Kids' Meds Overprescribed?
Drugs not the only treatment for ADHD, experts say
By Peter J. Wasson and Keith Uhlig
Originally published in the Marshfield News-Herald, November 11, 2001
John Pawelski has taken drugs for more than three-quarters of his life.
When he was 4 years old, Pawelski, 20, was found to have attention-deficit/hyperactivity disorder, and he began a drug and behavior therapy regimen that most likely will last the rest of his life.
There are scores of young people in central Wisconsin with similar experiences. Some medical professionals fear the disorder has become such a common, catch-all explanation for bad behavior that it is being diagnosed—and children are being drugged—unnecessarily. The number of U.S. residents taking Ritalin, Dexedrine and other amphetamines used to treat the disorder has increased fivefold in just the last 10 years by some estimates, although no one can name an exact number.
But parents like Pawelski's say Ritalin is a godsend that transforms problem children into model students with good grades and excellent behavior.
"I knew there was something different with my son, but I thought I was the worst parent in the world," said Jane Pawelski of Wausau. "It was a relief at the time, when he was diagnosed."
Defining the disease
The disorder, commonly called ADHD, is defined in medical texts as "a persistent pattern of inattention and/or hyperactivity-impulsivity that is more frequent and severe than is typically observed in individuals at a comparable level of development."
Even the definition presents problems, said Eric Heiligenstein, a psychologist and University of Wisconsin-Madison professor specializing in the disorder and its treatment. That's because all children are inattentive, hyperactive and impulsive. In a way, those are the defining characteristics of childhood.
With no clearly defined line between typical and severe b ehavior, diagnosing ADHD is purely a matter of a doctor's opinion, Heiligenstein said.
"There are extreme practice variations in how people are diagnosed," he said. "What one clinician will see as normal, another will see as ADHD."
It can be a murky process, and that's a problem, said Gary Adams, superintendent of the Marathon School District. Adams said physicians who prescribe medication for the disorder often are general practitioners who don't go into enough detail when making a diagnosis and then fail to follow up with the patient. There should be neurological indications of the disorder, and often it takes a specialist to see those indications.
"I think it needs to be approached more carefully," Adams said.
It's impossible to know precisely how many people are on ADHD medication.
About 2 percent, or 74, of the Wausau School District's elementary students have been found to have the disorder and take medication in school daily. The figure ranges from 3 percent to 5 percent in most districts, and it's almost 6 percent in the Marshfield School District.
Many more children take the drugs outside of school hours and are not counted by school officials.
Aaron Franck, a 15-year pharmacist at Southside Pharmacy in Wausau, said in the last five years manufacturers have begun marketing time-release capsules allowing most children to take one pill in the morning and none during school hours.
"I'm sure we probably go through 1,000 to 2,000 tablets a week of all different products, Ritalin, Dexedrine, the whole spectrum," Franck said of his small, neighborhood store.
According to the National Institute of Mental Health, ADHD is the most commonly diagnosed mental disorder among children, and that the number of children treated for the disorder has risen during the past decade.
Federal Drug Enforce-ment Administration De-puty Director Terry Wood-worth told Congress in May 2000 that his agency could not estimate overall numbers, but drug production indicates the number is soaring.
Between 1991 and 2001, the number of prescriptions for ADHD medication in the United States increased almost 500 percent, Woodworth said. And Ritalin production has gone from less than 2,000 kilograms in 1990 to almost 15,000 kilograms in 2000.
The problem is, there's no biological test for the disorder. It cannot be revealed through a blood test in the way other childhood maladies, such as mumps or mononucleosis, can.
"(The diagnosis) can be misused by people trying to explain behavior that can be explained better in other ways," Heiligenstein said. "You have people being diagnosed who are just having problems. We see it all the time."
Adams believes that doctors often jump to conclusions.
"It should be the alternative of last resort," he said. "But too often it's the first choice."
Jane Pawelski said drugs were her only choice when her son was found to have the disorder. John Pawelski was simply uncontrollable, constantly on the move, forever arguing, crying and creating havoc, she said.
With medication and therapy, he got through classes, graduated high school on time and now holds down a full-time job. But it hasn't been easy for him or his family as they struggle to understand his disorder and attempt to control it.
Treatment
While diagnoses of ADHD or its variations have skyrocketed, treatment of the illness has changed little. Those who suffer from the disorder most frequently are given prescriptions for the amphetamines Ritalin or Dexedrine.
It seems counterintuitive to give a hyperactive child a stimulant. But amphetamines work on the parts of the brain that help a person concentrate and focus.
"Stimulants, at the most basic level, are awakening agents that increase someone's vigilance," Heiligenstein said. "A good part of the therapeutic effect is they enhance cognitive oversight of thinking and action. What kicks you in the pants when you take a stimulant is that increased vigilance."
