adhd 1

Hyperactivity: what we need to know (part I of a II-part series)

by Barry Bittman, MD

If the first few weeks of school are spent anticipating a desperate call from your child’s teacher advising you that your youngster is disruptive and demanding that something be done NOW, read on!

If you’re a parent facing such a situation, what you’re about to learn can make a meaningful difference for you and your child.

What we’re about to discuss is one of the most poorly understood behavioral condition of our era. It’s called ADHD or Attention Deficit Hyperactivity Disorder, and it refers to a developmentally inappropriate level of attention, concentration, activity, distractibility and impulsivity. The term, “developmentally inappropriate” is important considering the normal behavior for a two-year-old is clearly unacceptable for a second grader. When one considers the broad spectrum of age-specific acceptable behaviors, coupled with failure to offer a reliable diagnostic test, it’s no surprise that this condition is often incorrectly identified and poorly treated.

In a recent report in the American Journal of Public Health, Gretchen LeFever, pediatric psychologist and lead author of the study noted that children in two districts of southeastern Virginia took drugs for ADHD at two to three times the expected rate. While it has been estimated that ADHD occurs in 3-5% of school-age children in our nation, her research revealed 8-10% of second to fifth graders took medication for the disorder. More startling, however, is the fact that 19-20% of white boys were taking ADHD medications!

LeFever’s data leaves us with the question of whether or not ADHD can be reliably diagnosed. Many experts contend that using well-tested interview techniques, (not blood tests or brain scans) proper identification is possible. Although there isn’t a lab test that confirms the diagnosis, recent research performed at Duke University is helping us to understand how drugs for ADHD may actually work. In studies of laboratory mice, medications like Ritalin and Dexedrine (both commonly prescribed for the disorder) boost levels of dopamine and serotonin in the brain. Both of these substances are called, “neurotransmitters,” or signaling substances that help relay messages between key areas of the nervous system.

The Duke team, led by Dr. Paul Gainetdinov is convinced that treating ADHD is not as simple as increasing levels of these substances. He stated, “Hyperactivity may develop when the relationship between dopamine and serotonin is thrown off-balance.” He also noted that prescriptions for ADHD have risen 81% over the last five years.

From a public health perspective, we must question whether or not such an increase is justifiable. Frankly, due to the complexity of this issue, the answer isn’t likely to surface in the near future.

While the question of medication overuse has been brought to media attention on several occasions, an acceptable standard of care has not been clearly established. Both sides of the argument are easy to understand. The critics contend that we’re not allowing children to simply be themselves. They often argue that that our school system needs to be more accommodating. As a neurologist, I do not agree. The educational experiences of 25 students can be easily disrupted for an entire school year by one child with ADHD who cannot be controlled by a well-intentioned, caring and capable teacher. Over the last 17 years, I have treated many ADHD children identified by our local school systems who are now well-functioning college students or adults. In the context of enlisting a multifaceted treatment approach of behavioral management, counseling and medication, the majority have thrived.

Yet a number of questions brought forth by the critics are also worth addressing. Is ADHD frequently misdiagnosed? Are we incorrectly labeling kids who are actually suffering from depression or anxiety disorders? Is Ritalin being used as a substitute for nurturing and discipline at home? Do we live in a society that expects to shape behavior with drugs alone? Is ADHD a real disease? I believe their points are clearly worth addressing.

Let’s spend a few moments on these issues. First, without a doubt, the diagnosis of ADHD may be challenging, difficult and ultimately, incorrect. Depression, anxiety and attention-getting behaviors often cloud the issue. Other factors such as parental discord, abuse, broken homes, and mental illness within the household must also be considered. Child rearing practices also vary considerably and may contribute significantly to the child’s behavior.

There’s also no doubt that many prescriptions may be inappropriate. Let us not forget that we live in a society that tends to take the easy way out. Just check the latest national sales reports for antidepressants. Treatment decisions are often difficult, especially in consideration of typical expectations for the instant, painless cure. And while over-prescribing has garnered a great deal of attention, I’m convinced that there are a number of untreated children who could benefit greatly from drugs like Ritalin.

Ultimately, I believe that ADHD is a bona fide disease, and that there’s a great deal to learn that can benefit children, parents and teachers alike. Stay focused for some practical suggestions about diagnosis and treatment next week¾ Mind Over Matter!