ADHD medication is not an easy subject for parents. Perhaps you have a child whose academic performance doesn’t seem to match up with the bright kid you know. Maybe the child can’t seem to control their behavior in the classroom, either. But what kind of person medicates children? Dr. Walt Karniski, a developmental pediatrician, makes the case that children with ADHD should almost certainly be treated with medication for the disorder. He lays it all out in his important book for parents in ADHD Medication: Does It Work and Is It Safe?
What follows here is a lengthy interview with esteemed ADHD specialist and now author of a book, Dr. Karniski. Walt Karniski is persuasive, as is his book. The book, in fact, reminds one of Dr. Spock’s Baby and Child Care, only for parents of kids with ADHD. ADHD Medication makes the experience of the parent and child with ADHD somehow understood by someone. That makes the parents want to trust Karniski as he leads them gently by the hand, through the intricate world of ADHD, and in particular, ADHD medication.
Who Is Dr. Walt Karniski?
Who then, is Dr. Walt Karniski? Karniski trained for his distinguished career at the Harvard Medical Center-affiliated Boston Children’s Hospital. He went on to direct the Division of Developmental Pediatrics at the University of South Florida, in Tampa, Florida, serving in that capacity for 15 years. Walt Karniski then went into private practice, evaluating and treating children with ADHD, Autism, Anxiety, Learning Disabilities and other developmental difficulties, for a further 20 years.
It is no stretch to say that over the 40 years he has been practicing, Karniski has evaluated and treated close to 10,000 children. He has also conducted numerous studies of brain activity in children. Walt Karniski’s approach as a physician is that each child he sees, he considers a unique individual, with distinctive strengths and weaknesses. His believe is that diagnosis does not matter as much as understanding the specific needs of each child.
In the following interview, Dr. Walt Karniski gives us a taste of what you can expect to learn more about in his book:
Varda Epstein: Why did you write your book?
Oh, medication is mentioned in many of these books, but it usually gets a few pages, maybe a chapter. And that is unfortunate. Parents have many questions when their child is diagnosed with ADHD.
They might have questions about what the school should be doing to help the child with ADHD in the classroom. They might have questions about a child’s social relationships. They might have questions about how to best manage their child’s behavior at home.
But the most frequently asked questions are almost always about medication. How does it work? Won’t medication cause him to be a zombie? Is medication addictive? I wrote this book to answer the questions that parents ask the most and to give them the information that they need to ask their physicians the right questions for their child.
Varda Epstein: How often do parents leave your office resistant to your suggestion that they treat their children with medication?
Walt Karniski: Parents often come INTO my office resistant to the treatment of ADHD with medication. Because I take over an hour to explain the diagnosis and the medication and non-medication treatments that are available for ADDHD, most of the parents LEAVE my office in agreement to at least give medication a try. The book explains what I talk to the parents about in those post-diagnostic meetings.
ADHD Medication: “Is He Depressed?”
Varda Epstein: What are some of the reasons parents don’t want to give their children medication for ADHD?
Walt Karniski: The most common reason that parents are reluctant to try medication for the treatment of ADHD is that they are concerned that the medication will cause their child to lose their personality. They say, “Yes, I know that Michael has difficulty concentrating and focusing, and I know that he needs some help with that, especially in school. But medication? I don’t want to turn him into a zombie.” Here is true story to emphasize this point:
David was a patient of mine, a bright, hyperactive, impulsive eight year-old child with ADHD, and, according to his teacher, he had a very positive response to stimulant medication. His mother saw things differently.
When I saw him back in my office, two weeks after starting on medication, his mother was perplexed. “I think he is depressed,” she said. When I asked her to elaborate, she said, “Well, when he comes home from school he goes to his room. He usually finishes his homework in twenty minutes, then he sits and reads till dinnertime.”
“So why do you think he is depressed?” I asked.
