Understanding ADHD in 2013
In the past ten years the number of children regarded as having ADHD has risen by 53% to more than 6.4 million. In the past five years, sales of stimulant medications have risen from 4 billion to 9 billion annually.
A lot of things affect how well a child with ADHD fares in society. One big factor is the set of criteria used for diagnosis. Most physicians and psychologists rely for their diagnostic standards on the DSM-IV, a manual issued by The American Psychiatric Association. The edition about to be released (DSM‑V) contains a substantially broader standard for defining Attention Deficit Hyperactivity Disorder.
The new criteria are both positive and potentially problematic. Up until now, according to the DSM-IV, ADHD symptoms had to be observed before the age of seven for a diagnosis to be given. Also, the condition had to be severe enough to “impair” the functioning of the child. Under the new guidelines, the child must be diagnosed before the age of twelve, and his or her life need only be “impacted” by the condition. These are a big changes. On the plus side, it means that children with milder symptoms will be able to receive treatment that could mean a world of difference—fewer missed assignments, lost belongings, and flubbed tests. It means fewer children will constantly feel they have failed or “messed up.” Fewer children—and their teachers and parents—will struggle with a perpetual sense of frustration.
But it means some less positive things, too. The trouble is that you can’t do a quick, sure test for ADHD as you can for strep throat. Most children are diagnosed on the basis of their teachers’ and parents’ reporting. These are likely to be loving and responsible people, but not trained professionals. Many physicians who make the diagnosis and write the prescriptions are not highly trained in this specific area of expertise. Under these circumstances, errors creep in. A little boy who runs, leaps, shouts, defies authority, and has no use for book learning could have ADHD or he could be a hero in a book by Mark Twain. Children in western societies are being asked to live more sedate and sedentary lives. Many experts contend that the mounting number of cases of ADHD for which children are medicated in part reflects an adult desire to enforce docility or enhance academic performance.
Fortunately there are ways to improve the accuracy of diagnosis, which we use at RNBC. These include a carefully administered battery of tests to quantify attention skills, executive functions and processing speed as part of a broader evaluation looking at intellectual ability, achievement, cognitive processing, as well as social and emotional status. We can then tell if a child has trouble maintaining focus or shifting focus, or whether a child’s attention is disturbed by something auditory or visual in the environment. More importantly we can discover if the problem is actually an issue with attention or with something else. Children often appear to have ADHD when they are suffering from anxiety or depression or a learning disability. It is hard to pay attention when you are anxious, or can’t make sense of the letters on the page, or if your depression causes you to feel a general indifference to everything around you. Even more common, in my experience, are children with multiple issues, who are struggling to cope with ADHD plus one or more of the conditions listed above.
Without a proper assessment, the child may simply receive medication with a drug such as Ritalin, Adderall, or Vyvanse. The quality of attention may improve. But other problems remain undiagnosed and untreated. The child’s progress, performance, and sense of well being may still be constrained.
A secondary but serious problem is that these drugs have a large potential for abuse. Even in children without ADHD, these pills can cause a big improvement in focus and productivity. They can boost performance in class and on tests. They are, in the words of one expert, Dr. Ned Hallowell, “Mental steroids.”
When my patients who take stimulant medications are transitioning to high school we have a conversation about friends or fellow students who might want to “borrow”—or offer them money for —their medications. We discuss how carefully we diagnose and assess each patient’s condition to establish the right medication and dosage, and how scrupulously we watched for any side effects. I point out that this would not be true for an unauthorized, undiagnosed user, which is why selling your medication to others is dangerous and actually illegal.
When the child enters college we have another conversation about whether the patient wants to be open about the use of these medications. I hope my patients can be honest about their condition and feel comfortable discussing it. But their openness can put them at risk of fellow students offering to buy—or even stealing—their medication.
By some estimates, one third of the medications prescribed for ADHD end up being given or sold to others. These medications are used recreationally or to enhance the performance of students who don’t really need them. And it’s not only the kids who are trying to obtain them. Recently I got a phone call from a father of a teenage boy. “My son has to take the SATs in a couple months, and I know he’ll do better if he’s on meds for ADHD,” he told me.
“At what age was your son diagnosed?” I asked him.
“He hasn’t been diagnosed with anything,” the father said. “He just needs meds for testing.”
“Oh, I see. Well, I only treat patients whose attention and self regulation issues have a negative impact on their performance in school and their social well being. My patients have a well-diagnosed disorder.”
There was a silence. Then the dad tried again. “You know, Dr. Lipton, this isn’t a big deal. Doctors do it all the time in New York.”
“Fine,” I said. “The area code is 212.”