Is ADHD Getting Out
of Control?
A record four million
children -- some as young as 2 -- are being diagnosed with ADHD, and
many are being put on powerful medications, perhaps for life. Now a
growing number of experts are sounding alarm bells.
It's a rare parent today who's not familiar
with the term attention deficit/hyperactivity disorder, or ADHD. Indeed,
this once-obscure abbreviation is now a household word, thanks in part
to the fact that the number of kids diagnosed with the condition has
skyrocketed -- from an estimated 150,000 in 1970, to a half million in
1985, to a whopping four million currently. (It is outranked only by
asthma and allergies among childhood disorders.)
Predictably, prescriptions for ADHD treatments have ballooned
proportionately, rising more than 47 percent over the past five years to
a current total of 31 million. The ADHD therapeutic arsenal -- a
$2.2-billion-a-year business -- now includes a dozen drugs, the use of
which has steadily drifted downward to ever-younger children.
A landmark 2000 Journal of the American Medical Association study
revealed that use among 2- to 4-year-olds of stimulants such as Ritalin
(which, paradoxically, have a calming effect on hyperactive kids) nearly
tripled from 1991 to 1995; Ritalin prescriptions for preschoolers rose
49 percent from 2000 to 2003. This is especially sobering in view of the
fact that Ritalin is not even approved for use in children under 6; all
these prescriptions are written off-label.
Is Medication Really Necessary?
Despite the galloping increase in the use of such drugs, there is still
considerable confusion as to exactly what ADHD is and how it should be
treated. Part of the problem is that there is no definitive test to
certify that a child has it. And because symptoms run the gamut from
constant frenzied activity and disruptive, impulsive behavior to
fidgeting, making careless mistakes in schoolwork, and failing to finish
tasks, it's not always easy to distinguish between normal kid behavior
and ADHD. Diagnosis is still a judgment call, says Timothy E. Wilens,
MD, author of Straight Talk About Psychiatric Medications for Kids
(Guilford, 2004).
In addition, the spectrum of ADHD has broadened. There are now thought
to be three distinct types. The most extreme -- and the one most
associated with the label -- is the hyperactive, impulsive child who is
disruptive, can't sit still, and may be a bully or a troublemaker.
Children with the second type are those who are inattentive, unable to
focus, and easily distracted. The third type, and the most common one,
usually combines inattention and hyperactivity.
For children whose extreme impulsivity and aggressiveness cause them to
fall hopelessly behind in school and to become social outcasts, a
parent's decision to medicate can be painful but clear-cut. But what
about the parents of the millions of other kids who also bear the ADHD
label but whose behavior is more ambiguous? These parents face thorny
questions: Is their child's energy, dreaminess, or inattentiveness
merely normal youthful behavior, or does it cross the line into a
neurological illness? And would putting the child on drugs be a help or
the chemical equivalent of handcuffs?
Behavioral pediatrician Lawrence H. Diller, MD, author of Running on
Ritalin (Bantam, 1999), believes the latter. "America uses 80 percent of
the world's Ritalin," he says. "We medicate our kids more, and for more
trivial reasons, than any other culture. We'd rather give them a pill
than discipline them." His view is shared by many others, who chalk up
the seemingly limitless numbers of antsy, disruptive kids to the
failures of a permissive society that can't control its children and
babysits them with MTV.
Others pointedly disagree. "ADHD has not increased, we're just
identifying it better," says Steven Pliszka, MD, chief of child
psychiatry at the University of Texas Health Science Center, in San
Antonio. "In the past, these kids were the ones who were always being
sent to the principal's office." Moreover, research shows that there is
a strong genetic component to the disorder. If a child has it, the odds
are good that a parent may, too (though he or she may be unaware of it).
But even if the data strongly suggest a biological origin to ADHD, says
William E. Pelham Jr., PhD, director of the Center for Children and
Families at the State University of New York at Buffalo, there is little
doubt that environmental factors can nudge a latent, largely benign
tendency into a full-blown disorder requiring medication. Several trends
in American life have converged to whip up this perfect storm.
Let's start with our schools. Faced with steadily dwindling resources
and the need to find time for everything in state-mandated curricula,
many have curtailed gym classes, even recess, where energetic kids can
let off steam. Teachers, already pushed to the limit, are often unable
to handle a "troublemaker" who creates chaos in their crowded classrooms
-- in turn putting parents under pressure to make their child conform.
(Three-quarters of initial referrals for an ADHD examination originate
with teachers, not parents.)
"Teachers are good at spotting a child who's different," says Mina K.
Dulcan, MD, head of child and adolescent psychiatry at Northwestern
University's Feinberg School of Medicine, in Chicago. And in doing so,
they perform a valuable service. But it's valid to wonder whether, in
the words of Barbara M. Korsch, MD, a professor of pediatrics at the
University of Southern California, in Los Angeles, "we're giving
youngsters Ritalin as a solution for poor classroom behavior."
Our healthcare system also helps make medication a likelier solution.
