Annual 2006
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Annual 2006
The ABC's of ADHD
Current thinking on diagnosis and medication. Cathy Cassinos-Carr
For the past three years, I’ve played stepmom to a young adult who at age 8 was diagnosed with ADD—shorthand for the condition known as Attention Deficit Disorder. I’ve seen firsthand how the ADD tag has crippled her self-confidence, causing her to doubt her ability to take a timed test, make a business call or drive a car (she’s 21, and still has no license). I’ve also seen her use it as a crutch when the going gets a little too rough. But just as frequently, I’ve seen her rise to the occasion in ways that contradict her diagnosis, causing me to wonder just how accurate that diagnosis is.
Had my experience existed in a vacuum, I wouldn’t be writing this article. But lately it seems that every other parent I meet has a child who has been diagnosed with the disorder, leading to a litany of questions. Why has ADHD become the disorder du jour? Are children being properly diagnosed? Are Ritalin and similar drug treatments safe? And what is the medical explanation for ADHD, anyway?
The answers don’t come easy.
ADD, ADHD: What’s the Difference?
First things first: Although the terms are often used interchangeably, ADD and ADHD are not one and the same. As Robert Hendren, D.O. and executive director of the M.I.N.D. (Medical Investigation of Neurodevelopmental Disorders) Institute at UC Davis explains, “It’s a tough one because our diagnostic manual calls it ADHD whether or not a patient has the H.” The H means hyperactivity—a symptom found in some but not all cases, and more frequently in boys. Parents find value in distinguishing between ADD (nonhyperactive) and ADHD, Hendren says, but it’s all under the ADHD umbrella.
There are three types of ADHD, according to diagnostic standards set forth by the American Psychiatric Association:
• Predominantly Inattentive (also known as ADD): These are the “daydreamers” who have a hard time paying attention, are easily distracted, are disorganized and often lose things. Among girls with ADHD, this form is most common—and is also the most commonly overlooked because its symptoms are the most subdued.
• Predominantly Hyperactive/Impulsive: These kids can be attentive, but are often in constant motion—squirming, having trouble sitting still, talking too much. Their impulsivity leads them to act and speak without thinking and to interrupt others.
• Combined Inattentive/Hyperactive/Impulsive: The trifecta of ADHD, children with this form show all three symptoms.
Just how many children have ADHD? According to 2004 data from the National Center for Health Statistics, some 4.5 million youths ages 3 to 17 have the disorder, representing 8 percent of all U.S. children under 18. It is the most commonly diagnosed behavioral disorder in children and adolescents.
But whether they are being overdiagnosed is a bone of contention worth chewing on.
The Diagnosis Debate
James Margolis, M.D., a child psychiatrist for Sutter Counseling Center, believes ADHD is vastly underdiagnosed, especially in females who lack the hyperactive component. “Any practitioner can spot ADHD,” he contends. “But ADD can be easily overlooked.”
Others say the disorder tends to be overdiagnosed, largely because it so often masquerades as something else. Sean Nealon, M.D., a pediatrician for Mercy Medical Group, says there are many conditions whose symptoms can mimic ADHD, including hearing problems, thyroid disease, allergies, anxiety, depression and conduct disorder.
“I don’t want to alienate anybody,” he begins. “But I think when kids have trouble in school, there’s a frequent tendency to jump to the conclusion that it’s ADHD.” Report-card time brings a lot of parents to Nealon’s door, as a significant drop in grades is often what prompts them to have their children tested. “A lot of times they want a medical explanation, so they come to the pediatrician,” he says. But school-related symptoms alone do not spell ADHD, he warns. “The symptoms need to occur in more than one setting—such as school, home and social situations—or it’s not ADHD.”
Nonetheless, it’s usually poor school performance that first rings the ADHD alarm, partly because kids are expected to fit the education “box,” notes Roseville psychologist Lani Jennings, Ph.D., who has post-doctoral training in ADHD. “Unfortunately, but which probably cannot be helped, schools are structured on a ‘one-size fits all’ approach. If children don’t fit the particular learning style ‘box’ of the school, they often will be considered ‘difficult’ and sent for an ADHD evaluation, which is often the only diagnosis that most teachers, parents and health care providers associate with this ‘difficult’ behavior.” Some 50 percent of those she evaluates do not have ADHD, says Jennings, who frequently finds that the real issue is an anxiety disorder.
Coexisting conditions are also common. When Genevieve Graff’s grades suddenly plummeted in the 7th grade, prompting a school counselor’s concern and a psychiatric evaluation, the dual diagnosis was ADD and depression. “In the beginning, she didn’t want to be alive,” says Holly Graff of her now 17-year-old daughter, who attends Folsom High. “She was depressed, and maybe that was part of the ADD too.” With medication, short-term therapy for self-esteem issues and school accommodations, Graff says, things turned around. “Her grades improved, and she’s happy again.”
But such happy endings depend on proper diagnosis, and with ADHD, diagnosis can be tricky. Since no single medical test for the disorder exists—a sticking point for skeptics who question ADHD’s validity as a medical condition—health care professionals rely instead on a battery of tools including a physical exam, medical and family history, interviews with the parents, child and teacher(s), behavior rating scales and psychological and cognitive tests. That’s why it’s paramount for children to be evaluated by a well-trained professional with extensive knowledge of ADHD, such as a developmental pediatrician, child psychologist, child psychiatrist or pediatric neurologist.