She looked at me like I was mad. “But that’s not David. He is usually running around the house, teasing the dog, accidentally knocking over lamps. I have never seen him sit and read for more than thirty seconds.”
I turned to David, who was sitting next to his mother, playing a video game on her phone. “David, what books have you read recently?”
He looked up. “Oh, yesterday I finished reading Harry Potter. He’s this kid who goes to this school to learn to be a wizard, and he plays Quidditch by flying around on a broomstick, and he fights off bad spirits, and he has a lot of friends. Have you read Harry Potter?”
“I have, and I think I loved it just as much as you do.” He smiled and went back to his video game.
I turned back to his mother. “If David had been born to act like he does when he is on medication, if he had been born with a tendency to sit and enjoy reading for hours, would you have been concerned?”
“Well, no. Of course not.”
“David is not depressed. This is the David that he would have been had he not been born with ADHD. Now that he is on medication, he is better able to express himself, and he is better able to communicate to you what he is thinking and feeling. So, medication is not depressing him but allowing him to be himself.”
Why Treat with Medication?
Varda Epstein: What are the main arguments for treating ADHD with medication?
Walt Karniski: There are 3 main arguments for treating ADHD with medication.
The first reason is that every year, over 350 research studies are published about ADHD medications. Almost all of this research documents that children with ADHD experience a significant reduction in the CORE symptoms of ADHD. That means that 80-90% of children with ADHD treated with medication will experience a reduction in hyperactivity, impulsivity, difficulty concentrating, distractibility, and difficulty paying attention. And the medications continue working for years.
The second argument is that treatment of children with medication lead to a far better outcome as adults, compared to children who were not treated with medication. For example,
- Adults diagnosed with ADHD as children are 3 times more likely to have been unemployed compared to non-ADHD adults.
- They change jobs frequently.
- They are more likely to have poor job performance, quit a job impulsively, or have been
- They often earn a lower salary (one study found the average salary of an adult with ADHD to be $41,500, whereas adults without ADHD had an average salary of $52,000).
- They use credit cards more.
- ADHD adults are more likely to have social difficulties than non-ADHD adults.
- They have fewer friends and they report less satisfaction with their social relationships.
- They move more frequently.
- They are more likely to parent a child at a younger age.
- They are twice as likely to be separated or divorced.
- They are more likely to have remarried.
- They are four times more likely to have contracted a sexually transmitted disease (STD), although this risk is minimal in adults who were taking medication for their ADHD.
- They are more likely to have a child born outside of marriage.
- ADHD adults are twice as likely to have been arrested and 15 times more likely to have been incarcerated for longer periods of time.
- They are 3-5 times more likely to have been convicted of a crime, although there was a 38 percent reduction in crime in ADHD adults who were taking medication for their ADHD.
- ADHD adults are more likely to have had traffic violations and more likely to have had a suspended license.
- They are 2-6 times more likely to have had a car accident.
- When they do have an accident, the damage to the car is greater than accidents that happen with non-ADHD adults, indicating more serious accidents.
- ADHD adults are more likely to smoke and to begin smoking at younger ages.
- They are more likely to use alcohol at a younger age and more likely to abuse alcohol as
- ADHD adults who are not taking ADHD medication are 2-3 times more likely to abuse drugs.
ADHD Medication: The Good News
Walt Karniski (cont’d): I know that it is very difficult to read this list and not worry about your child as he moves into adolescence and early adulthood. But there is good news. Research that follows children with ADHD into adulthood finds that almost every one of the above concerns occur less often in adults who were treated with medication as children. As a matter of fact, most of these studies show that the group of adults who were treated with medication as children experienced these outcomes about as often as adults who did not have ADHD!!
For example, many people believe that the stimulant medications used to treat ADHD are addicting. In fact, the opposite is true. Multiple research studies indicate that when children and adults have been treated with stimulant medication, they are less likely to abuse drugs in the future.
