Let’s Give These Wonderful Pediatricians a Break

Several of my psychiatric colleagues like to join me in characterizing personality traits associated with different medical specialties. Orthopedists tend to be “sports jocks”, and neurologists are architectural engineers of the nervous system and are obsessional to detail”. We like to joke that psychiatrists and diagnostic radiologists are the specialists that have the most in common –“they are able to see shadows that no one else can see.” But there is a consensus – pediatricians are the nicest people and the most patient in all of medicine. How is it that they can be paid so little to deal with such neurotic and anxious parents and so many bratty kids and dysfunctional families – all before even entertaining the complexities of being internists of bodies rapidly evolving through developmental stages? It sounds like trying to pick up mercury from a polished floor!

And now they are expected to attempt to be child and adolescent psychiatrists to a large number of patients who have extremely complicated psychosocial problems and disorders that even child and adolescent psychiatrists often find difficult to diagnose, and then need to treat with medications that have no FDA approvals or have controlled Schedule II status. They do this while parents are desperate for help and the next available child and adolescent psychiatrist has a 9-12 month waiting list!

To further raise the complexity, a study published in JAMA Psychiatry in November 2023 found that long-term use of stimulants is associated with an increased risk of cardiovascular diseases, especially hypertension and arterial disease. (JAMA Psychiatry. doi:10.1001/2023.4294.) In September, the journal Pediatrics published a study based on U.S. poison control centers’ reports of a nearly 300% increase in medication errors in children who take ADHD medications over a 22-year period (Pediatrics (2023 Sept.doi:10.1542/peds.2023-061942). This was a period of time in which the prevalence rate of ADHD in children rose from 6.1% to 10.9%. (jamanetworkopen.2023.368720). The study emphasized the need to provide more attention to patient and caregiver education. Knowing the time and effort this entails, all I can say is: “Give these wonderful doctors a break”!

Here is how:

• Recognize that mitochondrial dysfunction is a key component found in ADHD. Dr. Christopher Palmer, a highly regarded Harvard academic psychiatrist, highlights this in his breakthrough book “Brain Energy”. For more about this and explanations for this new perspective see Vol. 1, Nos. 1 and 2.
• Recognize that Methylene Blue (MB) is a remarkably effective agent for optimizing and stabilizing mitochondrial function and frequently substantially improves attention and other aspects associated with ADHD, often at low doses as monotherapy.
• Because mitochondrial dysfunction underlies many, if not most, chronic diseases, MB is healthy for cells throughout the body even though the greater energy demands of the brain make it especially important for brain disorders. MB is not a health risk, it is a wellness-promoting agent!
• MB has a long history of use in medicine. It is FDA-approved for several other conditions (at much higher doses) and has been generic for decades. As a result, there has not been financial reward for pharmaceutical companies to do the expensive studies needed for FDA approval for neuropsychiatric conditions, and therefore it is largely unknown in the mainstream practice of primary care including pediatrics.

Consider a different systematic approach to initiating treatment for attentional problems and symptoms suggesting ADHD.

1. Continue to use parent and/or teacher rating scales for ADHD. This is useful in clarifying the specific pattern of symptoms and severity of the concerns that they have. It is also a great educational tool. Remember, while you may make a diagnosis, you can document that you have explained alternatives and that MB is a well-supported and reasonable option. MB is available without a prescription, and they can simply order it online. This also allows you to bill for your time which is a precious commodity.
2. Suggest a “First Start” alternative to parents concerned about the side effects, the complexity of Schedule II drugs, the cost of medications, and the challenge of availability and need for recurring visits and DEA reporting. MB is available without a prescription and is very inexpensive. Parents can simply order it online.
3. I recommend ADHD365 (it comes in lower dose tablets of 2.5 mg/tablet or NeuroPro Plus which has 15 mg/tablets). Doses in the range of 0.25 mg/kg per day or less are good starting doses, and optimal doses generally fall in the range of 0.25 mg/kg -0.5 mg/kg. MB is not stimulating and, while improvement is often seen in the first few days, full efficacy often takes several weeks. It can be given once in the morning, but a divided dose is fine as it will not impair sleep if given late in the day. If MB alone does not control symptoms adequately, I have found that adding a low dose of stimulant (half of the dose usually needed for control) to the MB can be effective, often used only on days when cognitive demand is greatest.
4. Because MB is a reversible MAOI it has antidepressant and anxiolytic properties and may be helpful if those symptoms are present. As a result, it is likely that no antidepressant is needed, and tapering the SSRI to a half-dose while initiating MB is reasonable. Interestingly, a clinical study found that MB improved depression without triggering mania in a bipolar population.
5. Consider having a therapist who works with children and adolescents involved in this process. Since no prescription process is needed, work on the psycho-social aspect of the child and family issues involving parents and siblings while simultaneously tracking progress regarding symptom patterns is something they are fully capable of doing. This can give the overworked pediatrician a break!!! I think your patients and their parents and teachers will be very grateful to you for simplifying and improving their lives. You will greatly be simplifying your own as well.

It’s amazing how a breakthrough in medicine can come from a long-established medication, and that it can simultaneously improve care for many patients while lowering costs! Perhaps the best thing is that it can give overworked pediatricians a break!

Noel Gardner M.D., M.Div.