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MEDICATION: A NOT-SO-BITTER PILL

By Gerard A. Ballanco, M.D.

How many fairly normal people do you know who like to take medication? How many fairly normal parents do you know who like to give medication to their children? I don't know very many either, yet I know individuals who willingly take and parents who willingly give medication, sometimes for a lifetime. Why?

People take medication to prevent illness (vaccines, some asthma medication), to protect against the harmful effects of an illness or condition (insulin, heart medication), to modify pain or symptoms (aspirin, acetaminophen, cough medication), and, sometimes, to improve health or vigor (vitamin supplements, herbal preparations). Medication is not always used to save lives; it is also appropriately used to help painful symptoms and improve the quality of life.

Ideas about child rearing and education are in a continuing state of development. Unfortunately, children with learning problems are too often called lazy, stupid, and inadequate. The church of Scientology started and still promotes the idea that medication for attention deficits is inappropriate and harmful. Recently, Cylert has been implicated in several cases of liver failure and its labeling reflects that it is no longer a "primary" medication for attention deficits. The truth is, the history of development of safe medications has its share of dark tales, self-serving obstructionists, and reversals. Not very long ago, the surgeon who first suggested that all physicians wash their hands before deliveries and use antiseptic at surgery was shunned, publicly humiliated, and died in poverty. A short time later, the physician who suggested using a chemical to fight syphilis was virtually excommunicated; the very idea of spoiling the purity of the body with chemicals was abhorrent. Vaccines were introduced only after bitter struggles. The atrocities of Bedlam and similar psychiatric institutes were thought to be appropriate. The battles are far from over.

Many people have "heard" from "them" of bad effects of medications used to help with management of attention deficits. Most of these individuals are repeating hearsay and have no experience with the medications; nor do they have useful alternative choices. A second group of people, ignorant of their ignorance, believes that attention problems are a cop out for laziness or stupidity. In today's "age of information," that position is inexcusable. A third group of individuals sense that attention problems are over diagnosed and too much medication is being prescribed.

The first group should get a life. The second group should open their eyes and look at the mountains of information about attention deficits. The third group is probably right. Unfortunately, as Alice Thomas points out, it is also true that attention deficits are also under diagnosed and misdiagnosed. Because of fear, ignorance, and honest concern, some children are not getting medication who would benefit from it. And, because of laziness, lack of time, lack of understanding, medication is sometimes given improperly or inappropriately by individuals who have not taken the steps to determine to whom medication should be given, which medication should be used, and how it should be taken and monitored.

Recently, the National Institutes of Mental Health began conducting a multi-center trial to determine the best treatment options and combinations for children with ADHD. Accumulating information indicates that for children with ADHD, medication is a critical component of symptom management. Counseling, behavior management, education of family, teachers, and patient, alone or in combination, do not provide adequate symptom control.

Physicians do not have the same levels of training, experience, and interest in every aspect of the health of their patients. Children with attention deficit and significant learning differences often need a great deal of time if the needs of "the whole child" are to be addressed. The physician must be willing to spend the time and have the necessary training or experience to give advice in multiple overlapping areas. Tofranil, Norpramine, Wellbutrin, Prozac, Buspar, Clonidine, Tenex and Orap are medications that are not in the "comfort zone" category for many general pediatricians. More and more pediatricians are knowledgeable and comfortable with stimulant medications, methylphenidate (Ritalin, Concerta, Metadate, Methylin), dextro-amphetamines (Dexedrine), and perhaps the newer multiple amphetamine salt medication, Adderall. Recently, reliable, long-acting medications (Concerta, Metadate CD, and, for some, Adderall) have made the bother and embarrassment of mid-day dosage less necessary, improving compliance.

Your physician coach needs to know about children, medications, learning styles, learning problems, and conditions easily confused with attention deficits. Medication prescribed by this individual will be appropriate. It is appropriate to ask the pediatrician his (her) level of experience. Many will enlist the help of a good clinical psychologist, child psychiatrist, or pediatric neurologist. The physician helping with your child's attention, behavior, or school problem must be willing and able to help develop a plan to identify and manage difficult areas, refer you to the appropriate professionals for non-medical services, and monitor progress. Each of these steps is crucial to success. Regular, focused monitoring is the key.

There is much less suffering in the world, and lives are richer, stronger, longer and fuller because of medication. But not because of medication alone. All new understandings and discoveries are accompanied by recognition that something was being done in a way that could be improved: hand washing and antiseptic solutions needed development of the germ theory and safe solutions to become widely applicable; lifestyle, exercise, and diet are the mainstays of cardiac rehabilitation and health; and partner selection and barrier protection are critical in the control of sexually transmitted diseases. Medication, without these other measures, will work sometimes, but is not the sole or best answer. Change in diet, etc., without medication, will work sometimes, but is not necessarily the best answer either. Good sense dictates that we proceed with the least intrusive and most effective modalities that are available to help individuals become or remain healthy, self-respecting, successful people who are in control of their own destiny.

Children with attention deficits are no exception. Sometimes medication alone makes such a difference that the child easily adopts strategies on his or her own to make special efforts by others unnecessary. More often, however, medication is one of the measures that are found useful in helping the youngster achieve appropriate growth and development. Setbacks, like the recent evidence on Cylert (see box) occur. We should not refuse to use automobiles because some people are injured in them. The same is true of medications and interventions for attention deficits-we need to develop a plan of management, monitor the plan, make corrections as better practices are discovered or needs change, use common sense, and keep a commitment to the overall health and well being of the child and family. Medication is a part of the repertoire; it is not the only tool. It is not so bitter after all.

Recently, the Federal Drug Administration has issued a warning about Cylert, a medication sometimes used in management of attention deficits. A higher than expected number of fatal episodes of liver failure occurred in individuals who were taking Cylert. The medication is still available, but it has been removed from the list of medications that should be considered "primary" in treatment of children with attention deficits. This does not mean that the FDA has determined that Cylert causes liver failure.

Editor's Note: It makes sense that parents of children taking Cylert should contact the prescribing physician to discuss this warning and the pros and cons of continuing Cylert.

Dr. Ballanco, a pediatrician with the Rothschild-Ochsner Group in Metairie, Louisiana, devotes 40% of his practice to children experiencing learning and attentional problems. He is a member of the CDL Board of Trustees.