Researcher Published by CQ Press, an Imprint of SAGE Publications, Inc. CQ www.cqresearcher.com Treating ADHD Are attention disorders overdiagnosed?

nce 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,O 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 Blake Taylor, a student at the University of California, Berkeley, began taking medication for ADHD at age 5. skills, and some worry the condition is being overdiagnosed. At ADHD is widely seen today as a lifelong condition affecting both genders equally. the same time, non-drug treatments remain under-used. The in- creased availability of stimulants, which are addictive, is fueling I N prescription-drug abuse among students and others who do not THISREPORT S have ADHD but use the drugs as study aids or to get high. THE ISSUES ...... 671 I BACKGROUND ...... 678 D CHRONOLOGY ...... 679 E AT ISSUE...... 685 CQ Researcher • Aug. 3, 2012 • www.cqresearcher.com CURRENT SITUATION ...... 686 Volume 22, Number 28 • Pages 669-692 OUTLOOK ...... 687 RECIPIENT OF SOCIETY OF PROFESSIONAL JOURNALISTS AWARD FOR BIBLIOGRAPHY ...... 690 EXCELLENCE N AMERICAN BAR ASSOCIATION SILVER GAVEL AWARD THE NEXT STEP ...... 691 TREATING ADHD CQRe search er

Aug. 3, 2012 THE ISSUES SIDEBARS AND GRAPHICS Volume 22, Number 28 • Is ADHD being over- One in 10 Children MANAGING EDITOR: Thomas J. Billitteri 671 diagnosed? 672 Diagnosed With ADHD [email protected] • Are too many stimulants Diagnosis rates exceed ASSISTANT MANAGING EDITOR: Kathy Koch being prescribed? 14 percent in four states. [email protected] • Are ADHD therapies ef- CONTRIBUTING EDITOR: Thomas J. Colin Childhood ADHD, Drug [email protected] fective over the long term? 673 Treatment on Rise BACKGROUND Nine percent of children ASSOCIATE EDITOR: Kenneth Jost received ADHD diagnoses STAFF WRITER: Marcia Clemmitt between 2008 and 2010. Disorder Defined CONTRIBUTING WRITERS: Peter Katel, 678 Psychiatrists crafted the first Cultural Expectations Fuel Barbara Mantel, Jennifer Weeks definition of ADHD in 1968. 674 ADHD Diagnosis DESIGN/PRODUCTION EDITOR: Olu B. Davis School pressures help define Widening Spectrum normal behavior. ASSISTANT EDITOR: Darrell Dela Rosa 680 Most researchers agree FACT CHECKER: Michelle Harris ADHD traits lie on a con- More High School Seniors 676 Turning to Adderall INTERN: Kate Irby tinuum from normal to Nearly twice as many used damaging. the drug without a prescrip- tion in 2011 as in 2007. 681 Drug Abuse By the 1930s amphetamine 679 Chronology decongestants were used Key events since 1937. An Imprint of SAGE Publications, Inc. to enhance performance. Non-drug Therapies May VICE PRESIDENT AND EDITORIAL DIRECTOR, 680 Help With ADHD HIGHER EDUCATION GROUP: Under the Influence? Michele Sordi 683 In the 1960s fears grew A change in breathing can have rapid effects on the DIRECTOR, ONLINE PUBLISHING: that Ritalin and other stim- brain. ulants could be dangerous. Todd Baldwin Students Abuse ADHD Copyright © 2012 CQ Press, an Imprint of SAGE Pub- 682 Drugs as Study Aids lications, Inc. SAGE reserves all copyright and other CURRENT SITUATION Experts warn of potentially rights herein, unless pre vi ous ly spec i fied in writing. dangerous consequences. No part of this publication may be reproduced Numbers Rise electronically or otherwise, without prior written 686 ADHD prescriptions rose At Issue permission. Un au tho rized re pro duc tion or trans mis - 46 percent from 2002 to 685 Are ADHD and artificial food sion of SAGE copy right ed material is a violation of 2010. dyes linked? federal law car ry ing civil fines of up to $100,000. CQ Press is a registered trademark of Congressional Changing Policies Quarterly Inc. 686 ADHD diagnosis guidelines FOR FURTHER RESEARCH now cover children from CQ Researcher (ISSN 1056-2036) is printed on acid- For More Information free paper. Pub lished weekly, except: (March wk. 5) ages 4 to 18. 689 Organizations to contact. (May wk. 4) (July wk. 1) (Aug. wks. 3, 4) (Nov. wk. 4) and (Dec. wks. 3, 4). Published by SAGE Publica- Bibliography tions, Inc., 2455 Teller Rd., Thousand Oaks, CA 91320. OUTLOOK 690 Selected sources used. Annual full-service subscriptions start at $1,054. For Debate Continues pricing, call 1-800-834-9020. To purchase a CQ Re- 687 The Next Step searcher report in print or electronic format (PDF), Brain imaging and genetic 691 Additional articles. visit www.cqpress.com or call 866-427-7737. Single profiles eventually may reports start at $15. Bulk purchase discounts and Citing CQ Researcher help in diagnosing ADHD. 691 electronic-rights licensing are also available. Periodicals Sample bibliography formats. postage paid at Thousand Oaks, California, and at additional mailing offices. POST MASTER: Send ad dress chang es to CQ Research er , 2300 N St., N.W., Suite 800, Wash ing ton, DC 20037. Cover: AP Photo/Jeff Chiu

670 CQ Researcher Treating ADHD BY MARCIA CLEMMITT

children to succeed in school, many scholars say. THE ISSUES Prescriptions for Ritalin, Con- atricia Quinn, a pedi- certa, Adderall and other stim- atrician in Washington, ulant drugs — long the first- P D.C., specializes in at- line treatment for ADHD — tention deficit hyperactivity dis- also are increasing. For some order (ADHD), and she has medical experts as well as par- lots of personal experience to ents, that stirs fears that the back up her medical training. amphetamine-like drugs could Quinn is a self-described clas- cause unforeseen health prob- sic example of an adult ADHD lems, if taken long term. And sufferer who struggles with some worry about an epidemic organization, focus and time of stimulant abuse as people management. She’s also the without an ADHD diagnosis mother of four children, three use the drugs to help them of whom also have ADHD. concentrate or to get high. “I’ve forgotten to pick up Over the past three decades, my kids from soccer practice,” the number of children diag- she says. “I interrupt a con- nosed with ADHD has soared, versation to finish a conversa- /CaitlinTeal Price rising nearly eightfold between tion we were having three days 1980 and 2007. 1 The per- ago.” And without her busi- centage of children ages 4 to ness partner’s help, she says, 17 diagnosed with ADHD in- she’d often commit them to creased at an average rate of more clients and projects than 5.5 percent a year from 2003

they could reasonably handle. TheWashington Post to 2007. 2 In the mid- to late- Quinn didn’t fully realize 1990s, the nationwide preva- how hard it was for her to lence of ADHD among Amer- focus her attention until she ican children was estimated at 3 was in medical school in the GettyImages/ between 4 and 5 percent. 1960s. Despite being a high Michelle Suppers, a mother of two in Manassas, Va., gets By 2007 — the most recent her eldest son, Anthony, started on his homework as achiever, “I had to reread soon as he comes home from school so he doesn’t get year for which the Centers for and reread and reread” to get distracted. When she learned he had ADHD, Suppers Disease Control and Preven- the full meaning of texts, she also underwent testing and found she too has the tion (CDC) has analyzed data recalls. She didn’t identify condition. Nearly 10 percent of children ages 4-17 — 9.5 percent of children, or her problem as ADHD until have been diagnosed with ADHD 5.4 million, had been diag- at some point in their lives. much later, however. nosed. 4 That wasn’t unusual. In the ’60s, sidered: a developmental problem that Because young boys are most like- doctors were only beginning to iden- children outgrew in their teens. ly to exhibit hyperactivity, adults and tify the mental traits of hyperactivity, Like most mental disorders, ADHD girls with ADHD often have gone un- impulsiveness and attention-focusing is diagnosed by observations of be- diagnosed in the past, says Quinn. About problems as a psychiatric disorder. They havior, not physical abnormalities. Brain 13.2 percent of boys have had an ADHD called the condition “minimal brain imaging and genetic studies have turned diagnosis, compared to 5.6 percent dysfunction” and diagnosed it only in up clues about brain regions and func- of girls. 5 children, primarily below the age of tions that may be involved in ADHD, But many specialists now say ADHD puberty. Today, psychiatry holds a dif- but no consensus exists about its cause. is probably about equally prevalent in ferent view. Adults are increasingly di- As more and more adults are diag- both genders. They give more weight agnosed with ADHD, which many nosed with ADHD, so too are increasing to attention problems as the hallmark specialists view as a lifelong condition numbers of children and teens. Driving of the condition than in the past, which rather than what it used to be con- the increase is growing pressure on helps to extend the diagnosis to adults

www.cqresearcher.com Aug. 3, 2012 671 TREATING ADHD

them, Milich says. “The other kids hate One in 10 Children Diagnosed With ADHD them,” perhaps because they have poor Nearly 10 percent of children ages 4 to 17 have been diagnosed with impulse control. “They act like ADHD. Diagnosis rates exceed 14 percent in Alabama, Delaware, younger kids. They both give and re- ceive bullying.” 7 Louisiana and North Carolina. Rates are far lower in the West. Often, “in high school the problems get bigger,” encompassing more out-of-

