Two weeks ago in a HuffPost article, I wrote of the recent CDC report, which determined that now 9 percent of all children age 5 to 17 in America (about 5 million) have been noted by a health professional to "have" ADHD/ADD (attention deficit disorder with and without hyperactivity). I added, based upon data maintained by the U.N.'s International Narcotics Control Board, that the U.S., which constitutes 4 percent of the world's population, in 2009 produced 88 percent of the legally-prescribed amphetamines (drugs like Adderall, Concerta and Ritalin).
The article ignited another round of the "Ritalin-Adderall Wars," a public debate about ADHD/ADD and children's psychiatric drugs. The myriad comments, mostly anti-drug, were laced with hyperbole and polemic diatribes. In a second HuffPost piece, I called for restraint and reason in the discussion, if the serious questions about children's mental health and our society are to be addressed.
I tried to remain balanced in expressing my opinions in the first two articles. I said I've prescribed stimulant drugs to children for more than three decades (most often after attempting non-drug interventions like behavior modification and special education). Despite belief in the effectiveness and safety of these medicines, I remain worried about a medical system/society that is so dependent on this treatment. My belief that I maintain a sensible middle ground on ADHD and Adderall was reinforced by comments that attacked my position from both the pro and con sides of the war.
What follows are my opinions on the causes of the American ADHD/Adderall "epidemic." I believe epidemic a fair description for a drug that has multiplied in use ten-fold from 1996 to 2009, according to the Drug Enforcement Administration. I offer these ideas as opinions, not facts -- though many of the points are buttressed by academic research. A few are just common sense.
- Poverty, racism, adult violence and substance abuse are the main reasons for all children's mental health problems, including ADHD/ADD. A particularly revealing study showed that when a Native American tribe's income suddenly rose as a result of a nearby casino, all "acting out" children's problems (including ADHD) declined. However, Adderall treatment for ADHD/ADD is disproportionately directed to middle and upper middle class children.
- Since the 1980 publication of American Psychiatric Association's Diagnostic and Statistical Manual of Psychiatry, Edition III (DSM-III), more and more Americans have been willing to interpret children's under-performance and misbehavior as ADHD/ADD. As more and more people have accepted the idea of a "chemical imbalance" (never proven but only inferred by the response to drugs like Prozac and Adderall), the stigma of psychiatric diagnosis and use of psychiatric drugs in children has declined.
- While American organized psychiatry reintroduced the biology/genetics/chemical imbalance view of mental illness in 1980, the pharmaceutical industry grabbed this conceptual football and ran with it. Since the mid-1980s, the drug companies have been arguably the single biggest influence on America's thinking about children's mental health and illness -- by virtue of their financial clout to fund research and medical professional education (which in turn informs the education of other mental health and educational professionals), advertise first to physicians and then directly to parents, and offer free samples (vouchers, in this case, for amphetamine, a controlled substance).
- Larger class sizes and increased and earlier educational demands on children create stressors for the children, their teachers and parents. For example, more than 20 years ago kindergartners only had to sing the ABCs and play "ring around the rosie." Now, they are expected to read and do simple math before the start of first grade. The increased educational pressures to perform continue on toward getting into a good college and graduate school.
- The declining American standard of living for the middle class leads to both parents working, the need for preschool and more latch-key children. It's a long day for toddlers, school age children and their parents. Managing within the structured bureaucracies of preschool and after-school programs sets up behavioral demands that many children cannot meet. Parents are tired, too, when they finally get their kids at the end of the day.
- Insurance companies reimburse American psychiatrists significantly more when they see four patients in an hour for "med checks" rather than one 45-50 minute talking session with the child or his/her family.
- Therapy, when offered to ADHD/ADD children, is often individual play therapy, which is not effective for this problem. What works is family/parent oriented counseling for behavioral management strategies and support. It's harder to find a good family therapist than individual play-oriented therapists.
- Americans are mixed up about discipline and also worry more about their children than other cultures. A talking/cognitive approach to discipline is poorly suited to an impulsive or inattentive child. Worries about children's self-esteem undermine uncertain, tired parents' resolve about setting limits that may necessitate conflict or punishment.
- A 60-year cultural trend has made feelings more important in general. Pre-1970s parents simply didn't think about their kids as much. Parents worry about their children falling behind and feeling different and bad. Their concerns about their children drive them to professionals, who then offer medication. We are the only society that addresses sometimes minor differences in children's behavior or performance with drugs to such a degree.
