Experts, Educators Question A.D.D. Diagnoses
Marilyn L. Sandler and her husband struggled last fall with the decision to give their 12-year-old son a drug intended to combat his chronic inattentiveness and hyperactivity. The Sandlers were concerned about the long-term effects of the stimulant, and they were worried that their son might become addicted.
But after years of living with their son's social and behavioral problems--and his more recent talk of running away or committing suicide--the Sandlers decided to try the drug known by the brand name Ritalin.
"It's like Jekyll and Hyde," Ms. Sandler said of the change in her son. "He's gone from being the kid marked with the X to this wonderful child. My whole house is quieter because of Ritalin."
Their son, like a growing number of American children, has been diagnosed with attention-deficit disorder.
A.D.D. is characterized by an inability to concentrate and, in some cases, impulsivity and hyperactivity. It is estimated that 3 percent to 10 percent of the nation's school-age children have the disorder.
The Sandlers, who live in suburban Chicago, are just one of many families playing a part in a much larger debate: Is A.D.D. overdiagnosed--with drugs such as Ritalin being used as a "quick fix"--and how do the nation's schools figure in this equation?
In an attempt to dispel confusion about the disorder, the U.S. Education Department last week issued publications and videotapes that synthesize recent research on A.D.D. and outline promising strategies for teachers to help identify and work with students who have the disorder. The materials are being disseminated through several national education groups.
In addition, the National Institute of Mental Health this month announced the most comprehensive study to date on what treatment works best for children with attention-deficit disorder. The Education Department is helping to pay for the two-year, six-city study.
But for now, many questions remain.
Challenged by Church
Controversy has long been associated with the disorder and the drugs used to treat it.
In the late 1980's, a flurry of lawsuits were filed--many promoted by a group affiliated with the Church of Scientology--claiming that schools were pushing Ritalin on families and that the drug caused horrific side effects in some children. (See Education Week, Oct. 21, 1987.)
Ritalin, the trademark for methylphenidate, is the most widely used drug for treating A.D.D. It aids concentration by stimulating the brain's system for filtering out unwanted stimuli. Many medical experts believe that the disorder is caused by a chemical imbalance in the brain.
According to a spokeswoman for Ciba Pharmaceuticals, the company that sells Ritalin, the lawsuits challenging its use ultimately failed.
The Citizens Commission on Human Rights, an international group established by the Church of Scientology, was unable to confirm the lawsuits' outcomes.
"We haven't focused on the drug in recent years," said Bruce D. Wiseman, the president of the commission's U.S. office in Los Angeles. The church has a long history of fighting what it considers to be false psychiatric diagnoses and the drugs used to treat them.
In 1990, A.D.D. was the subject of debate when some parents and advocates pushed to have the disorder included as a separate eligibility category under federal special-education law. That effort was stymied by many education and civil-rights groups. (See Education Week, Sept. 5, 1990.)
Petition to D.E.A. Pending
The U.S. Drug Enforcement Administration, meanwhile, is reviewing a petition that seeks to remove Ritalin from the list of controlled substances for which the agency sets annual production quotas. The agency would continue to regulate the drug.
Several medical groups, including the American Academy of Child and Adolescent Psychiatry and a national advocacy group, Children and Adults with Attention Deficit Disorders, filed the petition last fall.
Petition supporters argue that Ritalin does not belong in its current classification because it has not been found to be highly addictive, given the typical dosages prescribed, medical experts say.
As the chairman of the Senate Judiciary Committee, Orrin G. Hatch, R-Utah, has oversight power for the D.E.A. He has pledged to insure that the petition is reviewed expeditiously.
Production Up 400 Percent
A widespread shortage of Ritalin in 1993--and frequent spot shortages in certain areas of the country in recent years--helped prompt the petition.
Regardless of the petition's fate, many educators and medical experts are nervous because demand for the drug continues to soar. Production levels have increased about 400 percent since 1990.
Medical experts say there are many factors that may be contributing to the increase: The drug is used by adults, who in recent years have been increasingly diagnosed with A.D.D., and by people with the sleep disorder narcolepsy.
But some experts suggest that the increasing number of children and teenagers being diagnosed with the disorder indicates an emerging epidemic.
The number of children being treated for the disorder has doubled since 1990, estimates one noted A.D.D. expert, James M. Swanson, a professor of pediatrics and the director of an A.D.D. center at the University of California at Irvine.
