CQR Treating ADHD - mentalhealthexcellence.org · certa, Adderall and other stim-ulant drugs —...

Treating ADHDAre attention disorders overdiagnosed?

Once viewed chiefly as affecting grade school-age

children — chiefly hyperactive boys — attention

deficit hyperactivity disorder (ADHD), which

makes it difficult to focus attention and control

impulses, today is widely seen as a lifelong condition affecting

both genders equally. As more and more children, adolescents and

adults are diagnosed with ADHD, prescriptions for stimulants such

as Ritalin and Adderall to fight the disorder are soaring. Yet many

experts say that while stimulants temporarily ease symptoms, they

do nothing to improve academic or work performance or social

skills, and some worry the condition is being overdiagnosed. At

the same time, non-drug treatments remain under-used. The in-

creased availability of stimulants, which are addictive, is fueling

prescription-drug abuse among students and others who do not

have ADHD but use the drugs as study aids or to get high.

I

N

S

I

D

E

THE ISSUES ....................671

BACKGROUND ................678

CHRONOLOGY ................679

AT ISSUE........................685

CURRENT SITUATION ........686

OUTLOOK ......................687

BIBLIOGRAPHY ................690

THE NEXT STEP ..............691

THISREPORT

Blake Taylor, a student at the University of California,Berkeley, began taking medication for ADHD at age 5.

ADHD is widely seen today as a lifelong conditionaffecting both genders equally.

CQResearcherPublished by CQ Press, an Imprint of SAGE Publications, Inc.

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CQ Researcher • Aug. 3, 2012 • www.cqresearcher.comVolume 22, Number 28 • Pages 669-692

RECIPIENT OF SOCIETY OF PROFESSIONAL JOURNALISTS AWARD FOR

EXCELLENCE ! AMERICAN BAR ASSOCIATION SILVER GAVEL AWARD

670 CQ Researcher

THE ISSUES

671 • Is ADHD being over-diagnosed?• Are too many stimulantsbeing prescribed?• Are ADHD therapies ef-fective over the long term?

BACKGROUND

678 Disorder DefinedPsychiatrists crafted the firstdefinition of ADHD in 1968.

680 Widening SpectrumMost researchers agreeADHD traits lie on a con-tinuum from normal todamaging.

681 Drug AbuseBy the 1930s amphetaminedecongestants were usedto enhance performance.

683 Under the Influence?In the 1960s fears grewthat Ritalin and other stim-ulants could be dangerous.

CURRENT SITUATION

686 Numbers RiseADHD prescriptions rose46 percent from 2002 to2010.

686 Changing PoliciesADHD diagnosis guidelinesnow cover children fromages 4 to 18.

OUTLOOK

687 Debate ContinuesBrain imaging and geneticprofiles eventually mayhelp in diagnosing ADHD.

SIDEBARS AND GRAPHICS

672 One in 10 Children Diagnosed With ADHDDiagnosis rates exceed 14 percent in four states.

673 Childhood ADHD, DrugTreatment on RiseNine percent of children received ADHD diagnosesbetween 2008 and 2010.

674 Cultural Expectations FuelADHD DiagnosisSchool pressures help definenormal behavior.

676 More High School SeniorsTurning to AdderallNearly twice as many usedthe drug without a prescrip-tion in 2011 as in 2007.

679 ChronologyKey events since 1937.

680 Non-drug Therapies MayHelp With ADHDA change in breathing canhave rapid effects on thebrain.

682 Students Abuse ADHDDrugs as Study AidsExperts warn of potentiallydangerous consequences.

685 At IssueAre ADHD and artificial fooddyes linked?

FOR FURTHER RESEARCH

689 For More InformationOrganizations to contact.

690 BibliographySelected sources used.

691 The Next StepAdditional articles.

691 Citing CQ ResearcherSample bibliography formats.

TREATING ADHD

Cover: AP Photo/Jeff Chiu

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Treating ADHD

THE ISSUESP atricia Quinn, a pedi-

atrician in Washington,D.C., specializes in at-

tention deficit hyperactivity dis-order (ADHD), and she haslots of personal experience toback up her medical training.Quinn is a self-described clas-sic example of an adult ADHDsufferer who struggles withorganization, focus and timemanagement. She’s also themother of four children, threeof whom also have ADHD.

“I’ve forgotten to pick upmy kids from soccer practice,”she says. “I interrupt a con-versation to finish a conversa-tion we were having three daysago.” And without her busi-ness partner’s help, she says,she’d often commit them tomore clients and projects thanthey could reasonably handle.

Quinn didn’t fully realizehow hard it was for her tofocus her attention until shewas in medical school in the1960s. Despite being a highachiever, “I had to rereadand reread and reread” to getthe full meaning of texts, sherecalls. She didn’t identifyher problem as ADHD untilmuch later, however.

That wasn’t unusual. In the ’60s,doctors were only beginning to iden-tify the mental traits of hyperactivity,impulsiveness and attention-focusingproblems as a psychiatric disorder. Theycalled the condition “minimal braindysfunction” and diagnosed it only inchildren, primarily below the age ofpuberty. Today, psychiatry holds a dif-ferent view. Adults are increasingly di-agnosed with ADHD, which manyspecialists view as a lifelong conditionrather than what it used to be con-

sidered: a developmental problem thatchildren outgrew in their teens.

Like most mental disorders, ADHDis diagnosed by observations of be-havior, not physical abnormalities. Brainimaging and genetic studies have turnedup clues about brain regions and func-tions that may be involved in ADHD,but no consensus exists about its cause.

As more and more adults are diag-nosed with ADHD, so too are increasingnumbers of children and teens. Drivingthe increase is growing pressure on

children to succeed in school,many scholars say.

Prescriptions for Ritalin, Con-certa, Adderall and other stim-ulant drugs — long the first-line treatment for ADHD —also are increasing. For somemedical experts as well as par-ents, that stirs fears that theamphetamine-like drugs couldcause unforeseen health prob-lems, if taken long term. Andsome worry about an epidemicof stimulant abuse as peoplewithout an ADHD diagnosisuse the drugs to help themconcentrate or to get high.

Over the past three decades,the number of children diag-nosed with ADHD has soared,rising nearly eightfold between1980 and 2007. 1 The per-centage of children ages 4 to17 diagnosed with ADHD in-creased at an average rate of5.5 percent a year from 2003to 2007. 2 In the mid- to late-1990s, the nationwide preva-lence of ADHD among Amer-ican children was estimated atbetween 4 and 5 percent. 3

By 2007 — the most recentyear for which the Centers forDisease Control and Preven-tion (CDC) has analyzed data— 9.5 percent of children, or5.4 million, had been diag-nosed. 4

Because young boys are most like-ly to exhibit hyperactivity, adults andgirls with ADHD often have gone un-diagnosed in the past, says Quinn. About13.2 percent of boys have had an ADHDdiagnosis, compared to 5.6 percentof girls. 5

But many specialists now say ADHDis probably about equally prevalent inboth genders. They give more weightto attention problems as the hallmarkof the condition than in the past, whichhelps to extend the diagnosis to adults

BY MARCIA CLEMMITT

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Michelle Suppers, a mother of two in Manassas, Va., getsher eldest son, Anthony, started on his homework assoon as he comes home from school so he doesn’t getdistracted. When she learned he had ADHD, Suppers

also underwent testing and found she too has thecondition. Nearly 10 percent of children ages 4-17

have been diagnosed with ADHD at some point in their lives.

672 CQ Researcher

and girls, who are less likely to be per-ceived as hyperactive, Quinn says.

For as long as ADHD has been di-agnosed, however, some clinicians havedebated the validity of diagnoses. Todaya few clinicians still argue that no mat-ter how many ADHD-type symptomsa person has they do not constitutean actual biological brain disorder thatshould be treated medically.

“ADHD is defined as involving hy-peractivity, inattention and impulsivi-ty. These are not diseases — they aredisciplinary and educational problems,”wrote Peter R. Breggin, a psychiatristin Ithaca, N.Y. “Very often these childrenimprove dramatically when parents de-velop a more consistent, rational andloving plan for discipline. . . . Or thechild may be especially full of life andneed more opportunity to run, to playand to be creative.” 6

However, most clinicians today seem

to agree that at least some people dohave traits severe enough to warranttreatment. (See box, p. 677.) But in-tense debate continues over whetherdoctors are making the diagnosis toofreely, whether medical researchers aredefining the disorder too broadly andwhether ADHD patients’ prognosis isfar less gloomy than the medical es-tablishment contends.

It’s hard to overestimate the areasof life in which children with ADHDmay experience — and cause — dif-ficulties, says Richard Milich, a profes-sor of psychology at the University ofKentucky in Lexington. They are morelikely to be held back in school, lesslikely to graduate and “they can be adiscouraging presence in the classroomand can disrupt a whole class,” he says.

Worse, “these children are often so-cially rejected by their peers, some-times within five minutes” of meeting

them, Milich says. “The other kids hatethem,” perhaps because they have poorimpulse control. “They act likeyounger kids. They both give and re-ceive bullying.” 7

Often, “in high school the problemsget bigger,” encompassing more out-of-school activities, Milich says. For exam-ple, when driving skills of young adultswith ADHD are tested in a simulator,“their driving is equivalent to the wayothers drive under the influence of al-cohol.” Yet, they are “more confident intheir driving” than others, he says.

Some experts, however, contend thatthe new notion of ADHD as a lifetimediagnosis is too extreme. Lawrence Diller,a developmental pediatrician in WalnutCreek, Calif., and author of the 2011 book,Remembering Ritalin, interviewed 10 ofhis former ADHD patients, now youngadults, and found they had fewer cop-ing difficulties than one might expect.

“The trend is unmistakable. Thesekids are getting better,” he says. “Someof the most hyperactive kids I’ve everseen were in this group,” but in theirlate 20s most are settling into jobs andacquiring stable, productive life pat-terns “as they’re finding what they liketo do. One kid was in the peniten-tiary. But now he’s a police officer.”Only two of the 10 — “both perfec-tionists,” Diller says — still take med-ication, while the others haven’t takenADHD drugs for years.

ADHD is no barrier to success.Grammy-winning pop singer Justin Tim-berlake, comedian Jim Carrey andswimmer Michael Phelps, the most dec-orated Olympic athlete of all time, forexample, all suffer from the condition.

The first line of treatment for ADHDhas long been prescription stimulants —amphetamines and similar drugs formu-lated as relatively low-dose pills such asRitalin. Seven percent of U.S. childrentake a psychiatric medication, and mostof the prescriptions are for ADHD. 8

The drugs are effective at temporar-ily quelling ADHD symptoms such ashyperactivity and lack of mental focus.

TREATING ADHD

14.0%-15.9%

11.0%-13.9%

9.6%-10.9%

8.0%-9.5%

5.6%-7.9%

One in 10 Children Diagnosed With ADHDNearly 10 percent of children ages 4 to 17 have been diagnosed with ADHD. Diagnosis rates exceed 14 percent in Alabama, Delaware, Louisiana and North Carolina. Rates are far lower in the West.

Source: “State-Based Prevalence Data of ADHD Diagnosis,” Centers for Disease Control and Prevention, December 2011, www.cdc.gov/ncbddd/adhd/prevalence.html

N.Y.

Ohio

Texas

Va.

Minn.

Iowa

Mo.

Calif.

Nev.

Ore.

Colo.

Wash.

Idaho

Mont.

Utah

Ariz. N.M.

Wyo.

N.D.

S.D.

Alaska

Okla. Ark.

La.

Ill.

Miss.

Tenn.

Ga.

Conn.

Mass.

R.I.

MaineVt.

W.Va. N.J.

Del.

Md.

Ala.

Fla.

Wis.

Mich.

Ind.

N.C.

S.C.

N.H.

Kan.Ky.

Hawaii

D.C.

Neb.Pa.

Percentage ofYouths 4-17

Ever Diagnosed With ADHD by

State, 2007


“There are patients who are quite de-bilitated” by their ADHD symptoms, andstimulants help them “get an even play-ing field” for school and jobs, says JoshuaIsrael, a San Francisco psychiatrist andassociate clinical professor at the Uni-versity of California, San Francisco.

But others point out that stimulantdrugs can be addictive and may carrycardiovascular risks if used over a longperiod.