There are items that are not on my list. I don't include sugar, processed foods, additives, TV, video games, Internet and cell phones. There is either no good research to support these factors or sometimes multiple studies that show no or very weak links at best (as with sugar). I know proponents of each factor will exaggerate its influence with at least one study that purports to "prove" a link. I anticipate many aggrieved disclaimers from readers (e.g., "My son stopped eating _______ and all his ADHD symptoms disappeared!").
I also believe there are no conspiracies to drug the children of America. Rather, a number of economic "invisible hands" work together to make children and families less able to cope and Adderall an attractive, efficient solution.
I welcome readers' comments. I am not denying the existence of ADHD/ADD or the value of Adderall for the particular child or adult using it. I am not presuming I "know" for certain why we are the "United States of Adderall." But I worry less about our children's chemical imbalances than their living imbalances, which may contribute to the ADHD/Adderall epidemic.
CORRECTION: A previous version of this post stated that Adderall use multiplied 10,000 times from 1996 to 2009. Adderall use multiplied ten-fold from 1996 to 2009, according to the Drug Enforcement Administration.
Such as the non-functioning family, as apposed to the functioning family. The family that lives and loves together and apposed to the substance abuse, verbal abuse, physical abuse non-functioning family.
The childrens' balanced life in the home, in the play areas, in the learning arenas of gladiator competition. The slaughter to get to higher education from the educational factories.
ADHD kids can’t be expected to attend and be as quiet as other children without accommodations. It’s a huge mistake to label these problems as lazy, irresponsible, or ‘you’re a trouble maker.’ When ADHD symptoms are treated as simply a lack of effort, there will be an increased risk of anxiety and depression disorders.
Accommodations need to be made. Schools need to supervise filling out an ADHD child’s planner every day. (Expect resistance to do this supervision.)
Treatment needs to be behavior based along with attention to repairing self-esteem. ADHD children need to know their failures are not just because they are lazy. Special structure at home and school is needed for ADHD children to feel adequately successful. When parents ask for the trash to bed taken out, they need to say it once and watch their child do it - now. No back talk or lecturing from parents, just action.
Certainly this disorder is extremely complex. Keep up you illuminating efforts to help these children and their parents. Gary M Unruh MSW, Author
I don't know much about the practice of obstetrics now, but in the past the use of pitocin for convenience was common. The massive amount routinely given to women then I'm told would not be preferred now. The reason I bring this up is neuro-psych evaluation told parents that there was a correlation between ADD features and length of labor or "birth time". In other words, extremely fast labor OR extraordinarily long labor increased pressure on the brain causing what used to be called MBD, minimal brain damage. I am convinced this may have caused many of those babies to later be catagorized with ADD. That would be one segment of the "ADHD population". If they are still using pitocin, I hope they have better knowledge in how to control/use it.
Then we have the obviously genetic group. One of the parents often demonstrates ADHD features.
We must remember that any group of patients demonstrating similar symptoms, in reality are often being caused by different things in different patients. As one neurologist said, "There is only one brain and spinal cord. Damage/dysfunction to the same areas in different patients will cause the same symptoms." They're just not due to the same reason in different patients. People think that.
With today's class sizes and the problems students bring into school from the outside, teachers are overwhelmed. Before, they only had to teach. Now they have to teach and "meet every child's need" (in educationese language), no matter what it is. Too, school personnel are afraid of being sued, so they will bring up every possibility for the cause of the behavior to have it documented that it was discussed with the parents to cover them legally.
You're right that we don't have appropriate expectations of children anymore, but that is often due to the pressure on teachers to teach as much as possible as quickly as possible for state testing. Unfortunately, the intense pressure from parents and administrators and politicians and the public in general led to many wrong diagnoses and excessive talk about "what's wrong with the kid" when the kid is just being a kid.
But really, aren't the doctors responsible for this? Isn't inappropriate treatment what they're so expensively trained to prevent?
It's very hard for me to see doctors as victims of circumstance. So many posture as mental giants. I find it incredible that they're hoodwinked by pharma marketing, or overly pressured by the requirements of health insurers. Is overmedicating patients their way of punishing society?
There's a self-serving cynicism about throwing psychiatric drug prescriptions at patients that I'm afraid emanates from psychiatry and infects the rest of medicine. As a patient, until recently I've thought doctors took their oaths to "do no harm" seriously. Now I know they don't, yet they bemoan the decrease in status they've suffered. A conscientious doctor is extraordinarily hard to find.