Common Beliefs Changing
The conventional wisdom among medical experts has been that many symptoms of the disorder fade as children enter puberty and that Ritalin has less effect on older children.
But those beliefs are changing.
Now more children take the drug outside of the school day to control their behavior and improve their concentration on weekends and school breaks, experts say.
While hyperactivity may decrease in some children with A.D.D. as they enter puberty, in up to 50 percent of those children some symptoms are thought to persist into adulthood.
Ritalin has proved effective for some children throughout adolescence and, contrary to previous beliefs, into adulthood. Thus, the chances of taking the drug for a lifetime have increased.
The gender trend also has started to change.
The disorder traditionally has been identified more frequently in boys than in girls, largely because girls are less likely to show its most conspicuous trait--hyperactivity. But within the past five years, the numbers have shifted, according to experts. At the University of Chicago's A.D.D. clinic, the gender ratio has shifted from 10 boys for every girl to 7 to 1, the director said.
In what he called a more disturbing trend, Mark A. Stein, the clinic director, said he regularly receives calls from parents of children as young as 3 who believe their toddlers have A.D.D.
"I mean, all 3-year-olds have problems paying attention and don't listen," said Mr. Stein, who is also an associate professor of psychiatry and pediatrics. "There's definitely some oversensitivity."
An 'Unorganized Conspiracy'
The terms of the debate over Ritalin's use appear to have shifted away from the drug's side effects, which include insomnia, irritability, appetite and weight loss, and, in rare cases, body tics or stunted growth.
Instead, educators and medical experts say they are concerned that the drug is being used as an inexpensive "fix" for A.D.D.
The drug is not a "cure" for attention-deficit disorder, they say, nor is it an effective treatment by itself without behavior modification, counseling, and teacher and parent training.
"What does it do to a child's development when he learns from an early age that to behave 'normally' he has to have the help of a drug?" asked Gerald S. Coles, an educational psychologist at the University of Rochester in New York and the author of a book on learning disabilities.
For the past few years Idaho has ranked first in the country in Ritalin consumption, according to the D.E.A.
Fred W. Balcom, who until recently was the state's director of special-education programs, said that is because putting a child on Ritalin at parental expense is viewed as an attractive option in times of tight budgets for public services.
"Everybody--the schools and parents and doctors--was suggesting medical management. It was almost an unorganized conspiracy among all players to put the kid on medication," Mr. Balcom said. "It makes life easier for all the adults involved."
Allegations that schools push the drug onto parents persist. Some parents in Philadelphia last year made such claims. Though the charges were never substantiated, there was an official rebuke, according to Herbert Hazan, the director of school-health services in Philadelphia.
Theresa R. Lemme, who was the acting schools superintendent at the time, issued a memo last March as a "reminder" that school staff members should not suggest to parents that their children need to be medicated and should not refer them to specific physicians.
An underlying problem is defining attention-deficit disorder.
Recent research suggests that experts may be moving closer toward developing a biologically based test to determine A.D.D., but for now, many physicians rely on what have been criticized as highly subjective criteria.
The American Psychiatric Association's newly revised diagnostic criteria make it possible for a child to be labeled as having A.D.D. for symptoms such as squirming in his seat, blurting out answers, or avoiding homework.
A child must have at least six symptoms of inattention or hyperactivity--manifested in at least two settings, such as school and home--and have sustained impairment from them before age 7.
The key to an accurate diagnosis, experts say, is assessing the consistency and severity of the symptoms. Many experts say they fear that children are not receiving comprehensive evaluations.
Physicians may be too quick to identify A.D.D. and prescribe Ritalin. Anxiety and depression produce symptoms similar to the disorder, and many children with A.D.D. have learning disabilities.
In such cases, drugs may mask the child's true problems.
Schools Look for Help
Some educators fear that parents may push to have their children labeled as having A.D.D. to receive special services--either through special education or through accommodations in the regular classroom.
What is clear is that as the number of schoolchildren diagnosed with A.D.D. increases, so do schools' cries for help.
Mr. Stein and other experts said there has been a massive increase in requests from schools to do in-service training on how to identify and accommodate students with A.D.D.
Meanwhile, Ms. Sandler said she realizes her son will likely stay on Ritalin through high school and maybe beyond. That notion would have bothered her before the family decided to try the drug, but not now.
"Things aren't perfect, but he's a happy kid now," she said. "I don't anticipate him outgrowing this."