TREATING ADHD

February 24, 2000
		There has been a rapid rise in the use of Ritalin and other drugs by preschool-age children for treatment of Attention Deficit Disorder and related problems. The Health Unit is a partnership with the Henry J. Kaiser Family Foundation.

Health Spotlight: Attention Deficit Hyperactivity Disorder Feb. 26, 2000: Concussions in sports Oct. 30, 1998: Nature vs. Nurture The NewsHour's Health Spotlight. More NewsHour health coverage.   The American Public Health Association	SUSAN DENTZER: Seven-year old Evan Lassiter is an active second-grader -- an especially active one, at that. TEACHER: Evan, look at me. Listen to me, sweetie. That's not the type of talk we need in here. Thank you. SUSAN DENTZER: To help curb his often agitated behavior, Evan sees a special education counselor each day here at his public elementary school in Virginia Beach, Virginia. COUNSELOR: The reading rug? Did you have trouble on that yesterday? EVAN: Umm, no. SUSAN DENTZER: The counseling is only one of the special interventions Evan receives at school each day. At about 1 p.m. he also visits the school nurse, who gives him a so-called psycho-stimulant medication called Adderall, and another drug, Risperdal, which is used to treat thought disorders. NURSE: OK. Here we go, Evan. Here is your medicine. And the water's right here, ready for you.
	Stimulants help control behavior
	SUSAN DENTZER: The medications were prescribed by Evan's physician for treatment of attention deficit and hyperactivity disorder, or ADHD. Dr. Peter Jensen is a leading child psychiatrist at Columbia University. He says ADHD is a disorder characterized by high levels of inattention, hyperactivity, or both. DR. PETER JENSEN: The child may have difficulty waiting turns, or standing in line, may have difficulty staying seated for dinner. Some of these children, when it's very severe, can't really keep their mind or eye on the game when they're playing soccer or baseball. SUSAN DENTZER: Although the cause is poorly understood, the evidence suggests ADHD has biological roots, in part because it is often passed down through families. One theory is that it may stem from under-active brain activity in an area of that organ known as the pre-frontal cortex. That in turn may disrupt communications with other parts of the brain and undermine the sophisticated neural network that produces what we think of as "attention." For reasons that also aren't well understood, psycho-stimulant medications help -- drugs like Adderall, and the well-known Ritalin, which are similar to amphetamines. They help to rein in impulsive behavior and boost the attention network into higher gear. Evan Lassiter's mother, Denise, says her son's case is proof that the medication works. DENISE LASSITER, Evan Lassiter's mother: If he didn't take medicine, he would struggle every day, not only at school but with his self-esteem. He would not understand why he was always in trouble. So he takes medicine so that he has a better quality of life, and so that he can function from day to day.
	Drugs and behavior modification work together
	SUSAN DENTZER: The federal Centers for Disease Control, or CDC, says more than two million American children and adolescents have ADHD. Some estimates suggest that the number may be substantially higher. A growing number of both children and adults are actively undergoing treatment for the disorder, a fact that is driving an explosion in use of psycho-stimulants. That troubles even some health care providers who routinely prescribe these medications. One is Dr. Lawrence Diller, who practices behavioral pediatrics in California. DR. LAWRENCE DILLER, University of California, San Francisco: I prescribed 700 prescriptions of Ritalin or Dexedrine or Adderall this year, so it's not like I don't prescribe medication. But we use 85 percent of the world's Ritalin. Our Ritalin use rates have skyrocketed in the last nine or 10 years. The question we have to ask ourselves as a society, 'Is this a good thing?' And I do have my concerns. SUSAN DENTZER: Even more concerned are people like Maryland psychiatrist Dr. Peter Breggin, who opposes all use of medication to treat ADHD. DR. PETER BREGGIN, Psychiatrist: That we are doing this, I believe, is ethically and scientifically wrong. We're the only country in the world, along with Canada, that is doing this to such massive numbers of our children. It's a reflection not on our children, but on ourselves as parents and as teachers. SUSAN DENTZER: Breggin rejects the view that ADHD is a biological or behavioral disorder. His opinion is widely dismissed by many in the mental health profession, yet there is a growing debate over just how prevalent ADHD really is and once the syndrome is properly diagnosed, what are the best ways of treating it. Recently, the controversy grew further with the publication of results from the first federally funded study of ADHD treatment in children. The study involved nearly 600 children in the U.S. and Canada, all of whom were diagnosed with severe ADHD. Researchers tested four different approaches. One group got only carefully monitored psycho-stimulant medication. Another got so-called "psychosocial" treatment, including intensive training classes for parents and a special summer camp for the kids. Still another group of children got both medication and the psychosocial treatment. And a fourth was referred back