Wash. Mont. N.D. N.H. school activities, Milich says. For exam- Minn. Vt. ple, when driving skills of young adults Maine S.D. Wis. with ADHD are tested in a simulator, Ore. Idaho Wyo. Mich. N.Y. Mass. Iowa “their driving is equivalent to the way Neb. R.I. Pa. others drive under the influence of al- Ill. Ind. Ohio Conn. Nev. Utah Colo. Kan. Mo. W.Va. N.J. cohol.” Yet, they are “more confident in Ky. Va. Calif. Del. their driving” than others, he says. Okla. Tenn. N.C. Some experts, however, contend that Ariz. Ark. Md. N.M. S.C. D.C. Miss. the new notion of ADHD as a lifetime Ala. Ga. Texas La. diagnosis is too extreme. Lawrence Diller, a developmental pediatrician in Walnut Percentage of Creek, Calif., and author of the 2011 book, Fla. Youths 4-17 Remembering Ritalin, interviewed 10 of Ever Diagnosed his former ADHD patients, now young Alaska With ADHD by State, 2007 adults, and found they had fewer cop- ing difficulties than one might expect. 14.0%-15.9% Hawaii “The trend is unmistakable. These 11.0%-13.9% kids are getting better,” he says. “Some 9.6%-10.9% Source: “State-Based Prevalence Data of ADHD Diagnosis,” of the most hyperactive kids I’ve ever Centers for Disease Control and Prevention, December 2011, 8.0%-9.5% seen were in this group,” but in their www.cdc.gov/ncbddd/adhd/prevalence.html 5.6%-7.9% late 20s most are settling into jobs and acquiring stable, productive life pat- and girls, who are less likely to be per- to agree that at least some people do terns “as they’re finding what they like ceived as hyperactive, Quinn says. have traits severe enough to warrant to do. One kid was in the peniten- For as long as ADHD has been di- treatment. (See box, p. 677.) But in- tiary. But now he’s a police officer.” agnosed, however, some clinicians have tense debate continues over whether Only two of the 10 — “both perfec- debated the validity of diagnoses. Today doctors are making the diagnosis too tionists,” Diller says — still take med- a few clinicians still argue that no mat- freely, whether medical researchers are ication, while the others haven’t taken ter how many ADHD-type symptoms defining the disorder too broadly and ADHD drugs for years. a person has they do not constitute whether ADHD patients’ prognosis is ADHD is no barrier to success. an actual biological brain disorder that far less gloomy than the medical es- Grammy-winning pop singer Justin Tim- should be treated medically. tablishment contends. berlake, comedian Jim Carrey and “ADHD is defined as involving hy- It’s hard to overestimate the areas swimmer Michael Phelps, the most dec- peractivity, inattention and impulsivi- of life in which children with ADHD orated Olympic athlete of all time, for ty. These are not diseases — they are may experience — and cause — dif- example, all suffer from the condition. disciplinary and educational problems,” ficulties, says Richard Milich, a profes- The first line of treatment for ADHD wrote Peter R. Breggin, a psychiatrist sor of psychology at the University of has long been prescription stimulants — in Ithaca, N.Y. “Very often these children Kentucky in Lexington. They are more amphetamines and similar drugs formu- improve dramatically when parents de- likely to be held back in school, less lated as relatively low-dose pills such as velop a more consistent, rational and likely to graduate and “they can be a Ritalin. Seven percent of U.S. children loving plan for discipline. . . . Or the discouraging presence in the classroom take a psychiatric medication, and most child may be especially full of life and and can disrupt a whole class,” he says. of the prescriptions are for ADHD. 8 need more opportunity to run, to play Worse, “these children are often so- The drugs are effective at temporar- and to be creative.” 6 cially rejected by their peers, some- ily quelling ADHD symptoms such as However, most clinicians today seem times within five minutes” of meeting hyperactivity and lack of mental focus.

672 CQ Researcher “There are patients who are quite de- bilitated” by their ADHD symptoms, and Childhood ADHD, Drug Treatment on Rise stimulants help them “get an even play- Nine percent of children ages 5 to 17 were diagnosed with ADHD ing field” for school and jobs, says Joshua between 2008 and 2010, up from 7 percent between 1997 and 1999. Israel, a San Francisco psychiatrist and Use of ADHD prescription drugs among children rose from less than associate clinical professor at the Uni- versity of California, San Francisco. 1 percent from 1988 to 1994 to 4 percent from 2005 to 2008. But others point out that stimulant Children Ages 5-17 Who Have drugs can be addictive and may carry ADHD in Children Ages 5-17 cardiovascular risks if used over a long Used ADHD Prescription Drugs period. 10% 4.0% Because many now see ADHD as 8 3.5 4% 9% 3.0 a long-term illness that also affects 6 2.5 7% 2.0 adults, the “medications aren’t being 4 1.5 <1% prescribed the same way they were 2 1.0 0.5 20 years ago,” says Mark Stein, a pro- 0 0.0 1997-1999 2008-2010 fessor of psychiatry and pediatrics at 1988-1994 2005-2008 the University of Illinois at Chicago. Back then, virtually all prescriptions were Source: “Health, United States, 2011,” National Center for Health Statistics, 2011, written for children, who stopped tak- p. 29, www.cdc.gov/nchs/data/hus/hus11.pdf ing the medications when they hit pu- berty. Today, Stein says, more people lack of such skills may be a special “The evidence for an organic basis for “are taking them for many years,” and problem for ADHD patients as they most children who are diagnosed with we “don’t have data” on the safety of come of age in today’s difficult job ADHD remains elusive,” writes Peter Con- long-term use or use by adults. market. “In this economy . . . , it’s rad, a professor of medical sociology at There also is “abundant evidence” harder and harder to just go out and Brandeis University, in Waltham, Mass. that people who have not been diag- grab a job,” Milich says. He said clinicians who are overdiagnos- nosed with ADHD take the drugs as As ADHD diagnoses continue ris- ing ADHD are engaging in a “classic case mood elevators and performance en- ing for children and adults, here are of the medicalization of deviance” from hancers, Nicolas Rasmussen, a professor some of the questions being debated: what is considered normal behavior. “Even of the history and philosophy of science if one found some validated biopsycho- at Australia’s University of New South Is ADHD being overdiagnosed? logical differences,” Conrad wrote, “the Wales, wrote in his 2008 book, On The percentage of children and adults sociological question remains: Does dif- Speed: The Many Lives of Amphetamine. with ADHD has risen steeply for two ference mean disease?” 10 “Reports of medication abuse have decades, causing some experts to Some recent research suggests that increased in step with attention deficit argue that the condition is overdiag- careless ADHD diagnoses are occur- drug prescriptions,” he wrote. And “the nosed. A minority of critics of the di- ring. In Germany, where the rate of shift from misusing unprescribed Rital- agnosis go farther, arguing that ADHD- ADHD increased by 381 percent be- in as an occasional study aid to straight- type traits should not be treated as a tween 1989 and 2001, a recent survey forward abuse can happen easily.” One disease or disorder because the traits of nearly 500 therapists found that many Harvard student discovered the dangers would be benign or might disappear of the clinicians diagnosed ADHD based of Ritalin abuse when she became “an altogether with proper response by on too few criteria. Clinicians diag- absolute speed-freak — up all night and teachers, parents and others. nosed ADHD in about 17 percent of strung out all day,” Rasmussen wrote. 9 Other analysts, however, argue that the cases deemed by experts not to (See sidebar, p. 682.) ADHD is clearly a biological condi- meet the criteria — compared to about Stimulants can also constitute a too- tion and that, while some diagnoses 7 percent of cases in which clinicians easy answer to complex behavioral or are “false positives,” many people who missed signs of ADHD. Moreover, boys learning problems, says Milich. While would benefit from treatment have were incorrectly deemed to have ADHD quelling symptoms may be useful, it never been told they have ADHD. more often than girls. 11 doesn’t help ADHD patients develop No brain scan or other medical test (The ADHD rate in Germany for appropriate social responses and ef- confirms ADHD, say critics of the di- children ages 3-17 is about 5 percent, fective learning strategies, he says. The agnosis. roughly half the U.S. rate.) 12

www.cqresearcher.com Aug. 3, 2012 673 TREATING ADHD

Cultural Expectations Fuel ADHD Diagnosis School pressures help define normal behavior.

illions of kids are restless, inattentive, disorganized and teenagers focus on academics for hours each day,” ADHD-type impulsive — but does that mean they have a psy- traits existed but were not seen as a problem, he says. M chiatric disorder? Additional evidence of how academic pressure shapes ADHD Some scholars argue that it’s wrong to label common child- diagnoses lies in state variations in ADHD rates, says Stephen hood traits that way. Doing so, they maintain, is an abdication of Hinshaw, a professor of psychology at the University of Cali- the responsibility that parents, society and, especially, schools share fornia, Berkeley. For example, among 4- to 17-year-olds in North to create environments in which children can function effectively. Carolina, 16 percent have had an ADHD diagnosis, compared “Hyperactivity is the most frequent justification for drugging to only about 6 percent in California — a nearly threefold dif- children. The difficult-to-control male child is certainly not a ference, says Hinshaw. He says that most states with high ADHD new phenomenon, but attempts to give him a medical diag- rates were among the first to punish schools that did not raise nosis are the product of modern psychology and psychiatry,” student test scores. wrote Peter R. Breggin, an Ithaca, N.Y., psychiatrist and long- Even the culture of an individual classroom can determine time critic of labeling children as having ADHD. 1 whether a child needs treatment, says Barkley. “If in second But Breggin is in the minority. More and more clinicians grade a child has a great teacher, he may be able to get off argue that ADHD has a biological basis, although most also medications” for that year but resume treatment in another contend that cultural forces play a powerful role in defining school year if the nature of the classroom makes concentra- ADHD-type traits as a disorder. tion tougher, he says. The fact that many cases are inherited demonstrates that ADHD Still, Barkley maintains that while supportive school environ- is a biological illness, says Russell Barkley, a professor of psy- ments can make it easier for ADHD students to function with- chiatry at the Medical University of South Carolina, in Charleston. out drugs, schools are not obliged to provide such environments. Studies of families show that genetics is responsible for about In the Americans With Disabilities Act — which requires institu- two-thirds of ADHD, he says. Most of the remaining third is due tions to make accommodations to assist disabled people, in- to other biological causes — mainly damage of various kinds to cluding those with ADHD — “there is a very important word,” the front portion of young brains, often caused by mothers smok- Barkley says. “It says that schools must make reasonable ac- ing or drinking alcohol during pregnancy, Barkley says. commodations. Society can’t afford every accommodation that is Yet, Barkley also maintains that social environment does help conceivable. We’re not going to design a separate curriculum for determine what mental traits we view as psychiatric illnesses. every child.” Before about the 18th century, when most people couldn’t — Marcia Clemmitt read, “there were no reading disorders,” although the traits rec- ognized today as reading disorders certainly existed in people 1 Peter R. Breggin, Toxic Psychiatry: Why Therapy, Empathy and Love Must of those times, says Barkley. “The same is true of ADHD,” he Replace the Drugs, Electroshock, and Biochemical Theories of the New Psy- argues. “Until society demanded that virtually all children and chiatry (1994), p. 277.

