Attention deficit hyperactivity disorder (ADHD) has become the most controversial medical topic in America when it comes to children. An estimated 6.4 million children between ages four and seven have been diagnosed with ADHD. Two thirds of these children are on prescription drugs. Among those millions of diagnoses, there are false ones. There are high-energy kids who were misdiagnosed and are taking pills every day for a disorder they do not have.
ADHD is usually treated with stimulants. The most famous brand names to deal with the symptoms of the psychiatric condition are Ritalin and Adderall, but newer ones include Vyvanse and Concerta. The Drug Enforcement Administration (DEA) classifies stimulants as Schedule II drugs, defined as having a "high potential for abuse" and "with use potentially leading to severe psychological or physical dependence." In addition to stimulants like Ritalin, Adderall, Vyvanse, and Concerta, Schedule II drugs include cocaine, methamphetamine, Demerol, and OxyContin.
According to manufacturers of ADHD stimulants, they are associated with sudden death in children who have heart problems. They are associated with "new or worse aggressive behavior or hostility." They can cause "new psychotic symptoms (such as hearing voices and believing things that are not true) or new manic symptoms." They can bring on a bipolar condition in a child who didn't exhibit any symptoms of such a disorder before taking stimulants. They commonly cause noticeable weight loss and trouble sleeping. In some children, some stimulants have caused the paranoid feeling that bugs are crawling on them. Some have exhibited facial tics. Another study reported fears of being harmed by other children and thoughts of suicide.
The drugs these children consume may work. They help them focus for longer periods of time. They can help them do better in school. But stimulants work on just about anyone. "These are powerful drugs," says Bob Schaffer, the former Colorado congressman. "They would work on me. They would make anyone more focused. And everyone's happy because the kid is now under control." The fact that the drugs would help you perform better at work doesn't mean you should take them. And it certainly doesn't mean a seven-year-old boy who doesn't suffer from a psychiatric disorder should be taking them.
The Centers for Disease Control in 1997 found that about 3 percent of American schoolchildren had received the diagnosis. After that year, the number of diagnosed cases began to increase by at least 3 percent every year. Then, between 2003 and 2007, cases increased at a rate of 5.5 percent each year. In 2013, the CDC released data revealing that 11 percent of American schoolchildren had been diagnosed with ADHD, which amounts to 6.4 million children between the ages of four and seventeen—a 42 percent increase since 2003. Boys are more than twice as likely to be diagnosed as girls—15.1 percent to 6.7 percent. By high school, even more boys are diagnosed—nearly one in five.
There are different explanations for the sudden rise. Increased awareness of ADHD and its use as an easy label for a challenging child, too much technology put onto a developing mind, too much refined sugar in the diet causing hyperactivity, pharmaceutical companies pushing ADHD drugs, and poorly supervised gym classes at schools.
According to Dr. Allen Frances, professor emeritus at Duke University School of Medicine, in August 1997—the same year the Centers for Disease Control and Prevention first started tallying ADHD cases in the United States—the Food and Drug Administration made it easier for pharmaceutical companies to advertise their drugs to consumers. Spending on direct-to-consumer drug advertising increased from $220 million in 1997 to more than $2.8 billion by 2002. Frances is not skeptical of whether ADHD is a real and valid diagnosis; he just believes that "it's been watered down so much in the way it's applied that it now includes many kids who are just developmentally different or are immature," he says. "It's a disease called childhood."
If you think about it, insurance companies don't reimburse or reward doctors for time spent doing the diligent work involved in giving a proper opinion. "You have to observe the behavior of the child over different environments. You have to talk to the parents. You have to talk to the teachers. I don't know an insurance company out there that pays for a pediatrician to call and talk to the teachers. They just don't," says Ruth Hughes, a psychologist who is the CEO of Children and Adults with ADHD (CHADD).
So what is the best treatment for children with this diagnosis? Many believe that medicine should be the first treatment, either combined with behavioral therapy or not. Others feel that drugs should be a last resort after making every other alleviative effort you can find or think of, from hypnosis to herbal treatments to neurofeedback.
In 2012 there was a study of nearly one million children between the ages of six and twelve, called "Influence of Relative Age on Diagnosis and Treatment of Attention-Deficit/Hyperactivity Disorder in Children." Researchers found that "boys who were born in December"—typically the youngest students in their class—"were 30 percent more likely to receive a diagnosis of ADHD than boys born in January," who were a full year older. And "boys were 41 percent more likely to be given a prescription for a medication to treat ADHD if they were born in December than if they were born in January." These findings suggest, that a wrong diagnosis can sometimes result from a developmental period that a boy can grow out of.
