|It is no secret that the ADD diagnosis is sometimes made haphazardly.|
It is no secret that the ADD diagnosis is sometimes made haphazardly, that doctors or psychologists, succumbing to the needs of weary parents, occasionally recommend Ritalin after asking only a few cursory questions. But when the Shipleys took Brent to see psychologist Betty Hart in February of his kindergarten year, the examination was anything but casual. Hart took a detailed family history and inquired into the minutiae of Brent's school and home life. She had Brent's kindergarten teacher fill out a questionnaire.
And Hart observed Brent herself. She put Brent alone in a playroom stocked with toys and told him to "entertain" himself. Through a one-way mirror, she and the Shipleys watched as he quickly emptied the toys from the shelves and then abandoned them in small piles on the floor. "He couldn't complete a single task," Cindy says. "And that's one of the main things that characterizes ADD."
After Hart's evaluation, just as Brent was about to turn 6, he began to take 5 milligrams of Ritalin three times a day: in the morning, at noon, and in the afternoon when he arrived home from school. A year later, he was taking 10 milligrams three times a day, which is a fairly typical dose for kids.
Ritalin allowed Brent to settle down and concentrate almost immediately, although he did experience some common side effects. He lost his appetite, so much so that he hardly ever ate lunch. And the effects of the 10-milligram dose peaked early and dramatically. A half-hour after ingesting the medication, Brent would become lethargic, going, as his mother describes it, "from hyper to staring at the TV."
In the 4th grade, Brent switched to a time-release tablet with an all-day effect. Consequently, Cindy says, things are much improved. Brent's appetite is still best in the morning, but he now eats lunch and dinner, as well. And the mood swings aren't so dramatic. Brent is now on a more even keel.
|For the majority of doctors who prescribe Ritalin, ADD is as much a medical condition as diabetes or hemophilia.|
For the great majority of doctors who prescribe Ritalin, attention deficit disorder is as much a medical condition as diabetes or hemophilia. It doesn't matter to them that researchers have been unable to find a definitive medical cause. Most would probably agree that Brent's symptoms--his pronounced inattentiveness, impulsiveness, and hyperactivity--point to a classic case of ADD.
"It's an inherited condition, a designer disorder," says Peoria psychologist Eric Ward, who has perhaps diagnosed more cases of ADD than any other local clinician. "Those who say that ADD doesn't exist or that its diagnosis is hopelessly subjective are usually those who don't get in the trenches and do a lot of this work. People come into this office with this list of complaints so strikingly similar that when I tell them what else is involved in the cluster of symptoms they have this kind of 'aha' experience. 'You really know,' they say. 'You've been to our house.' But, of course, I haven't. And what makes it even more remarkable is that many have other children with whom they've used the same parenting and discipline methods, and yet the children demonstrate behavior that's not at all similar."
In the 1980s, Ward trained with Russell Barkley, a professor of psychiatry and neurology at the University of Massachusetts Medical Center whose 1990 book, Attention Deficit Hyperactivity Disorders: A Handbook for Diagnosing and Treatment, is still considered the last word among those working in the field. From Barkley, Ward learned a simple but critical lesson: You can only diagnose ADD when you can make a clear distinction between a conduct problem and the attention deficit disorder. As Ward explains it, many children chronically and willfully misbehave on account of inadequate parenting and poor discipline. What distinguishes the ADD kid, on the other hand, is an absence of willful, intentional misbehavior. According to this line of thinking, kids like Brent really don't know why they do certain things. Much of the time, they are acting on sheer impulse.
"Parents with ADD children," Ward explains, "will say, 'So and so doesn't obey me because he's in a dream world and distractible.' It's not just a case of the child being defiant and angry."
ADD, Ward adds, tends to surface very early in a child's life, before parenting styles can have much influence. Parents are often aware of an ADD-type disorder by their child's second birthday. Some mothers know, or claim to know, while the child is still in the womb.
|The key to an accurate diagnosis is the "cross situational" nature of the disorder.|
But diagnosis, Ward insists, must never rely solely on parental testimony. The key to an accurate diagnosis is the "cross situational" nature of the disorder: ADD symptoms must appear in a variety of settings--both at home and in school, for instance. "If it's truly a chemical, biological disorder," Ward says, "then it's got to go with you from place to place." A difficult child who becomes calmer and more attentive after a few months in a disciplined classroom setting probably does not have ADD, Ward says. "The parents will say, 'We had a heck of a time in September and early October, but by the end of October everything was a lot better.' "
Although Ward has few doubts about his ability to diagnose and treat ADD, others are much less sanguine. In fact, they are deeply disturbed by the exuberant confidence of people like Boston psychiatrist Edward Hallowell, who, in the first sentence of his best-selling 1994 book, Driven to Distraction, declares, "Once you catch on to what this syndrome is all about, you'll see it everywhere."
Hallowell may see it everywhere, but other doctors and psychologists looking at the very same kids have a hard time spotting it at all. One of them is pediatrician Sharon Collins of Cedar Rapids, Iowa, where, according to a recent study, some 8 percent of children in elementary and middle school take Ritalin.
"I'm frustrated; I'm crying out," Collins says. "When our children are born, we're so pleased to have this wonderful child--a child who no one else is like. Then they enter preschool, and they're all supposed to be the same, and so we label those who are not, ADD."
Collins says she is under great pressure to prescribe Ritalin. And in fact she occasionally does. "I have people who come to me on Ritalin, and I can't always change their minds," she says. "So I prescribe it, though it's not in my heart. And I've had people for whom I won't prescribe it leave my practice."