A recent study of nearly a million With growing pressure on children Once believed to be a condition children in western Canada found to perform well in school, “it’s very that affected only children, ADHD is that the youngest in a class are more easy and popular to give this simple now estimated to afflict 9 million to likely to be diagnosed with ADHD diagnosis,” says Diller, the California 10 million U.S. adults, but fewer than — at a rate of 7.4 percent, com- pediatrician. Furthermore, in upscale 2 million have been diagnosed, says pared to 5.7 percent for the oldest neighborhoods, private clinics can Israel, the San Francisco psychiatrist. children. 13 That result “suggests make good money selling ADHD Historically, girls and women have younger, less mature children are in- therapies — proven or not — to par- been under-diagnosed because “we’ve appropriately being labeled and treat- ents anxious to raise high achievers, focused on the hyperactivity,” which ed,” presumably because their im- he says. shows up more in males, rather than maturity is mistaken for the disorder, Other analysts say, however, that problems with attention and orga- said lead author Richard Morrow, a fewer people have been diagnosed nizing, says Quinn, the Washington professor of counseling psychology with ADHD than actually are impaired pediatrician. “A lot of people still at the University of British Colum- by it, especially adults and females of think girls can’t have” ADHD, partly bia in Vancouver. 14 all ages. because girls often have quieter symp-

674 CQ Researcher toms that may cause less trouble in Those children should be located and In both Canada and the United classrooms. offered help, Pelham says. States, some serious health problems Many experts say misdiagnosis — in- among children, including heart attack cluding both over- and under-diagnosis Are too many stimulants being and stroke — some fatal — have been — is the real problem. prescribed? reported. However, a large 2011 study The average diagnosis occurs in “a Those who argue that ADHD is spurred by the reports found the rates 10-minute pediatric visit” after a teacher overdiagnosed worry mainly that stim- of such cardiovascular problems ex- or parent perceives that a child is hav- ulants such as Ritalin and Adderall used tremely low. Based on analysis of the ing problems, says Stephen Hinshaw, a to treat the condition can create health medical records of 1.2 million children professor of psychology at the Univer- risks, including addiction. Many and young adults, researchers found “no sity of California, Berkeley. “In a visit ADHD specialists say, however, that increased risk” for the conditions. 17 like that, you get tons of false positives stimulants are an important part of The researchers also analyzed data and tons of false negatives,” he says. ADHD therapy and that studies have for about 150,000 people ages 25 to 64 For example, under-diagnosis may not shown significant safety risks. (A who were currently prescribed ADHD occur if a doctor concludes that, “Well, few nonstimulant drugs, such as Strat- drugs and again found “no evidence of it can’t be ADHD because the child is tera, also are occasionally prescribed an increased risk” of serious cardiovas- sitting still in the [doctor’s’] exam room,” for ADHD; unlike stimulants, they are cular problems. However, because few says Hinshaw. That’s because ADHD’s not believed to be addictive but do adults have so far been prescribed the “symptoms are context-dependent,” and carry other health risks. 15) drugs, further study on safety for adults a child’s ability to sit still in one situa- Up to 80 percent of those diagnosed is needed, they said. 18 tion doesn’t rule out having a damag- with ADHD will need medications as Abuse of stimulants has turned some ing level of hyperactivity in another. part of their treatment, says Russell unwary people into “speed” addicts False-positive diagnoses can occur Barkley, a professor of psychiatry at the every time doctors began widely pre- because doctors don’t take the time Medical University of South Carolina, in scribing such drugs, says Diller, the to rule out the many other conditions Charleston, and author of several books Northern California pediatrician. “Every besides ADHD that may cause hy- on ADHD. And stimulants are far from 20 or 30 years we find a reason” to peractivity or attention problems, such the only drug that people abuse, he says. use stimulants for medical purposes, as seizure disorders or abuse of some “Are there some students on college and that’s “been followed each time kind, Hinshaw says. “It’s so easy to campuses using Adderall when they by an epidemic of abuse.” prescribe a stimulant,” he says. Physi- don’t have ADHD? Yes. We need to ADHD drugs are classified as “con- cians’ professional societies “have be careful about that, but it’s also true trolled substances” under U.S. and in- good guidelines now” that could pre- for Viagra.” ternational laws. U.S. law lists the stim- vent most misdiagnosis, “but the “As a society, it is hard to see why ulants as Schedule II drugs — drugs guidelines don’t have teeth,” so they’re it would be good for us to not let that have accepted medical uses but seldom consulted, Hinshaw says. people succeed” when the drugs can also have “a high potential for abuse But debating the “correct” preva- help, says Israel, the psychiatrist from which may lead to severe psychologi- lence of ADHD is beside the point San Francisco. “This is not cosmetic cal or physical dependence,” accord- when the real need is to locate the pharmacology” aiming to make peo- ing to the Drug Enforcement Adminis- children whose ADHD-type traits are ple “better than well.” tration (DEA). 19 Methylphenidate — a causing them problems and find ways The largest long-term study of ADHD stimulant whose commercial forms in- to help them, says William Pelham, a — the Multimodal Treatment of At- clude Ritalin and Concerta —“produces professor of psychology at Florida In- tention Deficit Hyperactivity Disorder many of the same effects as cocaine ternational University, in Miami. “I’ve Study, funded by the National Insti- or the amphetamines,” the agency says. never had a parent say, ‘I did a survey tute of Mental Health in the 1990s — Methylphenidate’s increased use as [of symptoms], so I brought in my child.’ found that the medications are largely an ADHD treatment is paralleled by They say, ‘I brought him because he safe for children. Of 289 children who an increased incidence of abuse, in- won’t stay in his seat, he drives the were randomly assigned to drug treat- cluding as a snorted or injected drug, teacher crazy.’ For that child, it doesn’t ments, only 4 percent had significant the DEA says. “Binge use, psychotic mean a hill of beans whether more or adverse effects, mainly loss of appetite, episodes, cardiovascular complica- fewer children are diagnosed. The im- sleep problems and crying spells. Chil- tions and severe psychological ad- portant question is: How many chil- dren also grew somewhat more slow- diction have all been associated with dren are having problems in school?” ly while taking the drugs. 16 methylphenidate abuse.” 20

www.cqresearcher.com Aug. 3, 2012 675 TREATING ADHD

group of children with ADHD was first More High School Seniors Turning to Adderall prescribed stimulants and, later, their More than 5 percent of high school seniors admitted in 2011 to parents were offered training in ef- fective techniques for dealing with taking Adderall without a prescription, nearly double the percentage ADHD. Only 15 percent of those par- in 2007. About 1 percent of seniors abused Concerta over the same ents ever took the training, Pelham period. Abuse of Ritalin declined since 2004 but is now trending up. says. By contrast, in families offered training first and prescriptions later, Non-prescribed ADHD Medication Use Among about 90 percent got the training. High School Seniors in Previous 12 Months, 2002-2011 “Drugs undermine parents’ willing-

Percentage of all seniors ness” to commit themselves to impor- 6% tant behavior changes, Pelham says. Ritalin 5 “Medications are grossly overutilized com- Adderall pared to behavioral treatment.” But “there 4 Concerta are no gigantic corporations that sell 3 and make a profit on behavioral treat- 2 ments, so nobody’s talking to pediatri- 1 cians about using these things.” 0 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Are ADHD therapies effective Source: Monitoring the Future, University of Michigan Institute for Social Research, over the long term? June 2012, p. 751, www.monitoringthefuture.org/pubs/monographs/mtf-vol1_2011.pdf Behind every dispute involving ADHD treatments lies the big ques- tion: What, if any, therapeutic meth- A United Nations treaty — the Con- lems and longer-term solutions, some ods improve the lives of people who vention on Psychotropic Substances, analysts contend. have more than average difficulty con- which took effect in 1971 — urges “Stimulant drugs ‘work’ by sup- trolling their impulses and focusing at- governments to ban companies from pressing all spontaneous behavior in tention on school or work? advertising Schedule II drugs directly normal children,” a consequence that Research shows that stimulant to consumers. 21 “looks like an improvement in a class- drugs effectively quell symptoms, ex- In 2001, a British company, Cell- room or home where the child has perts say. Research also shows that tech Pharmaceuticals, advertised its new seemed uncontrollable,” wrote Ithaca, training in social and learning skills as methylphenidate-based drug Metadate N.Y. psychiatrist Breggin. In fact, well as skills training for parents and in American magazines, and the DEA when children’s behavior becomes teachers also help. But drug treatment responded with a cease-and-desist order “age-inappropriate, excessive or disrup- does not have long-lasting effects that called the ads a threat “to the tive, the potential causes are limitless, against ADHD, and behavior-oriented public health and safety.” 22 including: boredom, poor teaching . . . strategies haven’t been fully researched Ultimately, the U.S. government did and underlying physical illness,” and and can be difficult for families and not ban direct-to-consumer advertis- these issues should be examined schools to adopt. ing for Schedule II drugs. But the Food rather than symptoms merely quelled “Medications can help improve at- and Drug Administration (FDA) has with medication, he argues. 25 tention and decrease impulsivity,” says continued to warn companies about “Multimodal” treatment — using the University of Kentucky’s Milich. misleading ads, and drug makers have drugs alongside parental training and “They work on the symptoms.” confined much of their advertising to training designed to help children fos- But research also shows that drug smaller outlets, such as websites and ter social skills, learning strategies and treatment doesn’t make a long-term cable TV channels. 23 Currently, the the like — is by far the most effective difference for patients, says Berkeley’s FDA is reviewing public comments on approach to ADHD, many experts say. Hinshaw, a researcher on the multi- a draft plan to require all TV ads for Unfortunately, using drugs as the modal treatment study. Follow-up re- Schedule II drugs to be screened by first line of treatment — the usual pat- search on the study found that a year the FDA before airing. 24 tern — may mean the multimodal ap- after being treated with drugs, chil- The ease of prescribing stimulants proach is never tried, says Florida In- dren with ADHD had “lost 80 percent” leads families to neglect deeper prob- ternational’s Pelham. In one study, a of what they’d gained in symptom

