect). However, if you plan to stop the medication don't do it abruptly. Turns out despite years of denial from the drug companies and their professional representatives there is a mild to moderate withdrawal from the SSRIs (mostly headache and feeling lousy). It isn't the depression returning as claimed for many years. Just ask the babies who were jittery and fed poorly for two weeks in the study of newborns whose mothers had taken Paxil during pregnancy. I don't think these babies were depressed.