Because many now see ADHD asa long-term illness that also affectsadults, the “medications aren’t beingprescribed the same way they were20 years ago,” says Mark Stein, a pro-fessor of psychiatry and pediatrics atthe University of Illinois at Chicago.Back then, virtually all prescriptions werewritten for children, who stopped tak-ing the medications when they hit pu-berty. Today, Stein says, more people“are taking them for many years,” andwe “don’t have data” on the safety oflong-term use or use by adults.

There also is “abundant evidence”that people who have not been diag-nosed with ADHD take the drugs asmood elevators and performance en-hancers, Nicolas Rasmussen, a professorof the history and philosophy of scienceat Australia’s University of New SouthWales, wrote in his 2008 book, OnSpeed: The Many Lives of Amphetamine.

“Reports of medication abuse haveincreased in step with attention deficitdrug prescriptions,” he wrote. And “theshift from misusing unprescribed Rital-in as an occasional study aid to straight-forward abuse can happen easily.” OneHarvard student discovered the dangersof Ritalin abuse when she became “anabsolute speed-freak — up all night andstrung out all day,” Rasmussen wrote. 9

(See sidebar, p. 682.)Stimulants can also constitute a too-

easy answer to complex behavioral orlearning problems, says Milich. Whilequelling symptoms may be useful, itdoesn’t help ADHD patients developappropriate social responses and ef-fective learning strategies, he says. The

lack of such skills may be a specialproblem for ADHD patients as theycome of age in today’s difficult jobmarket. “In this economy . . . , it’sharder and harder to just go out andgrab a job,” Milich says.

As ADHD diagnoses continue ris-ing for children and adults, here aresome of the questions being debated:

Is ADHD being overdiagnosed?The percentage of children and adults

with ADHD has risen steeply for twodecades, causing some experts toargue that the condition is overdiag-nosed. A minority of critics of the di-agnosis go farther, arguing that ADHD-type traits should not be treated as adisease or disorder because the traitswould be benign or might disappearaltogether with proper response byteachers, parents and others.

Other analysts, however, argue thatADHD is clearly a biological condi-tion and that, while some diagnosesare “false positives,” many people whowould benefit from treatment havenever been told they have ADHD.

No brain scan or other medical testconfirms ADHD, say critics of the di-agnosis.

“The evidence for an organic basis formost children who are diagnosed withADHD remains elusive,” writes Peter Con-rad, a professor of medical sociology atBrandeis University, in Waltham, Mass.He said clinicians who are overdiagnos-ing ADHD are engaging in a “classic caseof the medicalization of deviance” fromwhat is considered normal behavior. “Evenif one found some validated biopsycho-logical differences,” Conrad wrote, “thesociological question remains: Does dif-ference mean disease?” 10

Some recent research suggests thatcareless ADHD diagnoses are occur-ring. In Germany, where the rate ofADHD increased by 381 percent be-tween 1989 and 2001, a recent surveyof nearly 500 therapists found that manyof the clinicians diagnosed ADHD basedon too few criteria. Clinicians diag-nosed ADHD in about 17 percent ofthe cases deemed by experts not tomeet the criteria — compared to about7 percent of cases in which cliniciansmissed signs of ADHD. Moreover, boyswere incorrectly deemed to have ADHDmore often than girls. 11

(The ADHD rate in Germany forchildren ages 3-17 is about 5 percent,roughly half the U.S. rate.) 12

Childhood ADHD, Drug Treatment on RiseNine percent of children ages 5 to 17 were diagnosed with ADHD between 2008 and 2010, up from 7 percent between 1997 and 1999. Use of ADHD prescription drugs among children rose from less than 1 percent from 1988 to 1994 to 4 percent from 2005 to 2008.

Source: “Health, United States, 2011,” National Center for Health Statistics, 2011, p. 29, www.cdc.gov/nchs/data/hus/hus11.pdf

ADHD in Children Ages 5-17Children Ages 5-17 Who Have

Used ADHD Prescription Drugs

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674 CQ Researcher

A recent study of nearly a millionchildren in western Canada foundthat the youngest in a class are morelikely to be diagnosed with ADHD— at a rate of 7.4 percent, com-pared to 5.7 percent for the oldestchildren. 13 That result “suggestsyounger, less mature children are in-appropriately being labeled and treat-ed,” presumably because their im-maturity is mistaken for the disorder,said lead author Richard Morrow, aprofessor of counseling psychologyat the University of British Colum-bia in Vancouver. 14

With growing pressure on childrento perform well in school, “it’s veryeasy and popular to give this simplediagnosis,” says Diller, the Californiapediatrician. Furthermore, in upscaleneighborhoods, private clinics canmake good money selling ADHDtherapies — proven or not — to par-ents anxious to raise high achievers,he says.

Other analysts say, however, thatfewer people have been diagnosedwith ADHD than actually are impairedby it, especially adults and females ofall ages.

Once believed to be a conditionthat affected only children, ADHD isnow estimated to afflict 9 million to10 million U.S. adults, but fewer than2 million have been diagnosed, saysIsrael, the San Francisco psychiatrist.

Historically, girls and women havebeen under-diagnosed because “we’vefocused on the hyperactivity,” whichshows up more in males, rather thanproblems with attention and orga-nizing, says Quinn, the Washingtonpediatrician. “A lot of people stillthink girls can’t have” ADHD, partlybecause girls often have quieter symp-

TREATING ADHD

M illions of kids are restless, inattentive, disorganized andimpulsive — but does that mean they have a psy-chiatric disorder?

Some scholars argue that it’s wrong to label common child-hood traits that way. Doing so, they maintain, is an abdication ofthe responsibility that parents, society and, especially, schools shareto create environments in which children can function effectively.

“Hyperactivity is the most frequent justification for druggingchildren. The difficult-to-control male child is certainly not anew phenomenon, but attempts to give him a medical diag-nosis are the product of modern psychology and psychiatry,”wrote Peter R. Breggin, an Ithaca, N.Y., psychiatrist and long-time critic of labeling children as having ADHD. 1

But Breggin is in the minority. More and more cliniciansargue that ADHD has a biological basis, although most alsocontend that cultural forces play a powerful role in definingADHD-type traits as a disorder.

The fact that many cases are inherited demonstrates that ADHDis a biological illness, says Russell Barkley, a professor of psy-chiatry at the Medical University of South Carolina, in Charleston.

Studies of families show that genetics is responsible for abouttwo-thirds of ADHD, he says. Most of the remaining third is dueto other biological causes — mainly damage of various kinds tothe front portion of young brains, often caused by mothers smok-ing or drinking alcohol during pregnancy, Barkley says.

Yet, Barkley also maintains that social environment does helpdetermine what mental traits we view as psychiatric illnesses.

Before about the 18th century, when most people couldn’tread, “there were no reading disorders,” although the traits rec-ognized today as reading disorders certainly existed in peopleof those times, says Barkley. “The same is true of ADHD,” heargues. “Until society demanded that virtually all children and

teenagers focus on academics for hours each day,” ADHD-typetraits existed but were not seen as a problem, he says.

Additional evidence of how academic pressure shapes ADHDdiagnoses lies in state variations in ADHD rates, says StephenHinshaw, a professor of psychology at the University of Cali-fornia, Berkeley. For example, among 4- to 17-year-olds in NorthCarolina, 16 percent have had an ADHD diagnosis, comparedto only about 6 percent in California — a nearly threefold dif-ference, says Hinshaw. He says that most states with high ADHDrates were among the first to punish schools that did not raisestudent test scores.

Even the culture of an individual classroom can determinewhether a child needs treatment, says Barkley. “If in secondgrade a child has a great teacher, he may be able to get offmedications” for that year but resume treatment in anotherschool year if the nature of the classroom makes concentra-tion tougher, he says.

Still, Barkley maintains that while supportive school environ-ments can make it easier for ADHD students to function with-out drugs, schools are not obliged to provide such environments.In the Americans With Disabilities Act — which requires institu-tions to make accommodations to assist disabled people, in-cluding those with ADHD — “there is a very important word,”Barkley says. “It says that schools must make reasonable ac-commodations. Society can’t afford every accommodation that isconceivable. We’re not going to design a separate curriculum forevery child.”

— Marcia Clemmitt

1 Peter R. Breggin, Toxic Psychiatry: Why Therapy, Empathy and Love MustReplace the Drugs, Electroshock, and Biochemical Theories of the New Psy-chiatry (1994), p. 277.

Cultural Expectations Fuel ADHD DiagnosisSchool pressures help define normal behavior.


toms that may cause less trouble inclassrooms.

Many experts say misdiagnosis — in-cluding both over- and under-diagnosis— is the real problem.

The average diagnosis occurs in “a10-minute pediatric visit” after a teacheror parent perceives that a child is hav-ing problems, says Stephen Hinshaw, aprofessor of psychology at the Univer-sity of California, Berkeley. “In a visitlike that, you get tons of false positivesand tons of false negatives,” he says.

For example, under-diagnosis mayoccur if a doctor concludes that, “Well,it can’t be ADHD because the child issitting still in the [doctor’s’] exam room,”says Hinshaw. That’s because ADHD’s“symptoms are context-dependent,” anda child’s ability to sit still in one situa-tion doesn’t rule out having a damag-ing level of hyperactivity in another.

False-positive diagnoses can occurbecause doctors don’t take the timeto rule out the many other conditionsbesides ADHD that may cause hy-peractivity or attention problems, suchas seizure disorders or abuse of somekind, Hinshaw says. “It’s so easy toprescribe a stimulant,” he says. Physi-cians’ professional societies “havegood guidelines now” that could pre-vent most misdiagnosis, “but theguidelines don’t have teeth,” so they’reseldom consulted, Hinshaw says.

But debating the “correct” preva-lence of ADHD is beside the pointwhen the real need is to locate thechildren whose ADHD-type traits arecausing them problems and find waysto help them, says William Pelham, aprofessor of psychology at Florida In-ternational University, in Miami. “I’venever had a parent say, ‘I did a survey[of symptoms], so I brought in my child.’They say, ‘I brought him because hewon’t stay in his seat, he drives theteacher crazy.’ For that child, it doesn’tmean a hill of beans whether more orfewer children are diagnosed. The im-portant question is: How many chil-dren are having problems in school?”

Those children should be located andoffered help, Pelham says.

Are too many stimulants beingprescribed?

Those who argue that ADHD isoverdiagnosed worry mainly that stim-ulants such as Ritalin and Adderall usedto treat the condition can create healthrisks, including addiction. ManyADHD specialists say, however, thatstimulants are an important part ofADHD therapy and that studies havenot shown significant safety risks. (Afew nonstimulant drugs, such as Strat-tera, also are occasionally prescribedfor ADHD; unlike stimulants, they arenot believed to be addictive but docarry other health risks. 15)

Up to 80 percent of those diagnosedwith ADHD will need medications aspart of their treatment, says RussellBarkley, a professor of psychiatry at theMedical University of South Carolina, inCharleston, and author of several bookson ADHD. And stimulants are far fromthe only drug that people abuse, he says.“Are there some students on collegecampuses using Adderall when theydon’t have ADHD? Yes. We need tobe careful about that, but it’s also truefor Viagra.”

“As a society, it is hard to see whyit would be good for us to not letpeople succeed” when the drugs canhelp, says Israel, the psychiatrist fromSan Francisco. “This is not cosmeticpharmacology” aiming to make peo-ple “better than well.”

The largest long-term study of ADHD— the Multimodal Treatment of At-tention Deficit Hyperactivity DisorderStudy, funded by the National Insti-tute of Mental Health in the 1990s —found that the medications are largelysafe for children. Of 289 children whowere randomly assigned to drug treat-ments, only 4 percent had significantadverse effects, mainly loss of appetite,sleep problems and crying spells. Chil-dren also grew somewhat more slow-ly while taking the drugs. 16

In both Canada and the UnitedStates, some serious health problemsamong children, including heart attackand stroke — some fatal — have beenreported. However, a large 2011 studyspurred by the reports found the ratesof such cardiovascular problems ex-tremely low. Based on analysis of themedical records of 1.2 million childrenand young adults, researchers found “noincreased risk” for the conditions. 17

The researchers also analyzed datafor about 150,000 people ages 25 to 64who were currently prescribed ADHDdrugs and again found “no evidence ofan increased risk” of serious cardiovas-cular problems. However, because fewadults have so far been prescribed thedrugs, further study on safety for adultsis needed, they said. 18

Abuse of stimulants has turned someunwary people into “speed” addictsevery time doctors began widely pre-scribing such drugs, says Diller, theNorthern California pediatrician. “Every20 or 30 years we find a reason” touse stimulants for medical purposes,and that’s “been followed each timeby an epidemic of abuse.”