676 CQ Researcher alleviation; and after two years, their behavior was indistinguishable from Symptoms of ADHD that of children with ADHD who’d Several behavioral signs have been shown to be characteristic of never received the recommended level of drug treatments, Hinshaw says. ADHD. Experts say the number of symptoms matters less than the “The moment the medication has degree of impairment. Most experts agree that if significant impair- worn off, all the benefits are gone,” ment appears in at least five or six of the following behaviors, says Pelham, another researcher on the additional evaluation is advised. multimodal treatment study. This means that “medication has no long-term Screening for ADHD benefit at all” when it comes to learn- Resisting distractions Persisting toward a goal ing, at least in the studies of grade- Managing time Managing emotions school students, whose classroom work Learning from experience Completing work or tasks is mostly simple drills. “All the stud- ies on learning have failed to show Thinking or planning ahead Self-monitoring anything” in the way of improvements, Avoiding procrastination Accurately reading social cues he says. It remains unclear whether Sustaining effort Remembering what to do results would differ for older students, Getting started with work or tasks Retaining and retrieving information who often perform more complex tasks Controlling impulsivity Sitting still in the classroom. Pelham says no such Organizing materials Handling transitions research has been done because too Demonstrating flexibility few middle school and high school students take the drugs. Source: “Screening Form,” Center for Attention Disorders, 2009, www.centerfor In a study of children with ADHD attentiondisorders.com/downloads/cad-screening-test.pdf who played baseball, stimulant drugs significantly increased their attention less extensively researched than drug behaviors and accumulate points they to the game “but didn’t do anything treatments, have demonstrated long- can later redeem for rewards. Children for their play,” says Milich. term success in studies, many ADHD with ADHD generally have difficulties In another study, Milich examined scholars say. in social relations with their peers, and how well children with ADHD un- Hinshaw believes children with Stein runs a summer camp that uses derstood narrative stories — present- ADHD have abnormalities in the brain’s the report card to help. By meeting ed as TV programs to eliminate read- dopamine system, which is thought to specific behavior goals related to so- ing problems as a factor in the scores respond to rewards and punishments cial interaction, children earn points — before and after drug treatment, by sending signals that encourage the that they can redeem for a field trip compared with children without ADHD. brain to repeat rewarded behaviors or the next week. Following a narrative requires grasp- avoid punished behaviors. “With be- “The second week, they quickly real- ing the significance of “causal con- haviorally based strategies, you try to ize what they need to do if they didn’t nections,” and children with ADHD motivate kids who have [dopamine- get the trip,” he says. If parents are have been shown to be “somewhat system] problems,” he says. trained in the same techniques and impaired” in that skill, Milich says. Such strategies may include consis- use them, the results last, Stein says. After taking medication for two years tently providing prompt and specific Building new skills and finding ef- the children with ADHD had not pro- feedback on youngsters’ behavior and fective work-arounds for ADHD-related gressed in their ability to understand classwork. Teachers, for example, can deficiencies is key to helping adult narratives, while those without ADHD be coached to break each academic patients, says Israel, the San Francis- had, Milich says. skill down into small steps and then co psychiatrist. For example, he says Milich says quelling ADHD symp- provide clear and instant feedback as he helps patients find software pro- toms accomplishes nothing in the long students perform each step. grams that will help them organize term because “until you replace old One technique, called “the daily re- their lives and figure out “where they behaviors with appropriate behaviors” port card,” is “hugely effective,” says should keep their keys” so they don’t the child hasn’t progressed. Stein of the University of Illinois. Chil- forget them. On the other hand, behavior-mod- dren receive a daily assessment about Unlike drugs, behavioral interven- ification strategies, which have been their progress in improving specific tions have no side effects or health risks,

www.cqresearcher.com Aug. 3, 2012 677 TREATING ADHD

so they have little downside and po- ameliorating serious ADHD problems, period traits that make it difficult for tentially significant upsides, says Pelham. behavioral work must be intense. That children to sit still at a desk or focus Clinicians are careful to point out might mean “catching it at age 3 or 4 on lessons that bore them have in- that today’s effective behavioral inter- and doing 20 hours a week of training,” creasingly been viewed as a signifi- ventions are not the same as the psy- for example. cant disorder. chotherapeutic interventions that were A further difficulty is that ADHD is Yet, psychiatry has long struggled widely used beginning in the 1950s in often an inherited trait, he says. “You’ve to define ADHD in terms of its key hopes of uncovering hidden emotion- got to be a super-parent,” who scrupu- traits. What level of inattentiveness, rest- al roots of ADHD. Diller, the Califor- lously keeps charts of children’s behavior lessness or other characteristics is nia pediatrician, says enough to classify some- the most popular was one as having a true “play therapy,” in psychiatric disorder? The which a patient and question remains hotly therapist played to- disputed. 27 gether with toys as a Before the 1960s, chil- way of encouraging dren with traits such as a child to uncover hyperactivity and a lack and work through of focus were described anxieties or memo- in the Diagnostic and ries. As early as the Statistical Manual of 1980s, “it was gener- Mental Disorders (DSM), ally conceded that medicine’s mental- [play therapy] didn’t health diagnostic bible, do anything” for kids as having a “minimal with ADHD, Diller brain dysfunction.” But says. Despite that, the vagueness of that some psychothera- term didn’t lend itself eas- pists “continue to ily to diagnosis or to clear

waste time and en- AFP/GettyImages questions that medical re- ergy doing it,” he says. Widespread stimulant use in the 1960s led to passage of the 1970 searchers could explore. Many clinicians Comprehensive Drug Abuse Prevention and Control Act, signed into law Gradually, psychiatrists by President Richard M. Nixon, left, here with National Security Adviser say the best approach Henry Kissinger. The law placed restrictions on prescription stimulants honed the definition in to treating ADHD is and other drugs, and by the late 1970s stimulant abuse had subsided. an attempt to “standard- combining judicious- ize the field so the con- ly prescribed medication with behavioral and rewards points, “doing it all calmly dition could be recognized as a real en- work carried out with the child and the and without yelling,” he says. That’s not tity that people could research because child’s parents and teachers. easy for anyone, “but what if you’re a it was no longer amorphous,” says Is- In the multimodal treatment study, parent with the same problem?” rael, the San Francisco psychiatrist. children who received combination The definitions have shifted over treatment had less anxiety and better the years from a broad description of academic performance, parent-child re- “a misbehaving child” to “something lations and social skills, and they need- BACKGROUND treatable,” says Patricia Gerbarg, an as- ed less medication, than the drug-only sistant professor of clinical psychiatry group, according to the National In- at New York Medical College and a stitute of Mental Health. 26 specialist in integrative mental health “The gains can be amazing,” but the Disorder Defined treatment, which promotes alternative complexity and cost of such treatment therapies such as herbs and breathing mean that “so few children can get that,” ver the past half-century, suc- exercises alongside traditional ones. says Stein. O cess in American culture has In 1968, the DSM-II made the first But behavioral interventions remain been increasingly defined in terms of attempt at a specific definition, em- hard to implement. Hinshaw says that educational achievement. It may not phasizing hyperactivity in what the to “have a fighting chance” of truly be surprising, then, that over the same Continued on p. 680

678 CQ Researcher Chronology

(AMA) that allergenic foods and health caution — warning of cardio- 1930s-1940s synthetic food additives and dyes vascular risks; FDA rejects the label. Stimulant drugs gain popularity can cause hyperactivity. among college students. 2008 1980 American Academy of Pediatrics 1937 DSM-III shifts emphasis from “hyper- recommends that children be assessed Charles Bradley, a psychiatrist at a kinetic reaction” to problems of for heart conditions before taking Rhode Island mental institution, inattention, renaming the condition stimulants. . . . Sen. Charles Grass- discovers that the stimulant drug “attention deficit disorder.” ley, R-Iowa, accuses three Harvard amphetamine calms some severely Medical School ADHD experts — disturbed children. • Joseph Biederman, Timothy Wilens and Thomas Spencer — of hiding 1948 drug company payments. College students use the stimulant 1990-Present Benzedrine, sold as a decongestant, Newly named diagnosis of at- 2010 as a study aid. tention deficit hyperactivity ADHD prescriptions for children disorder (ADHD) gains popu- have risen 46 percent since 2002. • larity for children and adults. Use of drugs for performance 2011 enhancement also soars. Harvard Medical School disciplines 1960s-1980s the three ADHD experts for failing Medical interest grows in hyper- 1991 to disclose drug company income. activity and attention problems. Activists convince an initially reluc- . . . FDA rejects calls to ban artifi- tant Department of Education to cial food dyes, which may trigger 1961 include ADHD as a disability that hyperactivity in some children. Stimulant drug Ritalin first used to qualifies students for extra services. treat hyperactivity. 2012 1994 In a German study, doctors incor- 1968 DSM-IV includes both inattention rectly diagnosed ADHD in 17 per- First definition of ADHD appears and hyperactivity in its new term, cent of cases where the condition as “hyperkinetic reaction of child- “attention deficit hyperactivity dis- was not present. . . . Canadian re- hood” in second edition of Ameri- order (ADHD); patients with inat- searchers report that the youngest can Psychiatric Association’s Diag- tention, hyperactivity or both re- children in a school classroom are nostic and Statistical Manual of ceive the diagnosis. diagnosed with ADHD much more Mental Disorders (DSM). often than older ones, likely be- 1998 cause doctors confused ADHD 1969 Nearly 7 percent of U.S. children with immaturity. . . . FDA reviews Experts declare a “stimulant epi- ages 5 to 17 diagnosed with ADHD. comments on a plan to require demic” as 10 million Americans pre-approval before TV ads for use the addictive drugs, either 1999 Schedule II addictive drugs are with a prescription or illegally, for National Institutes of Mental Health aired. . . . Draft of DSM-5, due for weight control, performance en- study finds that stimulant drugs are final release in May 2013, further hancement or to get high. generally safe for children and that expands population eligible for children who receive both medication ADHD diagnosis. . . . Psychiatrists 1971 and behavior therapy do better in estimate that between 9 and 10 United Nations Convention on Psy- school and family relationships than million U.S. adults have ADHD; chotropic Substances seeks govern- those who get medication alone. under 2 million are diagnosed. . . . ment bans on direct-to-consumer Shortages of ADHD medications ads for stimulant medications. 2006 lead Drug Enforcement Administra- A Food and Drug Administration tion (DEA) to raise caps on how 1973 (FDA) panel recommends that stimu- much drug manufacturers may California allergist Benjamin Feingold lant drugs for ADHD carry a “black produce, despite DEA qualms tells American Medical Association box” label — the most serious about drug abuse.