The National Institutes of Mental Health study found that drugs combined with therapy are by far the most effective treatment for attention-deficit hyperactivity, and Heiligenstein agreed. But many doctors simply prescribe the drug as a cure-all and leave the treatment at that, Heiligenstein said.
"If someone is making the diagnosis without looking at and treating all the variables that can explain it, it becomes a misused medical term," he said.
In many cases, a child who is disruptive in class, disobedient or has problems concentrating doesn't have the disorder, he said. The child is reacting to a home life of domestic abuse, alcoholism or other problems.
"You don't give the diagnosis just because a child has problems in school," he said. "The proof in the pudding in this diagnosis is a lifelong pattern of behavior. It leaves a paper trail. There is evidence throughout their lives of some degree of problem."
On the other hand, Heiligenstein believes some attention-deficit patients go their entire lives without having a doctor discover they have ADHD.
Experts agree that every case of the disorder is unique, and needs to be treated differently. But in general, they say the key to successful treatment of ADHD is to incorporate behavior modification with the use of medications.
In addition to taking medication, John Pawelski has been seeing therapists for years. The drugs help settle him and allow him to concentrate, but the behavior therapy also teaches him the social and behavioral skills he needs to cope with life.
Pawelski has a severe case of ADHD, and also has been diagnosed with learning disabilities and a form of autism, so his case is more complicated than most. His mother, a former nurse, says she thinks he will need to take drugs for the rest of his life.
"I tell him it's just like people with diabetes have to take medication, or people with asthma," she said.
Adams, the Marathon superintendent, said in most attention-deficit cases, the drugs need to be looked at as an interim measure, with a clear-cut end. Learning to deal with difficulties in concentration is crucial. Too often he sees students dropping their medication and then having the same problems they did when they started it.
The real world
Franck said Ritalin and other ADHD drugs cost about $1 a day, and most parents with whom he speaks consider it money well spent. For children younger than 18, insurance usually pays for the medication.
"Parents really use terms like 'night and day difference' when they describe the effects," Franck said. "Teachers can really tell a difference. The parents I've talked to, the medication seems to have some real positive effects."
Those teachers who report improvement are in the perfect situation to assess performance because school is the most challenging environment for an ADHD patient, Heiligenstein said.
In school, students are required to raise their hands before speaking, concentrate on study materials and respect the possessions of others—exactly the kinds of behavior that the disorder makes most difficult.
"It's often the first question I ask when a kid is in trouble: 'Have you taken your meds?'" said Al Ostrowski, school liaison officer for the Everest Metro Police Department. Ostrowski works with students in the D.C. Everest junior and senior high schools.
"When they're not on them, they're a lot more hyper, a lot more out of control. They let every little issue ruin their day. Maybe they'll let an issue turn into a fight, start saying whatever they want, using profanity, being loud and rude."
In contrast, ADHD students who take their medication "seem more relaxed. They go with the flow more. A little issue doesn't become a big issue and they seem to mainstream better, get along better in classes and hallways. They don't let a little pushing incident get out of hand."
Properly used, the drugs can work wonders. Still, some students who need the medication will refuse to take it on occasion, and that's when trouble starts.
"They say, 'They make me sick,' or 'I just don't like them,'" Ostrowski said. "They cause some upset stomachs and it makes them kind of lethargic. When a kid starts taking meds, I think you see improvement gradually, not the next day. But once they've been on it for a while and they miss it, the change is real sudden. They go downhill fast."
Pawelski doesn't like taking drugs to control his disorder, but he knows what happens when he doesn't.
"I couldn't focus on what I was doing," he said.
Without the drugs, Jane Pawelski doesn't think her son could have made it through school, and she doesn't know what would have happened to their family. Life was, and is, difficult enough for them when John is medicated. She shudders to think about it without the medications.
The dangers
For those children who have attention-deficit disorder, taking Ritalin or other drugs is a risk most parents are willing to take.
The danger in the increasing number of ADHD cases is that "normal" children found to have the disorder often are given highly addictive drugs with dangerous side effects.
Improper use of amphetamines can lead to heart problems, psychotic episodes, weight loss, increased blood pressure and hair loss. Abuse can cause tremors, hallucinations, delirium and death.
Of greater concern to Adams is the idea that children are being taught that a pill can solve all their problems.
He said he thinks drugs should be used like casts are used to fix broken bones. The cast is put on only until the bone heals. If it were left on, muscles around the bone atrophy and weaken. Mostly, Adams said, kids should use the medicines only until their behavioral problems are fixed.
Dealing with the problems underneath the behavior is the long-term fix, and is important in the maturing process, Adams said.
"We all have problems and challenges in our lives, and we grow as a result of dealing with them," he said.