ADHD drugs are classified as “con-trolled substances” under U.S. and in-ternational laws. U.S. law lists the stim-ulants as Schedule II drugs — drugsthat have accepted medical uses butalso have “a high potential for abusewhich may lead to severe psychologi-cal or physical dependence,” accord-ing to the Drug Enforcement Adminis-tration (DEA). 19 Methylphenidate — astimulant whose commercial forms in-clude Ritalin and Concerta —“producesmany of the same effects as cocaineor the amphetamines,” the agency says.

Methylphenidate’s increased use asan ADHD treatment is paralleled byan increased incidence of abuse, in-cluding as a snorted or injected drug,the DEA says. “Binge use, psychoticepisodes, cardiovascular complica-tions and severe psychological ad-diction have all been associated withmethylphenidate abuse.” 20

676 CQ Researcher

A United Nations treaty — the Con-vention on Psychotropic Substances,which took effect in 1971 — urgesgovernments to ban companies fromadvertising Schedule II drugs directlyto consumers. 21

In 2001, a British company, Cell-tech Pharmaceuticals, advertised its newmethylphenidate-based drug Metadatein American magazines, and the DEAresponded with a cease-and-desist orderthat called the ads a threat “to thepublic health and safety.” 22

Ultimately, the U.S. government didnot ban direct-to-consumer advertis-ing for Schedule II drugs. But the Foodand Drug Administration (FDA) hascontinued to warn companies aboutmisleading ads, and drug makers haveconfined much of their advertising tosmaller outlets, such as websites andcable TV channels. 23 Currently, theFDA is reviewing public comments ona draft plan to require all TV ads forSchedule II drugs to be screened bythe FDA before airing. 24

The ease of prescribing stimulantsleads families to neglect deeper prob-

lems and longer-term solutions, someanalysts contend.

“Stimulant drugs ‘work’ by sup-pressing all spontaneous behavior innormal children,” a consequence that“looks like an improvement in a class-room or home where the child hasseemed uncontrollable,” wrote Ithaca,N.Y. psychiatrist Breggin. In fact,when children’s behavior becomes“age-inappropriate, excessive or disrup-tive, the potential causes are limitless,including: boredom, poor teaching . . .and underlying physical illness,” andthese issues should be examinedrather than symptoms merely quelledwith medication, he argues. 25

“Multimodal” treatment — usingdrugs alongside parental training andtraining designed to help children fos-ter social skills, learning strategies andthe like — is by far the most effectiveapproach to ADHD, many experts say.

Unfortunately, using drugs as thefirst line of treatment — the usual pat-tern — may mean the multimodal ap-proach is never tried, says Florida In-ternational’s Pelham. In one study, a

group of children with ADHD was firstprescribed stimulants and, later, theirparents were offered training in ef-fective techniques for dealing withADHD. Only 15 percent of those par-ents ever took the training, Pelhamsays. By contrast, in families offeredtraining first and prescriptions later,about 90 percent got the training.

“Drugs undermine parents’ willing-ness” to commit themselves to impor-tant behavior changes, Pelham says.“Medications are grossly overutilized com-pared to behavioral treatment.” But “thereare no gigantic corporations that selland make a profit on behavioral treat-ments, so nobody’s talking to pediatri-cians about using these things.”

Are ADHD therapies effectiveover the long term?

Behind every dispute involvingADHD treatments lies the big ques-tion: What, if any, therapeutic meth-ods improve the lives of people whohave more than average difficulty con-trolling their impulses and focusing at-tention on school or work?

Research shows that stimulantdrugs effectively quell symptoms, ex-perts say. Research also shows thattraining in social and learning skills aswell as skills training for parents andteachers also help. But drug treatmentdoes not have long-lasting effectsagainst ADHD, and behavior-orientedstrategies haven’t been fully researchedand can be difficult for families andschools to adopt.

“Medications can help improve at-tention and decrease impulsivity,” saysthe University of Kentucky’s Milich.“They work on the symptoms.”

But research also shows that drugtreatment doesn’t make a long-termdifference for patients, says Berkeley’sHinshaw, a researcher on the multi-modal treatment study. Follow-up re-search on the study found that a yearafter being treated with drugs, chil-dren with ADHD had “lost 80 percent”of what they’d gained in symptom

TREATING ADHD

More High School Seniors Turning to AdderallMore than 5 percent of high school seniors admitted in 2011 to taking Adderall without a prescription, nearly double the percentage in 2007. About 1 percent of seniors abused Concerta over the same period. Abuse of Ritalin declined since 2004 but is now trending up.

Source: Monitoring the Future, University of Michigan Institute for Social Research, June 2012, p. 751, www.monitoringthefuture.org/pubs/monographs/mtf-vol1_2011.pdf

Non-prescribed ADHD Medication Use Among High School Seniors in Previous 12 Months, 2002-2011

RitalinAdderallConcerta

0

1

2

3

4

5

6%

2011201020092008200720062005200420032002

Percentage of all seniors


alleviation; and after two years, theirbehavior was indistinguishable fromthat of children with ADHD who’dnever received the recommended levelof drug treatments, Hinshaw says.

“The moment the medication hasworn off, all the benefits are gone,”says Pelham, another researcher on themultimodal treatment study. This meansthat “medication has no long-termbenefit at all” when it comes to learn-ing, at least in the studies of grade-school students, whose classroom workis mostly simple drills. “All the stud-ies on learning have failed to showanything” in the way of improvements,he says. It remains unclear whetherresults would differ for older students,who often perform more complex tasksin the classroom. Pelham says no suchresearch has been done because toofew middle school and high schoolstudents take the drugs.

In a study of children with ADHDwho played baseball, stimulant drugssignificantly increased their attentionto the game “but didn’t do anythingfor their play,” says Milich.

In another study, Milich examinedhow well children with ADHD un-derstood narrative stories — present-ed as TV programs to eliminate read-ing problems as a factor in the scores— before and after drug treatment,compared with children without ADHD.Following a narrative requires grasp-ing the significance of “causal con-nections,” and children with ADHDhave been shown to be “somewhatimpaired” in that skill, Milich says.After taking medication for two yearsthe children with ADHD had not pro-gressed in their ability to understandnarratives, while those without ADHDhad, Milich says.

Milich says quelling ADHD symp-toms accomplishes nothing in the longterm because “until you replace oldbehaviors with appropriate behaviors”the child hasn’t progressed.

On the other hand, behavior-mod-ification strategies, which have been

less extensively researched than drugtreatments, have demonstrated long-term success in studies, many ADHDscholars say.

Hinshaw believes children withADHD have abnormalities in the brain’sdopamine system, which is thought torespond to rewards and punishmentsby sending signals that encourage thebrain to repeat rewarded behaviors oravoid punished behaviors. “With be-haviorally based strategies, you try tomotivate kids who have [dopamine-system] problems,” he says.

Such strategies may include consis-tently providing prompt and specificfeedback on youngsters’ behavior andclasswork. Teachers, for example, canbe coached to break each academicskill down into small steps and thenprovide clear and instant feedback asstudents perform each step.

One technique, called “the daily re-port card,” is “hugely effective,” saysStein of the University of Illinois. Chil-dren receive a daily assessment abouttheir progress in improving specific

behaviors and accumulate points theycan later redeem for rewards. Childrenwith ADHD generally have difficultiesin social relations with their peers, andStein runs a summer camp that usesthe report card to help. By meetingspecific behavior goals related to so-cial interaction, children earn pointsthat they can redeem for a field tripthe next week.

“The second week, they quickly real-ize what they need to do if they didn’tget the trip,” he says. If parents aretrained in the same techniques anduse them, the results last, Stein says.

Building new skills and finding ef-fective work-arounds for ADHD-relateddeficiencies is key to helping adultpatients, says Israel, the San Francis-co psychiatrist. For example, he sayshe helps patients find software pro-grams that will help them organizetheir lives and figure out “where theyshould keep their keys” so they don’tforget them.

Unlike drugs, behavioral interven-tions have no side effects or health risks,

Symptoms of ADHDSeveral behavioral signs have been shown to be characteristic of ADHD. Experts say the number of symptoms matters less than the degree of impairment. Most experts agree that if significant impair-ment appears in at least five or six of the following behaviors, additional evaluation is advised.

Source: “Screening Form,” Center for Attention Disorders, 2009, www.centerforattentiondisorders.com/downloads/cad-screening-test.pdf

Resisting distractionsManaging timeLearning from experienceThinking or planning aheadAvoiding procrastinationSustaining effortGetting started with work or tasksControlling impulsivityOrganizing materialsDemonstrating flexibility

Persisting toward a goalManaging emotionsCompleting work or tasksSelf-monitoringAccurately reading social cuesRemembering what to doRetaining and retrieving informationSitting stillHandling transitions

Screening for ADHD

678 CQ Researcher

TREATING ADHD

so they have little downside and po-tentially significant upsides, says Pelham.

Clinicians are careful to point outthat today’s effective behavioral inter-ventions are not the same as the psy-chotherapeutic interventions that werewidely used beginning in the 1950s inhopes of uncovering hidden emotion-al roots of ADHD. Diller, the Califor-nia pediatrician, saysthe most popular was“play therapy,” inwhich a patient andtherapist played to-gether with toys as away of encouraginga child to uncoverand work throughanxieties or memo-ries. As early as the1980s, “it was gener-ally conceded that[play therapy] didn’tdo anything” for kidswith ADHD, Dillersays. Despite that,some psychothera-pists “continue towaste time and en-ergy doing it,” he says.

Many clinicianssay the best approachto treating ADHD iscombining judicious-ly prescribed medication with behavioralwork carried out with the child and thechild’s parents and teachers.

In the multimodal treatment study,children who received combinationtreatment had less anxiety and betteracademic performance, parent-child re-lations and social skills, and they need-ed less medication, than the drug-onlygroup, according to the National In-stitute of Mental Health. 26

“The gains can be amazing,” but thecomplexity and cost of such treatmentmean that “so few children can get that,”says Stein.

But behavioral interventions remainhard to implement. Hinshaw says thatto “have a fighting chance” of truly

ameliorating serious ADHD problems,behavioral work must be intense. Thatmight mean “catching it at age 3 or 4and doing 20 hours a week of training,”for example.

A further difficulty is that ADHD isoften an inherited trait, he says. “You’vegot to be a super-parent,” who scrupu-lously keeps charts of children’s behavior

and rewards points, “doing it all calmlyand without yelling,” he says. That’s noteasy for anyone, “but what if you’re aparent with the same problem?”

BACKGROUNDDisorder Defined

O ver the past half-century, suc-cess in American culture has

been increasingly defined in terms ofeducational achievement. It may notbe surprising, then, that over the same

period traits that make it difficult forchildren to sit still at a desk or focuson lessons that bore them have in-creasingly been viewed as a signifi-cant disorder.

Yet, psychiatry has long struggledto define ADHD in terms of its keytraits. What level of inattentiveness, rest-lessness or other characteristics is

enough to classify some-one as having a truepsychiatric disorder? Thequestion remains hotlydisputed. 27

Before the 1960s, chil-dren with traits such ashyperactivity and a lackof focus were describedin the Diagnostic andStatistical Manual ofMental Disorders (DSM),medicine’s mental-health diagnostic bible,as having a “minimalbrain dysfunction.” Butthe vagueness of thatterm didn’t lend itself eas-ily to diagnosis or to clearquestions that medical re-searchers could explore.

Gradually, psychiatristshoned the definition inan attempt to “standard-ize the field so the con-

dition could be recognized as a real en-tity that people could research becauseit was no longer amorphous,” says Is-rael, the San Francisco psychiatrist.

The definitions have shifted overthe years from a broad description of“a misbehaving child” to “somethingtreatable,” says Patricia Gerbarg, an as-sistant professor of clinical psychiatryat New York Medical College and aspecialist in integrative mental healthtreatment, which promotes alternativetherapies such as herbs and breathingexercises alongside traditional ones.

In 1968, the DSM-II made the firstattempt at a specific definition, em-phasizing hyperactivity in what the

Continued on p. 680

Widespread stimulant use in the 1960s led to passage of the 1970Comprehensive Drug Abuse Prevention and Control Act, signed into lawby President Richard M. Nixon, left, here with National Security AdviserHenry Kissinger. The law placed restrictions on prescription stimulants

and other drugs, and by the late 1970s stimulant abuse had subsided.