Because HMOs and managed-care plans often either explicitly or
implicitly encourage primary-care physicians to limit referrals to
specialists, it is easier and cheaper for a doctor simply to prescribe a
pill than to direct the child to costly therapists.
Others point the finger at the beleaguered institution of the modern
family itself, with its (commonly) two working parents who may lack the
stamina to create a highly structured home environment and who may not
restrict television, video games, or Internet access. Indeed, a 2004
University of Washington study indicated a link between early exposure
to television and attention problems in children.
Add to this mix the fact that, in the early 1990s, kids with ADHD who
meet certain criteria became eligible for special services from their
schools, which has meant that more kids were identified. And the debut
of a new drug is usually accompanied by intensive sales campaigns aimed
at doctors and TV viewers. "New drugs always mean more people get
medication," explains Dr. Pelham.
"How Can I Be Sure It's ADHD?"
Even when a child's symptoms clearly point to something beyond the
normal vicissitudes of childhood, ADHD can be tricky to pin down.
Depression, anxiety, bipolar disorder, dyslexia, learning disabilities,
even impaired hearing or vision, can be mistaken for ADHD because the
symptoms (insomnia, impulsiveness, inattention) are similar.
Other factors that can spark ADHD-like behaviors include emotional
disruptions (divorce, the death of a close relative, a parent's job
loss), neglect or abuse, an unstructured home environment, and medical
problems such as epilepsy or hyperthyroidism. Sleep apnea also triggers
ADHD-like symptoms, according to recent research by Ronald Chervin, MD,
a sleep researcher at the University of Michigan, in Ann Arbor. "If kids
don't get undisturbed sleep," he says, "they're naturally going to be
inattentive and less able to learn."
The obvious first step in helping a child is to obtain an accurate
diagnosis. Given the murkiness of ADHD, such accuracy requires several
hours of careful evaluation, not a 15-minute office visit and a rush to
medicate because a teacher complains that a child is disruptive. As
tempting as it may be to give a child a pill to see whether he improves,
this is poor medical practice. As Dr. Wilens notes, a positive response
to a Ritalin-like stimulant does not mean a child has ADHD -- these
drugs can have the effect of making anyone who takes them more focused
(ask any college student who has used Ritalin to cram for finals).
If you suspect or have been told that your child has ADHD, first make an
appointment with the child's pediatrician to rule out a medical problem.
Next, have the youngster evaluated by a trained professional who
specializes in the disorder: a child psychiatrist, psychologist,
behavioral pediatrician, or behavioral neurologist. This expert should
gather information from the child's teachers, parents, and other people
who know him well and should have each person fill out a standardized
form.
To help experts distinguish ADHD from other conditions, the American
Academy of Pediatrics have devised guidelines, including the following:
Symptoms must meet the criteria for the disorder established by the
American Psychiatric Association. Make sure your evaluator uses these.
Behaviors must create a genuine impairment in at least two areas of the
child's life. If the only problem is in the classroom, it is more likely
to be a learning disability than ADHD.
Symptoms must have persisted for at least six months and have seriously
interfered with the child's friendships, school activities, home life,
and overall functioning.
Such evaluations typically cost anywhere from $600 to $2,000 and may be
covered by health insurance. Federal law also requires your child's
public school to provide both free evaluations and remedial classes for
eligible kids with ADHD. If you're not satisfied with your evaluator's
conclusions, insist on seeing another specialist for a second opinion.
"They Were Wrong!"
Patricia Mark's son Nicholas was diagnosed with ADHD at age 8, after his
third-grade teacher noticed he didn't pay attention, had trouble
reading, and wrote illegibly. "He'd have these momentary staring
spells," recalls Mark, 45, a mother of three in New Milford,
Connecticut. "And though he could spell any word in his head, the
letters would be all jumbled when he put them on paper."
The school district referred her to a psychologist, who attributed
Nicholas's symptoms to ADHD and suggested he take Ritalin. Convinced in
her gut that this diagnosis was wrong, Mark refused to give her son
drugs. She spent six years consulting one specialist after another.
Finally, a neurologist ordered a brain scan, which revealed that
Nicholas suffered from mild epilepsy. Earlier tests indicated he also
had dyslexia.
Tutoring and special-education classes have helped Nicholas cope with
his learning disability, but Mark feels that the boy, now a senior in
high school, will never recover academically from the years he lost.
Still, she remains grateful that she trusted her instincts. "Ritalin can
trigger seizures," she says. "If I had done what the 'experts' advised,
it might have killed him."
"Only Drugs Helped My Daughter"
From the moment her daughter, Juliet, was born, Leslie Pia knew she was
different from other babies. She cried inconsolably, rarely slept,
refused to stay in her stroller, and buzzed with nervous energy. By age
2, Juliet's fierce temper tantrums made her a social pariah among her
peers. "None of the mothers wanted her around their children," recalls
Pia, an event planner in Plainview, New York. As the terrible twos
progressed into the even-worse threes, Pia realized that Juliet wasn't
going to outgrow her erratic behavior, so she and her husband, Steven,
had her evaluated by a private psychologist. The verdict: Juliet
suffered from ADHD.