to their own family physicians for "routine care." Jensen says all four groups of children improved, but the group that received both medication and behavioral treatment improved the most. DR. PETER JENSEN: If you were to talk just about the ADHD symptoms, you'd have to say that medicine really carried the day. For other areas, like social skills, or getting along with mom and dad, doing better in school, being liked by peers, having fewer anxiety and worries, those kinds of symptoms, the combined treatment -- adding that behavior component in -- seemed to make a difference. KATIE DILLON: I love that study. It was -- it was a very satisfying piece of research to see, to read, to give some credibility to what I felt all along. SUSAN DENTZER: Forty-four-year old Katie Dillon, also of Virginia Beach, has been diagnosed with ADHD, as have three of her four school-age children. She says the study's findings only reinforced what she had learned from direct experience, especially with her hyperactive 11-year-old son, Steven. He was diagnosed with ADHD and depression at age 6, and has been on Adderall and undergoing psychotherapy for several years. KATIE DILLON: Steven gets up in the morning, and you know he's up. He gets up, and he is running. He comes down the stairs, he's happy, he is singing, he makes a lot of noise. He climbs on the couches. He plays with the dogs. He rolls under the table. He is a lot of energy, and a lot of noise. SUSAN DENTZER: So he takes the medication in the morning. What happens? KATIE DILLON: And it's interesting to watch because he'll go, within 20 minutes of climbing on the back of the couch, to sitting down and eating his breakfast; the silly comments go away. He sits and reads the comics, and then he can get on with his day, get his backpack loaded, get his lunch taken care of, and go out the door.
	Disorder diagnoses increasing greatly
	SUSAN DENTZER: The study's findings about the effectiveness of medication square with the experience of the Dillons, yet some experts worry that people may derive only one erroneous lesson: that high doses of medication are the only effective treatments for ADHD. DR. LAWRENCE DILLER: I fear very much that the media, the general public and managed-care companies will see this as a major green light for a medication-only strategy for children. SUSAN DENTZER: At the same time, Diller and other experts also are concerned about growing disparities in ADHD diagnosis and treatment. They say the disorder can be over-diagnosed in some communities, while under-diagnosed in others. DR. LAWRENCE DILLER: So there are some communities -- rural communities, the African American community, the Asian American community -- where Ritalin use rates are much, much less, or some approaching zero, and you've got to wonder, what, they have no ADD there? SUSAN DENTZER: And at the other extreme are cities, or suburban areas, where as many as one in 10 or even one in five school-age children is on Ritalin. And in fact, among those high-use areas is Virginia Beach, home to Evan Lassiter, Katie Dillon and their families. Consider a study published last year in the American Journal of Public Health. It found that a high proportion of elementary school students in both Virginia Beach and the nearby city of Portsmouth were receiving medication at school for ADHD. Gretchen LeFever, a clinical psychologist at Eastern Virginia Medical School, was lead author of that study. GRETCHEN LeFEVER, Eastern Virginia Medical School: We found, in fact, that 8 percent to 10 percent of the elementary school students were receiving a dose of ADHD medication in school. And mind you, this is looking at 30,000 students. It was a very large sample. SUSAN DENTZER: That's more than two to three times the estimated rate of ADHD in the general U.S. population of children. In a follow-up study, LeFever found even higher rates in another area school district. There, 17 percent of the parents of elementary school children reported that their child had been diagnosed with ADHD. And LeFever says that in some private schools, medication use may be sharply higher still. It isn't clear just why the use of ADHD medication is so high in this part of southeastern Virginia. But LeFever says it may be a case where two forces overlap. One is the inclination of local pediatricians and mental health providers to diagnose ADHD. The second is parents' eagerness to ensure their children's top performance in school. The trend appears to be national in scope. GRETCHEN LeFEVER: The Drug Enforcement Administration, the DEA, reports now that every state in the country has at least one region that looks comparable to southeastern Virginia in terms of the per-capita methylphenidate, or Ritalin, distribution rates. When we have communities -- and I think there are a number of them -- where we have so many children being labeled with ADHD and treated pharmacologically for this disorder, we have a major public health issue. SUSAN DENTZER: More and more experts are inclined to agree with LeFever, and, like her, they are calling for more research. Above all, they think it's increasingly important to distinguish among children. There may be millions with mild performance or behavior problems that can and should be managed without medication. And on the other hand, there are children are like Evan Lassiter, with severe ADHD that carefully managed medication really helps.