AFP

/Get

ty I

mag

es


Chronology1930s-1940sStimulant drugs gain popularityamong college students.

1937Charles Bradley, a psychiatrist at aRhode Island mental institution,discovers that the stimulant drugamphetamine calms some severelydisturbed children.

1948College students use the stimulantBenzedrine, sold as a decongestant,as a study aid.

•

1960s-1980sMedical interest grows in hyper-activity and attention problems.

1961Stimulant drug Ritalin first used totreat hyperactivity.

1968First definition of ADHD appearsas “hyperkinetic reaction of child-hood” in second edition of Ameri-can Psychiatric Association’s Diag-nostic and Statistical Manual ofMental Disorders (DSM).

1969Experts declare a “stimulant epi-demic” as 10 million Americansuse the addictive drugs, eitherwith a prescription or illegally, forweight control, performance en-hancement or to get high.

1971United Nations Convention on Psy-chotropic Substances seeks govern-ment bans on direct-to-consumerads for stimulant medications.

1973California allergist Benjamin Feingoldtells American Medical Association

(AMA) that allergenic foods andsynthetic food additives and dyescan cause hyperactivity.

1980DSM-III shifts emphasis from “hyper-kinetic reaction” to problems ofinattention, renaming the condition“attention deficit disorder.”

•

1990-PresentNewly named diagnosis of at-tention deficit hyperactivitydisorder (ADHD) gains popu-larity for children and adults.Use of drugs for performanceenhancement also soars.

1991Activists convince an initially reluc-tant Department of Education toinclude ADHD as a disability thatqualifies students for extra services.

1994DSM-IV includes both inattentionand hyperactivity in its new term,“attention deficit hyperactivity dis-order (ADHD); patients with inat-tention, hyperactivity or both re-ceive the diagnosis.

1998Nearly 7 percent of U.S. childrenages 5 to 17 diagnosed with ADHD.

1999National Institutes of Mental Healthstudy finds that stimulant drugs aregenerally safe for children and thatchildren who receive both medicationand behavior therapy do better inschool and family relationships thanthose who get medication alone.

2006A Food and Drug Administration(FDA) panel recommends that stimu-lant drugs for ADHD carry a “blackbox” label — the most serious

health caution — warning of cardio-vascular risks; FDA rejects the label.

2008American Academy of Pediatricsrecommends that children be assessedfor heart conditions before takingstimulants. . . . Sen. Charles Grass-ley, R-Iowa, accuses three HarvardMedical School ADHD experts —Joseph Biederman, Timothy Wilensand Thomas Spencer — of hidingdrug company payments.

2010ADHD prescriptions for childrenhave risen 46 percent since 2002.

2011Harvard Medical School disciplinesthe three ADHD experts for failingto disclose drug company income.. . . FDA rejects calls to ban artifi-cial food dyes, which may triggerhyperactivity in some children.

2012In a German study, doctors incor-rectly diagnosed ADHD in 17 per-cent of cases where the conditionwas not present. . . . Canadian re-searchers report that the youngestchildren in a school classroom arediagnosed with ADHD much moreoften than older ones, likely be-cause doctors confused ADHDwith immaturity. . . . FDA reviewscomments on a plan to requirepre-approval before TV ads forSchedule II addictive drugs areaired. . . . Draft of DSM-5, due forfinal release in May 2013, furtherexpands population eligible forADHD diagnosis. . . . Psychiatristsestimate that between 9 and 10million U.S. adults have ADHD;under 2 million are diagnosed. . . .Shortages of ADHD medicationslead Drug Enforcement Administra-tion (DEA) to raise caps on howmuch drug manufacturers mayproduce, despite DEA qualmsabout drug abuse.

680 CQ Researcher

manual dubbed a “hyperkinetic reactionof childhood.” In 1980, the DSM-IIIdubbed the condition attention deficitdisorder, or ADD, shifting the defin-ition from hyperactivity to problemsin focusing attention, which likely af-fect more people. In 1994, in DSM-IV,the current definition appeared, la-beling the illness as ADHD — at-tention deficit hyperactivity disorder— and distinguishing three subtypes:one consisting mainly of inattentive-ness, one of hyperactivity and im-pulsivity, and one exhibiting all ofthose traits. 28

Widening Spectrum

M ore recently, some ADHD spe-cialists have argued for dubbing

ADHD a disorder of the brain’s “ex-ecutive functions.”

Calling the condition ADD or ADHD“is like calling autism hand-flappingdisorder,” says Barkley of the MedicalUniversity of South Carolina. “The namesof the disease have trivialized it. Whatyou’re really finding is a developmen-tal delay in the self-regulating” regionsof the brain — the areas, located most-ly in the frontal lobe, that controlthoughts, emotions and behaviors, hesays. The development of those func-tions to full adult capacity is delayedby two to three years in children withADHD, Barkley says.

Furthermore, he says brain imagingfinds that in children with ADHD, theregions of the brain that perform thesefunctions are 4 to 10 percent smallerand 25 percent less active than in otherchildren. And while the brain structuresmay catch up in size to those of theaverage person by the time a personreaches the late teens or 20s, “the func-tion doesn’t catch up” but continues to

be less robust than in the average per-son of the same age, Barkley says.

That view strikes a chord with someclinicians. “We’re talking about the man-agement, the CEO of the brain — or-ganizing and managing the functionsfor daily life,” says Quinn, the Wash-ington pediatrician. The difference be-tween people with and without ADHDis that “if you have two people whosedesks are a mess, one can organize itif she has time, but the ADHD per-son, no matter how much time yougive them, can’t organize the desk,”she says.

Others remain skeptical. Describingthe condition as affecting the brain’s“executive function” is another theoryinto which clinicians try to fit the symp-toms they observe, just like earlier de-finitions, San Francisco psychiatrist Is-rael says. “But people can’t even agreeabout what [the brain’s] executive func-tion is,” he notes.

TREATING ADHD

Continued from p. 678

Medications such as Ritalin can bring immediate relieffrom the symptoms of attention deficit hyperactivitydisorder (ADHD), but many experts say non-drug ther-

apies are more effective at controlling the condition over thelong term.

Yet, those therapies — which range from meditation anddiet to one-on-one help from teachers — are often difficult toimplement, researchers say, making pills the default choice formany patients.

ADHD problems “manifest themselves at home and schooland should be treated in both places” because providing quickfeedback that clearly connects behavior with a reward or penal-ty is crucial, says Julie Owens, an associate professor of psy-chology at Ohio University.

Researchers have found that classroom-management tech-niques such as careful, step-by-step instructions are effectivefor all students. But students who exhibit ADHD symptomsneed additional help, such as a “daily report card” that pro-vides instant feedback on student-specific goals. If teachers per-sist in these methods, “you get month-by-month incrementalimprovement” in students’ behaviors, Owens says.

Getting teachers to apply the techniques consistently isn’teasy, however. Teachers face heavy workloads, and many re-

port inadequate training in classroom management, Owens says.What’s more, says Richard Milich, a professor of psycholo-

gy at the University of Kentucky, “A teacher may even say, ‘Whywould I invest the effort when I have all these great kids whodon’t need these extra things?’” Owens points to a study inwhich all teachers initially used the daily report card. But overthe course of a school year, only some continued to do soconsistently while others nearly stopped altogether.

Some doctors are training ADHD patients in brain-alteringtechniques such as “mindfulness” meditation and “mind-body”approaches such as altering breathing patterns to enhancethinking.

ADHD is “a self-regulation disorder” that makes it difficult forsufferers to monitor and control their attention and impulses.Practicing mindfulness meditation — deliberately focusing at-tention on something specific and immediate, such as the sen-sations of breathing — can help ADHD suffers stay focused,says Lidia Zylowska, a Los Angeles psychiatrist and a cofounderof the Mindful Awareness Research Center at the University ofCalifornia, Los Angeles.

“We often recommend exercise for a physical weakness,” soit makes sense to do the same for mental capabilities, she says.Research to establish how mindfulness works in ADHD “is still

Non-drug Therapies May Help With ADHDA change in breathing “can have rapid effects on the brain.”


However ADHD’s traits are de-scribed, most researchers agree thatthey lie on a continuum, from normalto damaging and difficult to handle.But experts disagree sharply on whethercurrent clinical standards deem toomuch of that spectrum as illness inneed of treatment.

Largely because of the dominanceof the pharmaceutical industry, psy-chiatrists have pushed the ADHD di-agnosis beyond impaired people to in-clude many who function normally,charged Allen Frances, a professoremeritus of psychiatry at the DukeUniversity School of Medicine.

ADHD “consists of nonspecificsymptoms . . . widely distributed in thegeneral population: poor concentra-tion, distractibility, impulsivity andhyperactivity,” wrote Frances, whochaired the panel that assembled theDSM IV. “The kid who presents withclassic early onset, severe [ADHD] is

unmistakable,” while “most kids clear-ly do not have” the disorder, Franceswrote. 29

In between, however, it’s tough todistinguish children with a clinicalcondition “from normal kids who areno more than extremely frisky and dif-ficult to manage.” Those kids in themiddle have increasingly been diag-nosed with ADHD, Frances wrote. “Theepidemic started precisely when ag-gressive drug company marketing suc-ceeded in ‘educating’ and sensitizingdoctors, parents, and teachers to spot”illness “in kids previously consideredto be on the normal side of the . . .boundary.” 30

Drug Abuse

T he vast majority of people diag-nosed with ADHD are treated at

some point with drugs, and most

ADHD medications are compounds re-lated to amphetamine — a stimulantfirst formulated in 1887. The full ef-fects of amphetamine-like drugs on thebrain remain unclear. But, among otherthings, they may enhance the systemthrough which the chemical dopamine— a major neurotransmitter active infunctions including attention, memory,motivation, learning and the process-ing of punishments and rewards —carries messages through the brain.That stimulant drugs are used to treatpeople who already act overstimulat-ed is an often-noted mystery. But, likemost other drugs, stimulants found theirmedical use through the most com-mon process used for drug discovery:trial and error. Even today, little isknown about the actual cellular process-es involved in most medical conditionsand how chemicals interact with thoseprocesses, and ADHD and stimulantsare no exceptions.

in an early stage,” she says. However, studies have demon-strated that meditation can strengthen the brain’s prefrontal cor-tex region, which manages the brain’s regulatory functions, ac-cording to Zylowska. 1

A change in breathing “can have rapid effects on the brain.”says Patricia Gerbarg, an assistant professor of clinical psychi-atry at New York Medical College. A “communication system”called the autonomic nervous system “lets the brain know what’shappening in every part of the body” and allows messagescoming from the body to affect the brain, she explains.

While the system involves the heartbeat, digestive process-es and more, the only function it manages that can be volun-tarily changed is breathing, she says. For example, slowingbreathing to five steady, rhythmic in-and-out breaths per minutecalms anxiety, improves mental focus and allows the brain “tosolve problems better,” Gerbarg says.

Even children can learn the technique quickly, she says. Afterone training session, “they can get a CD for 15 bucks and prac-tice at home for free. The kids like it. It doesn’t matter whatyour mind is doing. All you have to do is breathe.”

In the early 1970s, when the ADHD diagnosis was in itsinfancy, Los Angeles-based allergist Benjamin Feingold deviseda diet aimed at quelling hyperactivity. The diet eliminates in-

gredients to which Feingold hypothesized children might beoverly sensitive: mainly naturally occurring organic chemicalscalled salicylates, found in foods such as blueberries and toma-toes, and artificial flavors, dyes and other additives that werenew to American diets at the time.

The diet has been studied repeatedly over the years, andsome researchers — and many families — have reported thatit quiets some children’s symptoms. But dietary research is hardto verify, and many analysts speculate that probably few chil-dren have these food sensitivities. 2

The European Union requires foods with certain artificialcolors to carry a warning about possible ADHD effects, butthe U.S. Food and Drug Administration rejected such a warn-ing last year. 3 (See “At Issue,” p. 685.)

— Marcia Clemmitt

1 Stephanie Sarkis, “ADHD & Mindfulness: An Interview with Lidia Zylowska,”Psychology Today, June 19, 2012, www.psychologytoday.com/blog/here-there-and-everywhere/201206/adhd-mindfulness-interview-lidia-zylowska-md.2 For background, see Matthew Smith, An Alternative History of Hyperactivity:Food Additives and the Feingold Diet (2011).3 “FDA Panel: Studies Needed for Food Dye Side Effects, But No Warnings,”AboutLawsuits.com, April 4, 2011, www.aboutlawsuits.com/fda-panel-food-dye-side-effects-17270.