www.cqresearcher.com Aug. 3, 2012 679 TREATING ADHD

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

edications such as Ritalin can bring immediate relief port inadequate training in classroom management, Owens says. from the symptoms of attention deficit hyperactivity What’s more, says Richard Milich, a professor of psycholo- M disorder (ADHD), but many experts say non-drug ther- gy at the University of Kentucky, “A teacher may even say, ‘Why apies are more effective at controlling the condition over the would I invest the effort when I have all these great kids who long term. don’t need these extra things?’” Owens points to a study in Yet, those therapies — which range from meditation and which all teachers initially used the daily report card. But over diet to one-on-one help from teachers — are often difficult to the course of a school year, only some continued to do so implement, researchers say, making pills the default choice for consistently while others nearly stopped altogether. many patients. Some doctors are training ADHD patients in brain-altering ADHD problems “manifest themselves at home and school techniques such as “mindfulness” meditation and “mind-body” and should be treated in both places” because providing quick approaches such as altering breathing patterns to enhance feedback that clearly connects behavior with a reward or penal- thinking. ty is crucial, says Julie Owens, an associate professor of psy- ADHD is “a self-regulation disorder” that makes it difficult for chology at Ohio University. sufferers to monitor and control their attention and impulses. Researchers have found that classroom-management tech- Practicing mindfulness meditation — deliberately focusing at- niques such as careful, step-by-step instructions are effective tention on something specific and immediate, such as the sen- for all students. But students who exhibit ADHD symptoms sations of breathing — can help ADHD suffers stay focused, need additional help, such as a “daily report card” that pro- says Lidia Zylowska, a Los Angeles psychiatrist and a cofounder vides instant feedback on student-specific goals. If teachers per- of the Mindful Awareness Research Center at the University of sist in these methods, “you get month-by-month incremental California, Los Angeles. improvement” in students’ behaviors, Owens says. “We often recommend exercise for a physical weakness,” so Getting teachers to apply the techniques consistently isn’t it makes sense to do the same for mental capabilities, she says. easy, however. Teachers face heavy workloads, and many re- Research to establish how mindfulness works in ADHD “is still

Continued from p. 678 Calling the condition ADD or ADHD be less robust than in the average per- manual dubbed a “hyperkinetic reaction “is like calling autism hand-flapping son of the same age, Barkley says. of childhood.” In 1980, the DSM-III disorder,” says Barkley of the Medical That view strikes a chord with some dubbed the condition attention deficit University of South Carolina. “The names clinicians. “We’re talking about the man- disorder, or ADD, shifting the defin- of the disease have trivialized it. What agement, the CEO of the brain — or- ition from hyperactivity to problems you’re really finding is a developmen- ganizing and managing the functions in focusing attention, which likely af- tal delay in the self-regulating” regions for daily life,” says Quinn, the Wash- fect more people. In 1994, in DSM-IV, of the brain — the areas, located most- ington pediatrician. The difference be- the current definition appeared, la- ly in the frontal lobe, that control tween people with and without ADHD beling the illness as ADHD — at- thoughts, emotions and behaviors, he is that “if you have two people whose tention deficit hyperactivity disorder says. The development of those func- desks are a mess, one can organize it — and distinguishing three subtypes: tions to full adult capacity is delayed if she has time, but the ADHD per- one consisting mainly of inattentive- by two to three years in children with son, no matter how much time you ness, one of hyperactivity and im- ADHD, Barkley says. give them, can’t organize the desk,” pulsivity, and one exhibiting all of Furthermore, he says brain imaging she says. those traits. 28 finds that in children with ADHD, the Others remain skeptical. Describing regions of the brain that perform these the condition as affecting the brain’s functions are 4 to 10 percent smaller “executive function” is another theory Widening Spectrum and 25 percent less active than in other into which clinicians try to fit the symp- children. And while the brain structures toms they observe, just like earlier de- ore recently, some ADHD spe- may catch up in size to those of the finitions, San Francisco psychiatrist Is- M cialists have argued for dubbing average person by the time a person rael says. “But people can’t even agree ADHD a disorder of the brain’s “ex- reaches the late teens or 20s, “the func- about what [the brain’s] executive func- ecutive functions.” tion doesn’t catch up” but continues to tion is,” he notes.

680 CQ Researcher in an early stage,” she says. However, studies have demon- gredients to which Feingold hypothesized children might be strated that meditation can strengthen the brain’s prefrontal cor- overly sensitive: mainly naturally occurring organic chemicals tex region, which manages the brain’s regulatory functions, ac- called salicylates, found in foods such as blueberries and toma- cording to Zylowska. 1 toes, and artificial flavors, dyes and other additives that were A change in breathing “can have rapid effects on the brain.” new to American diets at the time. says Patricia Gerbarg, an assistant professor of clinical psychi- The diet has been studied repeatedly over the years, and atry at New York Medical College. A “communication system” some researchers — and many families — have reported that called the autonomic nervous system “lets the brain know what’s it quiets some children’s symptoms. But dietary research is hard happening in every part of the body” and allows messages to verify, and many analysts speculate that probably few chil- coming from the body to affect the brain, she explains. dren have these food sensitivities. 2 While the system involves the heartbeat, digestive process- The European Union requires foods with certain artificial es and more, the only function it manages that can be volun- colors to carry a warning about possible ADHD effects, but tarily changed is breathing, she says. For example, slowing the U.S. Food and Drug Administration rejected such a warn- breathing to five steady, rhythmic in-and-out breaths per minute ing last year. 3 (See “At Issue,” p. 685.) calms anxiety, improves mental focus and allows the brain “to — Marcia Clemmitt solve problems better,” Gerbarg says. Even children can learn the technique quickly, she says. After 1 Stephanie Sarkis, “ADHD & Mindfulness: An Interview with Lidia Zylowska,” one training session, “they can get a CD for 15 bucks and prac- Psychology Today, June 19, 2012, www.psychologytoday.com/blog/here- tice at home for free. The kids like it. It doesn’t matter what there-and-everywhere/201206/adhd-mindfulness-interview-lidia-zylowska-md. your mind is doing. All you have to do is breathe.” 2 For background, see Matthew Smith, An Alternative History of Hyperactivity: In the early 1970s, when the ADHD diagnosis was in its Food Additives and the Feingold Diet (2011). 3 “FDA Panel: Studies Needed for Food Dye Side Effects, But No Warnings,” infancy, Los Angeles-based allergist Benjamin Feingold devised AboutLawsuits.com, April 4, 2011, www.aboutlawsuits.com/fda-panel-food- a diet aimed at quelling hyperactivity. The diet eliminates in- dye-side-effects-17270.

However ADHD’s traits are de- unmistakable,” while “most kids clear- ADHD medications are compounds re- scribed, most researchers agree that ly do not have” the disorder, Frances lated to amphetamine — a stimulant they lie on a continuum, from normal wrote. 29 first formulated in 1887. The full ef- to damaging and difficult to handle. In between, however, it’s tough to fects of amphetamine-like drugs on the But experts disagree sharply on whether distinguish children with a clinical brain remain unclear. But, among other current clinical standards deem too condition “from normal kids who are things, they may enhance the system much of that spectrum as illness in no more than extremely frisky and dif- through which the chemical dopamine need of treatment. ficult to manage.” Those kids in the — a major neurotransmitter active in Largely because of the dominance middle have increasingly been diag- functions including attention, memory, of the pharmaceutical industry, psy- nosed with ADHD, Frances wrote. “The motivation, learning and the process- chiatrists have pushed the ADHD di- epidemic started precisely when ag- ing of punishments and rewards — agnosis beyond impaired people to in- gressive drug company marketing suc- carries messages through the brain. clude many who function normally, ceeded in ‘educating’ and sensitizing That stimulant drugs are used to treat charged Allen Frances, a professor doctors, parents, and teachers to spot” people who already act overstimulat- emeritus of psychiatry at the Duke illness “in kids previously considered ed is an often-noted mystery. But, like University School of Medicine. to be on the normal side of the . . . most other drugs, stimulants found their ADHD “consists of nonspecific boundary.” 30 medical use through the most com- symptoms . . . widely distributed in the mon process used for drug discovery: general population: poor concentra- trial and error. Even today, little is tion, distractibility, impulsivity and Drug Abuse known about the actual cellular process- hyperactivity,” wrote Frances, who es involved in most medical conditions chaired the panel that assembled the he vast majority of people diag- and how chemicals interact with those DSM IV. “The kid who presents with T nosed with ADHD are treated at processes, and ADHD and stimulants classic early onset, severe [ADHD] is some point with drugs, and most are no exceptions.

