ADHD is one of the most treatable conditions in psychiatry if patients adhere to medication regimens. So, why are parents so resistant to stimulant medications and how can we approach these misconceptions?

Published On: 04/21/2022

Duration: 13 minutes, 38 seconds

Referenced Article: “Talking with Parents about Stimulant Treatment,” The Carlat Child Psychiatry Report, April/May/June 2022

“Cultural Competence: Impact on Clinical Care”, The Carlat Child Psychiatry Report, January/February/March 2021

Joshua Feder, MD, and Mara Goverman, LCSW, have disclosed no relevant financial or other interests in any commercial companies pertaining to this educational activity.

Disclaimer: We had some technical difficulties while recording this episode and apologize for the sections of poor audio quality. We are improving our recording methods to provide you with the highest quality audio. Enjoy the episode.

Transcript:

Dr. Feder: ADHD is one of the most treatable conditions in psychiatry if patients adhere to medication regimens. Stimulants have been widely used and are usually safe when taken as prescribed, however, parents are often skeptical and concerned about psychotropic medications. In this episode, we’ll discuss why  parents are so resistant to stimulant medications and how can we approach misconceptions surrounding the treatment of ADHD in youth?

Hello! I’m Dr. Joshua Feder, the Editor-in-Chief of The Carlat Child Psychiatry Report.

Mara: And I’m Mara Goverman, a Licensed Clinical Social Worker in Southern California with a private practice

Dr. Feder: We have some exciting news for you! You can now receive CME credit for listening to this episode and all new episodes going forward on this feed. Follow the Podcast CME Subscription link in the show notes to get access to the CME post-test for this episode and future episodes.

Mara:  Let’s begin our discussion today with an overview of the most common concerns that parents have about their child starting stimulant treatment for their ADHD. 

Dr. Feder: Well to begin, many parents believe psychotropic medication will increase their child’s risk of  developing a substance abuse disorder  later on in life. This is a valid concern that many parents  have. Even some professional organizations, such as the American Academy of Pediatrics, recommend cognitive behavioral therapy as the first-line treatment for ADHD in school-age children, despite the findings in the Multimodal Treatment Study of Children with Attention Deficit/Hyperactivity Disorder, also known as the MTA study. The MTA study demonstrated that stimulant medications are more effective than behavioral treatments for core symptoms of ADHD.

Mara: I completely agree. In fact, another study, involving children with ADHD, concluded that methylphenidate reduced the likelihood of alcohol or substance use later in life, compared to children who did not receive pharmacotherapy. 

Dr. Feder: Definitely! Parents may also believe that supplements are natural and less harmful than psychotropic medications. However, with the possible exception of saffron, most have little evidence of efficacy in ADHD. Long chain polyunsaturated fatty acids and minerals have “at best marginal beneficial effects” and zinc, iron, and magnesium lack convincing evidence. Micronutrients showed no effect in ADHD as well. 

ADHD is also surrounded with public and self stigma. Many times parents have a specific idea of how they want their children to grow up and be seen by society, so when they learn that their child has difficulties in certain areas of life they begin to think about how it will be perceived by others. This is a common theme. I'm sure we all know very well in the field of mental health. However, this is a great opportunity to empathize with parents and provide them with the right information to make them feel more at ease.

Mara: Exactly! But, how should we discuss the evidence supporting specific treatments for ADHD with parents? , 

Here are some of the main tips and ways we can talk to medication-hesitant parents about their most common concerns. 

So, to start off, it's important to find out what each parent thinks about pharmacotherapy and what their hesitations or worries might be. A good way to initiate this conversation is to simply state, “Please help me understand your specific concerns.” Some parents are truly set against using medication, but most can engage in productive conversation. Once you know what the concerns are, there are various approaches to encourage parents to partner with us in treating children and teens.

To begin, make sure to place medications in context. Break down the misconception that a pill alone will solve all problems. Remind them that medications are part of an overall plan that includes exercise, structure, nutrition, and sleep.

Next, share the pros and cons of the various medication options. For example you can say “Every medication has its good and bad points. Let’s go over them one by one in detail. And remember, we will learn very quickly whether the medication is helpful or not, most likely within a few weeks.”

Dr. Feder: And we should always remind parents that we understand it is not always sunshine and rainbows. Unfortunately, medications  come with side effects, however, there’s a far greater benefit to cost ratio when receiving ADHD medication. As a result, discussing the benefits of medication is vital when talking to parents. Nonadherence or avoiding medication altogether increases the morbidity of ADHD, as patients are less likely to have improvement of their symptoms or achieve remission. For example, common risks of untreated ADHD include underachievement at school and work, family conflict, mood disorders, anxiety disorders, addiction, injuries, including traumatic brain injury, accidents, premature death, and suicide. When talking about the benefits of medication you can say “Most kids can focus better when they take these medications. They learn better and get their work done more easily, more like the other kids. Kids often feel a lot better about their abilities, and they have more time for recreation and to enjoy life.” When reminding them of the risks of not treating ADHD, you can remind them that, “ Kids struggle harder to get their work done. It takes them longer than their friends. They are often criticized for errors, failing to follow instructions, or for not turning in assignments”. These examples can help parents gain a better perspective of the real life consequences of not treating their child's ADHD.

