2002 August 09
English 135 Ms. Kilbridge
From the 1980's on, there have been a rising number of increasingly younger children diagnosed with Attention Deficit Disorder/Attention Deficit Hyperactivity Disorder (ADHD). The standard treatment is the prescription of certain strong stimulants, such as Ritalin and Dexedrine, to allow the children to calm and focus themselves. With this information, we have to ask a few questions. Why are so many young children being given these dangerous drugs? Where did these huge numbers of ADHD children come from? What are the side effects of the medication, and how do the benefits outweigh the dangers? ADHD is being misdiagnosed in young children, and, if correctly diagnosed, overmedicated.
Everyone has known the child, or even youth, who will not sit still, will not behave, and acts erratically. A little bit of hyperactive behavior can be put down to circumstance, to high energy levels, to simple childhood; however, there are some children who always act as if they have been worked up to a high emotional pitch, loaded with sugar and caffeine, and released to do their worst. Doctors have known of ADHD for over one hundred years (Millichap 4). It has been described, variously, as "organic drivenness", "hyperkinetic syndrome", "brain-injured", "minimal brain dysfunction", among other aliases, the list totaling nearly forty (Millichap 4-5). When the widely-used Diagnostic and Statistical Manual of the American Psychiatric Association was first released in 1968, some of these early terms were included (Millichap 6). The term 'attention deficit disorder' was applied in the DSM-III in 1980, and, as of 1994, was classified into three types of Attention Deficit Hyperactivity Disorder: Inattentive, Hyperactive-Impulsive, and Combined (Millichap 6).
According to the DSM-IV as quoted by Millichap, six of each set of nine symptoms must be observable for at least six months in order for a child to be diagnosed with either single form of ADHD, and six of each set must be present for the Combined form (7). For inattentive ADHD, the symptoms are: "makes careless mistakes; can't maintain attention; doesn't listen when spoken to; fails to finish tasks; seems disorganized; avoids tasks; loses things; easily distracted; forgetful"; for the hyperactive-impulsive ADHD, the symptoms are: "Fidgety; leaves seat in classroom or at dinner table; runs or climbs excessively; can't play quietly; always 'on the go'; talks a lot; blurts out answers to questions; can't wait in line or take turn; often interrupts" (Millichap 7). But wait: aren't all of these normal behaviors for children? In moderation, yes they are. Everyone makes mistakes, gets distracted, doesn't listen, and leaves one game to go to another. However, in ADHD children, these activities are not isolated incidents, but are everyday occurrences, part of a pattern.
It is vital that the diagnosis of ADHD be based on careful observation of the symptoms, as other potential causes for the behaviour are ruled out. Unfortunately, a teacher's automatic reaction on seeing a fidgety, hyperactive child is to question if the child has ADHD. Not all doctors are careful enough in screening out other possibilities if teachers and parents are pushing for a quick, easy diagnosis, with a simple solution. However, there is no such test. "The Drug Enforcement Adminstration stated in 1996 that no 'specific neurological lesion or defect' has been found" relating to ADHD (Stein 8).
ADHD may first show up when the child is placed in a highly structured environment: behavior that may be only slightly exceptional at home can spiral out of control at school (Millichap 11). Some people say that eating too much sugar, bad parenting, and a host of other easily correctable sources, are the cause of ADHD. It is true that when these problems exist and are corrected, behavior that answers to the description of ADHD will go away. However, for some people, even the most careful diet and well-ordered supervision and guidance will not solve the problems of distractibility and constant motion. In these cases, ADHD is treated with any one of a list of drugs.
The most notorious ADHD-treating drug on the market is Ritalin. Other drugs used to treat ADHD include Dexedrine, Benzedrine, and Adderall (Stein 3). Ritalin is classified as a "Schedule II drug", a highly addictive drug that must be kept under constant government monitoring (Stein 3). The drug is a stimulant, but calms down people with ADHD. Other Schedule II drugs include morphine, opium, cocaine, and amphetamines (Stein 3). Is it really wise to be giving children drugs that have been put under close control for their potential to "trigger an addiction process that, once started, probably cannot be readily reversed" (Stein 3) before the age of seven? Only as a last resort.
It is hypothesized that Ritalin works to calm down hyperactive children by especially exciting the "inhibitory center of the brain" (Stein 6), that part of the mind responsible for controlling impulses, settling down the body, and doing most of the things that hyperactive children have extreme difficulty with. However, everyone given Ritalin will experience increased alertness and enhanced focus (Stein 6). In fact, some high school and college students will buy black-market Ritalin to use as a study aid; an enterprising high-function ADHD teen can supplement her allowance by selling her medication to classmates (Lerner). Giving Schedule II drugs to people who do not truly need it and can function well without it, making it easy to have the doctor renew a prescription once it has been initially prescribed, is a bad idea, if easy drug abuse is considered bad.
