Hide your Children; CHILD PSYCHIATRISTS ARE HERE!

In 2018, I attended IACAPAP Congress in Prague, and I can never forget the feeling when there were protestors outside the building carrying placards saying: HIDE YOUR CHILDREN; CHILD PSYCHIATRISTS ARE HERE!

USE OF STIMULANTS:

Undoubtedly, the number of prescriptions and children who take ADHD drugs has increased drastically worldwide, with recent and similar trends observed in adults. However, this trend has provoked anxious reactions and concerns that children may be over-treated in some parts of the world.

But it’s important to acknowledge that despite the increase in the prevalence of psychotropic drugs in some countries, there are instances where medications are prescribed so rarely that it is likely that not all children who have clinical indications and could benefit get prescribed the medication regardless of the access and affordability. For example, in the USA, for each individual using the medication without a formal ADHD diagnosis, three patients with a proper diagnosis might benefit from the drug but do not receive it.

Clinically, the choice of treatment by doctors is often limited by theoretical ideologies, training, the fraternity’s reaction to ADHD, health care culture, the impact of institutions that deny the existence of ADHD, disparate diagnostic practices and algorithms; social context — including historical, cultural, and economic factors — all of them greatly influencing perceptions, diagnoses, and treatments related to ADHD.

Socially, how school settings perceive and react to ADHD symptoms in children may also determine these choices indirectly in the form of referral pathways and the pressure to medicate. For example, Israel is tolerant of high classroom activity levels, whereas schools from China expect children to remain still and on task for long hours in large, structured, quiet classrooms. Similarly, Brazil retains a highly psychoanalytic perspective on ADHD, resulting in low referral rates from schools.

Doctor’s Perspective

The widespread use of ADHD medicines, especially methylphenidate in children, has been criticized for medicalizing normal behavior, i.e., doctors have categorized typical human experiences and emotions as medical conditions.

Are doctors over or under-prescribing is a vast territory, along with divergent professional training and belief systems, that ultimately affects the choice of treatment models.

Doctors who lack specialized psychiatric training might not be the ideal help. Nevertheless, patients, families, and parents always turn to them because of the lack of trained psychiatrists (child, adolescent, adult, and geriatric). Moreover, with limited availability, patients and families rely on the most accessible treatment services.

Now, lack of training could lead to some fears that include:

1. Risk: One of the fears that come with the lack of exercise is that those who take ADHD medication are more likely to abuse drugs. But in reality, it’s just the opposite. Untreated ADHD increases the risk of substance abuse; appropriate treatment reduces this risk.
2. Safety: Stimulants are not safe. On the contrary, stimulants have been proven safe and effective over more than 70 years of their use.
3. Cure vs. Big pharma: The notion of how these drugs don’t cure ADHD. But experience and training teach how stimulants are highly effective at easing symptoms of the disorder; there is a reason why they are the first line of treatment.
4. Medical vs. Moral problem: Since ADHD has a behavioral manifestation of its symptoms, many clinicians don’t regard them as a neurodevelopmental concern
5. Personal factors: Prescribing volume, gender, and recency of subspecialty training also influence these decisions
6. Accountability: This comes with prescribing Schedule II–a controlled drug with a disclaimer of being a high potential for abuse and psychological or physical dependence
7. Fear of Stimulant misuse and diversion: Diversion refers to exchanging, selling, or giving away controlled medications. Misuse refers to the use of a controlled medicine either in a way that was not prescribed or by a person who was not prescribed the drug by a licensed clinician. Both have associated health and legal consequences.
8. Assurance: Being unsure of one’s ability to recognize when a patient is attempting to obtain these prescriptions for abuse or diversion

ADHD medications are the most prescribed psychotropic drugs globally, with notable exceptions in France and Italy. Though trends in prescribing these medications vary widely internationally, the increasing numbers of neurodevelopmental and psychiatric disorders only cannot explain up to tenfold or more differences in the choice of treatment methods. This mainly depends upon the multiple contexts.

This debate of whether there is an over or underuse of ADHD medications will continue to exist. Priority must be to promote optimal evidence-based treatment plans, which might reasonably include prescription and monitoring.

References:

1. Goodman, Geoff, a psychoanalyst, described this struggle effectively; “‘Knowledge equals power,” and its corollary, lack of knowledge equals vulnerability, made the therapeutic work especially challenging for me.
2. https://psycnet.apa.org/doi/10.1037/a0030894