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At age 4, Jeremiah Ryans routinely refused to wait in line at the water fountain at his summer day camp. Sometimes he'd get so cranky he would hit his classmates. But an alarm bell went off when he grabbed a pair of children's scissors and cut his teacher's hair.
Just a kid being a kid -- or extreme behavior that may need medical help? The answer isn't clear-cut, and it's different for every family.
"He was on the verge of being expelled from day care," remembers his mother, Mimi, of Columbia, Md., who, with her husband, Richard, adopted Jeremiah when he was 16 months old.
As the father of a teenager from a previous marriage, Richard did not consider Jeremiah's behavior typical. So he and Mimi took Jeremiah to a therapist, who diagnosed separation anxiety. The Ryanses were unconvinced.
Then, after the scissors incident, they opted for a complete physical examination for Jeremiah. A pediatric and neurological specialist independently confirmed that it was attention deficit hyperactivity disorder (ADHD). Mimi's reaction? Fear of putting her child on drugs. "I didn't want Jeremiah to be one of those kids who was misdiagnosed and overmedicated."
Mimi's concerns about ADHD drugs are well-founded. Parents, physicians, and educators are questioning the rising numbers of kids under 18 now on ADHD medication. According to a recent report in the journal Psychiatric Services, ADHD-related doctors' office visits by children ages 3 to 18 more than doubled, from 3.2 million to 7.4 million, between 1993 and 2003. The number of visits that included a prescription for an ADHD medication also more than doubled, from 2.7 million to 6.6 million.
Drug Warnings
And experts are currently debating whether these same medications, which are used widely in children, should carry a warning label about the risk of heart attackheart attack or even suicide. Other experts argue that these frightening side effects are extremely rare and that the drugs' benefits outweigh the risks.
The jury remains out. In February 2006 an FDA advisory committee recommended that stimulants prescribed for ADHD carry a "black box" label -- the FDA's strongest warning -- informing consumers about the risk of heart attack, sudden death, and strokestroke. The committee reviewed 25 cases of sudden death, 19 of them in children who were 18 and younger, associated with ADHD drugs. Because some of these people had previously had underlying heart diseaseheart disease, the reviewers did not think the data were definitive in proving cause and effect.
The recommendation for the black-box warning created controversy, with some FDA consultants maintaining that the label was especially important for adults (increasingly being prescribed ADHD medications), who might have high blood pressurehigh blood pressure. Many calling for the warning label concede that the drugs have important benefits but say that increasing the awareness of the potential risks is crucial.
"The real question is whether there is any risk for children without heart problems," says Andrew Adesman, MD, chief of developmental and behavioral pediatrics at the Schneider Children's Hospital, Lake Success, N.Y.
As for the possible link to suicides, the ADHD drug Strattera is under special scrutiny. In late 2005, the FDA issued a public health advisory after reports of suicidal thoughts in five kids and a suicide attempt by one child in a clinical trial involving 2,200 participants. The advisory cautioned doctors and parents to watch for any behavior changes in children who were on the drug.
Parents such as the Ryanses worry about misdiagnoses and overprescribing, and experts concede that both can happen. But, Adesman says, overprescribing and misdiagnosis are more likely to happen if the evaluation is not thorough and is not done by a health care professional experienced in diagnosing and treating the condition.
What Is ADHD?
Kids diagnosed with ADHD -- which was once known as attention deficit disorder (ADD), or hyperactivity -- have trouble focusing on tasks, sitting still, and paying attention. While most parents have occasionally wished that their child would calm down and focus, ADHD behavior is more frequent and extreme. The condition is diagnosed three times more often in boys than girls.
ADHD is now the most common neurobehavioral disorder of childhood, according to the American Academy of Pediatrics. "That doesn't mean [every child] needs treatment," says Martin T. Stein, MD, professor of pediatrics at University of California-San Diego. But, he adds, "It is very treatable."
Making the Diagnosis
ADHD tends to run in families, says Stein, who co-chaired the American Academy of Pediatrics committee that developed guidelines for diagnosing and treating ADHD. "It refers to three behaviors that cause impairment: hyperactivity, impulsiveness, and inattention."
According to Stein, the health care professional who is evaluating the child should do a thorough medical exam, being careful to rule out other problems that might explain the behavior, such as hearing or vision problems. Then he or she must take a history of symptoms from an established list from the Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric Association. (See also the "Signs of ADHD," below.)
After his testing, Jeremiah was diagnosed with the type of ADHD marked by hyperactivity and impulsiveness. And his symptomatic behaviors -- impatience and hitting other children -- are typical, says Adesman. "Cutting the [teacher's] hair is more extreme," he says of Jeremiah's experience, "although it is not uncommon for the child to cut his own hair."
Drug Treatment
Jeremiah's doctor recommended a combination of behavior modification therapy and medication, a typical approach to treating ADHD.
Psychostimulants - or simply stimulants, such as Ritalin, Adderall, and Concerta -- are most commonly prescribed. Experts believe they work by helping the network of nerve cells in the brain communicate better with each other and increase chemicals that "arouse" the parts of the brain that help people pay attention and control impulses. The drugs don't cure the condition but rather help control the symptoms that are causing problems.
