COMMENTARY

ADD and Stimulant Use: An Epidemic of Modernity

Michael E. Ruff, MD, FAAP

Disclosures

February 06, 2007

Placing the Pendulum of Perspective in Better Balance

In addition to television and video games, how much of ADD is the brain's maladaptive response to crowded classrooms, maternal smoking, iron deficiency, marital discord, or bad parenting?[36,37] These putative factors also need to be researched. The fact that neurobiology and psychopharmacology suffuse almost everything in the pediatric literature and the presentations at CME conferences unwittingly affords the general pediatrician with an unbalanced perspective. For example, the December 2003 issue of Contemporary Pediatrics was largely devoted to ADD. However, there was not a single mention of potential environmental contributions in the entire issue.[38] Likewise, in the lay literature, ADD is routinely referred to as a neurologic disorder or a chemical imbalance. The public tends to imbibe and apprehend this as biologic determinism whereby only heredity and brain chemistry determine behavior.[23] This perspective makes medication more easily justified and potentially marginalizes other interventions. Espousal of neurobiologic causes of ADD also satisfies parents craving for a brain-based explanation because it allays stigmatization and guilt. Nonetheless, the late Frank Oski stated there was nothing wrong with using guilt to try to modify parenting behavior.[39] Organizations such as CHADD [Children and Adults with Attention-Deficit/Hyperactivity Disorder] also desire a biological explanation because it serves to leverage ADD as a legitimate disability. Neurobiology "medicalizes" ADD and thus brings reimbursement from insurers and HMOs. Because behavioral issues are now such a large part of general pediatric practice, the stakes are high and we need to be afforded a more balanced perspective.

Increasing numbers of preschool children have been diagnosed with ADD in the last decade. In a recent Michigan Medicaid study, Rapley identified 223 kids aged 3 years or younger who received a diagnosis of ADHD; 60% received stimulant medication.[40] Eight published randomized controlled studies attest to the robust efficacy of stimulants in the preschooler.[41,42] We are bombarded with the promise of safe treatment in this age group by leading authorities.[43,44] Yet early childhood is a time of tremendous change for the developing brain. Cerebral metabolic rate and cortical synaptic density peaks at age 3 years and is substantially modified by pruning the next 7 years. Treatment with neuropsychiatric drugs in young rats alters lifelong levels of dopamine and norepinephrine.[40] Young adult monkeys exposed to just 2 doses of amphetamine (2 mg/kg) showed substantial decreases in striatal dopamine synthesis capacity and took up to 32 weeks to recover.[45] Thus, it would be prudent to pause before committing to treatment in this age group. Like a child who languishes because he is not exposed to adequate amounts of language at this critical developmental period, so too will kids struggle with behavior if they are not provided with the basic framework of security, discipline, and limit setting.

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