Part of the problem is subjectivity, and the power of a culture that has settled on a drug-based solution. The ADHD clinical-practice guidelines published by the American Academy of Pediatrics—the document doctors are supposed to follow when diagnosing a disorder—state only that doctors should determine whether a patient's symptoms are in line with the definition of ADHD in the DSM. To do this accurately requires days or even weeks of work, including multiple interviews with the child and his parents and reports from teachers, plus significant observation. And yet a 2011 study by the American Academy of Pediatrics found that one third of pediatrician visits last less than ten minutes.
Managing ADHD, for most people who receive the diagnosis, includes taking medication. If the diagnosis is real, a prescription can turn around a child's life in an instant, improving his ability to concentrate and jacking up his self-esteem. Denying a child who needs the medicine is as cruel as forcing it on a kid who doesn't.
In 1999 the National Institute of Mental Health published its landmark study "Multimodal Treatment of ADHD," which was led by Peter Jensen; 579 children ages seven to nine took part. The study declared that the best treatment, across the board, is medication combined with behavioral therapy—but that the combination works only marginally better than medication on its own, with no behavioral component. This made a lot of parents feel better about accepting a prescription for their children, and the study is frequently cited by pharmaceutical companies, psychiatrists, and organizations like CHADD.
However, research published since the multimodal study, suggests that treating kids who have ADHD with cognitive behavioral therapy can have the same positive effect as stimulants. A new study in the Journal of Abnormal Child Psychology shows that behavioral therapy, alone or in combination with stimulants, is far more effective than medication alone. The children in the study—forty-four boys, four girls, all diagnosed with ADHD—were given varying doses of medication and behavioral therapy, and researchers monitored their episodes of "noncompliance" each day. The worst-behaved children were the ones receiving only drugs and no behavioral therapy. Even kids given a placebo while also receiving some behavioral therapy behaved far better than kids being treated with drugs alone. The sweet spot was a low dose of medication plus behavioral therapy
There's no culture about ADHD, no test. To find out if you have it, or if your son has it, or if your daughter has it, you just need a human being to say so—a physician or a psychiatrist. James Forgan, a psychologist and coauthor of a book called Raising Boys with ADHD, speaks from experience about raising a child with this condition. "My son doesn't like to take the medications because he feels like it makes him feel flat, and he doesn't like what it does to his personality. And he says he's not the same fun person that he is when he's not on the medication. And some of that fun gets him in trouble at school, because he's funny and knows how to entertain people. But at the same time, he likes that characteristic about himself—that he is fun and knows how to get people laughing and working together and bring energy into a room. Kinda like the life of the party." Forgan knows all the warning signs, and he tells parents about them. He's in favor of drugs when they're administered correctly—starting with low doses, watching vigilantly for side effects, stopping use if the side effects outweigh the benefits.
Howard Glasser believes that what is called attention-deficit/hyperactivity disorder might in fact be a boy's greatest gift, the gift of energy. And that the best way to treat it is to first teach the boy to control the energy all by himself, because by learning to control it himself, a boy can channel that energy to help him succeed. That the responsible thing to do is first to see if there is some problem with the boy's heart, with its ability to show and accept love. Glasser, and he is one of those countercultural clinicians who, as American society has become inured to giving psychotropic drugs to kids, has built a practice predicated on opposing the very idea. If he were a child today, Glasser would be given a prescription for a stimulant in about five minutes.
There is something great about having ADHD. The question is how to treat the difficult parts in a way that pushes the greatness forward. Howard Glasser's biggest fear in life is that a child might grow up not knowing how great a person he is. "I confront kids with their own greatness," the creator of the Nurtured Heart Approach says. "Because that's what I think allows a kid to go from an ordinary life to a purposeful life. To see who they really are. The worst-case scenario in life is that a boy grows up thinking: Who I really am is a kid who annoys everybody." Glasser feels it is our responsibility as a society—as grown-ups—to do everything we can for a child's heart before we start adding chemicals to his brain, because what if his brain is fine? What if the diagnosis isn't right? And even if it is, what if something else works?
"It's much more about reaction than attention." That sentence appears on page 10 of Glasser's book, Transforming the Difficult Child. Parents of intense boys can shower their children with love and attention, and still the boys might be difficult boys. What's important is how you react to what a child does, good or bad, Glasser says. Mostly, we get animated when our kids do something bad. We get worked up, and we give them energy—negative energy, but energy nonetheless. But when a difficult child is sitting quietly, playing or writing or drawing, not disturbing anyone, not throwing food, not picking on a sibling—we do nothing. We don't acknowledge it at all. The way a difficult child gets a parent's energy, then, is to do something bad. "Most parenting approaches have you giving a strong punitive consequence that's all energy and that confirms that, as a parent, you're highly available through negativity—you're a toy that works when they push buttons," he says. "And you work if and only if they act out bigger."