Sys­temic Healthcare Is­sues

Rotman Management Magazine - - FRONT PAGE - In­ter­view by Amy Stu­pavsky

Tell us about your re­search into the ef­fec­tive­ness of Ri­talin on kids with at­ten­tion deficit hy­per­ac­tiv­ity dis­or­der (ADHD). How does this is­sue il­lus­trate the com­plex­i­ties of ‘wicked’ healthcare prob­lems?

ADHD is the most com­mon child­hood ‘dis­abil­ity’ in the U.S., the most com­mon men­tal health prob­lem in the UK, and it is be­com­ing a big prob­lem here in Canada, too. Clin­i­cal tri­als show that Ri­talin helps kids con­cen­trate and con­trols out­bursts of hy­per­ac­tive be­hav­iour. The prob­lem is, the en­vi­ron­ment of a clin­i­cal trial is very dif­fer­ent from the real world, where you are no longer in con­trol of how chil­dren take the med­i­ca­tion, the dosage they take, who pre­scribes it, or whether the child ac­tu­ally has ADHD in the first place.

Go­ing into this re­search, my col­leagues and I thought we’d find mainly pos­i­tive ef­fects of Ri­talin; in­stead, we found a pic­ture of deeper, sys­temic prob­lems. Ri­talin it­self is prob­a­bly not hurt­ing kids, but I would say that doc­tors are very quick to pre­scribe it (or sim­i­lar stim­u­lants), and that par­ents and teach­ers tend to think that solves the prob­lem. From the per­spec­tive of a teacher, if Ri­talin stops a child from run­ning around and mis­be­hav­ing, the prob­lem might seem solved; but it doesn’t mean that the child is ac­tu­ally learn­ing and he or she is prob­a­bly now get­ting much less at­ten­tion. So these drugs can mask other prob­lems.

This is an in­ter­est­ing wicked prob­lem be­cause we are con­tin­u­ing to learn about how the brain func­tions, and there is still a stigma sur­round­ing men­tal health. When­ever I talk about our find­ings, some­one says, “Isn’t ADHD just what we used to call bad be­hav­iour? Just be stricter, and this prob­lem won’t hap­pen any­more.” There is still a dis­be­lief among some peo­ple that men­tal health prob­lems can be par­tially cor­rected through med­i­ca­tions that change the bal­ance of the brain’s chem­istry. On top of that, a lot of peo­ple who prob­a­bly don’t have ADHD are tak­ing these drugs. So, there is this cu­ri­ous com­bi­na­tion of some peo­ple not tak­ing the prob­lem se­ri­ously enough, and oth­ers over-treat­ing it. Overprescription is prob­lem­atic be­cause these drugs can have se­ri­ous side ef­fects — ev­ery­thing from nau­sea to sui­ci­dal thoughts.

Com­pli­cat­ing mat­ters, most peo­ple seek help from their fam­ily doc­tor, many of whom don’t spe­cial­ize in men­tal health, so you end up with a par­ent who’s des­per­ate, a kid who’s not do­ing well, and a doc­tor who doesn’t have a lot of ex­pe­ri­ence with the prob­lem. If all these kids re­quired di­ag­no­sis and treat­ment from doc­tors who spe­cial­ize in ADHD — which is re­quired in France, for ex­am­ple — I think the rates of over-pre­scrip­tion would be much lower.

There is also a will­ing­ness among the gen­eral public to be­lieve that we can solve ev­ery­thing with med­i­ca­tion. Pills can help, but they are not the whole an­swer — it also re­quires time and hard work. There is ev­i­dence sug­gest­ing that in­ten­sive train­ing for par­ents is a help­ful way to com­bat ADHD, but this treat­ment is ex­pen­sive, and it re­quires a large com­mit­ment of time and ef­fort from the par­ents and ed­u­ca­tors.

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