Guest Blog: Do You Have the Right Stuff?

My favorite parent advocate, Louise Woo, shares a new concern about the fate of our kids. Louise, please tell us what's on your mind ...

Thank you, John.

The world of high-anxiety, achievement-oriented American parents is abuzz this week about Margaret Talbot's grimly-reported New Yorker article, "Brain Gain: The Underground World of 'Neuroenhancing' Drugs."

(For those of you who haven't read the article yet, here it is: http://www.newyorker.com/reporting/2009/04/27/090427fa_fact_talbot?currentPage=all )

The initial premise of the article wasn't particularly shocking. Most parents already know that teenagers and college kids have been abusing ADHD stimulant medications for over a decade now.

What was sobering was Talbot's revelation about the growing number of studies showing that prescription stimulants do indeed provide measurable improvement in cognitive abilities for people who do not have ADHD. That, and reports of drug manufacturers like Cephalon (makers of Provigil) who have already been reprimanded for efforts to subtly market the drug for "neuroenhancement" purposes.

Why should this bother me? Isn't it a good thing that relatively safe prescription drugs can help people be smarter and more productive?

On the face of it, it's hard to oppose it as a bad thing. Certainly many bright, highly-productive researchers think it's just fine as evidenced by a 2008 survey of readers of the scientific journal Nature, where the majority of respondents said healthy adults should be allowed to take medications for cognitive improvement.

But in our household, we face an ironic dilemma. Both of my sons are diagnosed with ADHD and mood disorders. And while the mood disorders (bipolar and depression) have been successfully stabilized with medication, neither teenager can take standard ADHD medications.

We've done a trial of every common ADHD medication in the book: Ritalin, Concerta, Adderall, Strattera. These medications make my son with bipolar disorder go manic and the one with depression irritable and nasty. So their ADHD must be left untreated, which puts them at a distinct disadvantage in a highly-competitive, above-average school district where ALL kids are expected to perform at peak ability from middle school onwards.

I have a sickening feeling in my stomach as tide surges forward. Clearly if scientists and doctors think it's OK and the research supports it, most high school and college students will be taking "neuroenhancement" drugs in the near future.

And where does that leave kids who can't take these drugs? Or the kids whose families don't have health insurance? Or the kids from uneducated families in less-competitive (i.e. poor) public schools? I don't know. It threatens to create a Cognitive Abilities Gap, where the bright get brighter and everyone else just has to drink more coffee.

Here in California, where the public schools are already slaves to the No Child Left Behind law and the curriculum is skewed to have children focus on annual statewide standardized tests, things will get ugly.

Teachers are already under tremendous and unrealistic pressure to improve their class's test scores every year. For high-scoring schools, this is a bizarre challenge. How much better can the scores get?

Can the scores be improved if more kids are on "neuroenhancement" drugs? Maybe. Will there be (more) pressure placed on parents to "do something" about their "only average" kids? Probably.

Will parents, rich and poor alike, become alarmed by this? Absolutely. But how do you fight the incoming tide?

In the past 20 years, we have already been swept out to sea by the tide of Higher Achievement. It is standard practice -- NOT a luxury -- in "good" school districts that we hire after school tutors for our elementary school kids and put our teenagers in private SAT prep courses.

Teenagers are encouraged to take Honors and Advanced Placement courses in high school, discouraged from having jobs (because it takes time that could be used for academic work) and assigned hours of homework -- even over school vacations.

And for what? To make the grade so they can be accepted by colleges which don't have enough seats for every qualified applicant anyway?

I don't know where the end of this will be, but I certainly don't like where I see things going.

Every year the competition gets stiffer for good grades, good colleges and finally good jobs. As Talbot noted in The New Yorker article, even middle-aged workers are feeling the pressure to take these drugs to keep-up with younger colleagues.

Will this ultimately change the meaning of the question: Does he or she have "the right stuff?" Yesterday, having the "right stuff" meant having intelligence, perseverance and bravery.

Tomorrow, it seems, it will just mean having a prescription for Adderall.

Guest Blog - Bipolar Kids: Is There a Doctor in the House?

The people I love being around the most are the parents of bipolar kids. The stories they tell would break your heart, but one minute in their presence and I'm experiencing one of those rare states they have no words for. It's my pleasure to introduce my good friend Louise Woo, who is active in the Los Angeles area Child and Adolescent Bipolar Foundation (CABF). Louise, over to you ...

Thank you, John.

For the last nine years, I've run a support group in Los Angeles for parents whose children have bipolar disorder.

It's a nice group of moms - and it is almost always the moms, I'm sorry to say. There are about 50 active families in the group and every month or two, a dozen of us convene for lunch, order salads and a glass of wine. If anyone needs to share a drink with their comrades, it's these soldiers. Each and every one knows how grueling and relentless it is to get good treatment and schooling for our kids.