682 CQ Researcher

In the early decades of the 20th cen-tury, as the fledgling pharmaceutical in-dustry first began to search for “block-buster drugs” — relatively safecompounds to treat chronic conditionsthat afflict many people — chemistsand clinical researchers spent consid-erable time testing amphetamines onpatients and on themselves, based onhunches about what the drug mightdo in the body.

By the 1930s, amphetamines andchemically similar drugs were beingsold as decongestants, for example.

At the same time, the drugs, whichcould be bought without a prescription,

developed a reputation as remedies forfatigue and as largely overhyped perfor-mance enhancers. “During the SecondWorld War, amphetamine and metham-phetamine were adopted in the militaryservices on all sides, in quasi-medical ef-forts to tune mind and body beyondnormal human capabilities,” wrote Aus-tralian medical historian Rasmussen. 31

Students were among those whobought the drugs — mainly a decon-gestant sold under the name Benzedrine— for their hoped-for performance-enhancing abilities. In January 1948,for example, The Harvard Crimsonreported on the “usual semi-annual”

influx of “Benzedrine-happy students”who tried to use the stimulant as astudy aid for semester exams butsometimes ended up suffering anoverdose-fueled disaster. “There is arumor of the physics major who stayedup three nights in a row and left hisexam confident of an ‘A,’ ” said the paper.“Actually, he had filled the blue bookwith nothing but his name, written overand over.”

If a student “takes a little too much,he will fall into a delusional or ‘euphoric’state, in which he does everything wrongwithout ever realizing it,” a health pro-fessor told The Crimson. 32

TREATING ADHD

A s a double major at Rhode Island’s Brown University,“Sarah” (not her real name) takes a rigorous course loadto ensure she’ll graduate within four years. Not only that,

but she engages in summer internships and plans to study abroadin the fall.

To keep it all going, Sarah, a senior, admits to taking Adder-all, a highly addictive amphetamine, twice a week, which sheobtains without a prescription from fellow students, whose doc-tors prescribed it for attention deficit hyperactivity disorder(ADHD).

Illicitly obtained prescription stimulants increasingly are usedas study aids — and sometimes to get high — on college cam-puses. Research conducted at 119 U.S. colleges in 2001 foundthat, on average, one in 25 students had used Adderall or an-other prescription stimulant in the past year, with a dozenschools reporting a 10 percent or higher usage rate. 1 Six yearslater, a study at a large, public research university found thatabout one in three students said they had illegally used Adder-all or some other prescription stimulant. 2

Sales of Adderall, in a class of stimulants known colloqui-ally as “speed,” are regulated because the drug is classified bythe U.S. Drug Enforcement Administration as a Schedule II sub-stance, meaning it has a high potential for abuse and psycho-logical and physical dependence.

However, it is readily available for about $3 to $10 per pillfrom other students, according to Sarah, although prices riseduring midterms and finals, when “people are rushing to getit. It’s almost a desperation.” 3

Darlene Trew Crist, director of news and communication atBrown, says the university is aware that some students are abus-ing Adderall and that those caught illegally distributing drugs at

Brown are subject to immediate suspension or expulsion. Casesof simple possession of Adderall and other drugs by studentsare handled on a case-by-case basis. Many students claim pre-scription stimulants help them stay awake all night without fa-tigue, providing them with crucial endurance in a competitivecollege atmosphere.

Sarah says she first used Adderall during the summer be-fore she entered Brown. After procrastinating on a summerreading assignment until the last day, she says, she took thedrug at a friend’s recommendation. “I finished the assignmentso quickly, it was shocking,” she recalls.

During her sophomore year, she began using the drug regularly— usually twice a week. Each of her classes required massive amountsof reading, sometimes eight to 12 hours at a stretch. Sarah describesAdderall as a “robotic drug” that makes her so focused on school-work that she forgets to eat, drink and go to the bathroom.

One academic study found that many students excuse theirillegal use of Adderall by claiming not to use the drug recre-ationally. In addition, the study found, many students view itas safer than street drugs such as cocaine and ecstasy becauseAdderall is a prescription medicine manufactured under gov-ernment supervision. 4

Even students who say they don’t take the drug defend itsuse. Josh Lundfelt, a recent Ohio University graduate in actuarialscience, says people exaggerate Adderall’s harmfulness. “Peoplemake it out to be some horrible thing, but it’s just an aid toaccelerate your [academic] process,” he says.

However, ADHD drugs may not give the boost to academicperformance that students think they provide. According to a2012 analysis of data on more than 1,200 students conductedby researchers from the University of Maryland, using ADHD

Students Abuse ADHD Drugs as Study AidsExperts warn of potentially dangerous consequences.


Under the Influence?

T hroughout this period, Benzedrine’smanufacturer, the Philadelphia firm

Smith, Kline & French, sent many sam-ples of the drug to physicians aroundthe country, to test as a treatment forvarious conditions. As early as 1937Charles Bradley, a psychiatrist at a RhodeIsland institution for children with severeneurological and emotional problems, wastesting the drug as a mental-performanceenhancer. In the process, he discoveredthat it made many children calmer andeasier to work with.

Stimulants were not sold commer-cially as hyperactivity treatments untila quarter-century later, however.

In 1961, Ritalin — methylphenidate— was formulated as a stimulant sim-ilar to amphetamine but somewhatgentler and with fewer side effects.At the same time, the diagnosis ofhyperactivity was first being appliedto significant numbers of childrenwho, unlike Bradley’s patients, werenot seriously ill. Ritalin soon gainedpopularity as the treatment of choicefor the new diagnosis.

Only in the late 1950s did researchersbegin turning up evidence that stimu-

lant drugs can be highly addictive anddangerous. 33 As a result, in the 1960s,for the first time, the government beganrequiring prescriptions for amphetamineand other stimulant drugs. Despite thesenew restrictions, however, stimulantsremained popular mood lifters and per-formance enhancers, both as pre-scribed by physicians and illegally.

By the late ’60s, one in 20 Ameri-can adults had a prescription for a stim-ulant, and “at least half as many wereusing ‘speed’ without prescriptions —altogether around 10 million people,equal to the entire combined popula-tions of New York and Philadelphia at

drugs without a prescrip-tion actually correlates tohaving a lower grade-pointaverage. 5

Moreover, Adderall canhave serious side effects.Food is “displeasing, evennauseating” when she isusing the drug, Sarah says.Her weight dropped from110 pounds to 97 during herjunior year.

She also experiences light-headedness, headaches, de-hydration and an irresistible desire to smoke cigarettes whileon Adderall. “I’d go through a pack every two days,” she says,adding that when she isn’t taking the drug she smokes onlyoccasionally.

David Goodman, a psychiatrist who is founder and directorof the Adult Attention Deficit Disorder Center of Maryland, inBaltimore, says Adderall can be deadly if taken by students withundiagnosed cardiac conditions that could result in an irregularheartbeat or even death.

Doctors and students must take responsibility for controllingAdderall abuse, Goodman says. Because of the drug’s popu-larity with college students who don’t have ADHD, he tells stu-dents who come to him for prescriptions that he feels he firstmust call their parents to find out whether they showed signsof ADHD in childhood. “The fakers tend not to want to in-volve the parent,” he says.

Goodman says he also warns patients that selling or giv-

ing away prescription medi-cine is a felony. In Washing-ton, D.C., for example, dis-tributing Adderall is punishableby up to five years in prisonand a $50,000 fine. TakingAdderall without a prescription,on the other hand, is a mis-demeanor, punishable by upto 180 days in jail and a $1,000fine. 6 Distributing Adderall inRhode Island is punishable byup to 30 years in prison anda $100,000 fine. 7

— Kate Irby

1 Sean Esteban McCabe, John R. Knight, Christian J. Teter and Henry Wechsler,“Non-medical use of prescription stimulants among US college students: preva-lence and correlates from a national survey,” Harvard School of Public Health,2005, www.hsph.harvard.edu/cas/Documents/stimulants/McCabe_2005.pdf.2 Alan D. DeSantis and Audrey Curtis Hane, “‘Adderall is Definitely Not a Drug’:Justifications for the Illegal Use of ADHD Stimulants,” Substance Use & Misuse,45:31-46, Informa Healthcare USA, 2010, p. 34, http://andrewvs.blogs.com/files/adderall-is-definitely-not-a-drug.pdf.3 For background, see Michelle Trudeau, “More Students Turning Illegally to‘Smart’ Drugs,” NPR, Feb. 5, 2009, www.npr.org/templates/story/story.php?storyId=100254163.4 DeSantis and Hane, op. cit., p. 36.5 Laura M. Garnier-Dykstra, et al., “Nonmedical Use of Prescription StimulantsDuring College: Four-year Trends in Exposure Opportunity, Use, Motives andSources,” Journal of American College Health, March 15, 2012, pp. 226-234.6 DC Official Code, 2001 Edition, § 48-904.01.7 Rhode Island Official Code, Uniform Controlled Substances Act § 21-28-4.01,http://webserver.rilin.state.ri.us/Statutes/TITLE21/21-28/21-28-4.01.HTM.

The stimulant Adderall — a form of “speed” — is classifiedas a Schedule II substance because of its high potential for

abuse and psychological and physical dependence.

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TREATING ADHD

the time,” wrote Ras-mussen. Stimulantabuse was the lead-ing drug problem ofthe day. 34

The 1970 Com-prehensive DrugAbuse Preventionand Control Act,signed into law byPresident Richard M.Nixon, placed re-strictions on pre-scription stimulantsalong with otherdrugs, and by thelate 1970s stimulantabuse had subsided.

The use of stim-ulants to treat chil-dren with ADHDwas just beginningits long ascent, how-ever.

In 1969, at theheight of the nation’sbiggest stimulant epidemic, U.S. drugcompanies manufactured about 2.5 bil-lion standard doses of prescription stim-ulants annually, according to Rasmussen.That amount dropped off substantiallyin the 1970s, but then, as the ADHDdiagnosis gained steam, it began risingagain, first gradually but then steeply,beginning in the mid-1990s.

Between 1998 and 2009, the per-centage of children between ages 5 and17 who had been diagnosed withADHD increased from 6.9 percent toaround 9 percent. 35 Meanwhile, “Amer-ica’s annual consumption of pharma-ceutical “speed” has risen almost ten-fold since 1995,” and in 2005 it exceededthe number of doses being producedin 1969, Rasmussen said. 36

In many ways, that’s a medical suc-cess story, some ADHD experts say.

Many parents are hesitant to ex-pose young children to long-term pre-scription drug use but change theirminds when they discover that otherapproaches they try don’t quell symp-

toms, says Quinn, the Washington pe-diatrician. “It’s the most difficult thingin the world to put a kid on med-ications,” she says. But “often the fam-ilies try other things” — such as elim-inating sugar from a child’s diet— “and then they come back.” Evennon-drug therapies that do work, suchas behavior-modifying techniques, workbetter when used alongside medica-tions, she says.

But others worry that the rising rateof ADHD diagnosis — and the near-total reliance on drug therapy — isdriven as much by drug company in-fluence as by medical understanding.

At most, only one in 10 familieswith an ADHD child receives parentaltraining on managing the condition,but nine in 10 children diagnosed withADHD get drugs, says Florida Inter-national’s Pelham. “Mainly the teachercomplains to the parent, the parentgoes to the pediatrician, who’s nottrained to do a full screen” for ADHD,and the simple, well-publicized drug

fix is prescribed, he says.“In recent years, I

have come to believethat the individualswho advocate moststrongly for medication— both those from theprofessional communi-ty, including the NationalInstitutes of MentalHealth, and those fromadvocacy groups — . . .have major and undis-closed conflicts of in-terest with the pharma-ceutical companies,”Pelham said in 2004. 37

But virtually all med-ical researchers maintainthat they are not influ-enced by pharmaceuticalcompany funding be-cause as academics theirprimary interest is in un-covering facts. “My in-terests are solely in the

advancement of medical treatmentthrough rigorous and objective study,”and conflict-of-interest issues are some-thing to be taken “very seriously,” saidHarvard Medical School psychiatry pro-fessor Joseph Biederman, an ADHD ex-pert who was sanctioned by the schoolin 2011 for failing to disclose some pay-ments he got from drug companies. 38

The nonprofit disease-advocacygroup Children and Adults with At-tention Deficit/Hyperactivity Disor-der (CHADD) says that it is “com-mitted to avoiding conflict of interestor even its appearance in acceptingfinancial support from corporations”with an interest in promoting ADHD-related products. To that end, “forany . . . fiscal year, no more than30 [percent] of CHADD’s revenue canbe derived from donations and grantsfrom pharmaceutical companies,”and the group will accept donationsfor education and information cam-paigns only if it has “complete edi-

Continued on p. 686

ADHD is no barrier to success. Swimmer Michael Phelps, the mostdecorated Olympic athlete of all time, Grammy-winning pop singer Justin

Timberlake and movie star Jim Carrey, for example, all suffer from thecondition. Diagnosed at age 9, Phelps stopped taking medication in

seventh grade. His highly structured life as an athlete in training helpedkeep his symptoms in check, said his mother. “ADHD kids have greatpassion. It just needs to be funneled,” said Debbie Phelps, who used

intense behavioral therapy to help her son. Above, Phelps after winninghis 19th Olympic medal at the London Summer Games on July 31.