ADHD is described as a neurobiological disorder, so it would logically seem to follow that brain scans would be part of the diagnostic process. But such testing has not yet been adopted in the mainstream, according to UCD’s Hendren. “Brain scans such as the MRI, PET, SPECT and EEG are used in research to learn more about how the brain works in ADHD. But as yet they are not specific enough to make a definitive diagnosis and do not add enough information to the clinical interview and rating scales to add them to the routine evaluation.” While Hendren predicts they may be added to the evaluation process as the technology improves, some have already fast-forwarded in that direction: At the Amen Clinic in Fairfield, for example, brain SPECT imaging is being used to diagnose a variety of neuropsychiatric problems, especially ADHD.
Drugs: A Hot-Button Issue
If you really want to get the ADHD party started, whisper “Ritalin” in a roomful of parents (or teachers or doctors, for that matter). This is where civilized conversation ends and testiness begins.
“If your child had diabetes, wouldn’t you give him insulin?” challenges Theresa, a friend whose somewhat wayward son was prescribed Ritalin as a middle-schooler (he’s in college now, and no longer using meds). Her point is well taken, as no one would think twice about insulin for a diabetic; most would probably even abide by psychotropic drugs for a child with a mental disorder. But Ritalin, Adderall, Concerta and other stimulants prescribed to treat ADHD are often compared to legalized speed—and that’s what many find so disturbing.
“Let’s face it, this is methamphetamine,” says Susan Peterson, a Lincoln mom whose 9-year-old ADHD-diagnosed son started on Ritalin and graduated to Concerta. A mother of three, Peterson says she doesn’t even like to put her kids on cold medication, so the idea of starting her son on stimulant drugs “freaked me out.” But she can’t deny how well the medication is working, especially when it comes to school. “With the medication, all his grades skyrocketed,” she says. “Kyle has always been very smart, but he wasn’t able to focus until he started on the meds.” Her story is not unusual: Studies show that about 80 percent of children with ADHD perform better with the medication than without it.
“Who would have thought that kids with a hyperactive disposition would be helped by stimulants?” asks Mercy’s Nealon. “But it does seem to help them drop down into that zone of concentration.”
Critics have long argued that the drugs are overprescribed, especially for children, who remain the largest population of ADHD medication users. In 2005, an estimated 1.7 million adults ages 20 to 64 were treated with the drugs, compared to nearly 3.3 million patients 19 and under, according to reports by Medco Health Solutions.
“Are we overtreating this?” asks Sutter’s Margolis. “Absolutely. Fifty percent who are on medication could be off medication if there were a change in the educational environment. But that would mean tripling the educational budget, so it’s not gonna happen.”
Doing well in school “is one of the good reasons to treat children for this disorder,” says Robert Diamond, M.D., a child and adolescent psychiatrist for Kaiser Permanente. “To function in our society, you have to be a good second and third and fourth grader, and it’s harder to do that if you have ADHD.”
Though safety questions surrounding ADHD drugs have caused countless parents to seek holistic solutions, most conventional practitioners purport that ADHD medications are safe when properly prescribed and monitored. Still, all stimulant drugs carry the risk of cardiovascular consequences, and, as Diamond points out, “anything that affects the brain can have negative effects.” Psychosis, mania and hallucinations are among the reported risks for children taking ADHD drugs, a concern driving the FDA to consider increasing its safety warnings.
For the most part, though, parents find themselves fretting about the more common side effects found in their ADHD-medicated kids, such as anxiety, insomnia, irritability and loss of appetite.
“Honestly, I’m worried about his weight,” says Peterson of her son Kyle, who is “very tall [for a 9-year-old] and very thin—5 feet tall and 68 pounds.” Over the four years he’s been on medication, Peterson says, she’s had to train her son to eat regularly, taking extra precautions to make sure he gets enough protein. On weekends, and whenever possible, Peterson takes him off the drugs, such as during a recent week-long vacation in Vegas. “He ate like I’ve never seen him eat before,” she says. Still, Peterson says, “if this [medication] is what works for him and helps him do well in school, I’m going to support it.”
Team Effort Is Needed
Drugs alone are not enough. Children with ADHD also need tools—life tools—and a multi-disciplinary team effort that doesn’t happen as often as it should, notes Diamond.
“Medication is usually the easy part,” he says. “The bigger challenge is getting the other parts of the system working together—the schools, the parents, the health care providers—to provide children with appropriate behavioral, social and educational therapy.”
Jennings concurs: “The unfortunate part is that most people stop at medication and don’t utilize the other important elements of effective treatment. Behavioral approaches are almost always a necessary adjunct.”
Taking the time to understand what works best for an ADHD child is a parent’s responsibility, says Graff, who regularly compares notes with other parents as coordinator of the Sacramento chapter of the support group CHADD (Children and Adults with Attention Deficit/Hyperactivity Disorder). Sometimes it’s just a matter of trying new strategies: Graff discovered, for example, that her daughter’s organizational abilities improved tenfold by simply switching to brightly colored index cards.
Peterson, too, works diligently to help keep her son on track—a relentless day-in, day-out routine she admits can be frustrating. “I almost have to micromanage his schoolwork,” she says. But she’s training him for life, she says, so the effort is worth it.
“I hope one day I won’t have to do this for him anymore,” she says. “Hopefully one day he’ll be able to do it on his own.”
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