More than 200 scientific studies have found the medications effective, although the stimulants can cause reduced appetite, sleeping difficulties, and tics, such as excessive blinking or facial grimacing.
The FDA recently approved Strattera, a nonstimulant drug that affects the brain chemical norepinephrine and helps improve ADHD symptoms -- but without the stimulant side effects. Strattera can cause abdominal pain, headache, reduced appetite, dry mouth, and insomniainsomnia. This drug, along with the stimulants already mentioned, is FDA-approved for children, Stein says.
Antidepressants are also sometimes prescribed because they can help decrease impulsivity, hyperactivity, and aggression. Even though these drugs are not specifically approved for ADHD, doctors sometimes prescribe them "off label."
More than 70% of children do well on the stimulants or Strattera, says Stein. And of the 30% who don't -- those whose symptoms do not improve or who have side effects such as nervousness or insomnia -- half of those will do well on other medications such as antidepressants.
Behavior Modification
Behavior therapy conducted by psychologists, psychiatrists, or social workers is typically the other mainstay treatment. This approach is based on the principle of rewarding positive behaviors. Parents and teachers work on a "target" behavior and then move on to the next one. For instance, a teacher might tell a child, "If you can stay in your seat all morning, you will get a star. Three stars and you get a privilege." Next, they might work on getting the child to turn in homework promptly, Stein says.
Behavior modification also involves using punishment correctly, says Ann Abramowitz, PhD, chair of the advisory board for CHADD (Children and Adults with Attention Deficit Disorders) and a psychologist at Emory University, Atlanta. That means taking away a privilege or using time-outs when behavior is unacceptable. Can behavior modification alone work? "It's feasible [to manage] kids without medication," she says, but it requires a consistent approach from everyone involved.
In a landmark study, the Multimodal Treatment Study of Children with ADHD, research shows that both medication alone and medication coupled with behavior therapy were effective in curbing ADHD behaviors. However, children who were given drugs and behavior therapy were able to take lower doses of medication.
According to the National Institute of Mental Health analysis of the study, some children did very well with behavior therapy alone. "Therefore," the analysis concludes, "medication alone is not necessarily the best treatment for every child, and families need to pursue other treatments, either alone or in combination with medication." (This study was done before Strattera was approved and therefore did not include that medication.)
Behavior therapy alone requires patience and a commitment to see it through. "Everyone has to do it the same," says Michelle Blanton of Durango, Colo., referring to the use of the strategies to reward good behavior and effectively punish unacceptable behavior. Blanton's son Tyler, now 9 and in third grade, was diagnosed with ADHD in first grade, and had typically used medication and behavior therapy during the school year, going off his medications during the summer. Tyler did so well this summer, she says, that he had no privileges taken away at his day camp. She's hoping to continue to control his behavior naturally. "His doctor thinks he might be ready to do behavior modification " for the next school year, she says.
Jeremiah's Progress
The Ryanses decided that medication was the best course, and Jeremiah's doctor recommended Strattera. "Jeremiah was put on medication on a Wednesday," Mimi recalls. "On Friday we got a note from the teacher asking for a conference. She wanted to know what we were doing at home, because she saw such a great change."
Jeremiah, now 5, is doing well, his parents report, although it took effort on everyone's part to achieve this success. "Jeremiah is much more patient and able to maintain his composure," says his mother.
Easier to accept than the medication regimen, at least for Mimi, was the behavior modification, which Jeremiah continues to learn during his frequent visits to a social worker. Also, every six weeks, they visit a psychiatrist to assess how well the medication is working.
Mimi recalls how it was before the treatment -- and after. "When you have a child with ADHD, his peers really don't like him," she says. But since Jeremiah has followed the medication and behavior modification plan, he has "settled down."
Success has come in stages, and every day isn't perfect. "Yes, he's a typical little boy, running, jumping, and losing control, but the aggression has almost come to a complete halt." Occasionally he misses his medication -- usually because he falls asleep and Mimi doesn't wake him up to give it to him -- and the effect is noticeable. "He's all over the place" when this happens, she says.
But the rites and joys of childhood that other families take for granted are now within Jeremiah's reach. For instance? "He's gotten invited to a couple of birthday parties this year," his mother says, and "he's had a great time."
Questions to Ask Your Doctor
Signs of ADHD
Symptoms of ADHD typically occur in early childhood. Health professionals look for specific symptoms and categorize them by type of ADHD. Before a diagnosis can be made, children must exhibit multiple symptoms within a category for six months or more before age 7.
ADHD of the Inattentive Type
ADHD of the Hyperactive-Impulsive Type
ADHD of the Combined Type
SOURCES: Andrew Adesman, MD, developmental pediatrician, Lake Success, N.Y. Mimi Ryans, Columbia, Md. Martin T. Stein, MD, professor of pediatrics, University of California San Diego; Bryan Goodman, spokesman for CHADD. Ann Abramowitz, PHD, chair of the national professional advisory board for CHADD; psychologist, Emory University, Atlanta. Michelle Blanton, Durango, Colo. FDA. CDC. New England Journal of Medicine. April 6, 2006. Archives of General Psychiatry, December 1999.
Published August 2006.