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At Issue:Are ADHD and artificial food dyes linked?yes

yesMICHAEL F. JACOBSONEXECUTIVE DIRECTOR, CENTER FORSCIENCE IN THE PUBLIC INTEREST

WRITTEN FOR CQ RESEARCHER, JULY 2012

w ithout question, food dyes serve a very useful pur-pose for food manufacturers. They make a wide vari-ety of low-nutrition junk foods — candy, soft drinks,

sugary cereals — more appealing to children. Dyes can help dis-guise the absence of healthy fruit and vegetable ingredients in aproduct expected to include them, as was the case in a nearlyavocado-free “guacamole” dip Kraft used to sell. But given thatthey provide no nutritive or preservative function, food dyes havequite a high bar to clear when it comes to their safety.

Thanks to numerous controlled studies conducted in theUnited States, Europe and Australia, we now know that Yellow 5, Red 40, Blue 2 and other petroleum-based fooddyes have a powerfully disruptive impact on some children’sbehavior.

A comprehensive 2004 meta-analysis of the medical litera-ture and two important studies funded by the British govern-ment found that dyes (and possibly the preservative sodiumbenzoate) adversely affect kids’ behavior. These studies sup-port what many parents who have placed their hyperactivechildren on a diet developed by allergist Benjamin Feingoldhave discovered: that eliminating foods with artificial dyes(and in other cases, other foods) leads to marked improve-ment in behavior and performance in school.

In 2008, the Center for Science in the Public Interest calledon the Food and Drug Administration (FDA) to ban severaldyes. At a follow-up 2011 hearing, the FDA agreed that dyesdo adversly affect some children.

European food-safety officials are several steps ahead of theFDA and have successfully spurred positive changes in theindustry. Thus, a strawberry sundae from a McDonald’s in theU.K. gets its red color from strawberries; McDonald’s treats itsU.S. consumers to strawberries and Red 40.

As it happens, safe natural colorings are abundant. (NoEuropean consumers seem to miss the fake ones.) Getting ridof food dyes here would certainly be a safer step than dealingwith hyperactivity or other behavioral problems in childrenwith powerful stimulant drugs such as Ritalin. (Irony alert:Some Ritalin pills have Green 3.)

The question I pose to American food-safety regulators andcompanies is why tolerate any risk, even in just a small per-centage of children, from something that serves only a cos-metic purpose in food?no

SARAH MECHUMINTERNATIONAL ASSOCIATION OF COLORMANUFACTURERS

WRITTEN FOR CQ RESEARCHER, JULY 2012

t he scientific evidence does not support the claims madeby the Center for Science in the Public Interest and otherslinking synthetic color additives and hyperactive behavior

in children. Reviews of several studies on hyperactivity and syn-thetic food color conducted by U.S. experts and internationalregulatory bodies have found no correlation between the intakeof synthetic food colors and hyperactivity among children.

Just last year, the FDA Food Advisory Committee, an expertpanel of pediatricians, toxicologists, behavioral scientists, neuro-scientists and food scientists, reviewed all of the available evi-dence and concluded there is no established causal relationshipbetween color additives and hyperactivity in children. The com-mittee voted against recommending additional labeling beyondthe name of the color but agreed additional studies are warrant-ed. The International Association of Color Manufacturers supportsthe committee’s conclusions. We are currently conducting a studyto further improve the understanding of color additive consump-tion, and the results will be shared with the FDA.

The color industry takes its responsibility for consumersafety seriously. In addition to complying with FDA regulationsand procedures for certification of colors, the industry alsosponsors many safety studies, the results of which have beenevaluated by the FDA and international regulatory bodies, in-cluding the Joint Expert Committee on Food Additives and theEuropean Food Safety Agency. The transparent safety-evaluationprocess includes commentary from all stakeholders, includingregulators, consumers, public health advocates and industry.These studies confirm the safety of FDA-certified colors, andas a result, various coloring additives have been approved foruse in food, beverages and other products around the world.

While they are not nutritional, color additives play an impor-tant role in food, and they do so without posing a health riskto consumers. Color is one of the principal contributors to thepalatability of foods. Color additives enhance colors that occurnaturally, correct natural variations in color and provide a color-ful identity to foods that would otherwise be virtually colorless.Additionally, they provide a means to identify drugs and dietarysupplements, helping to prevent medication errors.

Our industry is vigilant about the safety of our products,and we will continue to stay on top of new scientific devel-opments related to color additive safety. We will continue towork closely with regulatory authorities around the world toensure that food colors are safe.

686 CQ Researcher

torial and managerial control” of theprojects. 39

In his own pharmaceutical-sponsoredresearch, Pelham said he was pres-sured to delete a portion of an ar-ticle being prepared for publication“where I was saying it was impor-tant to do combined treatments(medication and behavioral)” ratherthan drugs alone. “It was intimidat-ing to be one researcher and haveall these people pushing me tochange the text.” 40

Such qualms have been reinforcedin the past few years as Biedermanand two other leading ADHD experts,all in the psychiatry department ofHarvard Medical School, have facedsanctions over failure to disclose pay-ments they’ve received as consultantsto drug companies. NIH requires re-searchers it supports to report to theiruniversities any outside earnings of$10,000 a year or more, in a bid tomake transparent conflicts of interestthat may shade the researchers’ find-ings. In 2008, Sen. Charles Grassley,R-Iowa, announced that he’d discov-ered serious under-reporting of incomeby Biederman and Harvard professorTimothy Wilens and associate profes-sor Thomas Spencer. Based on themen’s disclosure documents, “over thelast seven years, it looked like theyhad taken a couple hundred thousanddollars” from drug companies, whenin fact they had received over a mil-lion dollars each, Grassley said. 41

In 2011, Harvard Medical Schooland Massachusetts General Hospital,where the three are also employed,announced that they were barredfrom all industry-sponsored outsideactivities for a year, followed by atwo-year probationary period duringwhich they would need approval forsuch work. 42

The conflicts of interest in the caseinvolved mostly the psychiatrists’ pro-motion of increased diagnosis of anddrug treatment for more severe child-

hood psychiatric illness than ADHD,such as bipolar disease. But the men’sworldwide prominence as ADHD re-searchers raised questions for manyabout drug-company influence in thatfield. An Australian government panelordered a review of ADHD-treatmentguidelines being prepared for thecountry’s national health insuranceprogram following the investigation.At the time, the draft guidelines re-ferred to Biederman’s research 50 times,while seven of the 10 people on Aus-tralia’s guideline-drafting panel alsohad financial ties to companies suchas Swiss-based Ritalin manufacturerNovartis. 43

Meanwhile, it has remained difficultfor researchers to get funding to studybehavioral therapies and other non-drug approaches. Pelham, for exam-ple, is currently pursuing a federal grantto explore the limitations of drug treat-ments. He’d prefer to do a study onnon-drug therapies, he says, “but NIHdoesn’t fund those.”

CURRENTSITUATION

Numbers Rise

T he total number of drug prescrip-tions written for U.S. children and

teens has dropped for the past sever-al years, but the rate of ADHD pre-scriptions continues to climb, accord-ing to the Food and Drug Administration.

ADHD prescriptions rose 46 per-cent between 2002 and 2010 (the lat-est year examined), the second-highestincrease of any category. Contracep-tive prescriptions increased 93 percent,while prescriptions for antibiotics andsome cough medicines dropped, afternew medical guidelines recommendedlimiting their use. 44

Driving the increase in ADHD pre-scriptions has been a steady rise in thenumber of young people under age 18diagnosed with the disorder. It grew66 percent between 2000 and 2010, ac-cording to a study this year by researchersat Northwestern University. By 2010, doc-tors had diagnosed 10.4 million U.S. chil-dren and teens, up from 6.2 million in2000, according to the analysis. 45 (Thenumber of Americans ages 5 through17 — the prime ages for an ADHDdiagnosis — hovered between 53 and54 million in both years.) 46

“The magnitude and speed of thisshift in one decade is likely due toan increased awareness of ADHD,” saidstudy author Craig Garfield, an assis-tant professor of pediatrics at the North-western University Feinberg School ofMedicine. 47

Changing Policies

L ate last year, the American Acad-emy of Pediatrics expanded its

ADHD diagnosis guidelines to coverchildren and teens from ages 4 to 18;earlier guidelines had covered onlychildren between 6 and 12. New med-ical findings about ADHD make it pos-sible to diagnose and treat the broad-er group, says the academy.

“Treating children at a young age”may “increase their chances of suc-ceeding in school,” said Mark Wolraich,lead author of the guidelines and a re-searcher on neural development at theUniversity of Oklahoma Health SciencesCenter, in Oklahoma City. 48

As for teens, “it’s been known for awhile” that stopping ADHD drugs at pu-berty — as recommended in the past —“was a mistake” and that attention prob-lems, in particular, still plague teenagers,says the University of Illinois’ Stein.

In the past year, the supply of sev-eral ADHD drugs has fallen short of de-mand. Besides the growing legitimatemarket, demand is swelling for stimu-lants as performance enhancers or recre-

TREATING ADHD

Continued from p. 684


ational drugs. Because stimulants are“controlled substances,” the Drug En-forcement Agency (DEA) caps theamount that companies can produce,and the combined legitimate and ille-gal demand has outstripped supply. 49

“The DEA is tasked with makingsure there is enough for legitimate needwithout making so much [that] it is di-verted for illicit purposes,” said agencyspokesperson Barbara Carreno. Thisyear, DEA has raised the cap formethylphenidate, the basis for suchdrugs as Ritalin and Concerta, from50,000 to 56,000 kilograms per yearand the cap for amphetamine, usedin drugs such as Adderall, from 18,600to 25,300 kilograms per year. 50

Meanwhile, implementing schoolprocedures that assist both ADHD stu-dents and their teachers continues tobe difficult.

Federal legislation is pending to limitschools’ leeway in using physical re-straints and seclusion to control stu-dents, often those with ADHD-relatedtraits. The bills — sponsored by Sen.Tom Harkin, D-Iowa, and Rep. GeorgeMiller, D-Calif. — would prohibitschools that receive federal funds fromphysically restraining a student unlessthe behavior poses immediate physi-cal harm to the student or others. Re-straints can be used only if they allowthe student to communicate, and ifother means of controlling the behaviorhave been tried and failed. 51

Many advocates for the disabledsupport the bills, but schools are leery.The legislation proposes “an extreme-ly high threshold” that schools mustmeet before restraints are allowed, saidthe National School Boards Association.For example, a student whose behav-ior threatens “to destroy a classroom”— a costly consequence — would notbe eligible for restraint under the billsas currently drafted, the group said. 52

A recent study by the Chicago Tri-bune points to serious inequities be-tween schools in high- and low-incomeneighborhoods when it comes to mak-

ing accommodations to help ADHDsufferers and other disabled students.Federal law authorizes schools tomake certain adjustments — such asallowing seating in the front of the class-room or providing more time to taketests — to create a level playing fieldfor all students. However, the Tribunefound that Illinois students who livein higher-income districts got the lion’sshare of such help. 53

Statewide, only about 1 percent ofpublic-school students had accommoda-tions in the 2009-2010 school year, ac-cording to the paper. But in some wealthydistricts near Chicago, 4 to 5 percent ofstudents got accommodations. The 20school districts with the highest percent-ages of students with accommodationshad student bodies that were 76 percentwhite and poverty rates well below thestate average of 45 percent; the 20 dis-tricts with the fewest accommodationswere 19 percent white, and the “vast ma-jority had far higher poverty than the stateaverage,” the Tribune reported. 54

OUTLOOKDebate Continues

W ith attention growing on ADHDin adults, teens, preschool chil-

dren and girls, diagnoses will likelyincrease for the foreseeable future.Many clinicians hope science can even-tually clear up doubts that ADHD isa “real” disorder, but others want re-searchers to take a closer look at thesocial trends, such as increasing com-petitiveness, that lead people to seekachievement-enhancing drugs.

