Over the past couple of years, I’ve taken the opportunity to blast away at stories published in the New York Times that propagate misinformation about the diagnosis and treatment of mental health conditions…ADHD in particular. The Times ran another story on its’ front page on Sunday that’s being circulated widely across the psychiatric community…describing in great detail the course of treatment of Richard Fee, a 24 year-old aspiring medical student who committed suicide in late 2011 two weeks after running out of his ADHD medication. I’d encourage you to read the story describing the experiences of Richard and his family throughout his course of his treatment. Sadly, his story is not atypical of histories I’ve heard from other kids (generally younger than Richard) and families coming through our practice. I’m going to make some comments based upon the article…
It’s not uncommon for kids to come to our office for an assessment after having obtained medication for ADHD from someone at school. I heard through the grapevine of a kid in a local middle school having been arrested for offering to sell ADHD medication. True addiction to ADHD medication is fairly rare. Most misuse in our area appears to be driven by pressure to perform academically.
When I’m in the process of evaluating kids for ADHD, I’m looking for corroborating information from as many different sources as possible. I’ll typically ask parents to bring in their child’s year-end report cards for as far back as they kept them…I’m looking for “red flags” in the teacher’s written comments and grades for behavior, work completion, time management and organization. Also, kids and adults with ADHD are notoriously poor at being self-observant. I would ALWAYS want another observer present (typically a parent) if evaluating a young adult for ADHD.
Kids with ADHD are complicated. In our practice (not necessarily a representative sample), the vast majority of our teens and young adults with ADHD have some other mental health condition in addition to ADHD…most commonly, anxiety disorders or OCD. Medications for ADHD frequently exacerbate those conditions. Lots of kids experience unpleasant side effects and it’s far more common for them to take less than their prescribed dose or lie and tell us they’re taking medication when they really aren’t. On the rare occasions when they start taking more medication than prescribed, the common denominator in my experience is that they’re kids with obsessive anxiety who get stuck on the thought that they need more medication to accomplish some task. They’re not physically addicted to the medication so much as they’re psychologically addicted. In these situations, the stimulant medication often intensifies obsessive thinking and produces inappropriate anger, meltdowns, irritability, aggression and emotional lability. In this case, Richard was a bright kid struggling to get the test scores necessary to get into med school when he first sought treatment.
Our mental health system leaves young adults in a limbo of sorts…we grant them complete autonomy in making decisions about their care and cut off the ability of their families to be fully engaged in their treatment when they’re still of an age when they continue to depend upon their parents for emotional and financial support. The same is true of our educational system…parents receive tuition bills from their kid’s college but are denied the ability to access information about their academic progress. If parents are paying for their young adult child to stay on their health plan they should be able to participate in their child’s treatment. In our practice, any kid I’m treating over the age of 18 has to agree to allow me to engage with their family as I see fit in order to continue with us.
A larger issue is how to explain a 141% increase in the number of prescriptions for stimulants being written for young adults over the past five years. Here are some thoughts…
- The consequences of academic failure are enormous. We have far more college graduates than we have jobs appropriate for their level of education. Students often accumulate significant debt. Many students seeking entry to medical school or other competitive programs have labored for years under pressure to get good grades. With so much time and money invested and anxiety running so high, many will do whatever it takes (as in the sports world) to get across the finish line.
- The insurance-driven practice model allows for little more than cursory evaluation and brief medication visits. This isn’t right, but there are many physicians who take the path of least resistance when patients come in asking for a specific product or treatment. The reason you see so many TV commercials that include the phrase “Ask your doctor about…” is because those commercials work. Some of this is the fault of the profession, some the fault of the pharmaceutical industry and some the fault of the insurance industry and their pharmacy benefit managers, but physicians in general and psychiatrists in particular are all too often viewed as prescription vending machines. I think many of our colleagues get to the point where they’re too tired to fight it anymore.
- Society has come to demand a level of productivity and responsiveness thanks to the wonders of technology that’s unsustainable for many, and more and more young adults find themselves looking for medical solutions in order to keep up. People routinely send (and expect return e-mails) on Saturday nights, weekends and holidays for non-emergent situations.
Our current system of caring for people with mental health disorders is in a near state of collapse. Sadly, I have little hope of the situation getting better and fear things are going to get much worse. What I found unsettling about this story is how accurately it represents the service delivery system that kids and families enter into when they leave our practice.
Updated May 16, 2014
Key Ministry has assembled resources to help churches more effectively minister to children and adults with ADHD, anxiety disorders, Asperger’s Disorder, Bipolar Disorder, depression and trauma. Please share our resources with any pastors, church staff, volunteers or families looking to learn more about the influence these conditions can exert upon spiritual development in kids, and what churches can do to help!