www.cqresearcher.com Aug. 3, 2012 681 TREATING ADHD

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

s a double major at Rhode Island’s Brown University, Brown are subject to immediate suspension or expulsion. Cases “Sarah” (not her real name) takes a rigorous course load of simple possession of Adderall and other drugs by students A to ensure she’ll graduate within four years. Not only that, are handled on a case-by-case basis. Many students claim pre- but she engages in summer internships and plans to study abroad scription stimulants help them stay awake all night without fa- in the fall. tigue, providing them with crucial endurance in a competitive To keep it all going, Sarah, a senior, admits to taking Adder- college atmosphere. all, a highly addictive amphetamine, twice a week, which she Sarah says she first used Adderall during the summer be- obtains without a prescription from fellow students, whose doc- fore she entered Brown. After procrastinating on a summer tors prescribed it for attention deficit hyperactivity disorder reading assignment until the last day, she says, she took the (ADHD). drug at a friend’s recommendation. “I finished the assignment Illicitly obtained prescription stimulants increasingly are used so quickly, it was shocking,” she recalls. as study aids — and sometimes to get high — on college cam- During her sophomore year, she began using the drug regularly puses. Research conducted at 119 U.S. colleges in 2001 found — usually twice a week. Each of her classes required massive amounts that, on average, one in 25 students had used Adderall or an- of reading, sometimes eight to 12 hours at a stretch. Sarah describes other prescription stimulant in the past year, with a dozen Adderall as a “robotic drug” that makes her so focused on school- schools reporting a 10 percent or higher usage rate. 1 Six years work that she forgets to eat, drink and go to the bathroom. later, a study at a large, public research university found that One academic study found that many students excuse their about one in three students said they had illegally used Adder- illegal use of Adderall by claiming not to use the drug recre- all or some other prescription stimulant. 2 ationally. In addition, the study found, many students view it Sales of Adderall, in a class of stimulants known colloqui- as safer than street drugs such as cocaine and ecstasy because ally as “speed,” are regulated because the drug is classified by Adderall is a prescription medicine manufactured under gov- the U.S. Drug Enforcement Administration as a Schedule II sub- ernment supervision. 4 stance, meaning it has a high potential for abuse and psycho- Even students who say they don’t take the drug defend its logical and physical dependence. use. Josh Lundfelt, a recent Ohio University graduate in actuarial However, it is readily available for about $3 to $10 per pill science, says people exaggerate Adderall’s harmfulness. “People from other students, according to Sarah, although prices rise make it out to be some horrible thing, but it’s just an aid to during midterms and finals, when “people are rushing to get accelerate your [academic] process,” he says. it. It’s almost a desperation.” 3 However, ADHD drugs may not give the boost to academic Darlene Trew Crist, director of news and communication at performance that students think they provide. According to a Brown, says the university is aware that some students are abus- 2012 analysis of data on more than 1,200 students conducted ing Adderall and that those caught illegally distributing drugs at by researchers from the University of Maryland, using ADHD

In the early decades of the 20th cen- developed a reputation as remedies for influx of “Benzedrine-happy students” tury, as the fledgling pharmaceutical in- fatigue and as largely overhyped perfor- who tried to use the stimulant as a dustry first began to search for “block- mance enhancers. “During the Second study aid for semester exams but buster drugs” — relatively safe World War, amphetamine and metham- sometimes ended up suffering an compounds to treat chronic conditions phetamine were adopted in the military overdose-fueled disaster. “There is a that afflict many people — chemists services on all sides, in quasi-medical ef- rumor of the physics major who stayed and clinical researchers spent consid- forts to tune mind and body beyond up three nights in a row and left his erable time testing amphetamines on normal human capabilities,” wrote Aus- exam confident of an ‘A,’ ” said the paper. patients and on themselves, based on tralian medical historian Rasmussen. 31 “Actually, he had filled the blue book hunches about what the drug might Students were among those who with nothing but his name, written over do in the body. bought the drugs — mainly a decon- and over.” By the 1930s, amphetamines and gestant sold under the name Benzedrine If a student “takes a little too much, chemically similar drugs were being — for their hoped-for performance- he will fall into a delusional or ‘euphoric’ sold as decongestants, for example. enhancing abilities. In January 1948, state, in which he does everything wrong At the same time, the drugs, which for example, The Harvard Crimson without ever realizing it,” a health pro- could be bought without a prescription, reported on the “usual semi-annual” fessor told The Crimson. 32

682 CQ Researcher drugs without a prescrip- ing away prescription medi- tion actually correlates to cine is a felony. In Washing- having a lower grade-point ton, D.C., for example, dis- average. 5 tributing Adderall is punishable Moreover, Adderall can by up to five years in prison have serious side effects. and a $50,000 fine. Taking Food is “displeasing, even Adderall without a prescription, nauseating” when she is on the other hand, is a mis- using the drug, Sarah says. demeanor, punishable by up

Her weight dropped from PatrickMallahan III to 180 days in jail and a $1,000 The stimulant Adderall — a form of “speed” — is classified 6 110 pounds to 97 during her as a Schedule II substance because of its high potential for fine. Distributing Adderall in junior year. abuse and psychological and physical dependence. Rhode Island is punishable by She also experiences light- up to 30 years in prison and headedness, headaches, de- a $100,000 fine. 7 hydration and an irresistible desire to smoke cigarettes while — Kate Irby on Adderall. “I’d go through a pack every two days,” she says, adding that when she isn’t taking the drug she smokes only 1 Sean Esteban McCabe, John R. Knight, Christian J. Teter and Henry Wechsler, occasionally. “Non-medical use of prescription stimulants among US college students: preva- David Goodman, a psychiatrist who is founder and director lence and correlates from a national survey,” Harvard School of Public Health, of the Adult Attention Deficit Disorder Center of Maryland, in 2005, www.hsph.harvard.edu/cas/Documents/stimulants/McCabe_2005.pdf. 2 Baltimore, says Adderall can be deadly if taken by students with Alan D. DeSantis and Audrey Curtis Hane, “‘Adderall is Definitely Not a Drug’: Justifications for the Illegal Use of ADHD Stimulants,” Substance Use & Misuse, undiagnosed cardiac conditions that could result in an irregular 45:31-46, Informa Healthcare USA, 2010, p. 34, http://andrewvs.blogs.com/files/ heartbeat or even death. adderall-is-definitely-not-a-drug.pdf. Doctors and students must take responsibility for controlling 3 For background, see Michelle Trudeau, “More Students Turning Illegally to ‘Smart’ Drugs,” NPR, Feb. 5, 2009, www.npr.org/templates/story/story.php?story Adderall abuse, Goodman says. Because of the drug’s popu- Id=100254163. larity with college students who don’t have ADHD, he tells stu- 4 DeSantis and Hane, op. cit., p. 36. dents who come to him for prescriptions that he feels he first 5 Laura M. Garnier-Dykstra, et al., “Nonmedical Use of Prescription Stimulants must call their parents to find out whether they showed signs During College: Four-year Trends in Exposure Opportunity, Use, Motives and Sources,” Journal of American College Health, March 15, 2012, pp. 226-234. of ADHD in childhood. “The fakers tend not to want to in- 6 DC Official Code, 2001 Edition, § 48-904.01. volve the parent,” he says. 7 Rhode Island Official Code, Uniform Controlled Substances Act § 21-28-4.01, Goodman says he also warns patients that selling or giv- http://webserver.rilin.state.ri.us/Statutes/TITLE21/21-28/21-28-4.01.HTM.

Stimulants were not sold commer- lant drugs can be highly addictive and Under the Influence? cially as hyperactivity treatments until dangerous. 33 As a result, in the 1960s, a quarter-century later, however. for the first time, the government began hroughout this period, Benzedrine’s In 1961, Ritalin — methylphenidate requiring prescriptions for amphetamine T manufacturer, the Philadelphia firm — was formulated as a stimulant sim- and other stimulant drugs. Despite these Smith, Kline & French, sent many sam- ilar to amphetamine but somewhat new restrictions, however, stimulants ples of the drug to physicians around gentler and with fewer side effects. remained popular mood lifters and per- the country, to test as a treatment for At the same time, the diagnosis of formance enhancers, both as pre- various conditions. As early as 1937 hyperactivity was first being applied scribed by physicians and illegally. Charles Bradley, a psychiatrist at a Rhode to significant numbers of children By the late ’60s, one in 20 Ameri- Island institution for children with severe who, unlike Bradley’s patients, were can adults had a prescription for a stim- neurological and emotional problems, was not seriously ill. Ritalin soon gained ulant, and “at least half as many were testing the drug as a mental-performance popularity as the treatment of choice using ‘speed’ without prescriptions — enhancer. In the process, he discovered for the new diagnosis. altogether around 10 million people, that it made many children calmer and Only in the late 1950s did researchers equal to the entire combined popula- easier to work with. begin turning up evidence that stimu- tions of New York and Philadelphia at

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the time,” wrote Ras- fix is prescribed, he says. mussen. Stimulant “In recent years, I abuse was the lead- have come to believe ing drug problem of that the individuals the day. 34 who advocate most The 1970 Com- strongly for medication prehensive Drug — both those from the Abuse Prevention professional communi- and Control Act, ty, including the National signed into law by Institutes of Mental President Richard M. Health, and those from Nixon, placed re- advocacy groups — . . . strictions on pre- have major and undis- scription stimulants closed conflicts of in- along with other terest with the pharma- drugs, and by the ceutical companies,” late 1970s stimulant Pelham said in 2004. 37 AFP/GettyImages/Christophe Simon abuse had subsided. ADHD is no barrier to success. Swimmer Michael Phelps, the most But virtually all med- The use of stim- decorated Olympic athlete of all time, Grammy-winning pop singer Justin ical researchers maintain ulants to treat chil- Timberlake and movie star Jim Carrey, for example, all suffer from the that they are not influ- dren with ADHD condition. Diagnosed at age 9, Phelps stopped taking medication in enced by pharmaceutical was just beginning seventh grade. His highly structured life as an athlete in training helped company funding be- keep his symptoms in check, said his mother. “ADHD kids have great its long ascent, how- passion. It just needs to be funneled,” said Debbie Phelps, who used cause as academics their ever. intense behavioral therapy to help her son. Above, Phelps after winning primary interest is in un- In 1969, at the his 19th Olympic medal at the London Summer Games on July 31. covering facts. “My in- height of the nation’s terests are solely in the biggest stimulant epidemic, U.S. drug toms, says Quinn, the Washington pe- advancement of medical treatment companies manufactured about 2.5 bil- diatrician. “It’s the most difficult thing through rigorous and objective study,” lion standard doses of prescription stim- in the world to put a kid on med- and conflict-of-interest issues are some- ulants annually, according to Rasmussen. ications,” she says. But “often the fam- thing to be taken “very seriously,” said That amount dropped off substantially ilies try other things” — such as elim- Harvard Medical School psychiatry pro- in the 1970s, but then, as the ADHD inating sugar from a child’s diet fessor Joseph Biederman, an ADHD ex- diagnosis gained steam, it began rising — “and then they come back.” Even pert who was sanctioned by the school again, first gradually but then steeply, non-drug therapies that do work, such in 2011 for failing to disclose some pay- beginning in the mid-1990s. as behavior-modifying techniques, work ments he got from drug companies. 38 Between 1998 and 2009, the per- better when used alongside medica- The nonprofit disease-advocacy centage of children between ages 5 and tions, she says. group Children and Adults with At- 17 who had been diagnosed with But others worry that the rising rate tention Deficit/Hyperactivity Disor- ADHD increased from 6.9 percent to of ADHD diagnosis — and the near- der (CHADD) says that it is “com- around 9 percent. 35 Meanwhile, “Amer- total reliance on drug therapy — is mitted to avoiding conflict of interest ica’s annual consumption of pharma- driven as much by drug company in- or even its appearance in accepting ceutical “speed” has risen almost ten- fluence as by medical understanding. financial support from corporations” fold since 1995,” and in 2005 it exceeded At most, only one in 10 families with an interest in promoting ADHD- the number of doses being produced with an ADHD child receives parental related products. To that end, “for in 1969, Rasmussen said. 36 training on managing the condition, any . . . fiscal year, no more than In many ways, that’s a medical suc- but nine in 10 children diagnosed with 30 [percent] of CHADD’s revenue can cess story, some ADHD experts say. ADHD get drugs, says Florida Inter- be derived from donations and grants Many parents are hesitant to ex- national’s Pelham. “Mainly the teacher from pharmaceutical companies,” pose young children to long-term pre- complains to the parent, the parent and the group will accept donations scription drug use but change their goes to the pediatrician, who’s not for education and information cam- minds when they discover that other trained to do a full screen” for ADHD, paigns only if it has “complete edi- approaches they try don’t quell symp- and the simple, well-publicized drug Continued on p. 686