Improvements in brain-imaging tech-nology provide hope that it eventual-ly can diagnose ADHD, says Israel,the San Francisco psychiatrist. Brainimages showing clear patterns of aber-rant activity in ADHD patients could

go a long way toward “clearing upthe uncertainty and discomfort peoplehave around the diagnosis,” he says.

Studying genetic profiles also mayeventually yield valuable information,Israel says. In particular, profiles thatshow variations among groups ofADHD sufferers may help to “matchthe right person to the right medica-tions” without trial and error.

The American Psychiatric Associa-tion plans to release the DSM-5 in May2013. 55 Current DSM guidelines statethat, to warrant an ADHD diagnosis,a patient must show symptoms byage 7, a threshold that the DSM-5 willraise to age 12. Drafters say recent re-search shows that people whosesymptoms appear by age 7 aren’t anydifferent from people who don’t ex-hibit them until later. Moreover, theysay raising the threshold will make iteasier to diagnose adults, who seldomremember what they were like beforeage 7 but do remember what theywere like as 12-year-olds. 56

But some medical professionalsworry the change will increase thealready skyrocketing rates of ADHDdiagnosis and expose too many peopleto “inappropriate treatment and stigma-tization” said Frances, the Duke profes-sor emeritus. 57

Perhaps most in need of examina-tion, however, is a culture that valuesachievement to the point that it drives“increasing use of stimulant drugs forenhancement, even among the gener-al population,” says Diller, the Cali-fornia pediatrician.

Notes

1 Daniel F. Connor, “Problems of Overdiag-nosis and Overprescribing in ADHD,” Psychi-atric Times, Aug. 11, 2011, www.psychiatrictimes.com/adhd/content/article/10168/1926348.2 “Attention Deficit/Hyperactivity Disorder,Data and Statistics,” Centers for Disease Con-trol and Prevention, www.cdc.gov/ncbddd/adhd/data.html.

688 CQ Researcher

3 Connor, op. cit.4 “Attention Deficit/Hyperactivity Disorder,”op. cit.5 Ibid.6 Peter Breggin, “Stimulants for ADHD Shownto Cause Sudden Death in Children,” Huffing-ton Post, June 17, 2009, www.huffingtonpost.com/dr-peter-breggin/stimulants-for-adhd-shown_b_216912.html.7 For background see Thomas J. Billitteri,“Preventing Bullying,” CQ Researcher, Dec. 10,2010, pp. 1013-1036; updated May 31, 2012.8 Marianne Szegedy-Maszak, “Psychological Sci-ence Weighs in on ADHD,” Daily Observa-tions blog, Association for Psychological Sci-ence, June 25, 2012, www.psychologicalscience.org/index.php/publications/observer/obsonline/psychological-science-weighs-in-on-adhd.html.9 Nicolas Rasmussen, On Speed: The ManyLives of Amphetamine (2008), p. 236.10 Peter Conrad, “The Changing Social Reality ofADHD,” Contemporary Sociology, Oct. 1, 2010,p. 525.11 Katrin Bruchmüller, Jürgen Margraf and Sil-via Schneider, “Is ADHD Diagnosed in Accordwith Diagnostic Criteria? Overdiagnosis andInfluence of Client Gender on Diagnosis,”Journal of Consulting and Clinical Psychology,February 2012, pp. 128-138, http://psycnet.apa.org/index.cfm?fa=buy.optionToBuy&id=2011-30100-001.12 M. Huss, et al., “How Often Are GermanChildren and Adolescents Diagnosed with ADHD?Prevalence Based on the Judgment of HealthCare Professionals: Results of the GermanHealth and Examination Study,” European Childand Adolescent Psychiatry, December 2008,www.ncbi.nlm.nih.gov/pubmed/19132304.13 Randy Dotinga, “Youngest Kids in Class MoreApt to Get ADHD Diagnosis: Study,” Health-Day, Healthfinder.gov, March 2012, http://healthfinder.gov/news/newsstory.aspx?docID=662425; Richard L. Morrow, et al., “Influence

of Relative Age on Diagnosis and Treatmentof Attention-Deficit/Hyperactivity Disorder inChildren,” CMAJ [Canadian Medical Associa-tion Journal], March 5, 2012, www.cmaj.ca/content/184/7/755.abstract.14 Rick Nauert, “Youngest Kids in Class GetMore ADHD Diagnosis, Drugs,” PsychCentral,March 6, 2012, http://psychcentral.com/news/2012/03/06/youngest-kids-in-class-get-more-adhd-diagnoses-drugs/35621.html.15 “Strattera Oral,” WebMD, www.webmd.com/drugs/drug-64629-Strattera+Oral.aspx?drugid=64629&drugname=Strattera+Oral; Monitoringthe Future, University of Michigan, 2011, pp.499-501, http://monitoringthefuture.org/pubs/monographs/mtf-vol1_2011.pdf.16 “The Multimodal Treatment of AttentionDeficit Hyperactivity Disorder Study (MTA):Questions and Answers,” National Institute ofMental Health website, November 2009, www.nimh.nih.gov/trials/practical/mta/the-multimodal-treatment-of-attention-deficit-hyperactivity-disorder-study-mta-questions-and-answers.shtml.17 William O. Cooper, Laura A. Habel, et al.,“ADHD Drugs and Serious Cardiovascular Eventsin Children and Young Adults,” New EnglandJournal of Medicine, Nov. 23, 2011, pp. 1896-1904, www.nejm.org/doi/full/10.1056/NEJMoa1110212.18 Laura A. Habel, William O. Cooper, et al.,“ADHD Medications and Risk of Serious Car-diovascular Events in Young and Middle-AgedAdults,” JAMA, Dec. 28, 2011, pp. 2673-2683,www.ncbi.nlm.nih.gov/pubmed/22161946.19 “Controlled Substance Schedules,” U.S. DrugEnforcement Administration, www.deadiversion.usdoj.gov/schedules/index.html.20 “Methylphenidate (Ritalin),” U.S. Drug En-forcement Administration, www.justice.gov/dea/concern/methylphenidate.html.21 “Warnings on Packages and Advertising,”Article 10, Convention on Psychotropic Sub-stances, 1971, p. 7, www.unodc.org/pdf/convention_1971_en.pdf.

22 Cease-and-desist order from U.S. DEA toCelltech Pharmaceuticals, purveyor of thecontrol substance methylphenidate, websiteof Ben Hansen, www.bonkersinstitute.org/medshow/kiddealetter.html; Karen Thomas,“Back to School for ADHD Drugs,” USAToday, Aug. 8, 2001, www.usatoday.com/life/2001-08-28-adhd.htm.23 Ed Silverman, “FDA Warns Five Drug-makers Over ADHD Ads,” Pharmalot blog,Sept. 26, 2008, www.pharmalot.com/2008/09/fda-warns-five-drugmakers-over-adhd-ads; Mar-guerite R. Lombardo, “Through the CorrectLens: Understanding Overprescription of Stim-ulant Drugs, Their Abuse, and Where theRemedies Lie,” student paper, Harvard LawSchool, April 2004, http://leda.law.harvard.edu/leda/data/674/Lombardo.html#fn274; Kevin P.Miller, “FDA Warns ADHD Drugmakers —Again,” Kevin P. Miller blog, Sept. 29, 2008,http://kevinpmiller.blogspot.com/2008/09/fda-warns-adhd-drugmaker-again.html.24 “Guidance for Industry Direct-to-ConsumerTelevision Advertisements — FDAAA DTC Tele-vision Ad Pre-Dissemination Review Program,”Food and Drug Administration, March 2012,www.fda.gov/downloads/Drugs/Guidance-ComplianceRegulatoryInformation/Guidances/UCM295554.pdf.25 Peter R. Breggin, “A Misdiagnosis, Any-where,” Room for Debate blog, The New YorkTimes, Oct. 13, 2011, www.nytimes.com/roomfordebate/2011/10/12/are-americans-more-prone-to-adhd/adhd-is-a-misdiagnosis.26 Ibid.27 For background, see Kathy Koch, “Re-thinking Ritalin,” CQ Researcher, Oct. 22,1999, pp. 905-928.28 “Types of ADHD: Making the Diagnosis,”WebMD, May 15, 2012, www.webmd.com/add-adhd/guide/types-of-adhd.29 Allen Frances, “Attention Deficit Disorder IsOver-diagnosed and Over-treated,” HuffingtonPost, March 5, 2012, www.huffingtonpost.com/allen-frances/attention-deficit-disorder_b_1206381.html.30 Ibid.31 Rasmussen, op. cit., p. 3.32 “Benzedrine-soaked Crammers May WindUp Behind an ‘E,’ Bock Warns,” The HarvardCrimson, Jan. 24, 1948, www.thecrimson.com/article/1948/1/24/benzedrine-soaked-crammers-may-wind-up-behind.33 Rasmussen, op. cit., p. 3.34 Ibid., p. 4.35 Lara K. Akinbami, et al., “Attention DeficitHyperactivity Disorder Among Children Aged

TREATING ADHD

About the AuthorStaff writer Marcia Clemmitt is a veteran social-policy re-porter who previously served as editor in chief of Medi-cine & Health and staff writer for The Scientist. She hasalso been a high school math and physics teacher. Sheholds a liberal arts and sciences degree from St. John’sCollege, Annapolis, and a master’s degree in English fromGeorgetown University. Her recent reports include “Trau-matic Brain Injury” and “Sleep Deprivation.”


5-17 Years in the United States, 1998-2009,” Na-tional Center for Health Statistics, August 2011,www.cdc.gov/nchs/data/databriefs/db70.PDF.36 Rasmussen, op. cit., p. 236.37 Quoted in “Leading ADHD Researcher BlowsWhistle on Concerta and Chadd,” Alliance forHuman Research Protection website, Dec. 3,2004, www.ahrp.org/infomail/04/12/03.php.38 Quoted in Gardiner Harris and BenedictCarey, “Researchers Fail to Reveal Full DrugPay,” The New York Times, June 8, 2008, www.nytimes.com/2008/06/08/us/08conflict.html?pagewanted=all.39 “CHADD Ethical Principles for Acceptanceof Corporate and Foundation Support,” www.chadd.org/AM/Template.cfm?Section=Home&section=Privacy_Policy&template=/CM/ContentDisplay.cfm&ContentFileID=1334.40 Quoted in Kelly Hearn, “Here, Kiddie, Kiddie,”AlterNet, Nov. 29, 2004, www.alternet.org/story/20594?page=entire.41 Quoted in Harris and Carey, op. cit.42 Xi Yu, “Three Professors Face SanctionsFollowing Harvard Medical School Inquiry,”The Harvard Crimson, July 2, 2011, www.thecrimson.com/article/2011/7/2/school-medical-harvard-investigation.43 Nicola Berkovic, “Urgent Review to be Un-dertaken of ‘Tainted’ ADHD Guidelines,” TheAustralian, Nov. 24, 2009, www.theaustralian.com.au/news/urgent-review-to-be-undertaken-of-tainted-adhd-guidelines/story-e6frg6n6-1225802595063.44 Grace Chai, et al., “Trends of OutpatientPrescription Drug Utilization in U.S. Children,2002-2010,” Pediatrics, July 2012, http://pediatrics.aappublications.org/content/130/1/23.full.pdf+html.45 Erin White, “Diagnosis of ADHD on theRise,” press release, Northwestern University,March 19, 2012, www.northwestern.edu/newscenter/stories/2012/03/adhd-diagnosis-pediatrics.html.46 “Resident Population by Sex and Age: 1980to 2010,” Table 7, Statistical Abstract of theUnited States, 2012, U.S. Census Bureau, www.census.gov/compendia/statab/2012/tables/12s0007.pdf.47 Quoted in White, op. cit.48 Quoted in “American Academy of PediatricsExpands Ages for Diagnosis and Treatment ofADHD in Children,” press release, AmericanAcademy of Pediatrics, Oct. 16, 2011, www.aap.org/en-us/about-the-aap/aap-press-room/pages/AAP-Expands-Ages-for-Diagnosis-and-Treatment-of-ADHD-in-Children.aspx.49 Daniel J. DeNoon, “ADHD Drug Shortages:

Why?” WebMD, Jan. 3, 2012, www.webmd.com/add-adhd/news/20120103/adhd-drug-shortages-why.50 Ibid.51 “S. 2020: Keeping All Students Safe Act,”govtrack.us, www.govtrack.us/congress/bills/112/s2020.52 “Statement for the Record: Beyond Seclu-sion and Restraint: Creating Positive LearningEnvironments for All Students,” National SchoolBoards Association, July 12, 2012, www.nsba.org/Newsroom/Spotlight-On/NSBA-Statement-for-the-Record-on-Senate-Committee-Hearing-on-Keeping-All-Students-Safe-Act-July.pdf.53 Diane Rado, “Special Help Starts as Early asGrade School — but Only for Select Students,”Chicago Tribune, June 6, 2012, http://articles.

chicagotribune.com/2012-06-06/news/ct-met-accommodations-folo-20120606_1_disabled-students-time-or-other-accommodations-poorest-schools.54 Ibid.55 “DSM-5: The Future of Psychiatric Diag-nosis,” American Psychiatric Association, www.dsm5.org/Pages/Default.aspx.56 “Rationale for Changes in ADHD in DSM-5,”American Psychiatric Association ADHD andDisruptive Behavior Disorders Workgroup,May 3, 2012, www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=383#.57 Allen Frances, “DSM 5 Continues to Ig-nore Criticism From Petitioners,” HuffingtonPost, June 20, 2012, www.huffingtonpost.com/allen-frances/dsm-5-petition_b_1610569.html.

