Medication for ADHD: Over-reliance is the Problem

At a panel discussion at the recent meetings of the American Psychoanalytic Association Esther Fine, PhD suggested that children might benefit from psychotherapy rather than medication to “understand the unconscious meaning of psychological symptoms.” It is statements like this that, in my opinion, give psychoanalysis a bad name.

Consider Sara, an eight-year-old girl in my pediatric practice(details have been changed to protect my patient's privacy). In third grade, she was unable to learn because she could not sit still, was extremely disorganized and would impulsively rush through her work. Many family members had a diagnosis of either ADHD or substance abuse, which may have been self-medicated ADHD. She had a dramatically positive response to medication. She mastered her math facts and began to enjoy going to school.

Yet at a follow-up visit about one year into her treatment, things were not going well. Her teacher reported that Sara was increasingly distracted. She suggested to her mother that she ask me to increase her medication dose. "Is anything else going on?" I asked. Sara looked directly at me and said, "I'm sad because I miss my Dad." I looked puzzled and turned to Mom, who then reluctantly told me that Sara's father was in jail for selling drugs, and that Sara had not seen him for several months.

I not only recommended psychotherapy, but explained that I could not in good conscience continue to prescribe medication unless both Sara and her mother were engaged in therapy. But my recomendation was certainly not aimed at helping her "understand her unconcious processes." It was aimed at validating her experience and offering her an opportunity to address the feeling of grief and rage around losing her father. My wish, in an ideal world, would have been for parent-child therapy, where the therapist could not only validate Sara's experience, but help her mother to understand why she did not recognize the impact of this event on Sara's emotional life.

This story is typical of many I hear on a daily basis. If we are going to help these kids, I believe it is important not to frame the discussion as therapy vs. drugs. Likely Sara has neurobiologically based ADHD in addition to significant environmental stress. Instead we should ask, "What can we do to validate the experience of both parent and child?" Limited access to quality mental health care and aggressive marketing by the pharmaceutical industry converge with a cultural acceptance of treating complex problems with medication. We need to support parents and children, not only on an individual level, but also in the form of improving access to high quality primary care and mental health care.