Cover story | TREATING ADHD Continued from Page 13 fectiveness of medication. “The research is just so robust,” Marshall said. “As much as I also like to think behavioral intervention is all it will take to support students — and certainly at different developmental milestones there’s going to be a need for more or less of what we’re doing — medication has the most bang for the buck. The medication definitely has a stronghold in terms of positive outcomes.” Parents’ concerns about medications range from worrying about the side effects —or fears about tinkering with a child’s brain chemistry and personality— to a sense of personal failure in raising their child. Others may have concerns when physicians prescribe the drug too quickly, without a full assessment process. “I think that makes them nervous that they can go to the physician and get a prescription that same day without getting ratings from teachers or observations from schools,” said John Carlson, an associate professor of school psychology at Michigan State University in East Lansing. When ADHD experts sought to define the symptoms that make up ADHD, it prompted many doctors to simply use the list as a checklist. With enough symptoms checked off by parents and teachers, some doctors would simply write a prescription without ever seeing the child. Surveys of pediatricians show that approach is less prevalent today, but it may have contributed to the general notion that it’s just too easy to get stimulants for a child. Still, Carlson acknowledges that the backlash over ADHD medication may be creating a barrier to kids getting timely care. “The stigma often gets in the way of parents even considering a med trial,” Carlson said. “I think for some parents and their values and beliefs, it does probably take longer than it needs to, but ultimately that’s right for that particular family.” When parents are opposed to medication, Carlson suggests documenting how a child is doing before and after non-medication interventions. If grades continue to slip and personal relationships continue to suffer, parents may change their minds. “I do find that this type of data really helps parents to break down their negative beliefs
HIGH DESERT PULSE • SUMMER / FALL 2010
How ADHD may be both over- and underdiagnosed A study trying to determine whether children were being overdiagnosed and overmedicated for ADHD found a pretty close correlation between diagnosis and medication rates. About 6.2 percent of the 1,422 kids studied had ADHD, and 7.3 percent were prescribed stimulants, such as Ritalin. But upon closer examination, researchers found a major mismatch. Half of the kids with ADHD were not prescribed stimulants, and more than half of those on stimulants didn't meet the criteria for an ADHD diagnosis. It's why experts argue that ADHD is both over- and underdiagnosed in the U.S.
Total number of children studied
1,422 88 children
104 children
met criteria for ADHD diagnosis
prescribed stimulants to treat ADHD
44
children with ADHD but not prescribed stimulants
44
children with ADHD and prescribed stimulants
60
children not meeting criteria for ADHD diagnosis, but prescribed stimulants anyway
Source: Child and Adolescent Psychiatry and Mental Health, The Great Smoky Mountain Study GREG CROSS
and helps them to bring some logic and rationale to even think about the possible benefits of a medication trial with their physician,” Carlson said. Collecting such data generally means partnering with teachers and schools. It’s in the classroom where an inability to focus and control behavior impacts kids most, and so it’s most often classroom performance issues that flag problems and are the best measure of the effectiveness of treatment. Yet parents sometimes don’t even want to admit to the teacher that a child is taking ADHD medication. “There is often a stigma, so much so that parents won’t share information with school
personnel,” Carlson said. That caution may ultimately serve a purpose, making parents and doctors think twice about a decision to medicate or not, taking extra time to ensure they’re making the right choice. “To me, if they’re not cautious, then I go the other way. Let’s make sure your decision is the right one and get you the data you need to prove that the treatment is effective for the concerns that you brought to the physician,” Carlson said. “We might think, wow, parents are overly cautious, but it’s all outweighed by the thinking that the kid can have a little bit better life if they go that route.” Dr. Martin Lakovics, a psychiatrist in Bend, said he’s seen a bit of shift in the way the public views medication for mental illness, in part because of heavy television advertising by drug companies. “There’s much less resistance than there used to be,” Lakovics said. “People are starting to realize this has come into the mainstream of society to some extent. And also, they’re tired of suffering.” While some kids might be able to manage with behavioral support programs, he says, such resources aren’t always available in schools. And parents may not have the time and money to pursue some of the nonmedication interventions. “You don’t use medicine unless you have to, unless the symptoms affect function or suffering. That’s true of all medicine,” Lakovics said. “Is it right to give kids (ADHD) medicine? I think the parents have to decide with the child. Often it’s not controversial. The child feels terrible, too. ‘I’m not functioning in school. I’m being made fun of.’ It’s not fun to be ADHD.” Still, it’s an odd dynamic for a culture that often turns to medication before lifestyle changes to address medical problems. Doctors have found it’s easier to prescribe a cholesterol-lowering drug than to get a patient to eat better and exercise. It may be because ADHD affects children or that it is a mental illness that gives the public pause. “I think the general sense in the press is that we overmedicate. I think there’s some truth to that,” Lakovics said. “On the other hand, if you meet parents or schoolteachers of kids who have been diagnosed with ADHD
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