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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.
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.
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:
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.
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."
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.
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.
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.
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.