I'm pleased to report that the quality of care has improved immensely in the past decade. Ten years ago, the most common complaint we heard was "Our doctor doesn't believe children can have bipolar disorder." Thanks to the 2005 treatment guidelines published by the American Academy of Child and Adolescent Psychiatrists, we hardly hear that at all anymore.

But one problem persistently, stubbornly remains: There just aren't enough qualified doctors to go around.

A new mom came to lunch this past Saturday. She has a 14 year-old son and her insurance is Medi-Cal. Because of this, Mom has to take her son to a public health clinic for treatment. The in-house psychiatrist only sees kids there a couple days each month and does not return phone calls from the parents.

Needless to say, you can see where this story is going: The poor boy is not stable and not improving in any significant way.

He's currently on a cocktail of four medications -- two of which caused the other mothers to look at Mom with concern and alarm. When the boy became agitated and violent after a few days on Medication No. 4, Mom called the clinic in a panic.

They relayed a message to the doctor... and the remedy was a new prescription for Medication No. 5!

"Did the doctor even see your son?" I asked, incredulous?

"No," said Mom. "It was all done over the phone."

Unanimously horrified, we urged Mom to find a new doctor as fast as possible.

"Do you know of any other doctors who take Medi-Cal," she asked. "How can I find one?"

We looked at each other, biting our lips. One mother said she had a friend down in San Diego who might know someone here in L.A. that had a list of doctors that accept Medi-Cal. I felt like we were looking to find a doctor to do an illegal abortion in Ireland. How could it be this hard?

But it is. It still is.

The American Academy of Child and Adolescent Psychiatrists has 7,500 members nationwide. That seems like a decent number, but when you figure there are roughly 10 million kids who need treatment in the United States that gives every doctor a caseload of approximately 1,333 kids.

And of course, statistics do not tell you the important part.

If you live in Los Angeles County, you can use the AACAP doctor-finder and start calling one of 140 doctors listed on the website. It won't tell you if the doctor is taking new patients, if the doctor takes your insurance or if the doctor is well-liked and respected by patients. But it is a place to start.

The further you drive from L.A., the shorter your cold call list gets.

In San Bernardino County, the largest in California, you'll only have five names to call.

In Fresno County, you can wrap it up in 15 minutes: Only two doctors.

And sadly, if you live in the beautiful rural towns of Kern County, you can call one doctor. One.

We have a terrific psychiatrist for our family. He is not on our insurance network and we pay out-of-pocket. But I fired three HMO-list psychiatrists for being uncaring, medical bureaucrats before we got to this man. In my mind, his expertise, his caring manner and his rapport with my two teenage sons is worth every penny. Nay, it is probably a bargain!

And yet, when other mothers ask that inevitable question: "Who do you see?" I have to pause.

In the same way that parents jealously guard the name of their best and most reliable babysitter, I am also reluctant to give up the name of our doctor.

Why? I don't know. It's not like he won't cap his patient list when it gets too large. I guess I just hate to flood him with referrals. And in my own selfish interest, I hate to make my own life harder by adding to the competition.

Because my sons are pretty stable and have been for years.

Why are they stable? Beyond good medical care, I think it's also the fact that I will rush them in for an appointment at the slightest hint of trouble. And that I make good use of our appointments by faxing in reports ahead of time.

If our doctor's patient load reaches critical mass, will he have time to read those faxes? Will I be able to get my kid in to see him in less than 4 days? Will he have less time and energy to care about my incredible sons?

That's a rhetorical question. We all know the answer.

But naturally, I give up the name. How could anyone ever deny good care to another child so desperately ill?

Even if we had nationalized health care or affordable health insurance offered by every employer, it would not solve the biggest problem: There aren't enough qualified doctors anyway.

My sons' conditions are serious, possibly even life-threatening. In the same way that I would not want my pediatrician treating my kid if he had cancer, nor do I want him treating my kid's neurological condition!

So what can we do about the shortage of specialists?

I don't have any ideas or answers. I don't know why more medical residents don't go into psychiatry, much less child psychiatry. They would certainly have job security and an abundant client roster. They get paid much better than pediatricians and still there's no shortage of underpaid pediatricians!

Is it just because medical school is expensive and specialists need additional training, which means additional education debt? Do our nation's student loan policies discourage students from getting more training because it just costs too much?

Can we do something -- anything -- to change that?

I hope so, because as parent awareness grows, so does the need for doctors. And if we have a shortage of doctors for cash-paying patients, why would any doctor ever bother to take Medi-Cal for low-income patients?

And if there are no child psychiatrists taking Medi-Cal, what are we Women Who Lunch going to tell that Mom? Pack up and move to Canada?

That's not the answer any of us are looking for.

***

For information and support:

Child and Adolescent Bipolar Foundation

From mcmanweb:

The Bipolar Child - What to Look For
The Bipolar Child - Treatment
The Bipolar Child - An Historic Book