The psychologists broached the possibility of medication, but the Pias
were adamantly opposed. "I was appalled at the idea of a child barely
out of diapers popping these powerful pills," says Pia, who notes that
even experts are unsure what long-term effects these medications may
have, especially when they're given at such a key stage of neurological
development (the brain undergoes the majority of its growth during the
first five years of life)
Instead, Pia scaled back her work schedule to spend more time with her
daughter, read everything she could find about ADHD, and learned
behavior-modification techniques. She even tried occupational therapy to
tame her unruly child, who wandered around during circle time at her
nursery school, bullied her classmates on the playground, and had
trouble transitioning calmly from one activity to another.
"These methods would work temporarily, but nothing had a lasting effect
-- her brain and body were just moving too fast," Pia says. "Since I
couldn't sit in the classroom with her all day long, nursery school was
just a horror."
As Juliet prepared to enter kindergarten, the desperate couple made the
"harrowing decision" to give their daughter the stimulant Concerta. As
heart-wrenching as it was to "give my 5-year-old a pill in her
applesauce," recalls Pia, the effects were immediate and dramatic.
Suddenly, Juliet could sit calmly and do her work without making a fuss;
she could play peacefully for short periods with other kids.
The girl, now 7, still attends behavioral therapy to improve her social
skills, but "there is just no comparison to the way she was before,"
marvels her mom.
"I Refused to Medicate My Son"
Sheila Matthews's nightmare began when her son entered first grade. His
teacher phoned regularly to complain about the boy's disruptive behavior
-- he would blurt out answers and refuse to sit still. His teacher
assigned him a special seat away from his classmates and used negative
and positive reinforcements to try to curb his disruptions.
"All she was doing was stigmatizing and humiliating him," recalls
Matthews, a mother of two in New Canaan, Connecticut. "This was a kid
who had loved school and was always excited about learning. Suddenly he
was telling me he hated school and hated himself. He was only 6!"
The school psychologist diagnosed the boy with ADHD and urged his
parents to consider medication. "The psychologist told me, 'If you don't
medicate him, research shows he'll self-medicate with drugs and
alcohol,'" says Matthews. "I was frightened and horrified." Convinced
the school district was trying to sedate her son to make him easier to
manage, Matthews stood firm.
She believed her child was merely outgoing and energetic, and that drugs
would dampen his natural high spirits. Instead, she paid $2,000 for an
evaluation by a private psychologist, who determined the boy had trouble
with sequencing, reasoning, and comprehension. This diagnosis qualified
him for special speech and language services through the school
district. She also enrolled him in an after-school program in third and
fourth grades that helped build communication skills.
Her persistence paid off. Her son, now 12, is bringing home B's on his
seventh-grade report card and learning to play guitar. "When he started
doing better academically, his behavioral problems diminished," Matthews
says.
The Anti-Drug Movement
In all but the most severe cases, ADHD can be treated as effectively
with intensive behavioral coaching as with medicine, according to
advocates such as Dr. Pelham. Most no-drug programs emphasize the use of
goal setting, organizational skills, and time management. Children with
ADHD need consistent rules, a high degree of daily structure, and stern
consequences for misbehavior. Here, simple techniques parents can use:
- Follow the same
routine every day, from waking to bedtime.
- Have a place for
everything -- clothing, backpacks, school supplies -- and keep them
in their places.
- Use notebook
organizers and stress the importance of writing down assignments and
bringing home needed books.
- Create a clean, quiet
study area at home with no distractions.
- Encourage exercise.
Kids burn off pent-up energy through sports.
- Play an active role in
your school. Persuade teachers to make their classrooms more ADHD
friendly.
- Change your own
thinking. Because ADHD kids tend to be exceptionally creative and
intuitive, a growing movement urges parents to see ADHD as a "gift,"
not an illness.
This Is Your Child's Brain on Ritalin
ADHD medications work by changing the levels of brain chemicals such as
dopamine and norepinephrine, which help modulate activity in the parts
of the brain that regulate attention, impulse control, motor activity,
and organization. But what do these drugs do to your child's body?
While medication is sometimes the only answer for kids with severe ADHD,
it's important to realize that these drugs can carry serious side
effects, including insomnia, appetite loss, upset stomachs, and tics --
and even, according to the most recent research, possible depression in
adults who took Ritalin as kids. A small percentage of kids are also
vulnerable to a "rebound effect" when the drugs wear off in the late
afternoon and symptoms resurface.
Experts point out, however, that this problem has largely been
eliminated in recent years. In rare instances, youngsters may experience
seizures, or their growth may be affected when they continuously take
medication. Most experts advise against the continuous use of these
medications, especially for years on end. And many advocate that your
child take a medically supervised "vacation" from medication at least
once a year to see how he or she fares without it.
Originally published in
Ladies' Home Journal magazine, April 2005. |
|
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