684 CQ Researcher At Issue:

Areyes ADHD and artificial food dyes linked?

MICHAEL F. JACOBSON SARAH MECHUM EXECUTIVE DIRECTOR, CENTER FOR INTERNATIONAL ASSOCIATION OF COLOR SCIENCE IN THE PUBLIC INTEREST MANUFACTURERS

WRITTEN FOR CQ RESEARCHER, JULY 2012 WRITTEN FOR CQ RESEARCHER, JULY 2012

ithout question, food dyes serve a very useful pur- he scientific evidence does not support the claims made pose for food manufacturers. They make a wide vari- by the Center for Science in the Public Interest and others w ety of low-nutrition junk foods — candy, soft drinks, t linking synthetic color additives and hyperactive behavior sugary cereals — more appealing to children. Dyes can help dis- in children. Reviews of several studies on hyperactivity and syn- guise the absence of healthy fruit and vegetable ingredients in a thetic food color conducted by U.S. experts and international product expected to include them, as was the case in a nearly regulatory bodies have found no correlation between the intake avocado-free “guacamole” dip Kraft used to sell. But given that of synthetic food colors and hyperactivity among children. they provide no nutritive or preservative function, food dyes have Just last year, the FDA Food Advisory Committee, an expert quite a high bar to clear when it comes to their safety. panel of pediatricians, toxicologists, behavioral scientists, neuro- Thanks to numerous controlled studies conducted in the scientists and food scientists, reviewed all of the available evi- United States, Europe and Australia, we now know that dence and concluded there is no established causal relationship Yellow 5, Red 40, Blue 2 and other petroleum-based food between color additives and hyperactivity in children. The com- dyes have a powerfully disruptive impact on some children’s mittee voted against recommending additional labeling beyond behavior. the name of the color but agreed additional studies are warrant- A comprehensiveyes 2004 meta-analysis of the medical litera- ed. The Internationalno Association of Color Manufacturers supports ture and two important studies funded by the British govern- the committee’s conclusions. We are currently conducting a study ment found that dyes (and possibly the preservative sodium to further improve the understanding of color additive consump- benzoate) adversely affect kids’ behavior. These studies sup- tion, and the results will be shared with the FDA. port what many parents who have placed their hyperactive The color industry takes its responsibility for consumer children on a diet developed by allergist Benjamin Feingold safety seriously. In addition to complying with FDA regulations have discovered: that eliminating foods with artificial dyes and procedures for certification of colors, the industry also (and in other cases, other foods) leads to marked improve- sponsors many safety studies, the results of which have been ment in behavior and performance in school. evaluated by the FDA and international regulatory bodies, in- In 2008, the Center for Science in the Public Interest called cluding the Joint Expert Committee on Food Additives and the on the Food and Drug Administration (FDA) to ban several European Food Safety Agency. The transparent safety-evaluation dyes. At a follow-up 2011 hearing, the FDA agreed that dyes process includes commentary from all stakeholders, including do adversly affect some children. regulators, consumers, public health advocates and industry. European food-safety officials are several steps ahead of the These studies confirm the safety of FDA-certified colors, and FDA and have successfully spurred positive changes in the as a result, various coloring additives have been approved for industry. Thus, a strawberry sundae from a McDonald’s in the use in food, beverages and other products around the world. U.K. gets its red color from strawberries; McDonald’s treats its While they are not nutritional, color additives play an impor- U.S. consumers to strawberries and Red 40. tant role in food, and they do so without posing a health risk As it happens, safe natural colorings are abundant. (No to consumers. Color is one of the principal contributors to the European consumers seem to miss the fake ones.) Getting rid palatability of foods. Color additives enhance colors that occur of food dyes here would certainly be a safer step than dealing naturally, correct natural variations in color and provide a color- with hyperactivity or other behavioral problems in children ful identity to foods that would otherwise be virtually colorless. with powerful stimulant drugs such as Ritalin. (Irony alert: Additionally, they provide a means to identify drugs and dietary Some Ritalin pills have Green 3.) supplements, helping to prevent medication errors. The question I pose to American food-safety regulators and Our industry is vigilant about the safety of our products, companies is why tolerate any risk, even in just a small per- and we will continue to stay on top of new scientific devel- centage of children, from something that serves only a cos- opments related to color additive safety. We will continue to metic no purpose in food? work closely with regulatory authorities around the world to ensure that food colors are safe.

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Continued from p. 684 hood psychiatric illness than ADHD, Driving the increase in ADHD pre- torial and managerial control” of the such as bipolar disease. But the men’s scriptions has been a steady rise in the projects. 39 worldwide prominence as ADHD re- number of young people under age 18 In his own pharmaceutical-sponsored searchers raised questions for many diagnosed with the disorder. It grew research, Pelham said he was pres- about drug-company influence in that 66 percent between 2000 and 2010, ac- sured to delete a portion of an ar- field. An Australian government panel cording to a study this year by researchers ticle being prepared for publication ordered a review of ADHD-treatment at Northwestern University. By 2010, doc- “where I was saying it was impor- guidelines being prepared for the tors had diagnosed 10.4 million U.S. chil- tant to do combined treatments country’s national health insurance dren and teens, up from 6.2 million in (medication and behavioral)” rather program following the investigation. 2000, according to the analysis. 45 (The than drugs alone. “It was intimidat- At the time, the draft guidelines re- number of Americans ages 5 through ing to be one researcher and have ferred to Biederman’s research 50 times, 17 — the prime ages for an ADHD all these people pushing me to while seven of the 10 people on Aus- diagnosis — hovered between 53 and change the text.” 40 tralia’s guideline-drafting panel also 54 million in both years.) 46 Such qualms have been reinforced had financial ties to companies such “The magnitude and speed of this in the past few years as Biederman as Swiss-based Ritalin manufacturer shift in one decade is likely due to and two other leading ADHD experts, Novartis. 43 an increased awareness of ADHD,” said all in the psychiatry department of Meanwhile, it has remained difficult study author Craig Garfield, an assis- Harvard Medical School, have faced for researchers to get funding to study tant professor of pediatrics at the North- sanctions over failure to disclose pay- behavioral therapies and other non- western University Feinberg School of ments they’ve received as consultants drug approaches. Pelham, for exam- Medicine. 47 to drug companies. NIH requires re- ple, is currently pursuing a federal grant searchers it supports to report to their to explore the limitations of drug treat- universities any outside earnings of ments. He’d prefer to do a study on Changing Policies $10,000 a year or more, in a bid to non-drug therapies, he says, “but NIH make transparent conflicts of interest doesn’t fund those.” ate last year, the American Acad- that may shade the researchers’ find- L emy of Pediatrics expanded its ings. In 2008, Sen. Charles Grassley, ADHD diagnosis guidelines to cover R-Iowa, announced that he’d discov- children and teens from ages 4 to 18; ered serious under-reporting of income earlier guidelines had covered only by Biederman and Harvard professor CURRENT children between 6 and 12. New med- Timothy Wilens and associate profes- ical findings about ADHD make it pos- sor Thomas Spencer. Based on the SITUATION sible to diagnose and treat the broad- men’s disclosure documents, “over the er group, says the academy. last seven years, it looked like they “Treating children at a young age” had taken a couple hundred thousand Numbers Rise may “increase their chances of suc- dollars” from drug companies, when ceeding in school,” said Mark Wolraich, in fact they had received over a mil- he total number of drug prescrip- lead author of the guidelines and a re- lion dollars each, Grassley said. 41 T tions written for U.S. children and searcher on neural development at the In 2011, Harvard Medical School teens has dropped for the past sever- University of Oklahoma Health Sciences and Massachusetts General Hospital, al years, but the rate of ADHD pre- Center, in Oklahoma City. 48 where the three are also employed, scriptions continues to climb, accord- As for teens, “it’s been known for a announced that they were barred ing to the Food and Drug Administration. while” that stopping ADHD drugs at pu- from all industry-sponsored outside ADHD prescriptions rose 46 per- berty — as recommended in the past — activities for a year, followed by a cent between 2002 and 2010 (the lat- “was a mistake” and that attention prob- two-year probationary period during est year examined), the second-highest lems, in particular, still plague teenagers, which they would need approval for increase of any category. Contracep- says the University of Illinois’ Stein. such work. 42 tive prescriptions increased 93 percent, In the past year, the supply of sev- The conflicts of interest in the case while prescriptions for antibiotics and eral ADHD drugs has fallen short of de- involved mostly the psychiatrists’ pro- some cough medicines dropped, after mand. Besides the growing legitimate motion of increased diagnosis of and new medical guidelines recommended market, demand is swelling for stimu- drug treatment for more severe child- limiting their use. 44 lants as performance enhancers or recre-