FOR MORE INFORMATIONADDitude, www.additudemag.com/adhd/about-additude.html. Advertising-supportedwebsite that provides information about ADHD.

American Academy of Child and Adolescent Psychiatry, 3615 Wisconsin Ave.,N.W., Washington, DC 20016-3007; 202-966-7300; www.aacap.org. Membershipgroup for psychiatrists that monitors legislation and policy activities related tochildren’s mental health.

Centers for Disease Control and Prevention, Attention-Deficit/HyperactivityDisorder, 1600 Clifton Rd., Atlanta, GA 30333; 800-232-4636; www.cdc.gov/ncbddd/adhd. Federal website that posts data and medical information on ADHD.

CHADD (Children and Adults with Attention Deficit Hyperactivity Disorder),8181 Professional Place, Suite 150, Landover, MD 20785; 800-233-4050; www.chadd.org.Nonprofit membership group that provides information on ADHD; hosts the Na-tional Resource Center on ADHD, a federally funded national clearinghouse forevidence-based research on the condition.

DSM-5 Development, American Psychiatric Association, 1000 Wilson Blvd., Suite 1825,Arlington, VA 22209-3901; 703-907-7300; www.dsm5.org. Draft proposal and com-mentary on the next edition of the Diagnostic and Statistical Manual of MentalDisorders.

Feingold Association of the United States, 11849 Suncatcher Dr., Fishers, IN46037; 800-321-3287; www.feingold.org. Membership group for parents who try tocontrol hyperactivity in children by eliminating food additives from the diet.

Multimodal Treatment of Attention Deficit Hyperactivity Disorder Study,National Institute of Mental Health, 6001 Executive Blvd., Room 8184, MSC 9663,Bethesda, MD 20892-9663; 866-615-6464; www.nimh.nih.gov/trials/practical/mta/multimodal-treatment-of-attention-deficit-hyperactivity-disorder-mta-study.shtml.Federal information website for the largest study of ADHD treatments.

Russell A. Barkley: The Official Site, www.russellbarkley.org. Website of a pro-fessor of psychiatry and pediatrics at the Medical University of South Carolina whospearheaded movement to gain recognition for ADHD as a serious affliction withbiological causes.

FOR MORE INFORMATION

690 CQ Researcher

Selected Sources

BibliographyBooks

Barkley, Russell A., Taking Charge of Adult ADHD, TheGuilford Press, 2010.A clinical professor of psychiatry and pediatrics at the Med-

ical University of South Carolina describes the relatively newdiagnosis of adult ADHD along with drug and non-drugstrategies for managing it.

Brown, Richard P., and Patricia L. Gerbarg, Non-drugTreatments for ADHD: New Options for Kids, Adultsand Clinicians, W.W. Norton & Co., 2012.An associate clinical professor of psychiatry (Brown) at Co-

lumbia College of Physicians and Surgeons, in New YorkCity, and his wife, an assistant clinical professor of psychia-try at New York Medical College, describe a variety of com-plementary treatments such as dietary changes, herbs, vita-mins and mind-body techniques such as breathing exercises,to help manage ADHD.

Diller, Lawrence H., Remembering Ritalin: A Doctor andGeneration Rx Reflect on Life and Psychiatric Drugs,Perigee, 2011.A developmental pediatrician and assistant clinical profes-

sor of pediatrics at the University of California, San Francis-co, recounts the stories of 10 young adults he treated forhyperactivity as children. Diller reflects on whether ADHDis overdiagnosed and says the long-term prognosis for childrenwith the disorder is better than many believe.

Rasmussen, Nicolas, On Speed: The Many Lives of Am-phetamine, New York University Press, 2009.A professor of the history and philosophy of medicine at

Australia’s University of New South Wales chronicles the 100-plus year history of stimulant drugs as medicines, perfor-mance enhancers and intoxicants.

Reiff, Michael I., ed., ADHD: What Every Parent Needsto Know, 2nd Ed., American Academy of Pediatrics, 2011.Authors from a pediatricians’ professional group describe

the current medical thinking on ADHD.

Smith, Matthew, An Alternative History of Hyperactivity:Food Additives and the Feingold Diet, Rutgers UniversityPress, 2011.A research fellow at Britain’s University of Exeter says the

emergence of ADHD as a diagnosis in the post-World War IIera made it almost inevitable that some would ascribe itsorigins to the presence of chemical additives in food. Skep-tics and supporters of that hypothesis continue producingdueling — but ultimately inconclusive — research studieson the question.

Articles

Harris, Dan, and Lana Zak, “Supermom’s Secret Addiction:Stepping Out of Adderall’s Shadow,” ABC News, June 26,2012, http://abcnews.go.com/Health/adderall-rise-mothers/story?id=16622475.Middle-aged women, including a mother of four and a

nurse, say they became addicted to the ADHD drug Adder-all after taking it to enhance their performance in their jobsand as homemakers. Adderall use has risen quickly amongadult women, and experts believe many users are obtainingthe drug illegally, such as by “doctor shopping” among physi-cians to get multiple prescriptions.

Rabin, Roni Caryn, “Drugs to Treat ADHD Reach thePreschool Set,” The New York Times, Oct. 24, 2011, www.nytimes.com/2011/10/25/health/25consumer.html.The American Academy of Pediatrics has revised its ADHD

treatment guidelines, approving the addition of drugs topreschoolers’ ADHD treatment if behavioral techniques don’tquell their symptoms. The recommendation makes some par-ents and medical professionals leery, however.

Thurm, Wendy, “Is There an ADHD Epidemic in MajorLeague Baseball?”SBNation, June 29, 2012, http://mlb.sbnation.com/2012/6/29/3104332/is-there-an-adhd-epidemic-in-major-league-baseball.Eight percent of major league baseball players have been

diagnosed with ADHD and prescribed stimulant drugs. Butthe National Institutes of Health estimates that only 4 per-cent of adults have ADHD, and skeptics wonder whetherplayers are being diagnosed illegitimately. The drugs wouldotherwise be off-limits to them under baseball’s rules for-bidding performance-enhancing drugs.

Reports and Studies

“Monitoring the Future: National Results on AdolescentDrug Use,” National Institute on Drug Abuse/Universityof Michigan Institute for Social Research, February 2012,www.monitoringthefuture.org/pubs/monographs/mtf-overview2011.pdf.The latest edition of a long-running national survey on drug

use by high school students describes trends in abuse of theADHD drugs Ritalin, Concerta and Adderall.

“Teaching Children with Attention Deficit HyperactivityDisorder: Instructional Strategies and Practices,” U.S.Department of Education, 2008, www2.ed.gov/rschstat/research/pubs/adhd/adhd-teaching-2008.pdf.The Education Department describes how teachers can

identify children with ADHD and employ the best classroomstrategies to manage their behavior and help them learn.


Drugs

Bankston, Amanda, “Students Faking ADHD to Get Drugs,”Star Tribune (Minneapolis), Feb. 17, 2012, p. A1, www.startribune.com/local/139491333.html?refer=y.University of Minnesota students reportedly are faking ADHD

symptoms to obtain prescriptions for Adderall.

Ellison, Katherine, “Mother’s New Little Helper,” Los Ange-les Times, Jan. 13, 2012, p. A17.Experts say some young mothers are taking their children’s

prescription ADHD drugs to boost their productivity.

Martin, Richard, “ADHD Drugs Dwindle and ParentsScramble,” St. Petersburg (Fla.) Times (now Tampa BayTimes), Dec. 3, 2011, p. A1, www.tampabay.com/news/health/adderall-shortage-has-adhd-patients-parents-scrambling-for-answers/1204576.Doctors say growth in the number of ADHD cases is caus-

ing a shortage of a generic form of Adderall.

Non-Drug Treatments

Andazola, Matt, “Struggling to Focus,”Albuquerque (N.M.)Journal, July 25, 2011, p. C1, www.abqjournal.com/main/2011/07/25/health/struggling-to.html.Alternative ADHD therapies often are preferred to drugs

because they don’t have side effects such as appetite loss.

Manziello, Evelyn Gilbert, “New Approach to ADD, ADHD,”Poughkeepsie (N.Y.) Journal, Sept. 16, 2011.Diet, exercise and acupuncture are several ADHD treat-

ments that don’t involve drugs.

Yim, Michael, “ADHD — Can the Disorder Be TreatedWithout Medication?” The Explorer (Tucson, Ariz.), Feb. 29,2012, explorernews.com/northwest_chatter/article_33e0bf8c-6250-11e1-abcd-0019bb2963f4.html.Many parents of children diagnosed with ADHD prefer al-

ternative treatments.

Prevalence

Hellmich, Nanci, “ADHD Seen As Early As Age 4,” USAToday, Oct. 17, 2011, p. D4, www.usatoday.com/LIFE/usaedition/2011-10-17-Attention-Deficit_ST_U.htm.ADHD can be diagnosed in children as young as 4, ac-

cording to updated diagnostic guidelines from the AmericanAcademy of Pediatrics.

Midey, Connie, “Women and ADHD,” Arizona Republic,Nov. 11, 2011, p. H1, www.azcentral.com/health/news/articles/2011/11/03/20111103adhd-diagnosis-women.html.ADHD estimates are low among adults because many af-

fected women haven’t been properly diagnosed.

Wen, Patricia, “ADHD Rates Low Among Latinos,” TheBoston Globe, Sept. 26, 2011, p. B1, articles.boston.com/2011-09-26/news/30205138_1_adhd-medication-latino-children-latino-youngsters.Fewer Latino children are diagnosed with ADHD compared

to white and black children, according to the Centers forDisease Control and Prevention.

Symptoms

Gerhart, Jacqueline, “Steps to Diagnosing ADHD,” Wis-consin State Journal, Dec. 13, 2011, p. C3, host.madison.com/wsj/news/local/health_med_fit/dr-jacqueline-gerhart-how-can-a-parent-know-if-child/article_0ef24598-2514-11e1-bbd8-0019bb2963f4.html.Children should display symptoms for at least six months

in two different settings — such as at home and at school— before being diagnosed with ADHD.

Johnson, Tim, “Inside a Teenager’s Brain,” Burlington (Vt.)Free Press, April 30, 2012, p. A1, www.burlingtonfreepress.com/article/BT/20120430/NEWS0213/120429012/university-of-vermont-teenage-brain-research.Behavioral scientists generally agree that ADHD is associated

with impulsivity but are unsure whether the impulses makepeople more prone to drug or alcohol use.

Mascarelli, Amanda, “Profile of ADHD Sharpens in EachSchool Year,” Los Angeles Times, Aug. 13, 2011, articles.latimes.com/2011/aug/13/health/la-he-adhd-20110813.ADHD symptoms can become clearer as children enter

classes requiring more attention and organizational skills.

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