The third argument for medication treatment is neurological. We know that if children with ADHD are studied with MRI scans, three areas of the brain are found to be smaller in children with ADHD. But the story gets fascinating here. When these same children who were diagnosed with ADHD were seen again as adults, their brain scans showed something stunning. Adults with ADHD who had not been treated with medication as children continued to have the reduction in size in the three areas of the brain identified in childhood. But when the brains of adults with ADHD who had been treated with medication as children, those previously smaller areas of the brain are now of normal size, the same size as in the brains of adults without ADHD.
The father of a child diagnoses with ADHD asked me, “Doc, I know my son has ADHD and I know that he would probably benefit from medication, but what happens to children when they become adults after they have been on medication for 10–15 years? Can the medication damage his brain over time? I can confidently tell parents that those children who were treated with medication have far better outcomes in many different social areas than those children who had not been treated with medication. And brain studies show us that children with ADHD have three areas of the brain that are smaller than children without ADHD. But when these children reach adulthood, those three areas of the brain became more normal in size, only in the group of adults who had been treated with medication for their ADHD as children.
Parental Disagreement and ADHD Medication
Varda Epstein: In your book, you describe how one parent wants to treat the child, but the other doesn’t. Have you seen a lot of this in your practice, where it’s difficult for parents to agree on what’s best for their children? How can the parent who agrees to medication persuade the other parent that this is the way to go?
Walt Karniski: It is not unusual for parents to disagree on how to parent a child, or how to explain why a child is not behaving. Here is a fictional example of how parents might react when medication is considered for the treatment of ADHD:
So last night, Danny had a lot of problems settling down and getting into bed. I let him watch a little TV, but he wanted more. I finally got him into the bathtub by promising him a popsicle after his bath, but during his bath he splashed so much water that I needed four towels just to wipe up the floor. I usually try to do counting games with Danny’s toys in the bathtub, but tonight he was just too scattered. But finally, I got him into his pajamas.
He ate his popsicle, we brushed his teeth, and he got into bed. He was not mad or angry or even irritable. He just still had too much energy. After reading three books, checking the closet and under the bed for monsters, and cuddling with him after I turned out the light, he finally fell asleep.
I walked down the stairs to the kitchen, opened a bottle of wine and sat down on the couch in the family room. The TV was still on, but I turned it off and basked in the silence for a moment, knowing what was to come.
A few minutes later, Chris walked in and sat down next to me. We didn’t say anything for a while, but then he asked, “So how did Danny’s visit to Dr. Lawrence go? Is he growing?”
“Oh God, Chris. I don’t know. I don’t know.”
“What do you mean?”
“Well, you know that Danny can be a little active, to say the least. He was at the top of his game today. He was all over Dr. Lawrence’s office, even broke that special flashlight on the wall that the doctor uses to look in his ears.”
Dr. Lawrence asked me a bunch of questions, but it was really hard to answer him when Danny was being so wild. He gave me a couple of questionnaires to fill out, but the bottom line is that he thinks Danny has ADHD and that he may need medication to help him concentrate and that…”
“Wait a minute, Liz. What do you mean, ADHD? Medication? No way. End of story. We just need to start disciplining him better.”
“Chris, I definitely don’t want him on medication either, but something has to be done. He starts second grade next month, and they say that the work gets much harder, and they start sending home more homework. I can’t get Danny to sit still for more than a minute, so I don’t see how he is going to do twenty minutes of homework. You know how much trouble he had last year and…”
“Liz, you know that even though Mrs. Miller may have been a good teacher in her time, she is older now and can’t handle the kids anymore.”
“Then why don’t the other kids in his class have the same problem? None of the other mothers say that their kids are having any trouble, and I always feel like they don’t want their kids playing with Danny.”
Chris stood up. “I don’t want him on medication. We need to start disciplining him more. End of story!”
“OK, OK. I won’t fill the prescription just now, but we have to fill out these questionnaires first anyway. They only have about fifty questions and should only take ten minutes. One for us to fill out and one for Mrs. Miller.”
