Originally created 05/14/00

Debate continues over ADHD diagnosis



During the next five years, a federal agency will spend $6 million on a nationwide study on whether Ritalin is safe and effective in treating preschool-age children with attention-deficit hyperactivity disorder.

The disorder is not a new problem - it was first diagnosed in 1991 - but recent reports show a substantial increase in behavioral drugs prescribed to young pupils.

On May 1, The American Academy of Pediatrics, the nation's largest group of pediatricians, released new recommendations for assessing children age 6 through 12 with ADHD.

Research from the pediatric group indicates that 4 to 12 percent of all school-age children - or 3.8 million children - may have ADHD.

The group says the disorder is either becoming more common or children are being misdiagnosed.

"We believe that parents, teachers, the child and pediatrician form a team, and together they should come to the decision about whether this is the right diagnosis," said Dr. Heidi Feldman, associate professor of pediatrics at the University of Pittsburgh.

Dr. Feldman, who also is a pediatrician at Children's Hospital of Pittsburgh, served on the committee that drafted the recommendations.

The group's new guidelines say a child must exhibit symptoms in at least two settings, such as home and school, and the symptoms must hurt the child's academic or social functioning for at least six months.

"Attention-deficit hyperactivity disorder is often accompanied by other problems," Dr. Feldman said. "They include learning disorders and depression and anxiety, destructive behavior. ... We're encouraging physicians to look at the total picture, not to stop once they've established a child does or does not have attention-deficit disorder, but to go forth and describe the whole profile. This will be important in the treatment and outcome."

Before the pediatrician's report, the National Institute of Mental Health said it would spend $6 million during the next five years researching the use of Ritalin among preschoolers. The group wants to know if the drugs are being over prescribed.

Rayford Kytle, a press officer for the mental health agency, said information regarding the study has to be kept confidential until grant money for the survey is awarded, but Clarissa Wittenberg, communication director, told The Associated Press that children at selected sites around the nation will be observed.

Parents who put their children on the drugs say the problems usually stem from behaviors exhibited in the classroom.

School officials, however, are adamant about not playing a role in whether a pupil is prescribed the behavioral drugs.

ONE PARENT, MRS. BROWN, who requested her real name not be used to protect the privacy of her daughters, said she wasn't pressured to put her daughters on drugs. Still, officials at her daughters' Richmond County elementary school had a list of doctors and clinics available from which to choose. The doctors on the list were ones her daughters' Student Support Team - made up of social workers, teachers and counselors - had worked with.

Mrs. Brown'sgirls went on dexedrine, a drug similar to Ritalin, after one of the doctors, Adair Blackwood, recommended it. She said one daughter could not stay focused and, though not hyperactive, had a limited attention span that caused her to receive failing grades.

The girl's sister received high grades, but Mrs. Brown said she would often exhibit explosive behavior in the form of tantrums.

"If she couldn't get a test done in two minutes, she would start crying uncontrollably and once had to be removed from class," Mrs. Brown said of her younger daughter. "We kept telling her she didn't have to get the test done in two minutes."

Still, she was hesitant when Dr. Blackwood recommended the drug, which she says is working. Dr. Blackwood did not return four telephone messages left at his office.

"I was concerned," Mrs. Brown said, adding that school officials did not believe her children had ADHD. "I didn't want them to be drugged to the point where their personalities, or who they were, were covered up. We're keeping them at fairly low dosages because I think all children have some attention deficit. It's a nice day, and their mind wanders, and they want to be outside playing. It's our hope that both of them will be able to come off the medication."

CAROL ROUNTREE, director of guidance and testing for Richmond County schools, was firm about schools not playing a role in the reasons parents take their children to see doctors who place them on the medication.

Mrs. Rountree suggests parents hear about the medications from other parents and the media.

"None of us can diagnose anything like that," Mrs. Rountree said. "A teacher would be very reckless in saying a child has attention-deficit disorder. We're not licensed practitioners who can go out and put a label on a child's behavior. We might say that he has a short attention span or he blurts out in class or has erratic behavior."

When questioned about whether using buzz words such as "short attention span" and "erratic behavior" - which are among the symptoms of ADHD - implies that a parent should seek professional help for the child, Mrs. Rountree said no.

"That's not suggesting that he has attention-deficit disorder," she said. "I am just addressing the fact that if I give him an assignment, that he's off task five minutes after he gets the assignment.

"We don't skirt around the issue to say things to parents to push them into the doctor's office," Mrs. Rountree said. "If anyone is making a statement like that, they are ill-advised."

Richmond County Superintendent Charles Larke said that, in 1996, his first year as superintendent, a parent complained about a teacher suggesting that her child be placed on Ritalin.

"I've told teachers they can't tell parents that students need to be on Ritalin or any other drug. It's a medical decision between the parent and physician, and we're not to comment on that," Dr. Larke said.

Still, Dr. Larke says administrators can suggest that parents seek professional help for their children.

"If they think a child needs to see a psychologist, that's fine," Dr. Larke said. "I don't have a problem with them asking a parent to consider having a child tested. What would be sad is if you felt a child had ADHD and he was not being properly treated for the symptom."

School officials in Columbia County said they watch pupils' behavior but do not make decisions about diagnosis.

"Initially what the teacher would want to do is talk with the parent and discuss the concerns to see what the parent's thoughts might be," said Kay Blanchard, director of testing and psychological service for Columbia County schools.

"We also have counselors in every school, which is another avenue of support for the child. Now if a child's behavior or their academic difficulty is significantly interfering with their learning, that's when the student support process would begin."

She said student support teams focus only on the child's behavior and how it affects the pupil's education.

"We're really not medical experts," Ms. Blanchard said. "We're educational people, and that's where we should keep our focus."

Dr. Feldman said both parents and school officials suspect each other as the reason children are placed on the drugs, but she said teachers are good observers and have no vested interest in seeing a child go on drugs.

Dr. Feldman said the new guidelines hopefully would help prevent physicians from making rash decisions about prescribing drugs.

"I think the lay public is sometimes worried that parents will have a struggle with their child on Tuesday and come to the doctor on Wednesday and say, `There's something wrong with my child; I think it's ADHD,' and the doctor will concur," she said. "This (criterion) is to say, we think this has got to be a pattern of behavior over a long period of time."

Mrs. Brown, whose daughters are on dexedrine, says she, too, believes a child's behavior should be cautiously watched for dramatic changes.

"Even in my situation, knowing my girls and knowing that they truly needed the medication, I still think a third-grade level or end of the second grade is really the time frame if a child is to be placed on the drugs," she said. "I think 6 and younger is too early because you don't know truly if this is kids being kids."

Reach Faith Johnson at (706) 823-3765 or faithj@augustachronicle.com.