It's terrible that so many children and teens are getting powerful hormonally disruptive psychiatric drugs while their minds and bodies are still maturing. What will happen to the Med Generation when they reach adulthood? I would hate to be a doctor confronted by them in 10 years or so, when the adverse effects of premature medication -- such as long-term sexual dysfunction -- come home to roost.
Why isn't your profession paying attention to this?
Wonder how many kids would have tested ADHD during the Great Depression?
But the bottom line is that it is a failure of the executive functions of the brain, making it difficult to focus, prioritize and recall correctly.
My guess is that 90% of the kids in your proposed group, given the proper learning environment, would do just fine. The remainder would have difficulties not because of their environment, but because of the way their brains were formed.
I'm glad you try to be level headed, but I have two big issues with your thinking.
First, children with ADHD or ADD are not mentally ill. I don't care what the diagnostic manual of mental health says. It wasn't long ago that homosexuals were also thought mentally ill.
Second, all of your ideas about what may cause these afflictions are based on societal or family reasons. Why aren't you looking for environmental and hereditary causes that affect neurobiology? How do you know it's not a genetic disorder? Or that we're seeing a lot of ADHD and ADD because of some kind of common chemical that children are exposed to in utero? Like preservatives, for example?
Also, there's no good reason to believe that ADHD and ADD children have parents who don't know how to discipline. No amount of discipline, punishment or consequences will ever cure a child with one of these afflictions, although punitive tactics, labeling and name-calling (lazy, not trying, just bad, needs to apply himself, wild, unruly, stupid, slow, special, developmentally delayed) and ignorant, sighing, scolding adults may well lead them into anger, frustration and acting out.
If there's a class difference in how these afflictions play out, the differences in parental and medical treatment should be obvious. Look at parental literacy -- slapping a kid will not cure him. Look at access to health care that may help mediate some of the associated problems of ADD and ADHD.
There are many, many times, when "it doesn't matter" and the parent can choose to choose the battles. Does a messy room really matter? No. Set thoughtful boundaries and let the kid roam around all he wants within them. My rules always concerned safety, self-respect, and respect for others and their possessions. That's it. No other rules. And remember that the root meaning of the word discipline" is "to teach," not to punish or vent anger.
The school is another matter, and that's when meds may have to come into play. Too many teachers are ignorant and unwilling to do simple things like seat the child near the front of the room, give him eye contact, and grade him on his verbal explanations rather than written work -- many of these children are dysgraphic. They have to think about how to shape the letters. So they have to carry out two cognitive tasks at once: shape letters and develop a thought. It doesn't work.
A Few Impertinent Questions about Autism, Freudianism and Materialism
http://30145.myauthorsite.com/
An addition to this should be the diagnosis of highly sensitive and creative children, who may be acting out and/or appear to have ADHD, but really just have sensory overload. A small percentage of these children are so sensitive that they are outright psychic and this creates its own challenges due to the stigma surrounding this personality characteristic.
Kids like this have to learn how to organize themselves b/c they sink into the quicksand fast and find it hard to recover.
I would say a low dose of effective medicine is not too steep a price to pay if it helps your child be a functioning, successful, and happy human being! My husband and I regret not getting this diagnosis earlier--we resisted it for all the reasons stated and implied in these comments.
I have a blog where I deal with the issues of psychic people and sometimes children come up. Children who are fully psychic have different issues than most people. They are acutely aware of the emotions of all the people around them, particularly their parents. They will suffer greatly if their emotions and psychic ability are suppressed and they have to learn that most people are completely unaware of how they are really feeling.
In addition, they can be affected by emotions of people who they are close to whether they are present or not. Creating boundaries is a necessary task, as is learning to shut up about what they observe without repressing themselves.
They are easily overstimulated and can become hyper, plus they can lose their attention easily to daydreaming if they are under stress, which they almost always are.
Unfortunately, many parents think just giving a pill will take care of everything and they don't make the changes necessary to help their child. I've had parents complain that their child "forgets" to take his pill and refuses to listen when we tell them that is their responsibility to give him the pill. Usually we just ask if we can give it at school because the parents "forget" so often the poor child's body can't cope with the instability of getting the medication, or not getting it, day after day. Most parents are happy to have us take that over for them. The ones who refuse are usually the ones taking the kid's medication for themselves. That's a whole other problem for the child and for us.