I took a sobering look at treatment side effects and have decided to change the recommendations I make to my patients with ADHD.
For background, let me point to an outpouring of popular press articles recently lamenting an ‘epidemic‘ of ADHD over-diagnosis and an ‘alarming‘ rise in use of stimulants. Every one of them refers to the side effects of medication and basically shames physicians and parents for short-cutting to medication’s “quick fix” when exercise, psychotherapy and tolerance (“let boys be boys”) should be used first and–according to these articles’ authors–exclusively in “all but a handful of cases”.
The argument that we should use the safest, least risky and most effective method for treating ADHD is so ridiculously obvious that I feel bad for using your computer’s pixels to point it out. Why would someone recommend stimulants if exercise works well enough for most?
The argument against stimulant use in each of the articles has been that they cause side effects. Not that they don’t work, but that they are dangerous. This point has been central to each article, emphasized so clearly and repeatedly that I felt compelled to do a little research. How common and how dangerous are stimulant side effects? Can they cause permanent disability? Actual death?
It’s hard for parents to make sense of risks when patient handouts are so detailed (and boring!), so I picked two of my most-often-recommended therapies to create this comparison. Let’s call them Treatment ‘A’ and Treatment ‘B’. The results, laid side-by-side, were sobering.
|Treatment ‘A’||Treatment ‘B’|
|Annual emergency room visits to treat side effects||2.6 per 100 patients||1.7 per 100 patients|
|Annual rate of side effects involving brain injury or damage||3 per 1000 patients||No reported cases|
|Deaths in US every year resulting from prescribed treatment||50 cases||No reported cases|
Laid out in black and white, the side effects of ‘A’ are making me nervous, while ‘B’ is looking comparatively better. So what is the safer-appearing of the two? Treatment ‘B’ is prescription methylphenidate, better known as Concerta or Ritalin.
Treatment ‘A’ is exercise. No kidding! I’ve unconditionally recommended it to virtually every ADHD patient for years, and that needs to change. Clearly, I need to warn patients and their parents about the risks of exercise for treating their ADHD. After all, people should think soberly about their treatment options, discount the latest fads or trends and consider potentially safer alternatives.
All kidding aside, there will be changes. All exercise is not equal. I’m still going to recommend it, but will ask people to accept a few guidelines to lower the risks. I’ll encourage people to moderate their exercise, increase slowly. I’m warn about the risks of football, hockey, lacrosse, soccer, rugby, boxing, kayaking, equestrian and bicycling. Helmets are a must. Signs of over-exertion must be learned and heeded.
One more sobering thought. Sports injury rates are almost twice as high for children with ADHD. Exercise, for children with ADHD, may have even more side effects than my analysis shows. We don’t know yet if medications lower that additional risk.
Nothing is completely good or completely bad. The notion that exercise done properly is a safer option than medication taken properly, though, has been getting a free pass, and that needs to end.