“Good. Now I’m going to watch the game.”
“First we will fill out the questionnaire. Together. And then you can watch the game. Here, I have it right here. Give me your pen. First question, ‘Does he have trouble sitting still? Never, Some of the time, Often,
“Well, some of the time, I guess.”
“Chris, he is always moving. Won’t sit at the dinner table for more than three minutes. He begs to watch a TV show, and then when we let him watch it, he runs to his room to get a toy.”
“Yeah, OK, let’s compromise and say, ‘Often.’”
“Next question, ‘Has trouble focusing?’ Well, Mrs. Miller said that was a problem all day long.”
“Trouble focusing? What does that mean? He can play a video game for an hour without moving. That’s not focusing?”
“Yeah, but he has trouble focusing on something that doesn’t interest him, and that is just about everything that happens at school.”
“Liz, you know that I was a lot like Danny when I was a kid. And I turned out OK.” Luckily Chris didn’t see me roll my eyes.
This went on for the next forty-eight questions, but we completed the questionnaire. I told Chris that I would ask Mrs. Miller to fill out the other questionnaire and then take them both to Dr. Lawrence. And I agreed not to fill the prescription. Not yet. So, we had a plan.
Chris went over to turn on the TV. I took another sip of wine.
Varda Epstein: How often do parents decide to stop the medication against your advice, and then return when things don’t work out?
Walt Karniski: Parents are usually frustrated and worried when they come to see me for the first time. They have usually been through both denial and guilt and they are usually ready to at least consider medication. But here is a true story that explains why parents do not return after the diagnosis is made and medication treatment recommended:
One day after lunch, I was looking through the list of patients I was scheduled to see for the afternoon. I recognized the name of a girl I had seen years ago when she was twelve years old. Michelle had been diagnosed with ADHD, primarily inattentive type, and treated with Ritalin LA. However, after a few visits, she had not returned. That was seven years ago. She came into my office without her parents. She said that she thought she should go back on medication, but her parents didn’t want her to, so she came by herself. She said, “I’m an adult now. I can make my own decisions.”
I asked what had happened before, when she was diagnosed and then started on medication, but then did not return. She paused for a while before responding. “Dr. Karniski,” she started, “when you put me on that medication, I hated you. I hated the way that medication made me feel. I was able to concentrate better and my grades improved, but I just didn’t like the way it made me feel.”
“So, how did you feel?” I asked.
“Well, when I was studying, I was able to concentrate better. But when I was with my friends, they told me that when I took that medicine, I wasn’t as much fun to be around. Before I took the medicine, we were always laughing and telling jokes. After I took the medicine, I was more serious, and they didn’t want to be around me anymore.”
“I’m a freshman at the University of Florida now. And I know I am smart, but I am failing all my classes. I just can’t seem to get organized.”
So, I started her back on medication, and she returned in three weeks. She proudly told me that her grades had improved. “I am getting A’s on all my tests now.”
“So, what do your friends think?” I asked.
“That’s the weird thing,” she answered. “They think that I am a better friend when I am on my medication. They said that before I started taking medication, I was easily distracted, and I wouldn’t listen to what they said. They said I interrupted all the time. But when I am taking my medication, I listen to them, and, well, I am just a better friend.”
What happened here? Why did Michelle react differently to medication at twelve and nineteen years of age? Well, she didn’t! She reacted the same way to medication at both ages. What changed was her friends. Her nineteen-year-old friends had different expectations from the friendship than her twelve-year-old friends.
Varda Epstein: What’s next for Walt Karniski?
Walt Karniski: I supposedly retired and stopped seeing patients a few years ago to work on the book. Now that it is finished, I am looking forward to “really retiring.” I am looking forward to spending more time with my two grown daughters and my two grandchildren and my beautiful wife.
(All story excerpts from ADHD Medication: Does It Work and Is It Safe?)