May 24, 2009

Claire 5: The Medication Paradox

About a week after starting medication, I called Claire's mother to check on any progress or side effects. Her mom is a very intelligent and perceptive well-educated woman. I respected her opinion.

“I don't think the medicine is doing anything,” she said. “Claire seems exactly the same.” I told her I was glad there weren't any obvious side effects. “I just don't think it has any effect on her,” her mother said helpfully. It was still early, I said, and suggested she continue the medication for the moment, which her mother was willing to do.

At the moment, it is very hard or impossible to predict which medicine will work best—or work at all—in which person. This is especially true for psychoactive medications. But it's pretty common for people to know that they act or feel differently when they are taking certain drugs, even if they aren't prescribed for their psychiatric effects. Prednisone, for example, is a medicine used for inflammation and asthma that often makes people act in surprising ways. Birth-control pills can have this effect. It was disappointing but not shocking that my first choice for a prescription was not doing what I thought it might. Still, I wanted to be thorough.

“Is she getting her homework done?” I asked. Her mother said that she hadn't been getting any reports of assignments not handed in. “But is she remembering the assignments?” To this, her mother said that Claire had started to use an online calendar for her assignments so she hasn't forgotten any yet. “How about exams. When are they coming up?” Her mom said that she had a history quiz and did well and hadn't mentioned it beforehand. Without my asking, her mother added that Claire probably just wasn't very worried about it. And so our conversation went. I asked about how she was getting along with her classmates and her siblings. I asked how her motivation was in general, if she had shown any interest in new things, if she was worried about her friends or how she looked or how she was doing in school.

There were a lot of changes, all improvements, all pretty small and hard to notice by themselves. I pointed this out tho her mom, who had to pause for a moment. All the changes occurred around the same time, a couple of days after she came to my office. The only thing that changed was the start of medication.

It was a revelation to Claire's mother that maybe the medication was helping—a lot, as it turns out. Yet she had been convinced that it was doing nothing at all.

Although this post is another true chapter in Claire's story, it is an experience I have had dozens of times. What is the ideal psychologically-effective medication? I think it's something that helps patients with the things they struggle with, but leaves them feeling and appearing just the same to themselves and those around them, with every ability unchanged. When a medicine isn't working, the targeted problems don't improve. When there are side effects, the specific problems might improve, but new problems arise (such as sleepiness, for example, or inability to sleep).

Claire herself had been equally convinced that the medicine was ineffective. She felt the same, she said. It was true, she acknowledged, that her assignments were getting remembered and done and that she studied for and wasn't too worried about that history test. But that wasn't because of the medicine, she told me. It was hard for her to remember the way she was even 2 weeks before, and how worried she was about everything. She wasn't very worried right now, and she felt that's the way it has always been.

This is a very serious problem for people who take medicine to control a chronic problem, such as asthma or depression. They start taking a very effective medication, which really works to control their symptoms. After a while without the problem symptoms, they get to feeling that the problem is gone so they no longer need the medication. They stop the medication and the problem returns.

With ADHD, the kids often get brought to me when they have been getting into trouble at school. With good therapy, they do well in school. But when they do well with medication, they get the feeling that they don't need the medication. When they stop, and start getting into trouble again, they will find specific explanations that don't include the fact that they stopped their medication.

There is, I believe, a medication paradox. If you take your medication, then you feel like you don't need it. If you don't take it, you will need it.

Next post in Claire's story: I make her believe she is a chicken.

The photograph at the top is from my collection and is by Emmet Gowin.


  1. Thanks for illustrating this important lesson.

    Without first establishing targets, regularly using rating scales or asking pointed questions such as yours, some improvements aren't noticed -- in children OR adults with ADHD.

    I think this is why Adderall, unfortunately, is popular with so many adults and ill-informed physicians. The adult typically will feel a "buzz" that assures them it's working, often giving super-human focus. Of course, the buzz often means there are side effects just around the corner -- crashing, irritability, sleep problems, etc.

    Of course, another possibility is that one parent (or two) might have ADHD themselves, and it remains untreated (and maybe even denied). Parents with untreated ADHD will be less likely to notice subtle changes in a child's behavior, be able to make it context-specific, and compare it accurately to past behavior.

  2. Gina--you're right about how some patients need the feedback from either the medication itself or the medicine dispensing system to fulfill their need for confirmation that it's working or that they really did take it. I think this is a little touch of anxiety/OCD that often goes with ADHD. Surprisingly, I often have greater compliance problems when the patient feels nothing, but suddenly they've gone from straight-F's to straight A's. Many of those patients make no connection beween the medication and the outcome, so they stop taking it. And the predictable happens.

  3. I found so many interesting stuffs in your blog especially its discussion. From the tons of comments on your articles, I guess I am not the only one having all the enjoyment here! keep up the good work.


Please let me know what you think. Do you know a child or situation like this?