Mara: These are great points! Leaving ADHD untreated can be far worse than a few side effects. To further place the effects of medication in perspective, make sure parents are aware that treatment can have other  benefits. Remind them that treating ADHD can reduce the risk of accidents, substance use, depression, criminal activity, and teenage pregnancy. 

Next, is to destigmatize treatment. You can say “It might be unfair to your child if we do not treat their symptoms. That might make their life unnecessarily difficult. Lots of kids have ADHD and are relieved to get treatment." This is something that is especially important to discuss with parents that have a long history of cultural stigma against acknowledging mental health. This brings us to another tip which is to address family and cultural aspects. You can bring this up by asking “Do you have family members with similar issues?  How do people in your family and culture understand and manage ADHD symptoms? For more on cultural competence, check out the CCPR article titled “Cultural Competence: Impact on Clinical Care” from our January/February/March 2021 issue. We attached a link to this article in the episode description. 

Dr. Feder: Despite all the positive impacts medication can have for a child with ADHD, we also need to acknowledge legitimate risks and how we manage them. Be sure to directly address appetite, growth or weight loss issues, height, sleep, blood pressure, and pulse. When addressing appetite you can say something along the lines of “Stimulants can reduce appetite so we will track growth.  If your child is not eating enough we can brainstorm some ideas together. We often use medication holidays during weekends and vacations, as well as other strategies to support growth and minimize the amount of medication you give to your child.” When addressing sleep you can say “If issues arise with sleep, we can adjust the timing of the medication to minimize these effects.” Just remember that although we are providing them information about the negative effects, remind them that these are aspects of the medication that you will be closely monitoring and changing with time.

If the child is already taking other prescribed medication and the parents are concerned about drug interactions, you can reassure them by saying “These medications can be taken with most other prescriptions, including antidepressants, birth control pills, and others. But we will need to talk about other meds your child is currently taking, including cold medications such as pseudoephedrine and be sure to keep me updated about future prescribed or OTC meds, as well as supplements.”

Mara: As providers, we should also take the initiative to bring up topics that may be of concern to the parents, but are uncomfortable for them to bring up. Some of these topics may be discussing the sexual side effects of ADHD medication, talking about addicition/diversion, and barriers to prescriptions. A good way to bring each of these topics up in order could include ”You may have heard that medications have sexual side effects. Stimulants can cause painful erections. This is rare but you should seek rapid medical attention if that happens.”

For addiction issues you can say “It is important for you to dispense the medication to your child and to keep careful control of it to prevent misuse, but stimulants actually can protect kids against substance use.”

 And for concerns surrounding the difficulties of acquiring stimulant prescriptions you might say, “Many of these medications are covered by insurance but some may need a prior authorization.” “These medications are more carefully controlled than most to avoid misuse – you may need to show identification when you pick it up.”

These are some of the most important tips you can use while talking to medication-hesitant parents.

Do you have any final thoughts or tips, Dr. Feder?

Dr. Feder: Yeah, As a bottom-line message, when talking to concerned parents the main priority is to listen. Make sure you understand each of their concerns and ask questions to gain further clarity. Follow up with thorough and honest answers that address their concerns point by point. Our goal is to ultimately have them understand that medication for ADHD can truly be life changing. In order to do this, we need to have the empathy and patience to make sure that they can leave feeling knowledgeable and heard.

Dr. Feder: This Clinical Update is available for subscribers to read in The Carlat Child Psychiatry Report. Hopefully people check it out. Subscribers get print issues in the mail and email notifications when new issues are available on the website. Subscriptions also come with full access to all the articles on the website and CME credits. 

Mara: And everything from Carlat Publishing is independently researched and produced. There’s no funding from the pharmaceutical industry. That’s right, the newsletters and books we produce depend entirely on reader support. There are no ads and our authors don’t receive industry funding. That helps us bring you unbiased information you can trust. 

Dr. Feder: And don’t forget to take the CME post-test for this episode! You can now subscribe to The Carlat Psychiatry Podcast CME product to receive CME credit for listening to our episodes.

Mara: As always, the links you need are in the episode description. Thanks for listening and have a great day!

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The Carlat CME Institute is accredited by the ACCME to provide continuing medical education for physicians. Carlat CME Institute maintains responsibility for this program and its content. Carlat CME Institute designates this enduring material educational activity for a maximum of one quarter (.25) AMA PRA Category 1 Credits^TM. Physicians or psychologists should claim credit commensurate only with the extent of their participation in the activity.