Side effects of amphetamines such as Ritalin include "insomnia, nervousness, irritable stomach, hypertension, … feelings of paranoia" (Stein 6). Are the side effects of the cure worse than the disease? It is vitally important that children who are given Ritalin are carefully screened to make sure that Ritalin is a truly necessary drug for them, to avoid casual use, which can easily lead to abuse. One doctor had parents insist on medication for three and four year olds despite his recommendations to the contrary (Perlman 1). While the children likely did have attention problems, "there were problems in the homes as well", and he "recommended that they first try behavior modification and parent training"; however, the pressure from the parents was so great that the doctor finally did prescribe Ritalin (Perlman 1). "…Ritalin carries a warning against its use in children younger than six" (Vatz 1), which is ignored by those parents wishing their fidgety kindergartener to sit still and mind Teacher. "It is hard to determine whether it is more shocking that, without testing, youngsters are given such serious drugs in early years of neurological development or that such testing on children is beginning" (Vatz 3). Ritalin is a relatively new drug, and, as such, has not been subjected to a great number of long-term studies of its effects. However, Stein’s investigation of the studies that do exist suggest that it does interfere with normal growth (28), and has been also associated with problems in the immune system (29).
ADHD should be the last-ditch classification, not knee-jerk answer. There are many other factors in childhood hyperactivity and inattentiveness besides a possible brain chemical imbalance or disease. In the experience of the North Shore Child and Family Guidance Center, more than 50% of the children suspected by parents and teachers to have attention deficit problems turn out to have no such thing (Perlman 1). Large class sizes lead to a greater number of squirming children. At a threshold number of twenty-five to thirty in grade-school children, with fewer children as the age decreases, a class of even normal, well-behaved children will be beyond the power of one teacher to keep under control. Diagnosed levels of ADHD may very likely be reduced if class sizes are kept at twenty students or fewer. The age of the children is another factor. Expecting a five-year-old to sit quietly with any project for more than twenty minutes is silly. Children get distracted by interesting things as part of their developmental process. Expecting uniformly excellent behavior in a classroom situation that is new to a child's experience, with new and interesting objects, and a large number of other children present, is somewhere on the same order of futility as attempting to collar, leash, and walk a cat who has never been trained to do so. Constant and consistent parental and teacher reinforcement of good behavior is necessary to keep children learning acceptable and unacceptable behavior; unfortunately, in today's high-paced society, the television and daycare can become more influential upon a child's behavior than a parent can.
Gender also plays an important role in activity level. Young boys are less inclined to sit still than young girls, and are encouraged to play more physically active games. It follows that boys are more likely to have difficulty sitting still if they are not accustomed to doing this, whereas girls are more likely to be encouraged to be ‘ladylike’ and play quietly. Ideally, the diagnosing doctor pays attention to the age and gender of the child when diagnosing, and only the two percent containing the most overactive, inattentive children are ultimately diagnosed with ADHD (Fiorello).
There are also solid medical reasons for not being hasty in a diagnosis of ADHD. When another medical condition mimics the overactivity and inattentiveness that are the two keystone symptoms that laymen notice in ADHD, and ADHD is misdiagnosed and perhaps a stimulant is prescribed, not only is the actual medical condition left unaddressed, but it may perhaps be exacerbated by the medication. Poor eyesight is a classic reason for failure to follow anything that the teacher writes on the chalkboard; poor hearing often results in a child not listening. Other conditions that can be commonly mistaken for ADHD are “depression, anxiety, medication side effects, abuse, lead poisoning, … and more” (Fiorello). When a study by Copeland et al. in 1987 showed, as cited by Fiorello, that “many pediatricians diagnose ADHD based on a short office visit and good response to a trial of Ritalin,” this bodes ill for children who have other problems who have the misfortune to act up in ways typical of ADHD. Furthermore, stimulants make conditions such as tics or anxiety worse, two more problems that are often mistaken for ADHD (Fiorello).
After a proper diagnosis process, and ADHD is the outcome, what then? In light of the problems with drugs, other solutions should be tried first. David Stein, the author of Ritalin is Not the Answer, has a program of positive reinforcement and patience for the control of hyperactive and inattentive behaviors. In his experience, 80% of children who were able to learn proper behavior at home through his methods were experiencing drastic improvement in school (Stein 38). For some people with ADHD, however, the only thing that has worked, after trying a variety of methods, has been medication, and for them, that is the only possible solution to their particular case (Greenburg).
While ADHD does exist, proper diagnosis of it is necessary, due to the number of more identifiable conditions that can be misidentified as ADHD by a careless doctor. Although ADHD is a very valid problem and can be combatted with drugs, the dangerous nature of the drugs involved makes it necessary that after ADHD is properly diagnosed, other solutions than drugs should be attempted first to make an attempt at a permanent solution to the problem.
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Greenburg, Jeri. Personal conversation. October 2002.
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Lerner, Alison. Personal conversation. Circa 1997.
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Vatz, Richard E., and Lee S. Weinberg. “Problems in Diagnosing and Treating ADD/ADHD.” USA Today Magazine March 2001: 64-65. Online. SIRS Knowledge Source. Internet. September 9, 2002