686 CQ Researcher ational drugs. Because stimulants are ing accommodations to help ADHD go a long way toward “clearing up “controlled substances,” the Drug En- sufferers and other disabled students. the uncertainty and discomfort people forcement Agency (DEA) caps the Federal law authorizes schools to have around the diagnosis,” he says. amount that companies can produce, make certain adjustments — such as Studying genetic profiles also may and the combined legitimate and ille- allowing seating in the front of the class- eventually yield valuable information, gal demand has outstripped supply. 49 room or providing more time to take Israel says. In particular, profiles that “The DEA is tasked with making tests — to create a level playing field show variations among groups of sure there is enough for legitimate need for all students. However, the Tribune ADHD sufferers may help to “match without making so much [that] it is di- found that Illinois students who live the right person to the right medica- verted for illicit purposes,” said agency in higher-income districts got the lion’s tions” without trial and error. spokesperson Barbara Carreno. This share of such help. 53 The American Psychiatric Associa- year, DEA has raised the cap for Statewide, only about 1 percent of tion plans to release the DSM-5 in May methylphenidate, the basis for such public-school students had accommoda- 2013. 55 Current DSM guidelines state drugs as Ritalin and Concerta, from tions in the 2009-2010 school year, ac- that, to warrant an ADHD diagnosis, 50,000 to 56,000 kilograms per year cording to the paper. But in some wealthy a patient must show symptoms by and the cap for amphetamine, used districts near Chicago, 4 to 5 percent of age 7, a threshold that the DSM-5 will in drugs such as Adderall, from 18,600 students got accommodations. The 20 raise to age 12. Drafters say recent re- to 25,300 kilograms per year. 50 school districts with the highest percent- search shows that people whose Meanwhile, implementing school ages of students with accommodations symptoms appear by age 7 aren’t any procedures that assist both ADHD stu- had student bodies that were 76 percent different from people who don’t ex- dents and their teachers continues to white and poverty rates well below the hibit them until later. Moreover, they be difficult. state average of 45 percent; the 20 dis- say raising the threshold will make it Federal legislation is pending to limit tricts with the fewest accommodations easier to diagnose adults, who seldom schools’ leeway in using physical re- were 19 percent white, and the “vast ma- remember what they were like before straints and seclusion to control stu- jority had far higher poverty than the state age 7 but do remember what they dents, often those with ADHD-related average,” the Tribune reported. 54 were like as 12-year-olds. 56 traits. The bills — sponsored by Sen. But some medical professionals Tom Harkin, D-Iowa, and Rep. George worry the change will increase the Miller, D-Calif. — would prohibit already skyrocketing rates of ADHD schools that receive federal funds from OUTLOOK diagnosis and expose too many people physically restraining a student unless to “inappropriate treatment and stigma- the behavior poses immediate physi- tization” said Frances, the Duke profes- cal harm to the student or others. Re- sor emeritus. 57 straints can be used only if they allow Debate Continues Perhaps most in need of examina- the student to communicate, and if tion, however, is a culture that values other means of controlling the behavior ith attention growing on ADHD achievement to the point that it drives have been tried and failed. 51 W in adults, teens, preschool chil- “increasing use of stimulant drugs for Many advocates for the disabled dren and girls, diagnoses will likely enhancement, even among the gener- support the bills, but schools are leery. increase for the foreseeable future. al population,” says Diller, the Cali- The legislation proposes “an extreme- Many clinicians hope science can even- fornia pediatrician. ly high threshold” that schools must tually clear up doubts that ADHD is meet before restraints are allowed, said a “real” disorder, but others want re- the National School Boards Association. searchers to take a closer look at the Notes For example, a student whose behav- social trends, such as increasing com- ior threatens “to destroy a classroom” petitiveness, that lead people to seek 1 — a costly consequence — would not achievement-enhancing drugs. Daniel F. Connor, “Problems of Overdiag- nosis and Overprescribing in ADHD,” Psychi- be eligible for restraint under the bills Improvements in brain-imaging tech- 52 atric Times, Aug. 11, 2011, www.psychiatrictimes. as currently drafted, the group said. nology provide hope that it eventual- com/adhd/content/article/10168/1926348. A recent study by the Chicago Tri- ly can diagnose ADHD, says Israel, 2 “Attention Deficit/Hyperactivity Disorder, bune points to serious inequities be- the San Francisco psychiatrist. Brain Data and Statistics,” Centers for Disease Con- tween schools in high- and low-income images showing clear patterns of aber- trol and Prevention, www.cdc.gov/ncbddd/ neighborhoods when it comes to mak- rant activity in ADHD patients could adhd/data.html.

www.cqresearcher.com Aug. 3, 2012 687 TREATING ADHD

3 Connor, op. cit. of Relative Age on Diagnosis and Treatment 22 Cease-and-desist order from U.S. DEA to 4 “Attention Deficit/Hyperactivity Disorder,” of Attention-Deficit/Hyperactivity Disorder in Celltech Pharmaceuticals, purveyor of the op. cit. Children,” CMAJ [Canadian Medical Associa- control substance methylphenidate, website 5 Ibid. tion Journal], March 5, 2012, www.cmaj.ca/ of Ben Hansen, www.bonkersinstitute.org/ 6 Peter Breggin, “Stimulants for ADHD Shown content/184/7/755.abstract. medshow/kiddealetter.html; Karen Thomas, to Cause Sudden Death in Children,” Huffing- 14 Rick Nauert, “Youngest Kids in Class Get “Back to School for ADHD Drugs,” USA ton Post, June 17, 2009, www.huffingtonpost. More ADHD Diagnosis, Drugs,” PsychCentral, Today, Aug. 8, 2001, www.usatoday.com/life/ com/dr-peter-breggin/stimulants-for-adhd-shown_ March 6, 2012, http://psychcentral.com/news/ 2001-08-28-adhd.htm. b_216912.html. 2012/03/06/youngest-kids-in-class-get-more- 23 Ed Silverman, “FDA Warns Five Drug- 7 For background see Thomas J. Billitteri, adhd-diagnoses-drugs/35621.html. makers Over ADHD Ads,” Pharmalot blog, “Preventing Bullying,” CQ Researcher, Dec. 10, 15 “Strattera Oral,” WebMD, www.webmd.com/ Sept. 26, 2008, www.pharmalot.com/2008/09/ 2010, pp. 1013-1036; updated May 31, 2012. drugs/drug-64629-Strattera+Oral.aspx?drugid= fda-warns-five-drugmakers-over-adhd-ads; Mar- 8 Marianne Szegedy-Maszak, “Psychological Sci- 64629&drugname=Strattera+Oral; Monitoring guerite R. Lombardo, “Through the Correct ence Weighs in on ADHD,” Daily Observa- the Future, University of Michigan, 2011, pp. Lens: Understanding Overprescription of Stim- tions blog, Association for Psychological Sci- 499-501, http://monitoringthefuture.org/pubs/ ulant Drugs, Their Abuse, and Where the ence, June 25, 2012, www.psychological monographs/mtf-vol1_2011.pdf. Remedies Lie,” student paper, Harvard Law science.org/index.php/publications/observer/ 16 “The Multimodal Treatment of Attention School, April 2004, http://leda.law.harvard.edu/ obsonline/psychological-science-weighs-in-on- Deficit Hyperactivity Disorder Study (MTA): leda/data/674/Lombardo.html#fn274; Kevin P. adhd.html. Questions and Answers,” National Institute of Miller, “FDA Warns ADHD Drugmakers — 9 Nicolas Rasmussen, On Speed: The Many Mental Health website, November 2009, www. Again,” Kevin P. Miller blog, Sept. 29, 2008, Lives of Amphetamine (2008), p. 236. nimh.nih.gov/trials/practical/mta/the-multimodal- http://kevinpmiller.blogspot.com/2008/09/fda- 10 Peter Conrad, “The Changing Social Reality of treatment-of-attention-deficit-hyperactivity-dis warns-adhd-drugmaker-again.html. ADHD,” Contemporary Sociology, Oct. 1, 2010, order-study-mta-questions-and-answers.shtml. 24 “Guidance for Industry Direct-to-Consumer p. 525. 17 William O. Cooper, Laura A. Habel, et al., Television Advertisements — FDAAA DTC Tele- 11 Katrin Bruchmüller, Jürgen Margraf and Sil- “ADHD Drugs and Serious Cardiovascular Events vision Ad Pre-Dissemination Review Program,” via Schneider, “Is ADHD Diagnosed in Accord in Children and Young Adults,” New England Food and Drug Administration, March 2012, with Diagnostic Criteria? Overdiagnosis and Journal of Medicine, Nov. 23, 2011, pp. 1896- www.fda.gov/downloads/Drugs/Guidance- Influence of Client Gender on Diagnosis,” 1904, www.nejm.org/doi/full/10.1056/NEJMoa ComplianceRegulatoryInformation/Guidances/ Journal of Consulting and Clinical Psychology, 1110212. UCM295554.pdf. February 2012, pp. 128-138, http://psycnet.apa. 18 Laura A. Habel, William O. Cooper, et al., 25 Peter R. Breggin, “A Misdiagnosis, Any- org/index.cfm?fa=buy.optionToBuy&id=2011- “ADHD Medications and Risk of Serious Car- where,” Room for Debate blog, The New York 30100-001. diovascular Events in Young and Middle-Aged Times, Oct. 13, 2011, www.nytimes.com/room 12 M. Huss, et al., “How Often Are German Adults,” JAMA, Dec. 28, 2011, pp. 2673-2683, fordebate/2011/10/12/are-americans-more-prone- Children and Adolescents Diagnosed with ADHD? www.ncbi.nlm.nih.gov/pubmed/22161946. to-adhd/adhd-is-a-misdiagnosis. Prevalence Based on the Judgment of Health 19 “Controlled Substance Schedules,” U.S. Drug 26 Ibid. Care Professionals: Results of the German Enforcement Administration, www.deadiversion. 27 For background, see Kathy Koch, “Re- Health and Examination Study,” European Child usdoj.gov/schedules/index.html. thinking Ritalin,” CQ Researcher, Oct. 22, and Adolescent Psychiatry, December 2008, 20 “Methylphenidate (Ritalin),” U.S. Drug En- 1999, pp. 905-928. www.ncbi.nlm.nih.gov/pubmed/19132304. forcement Administration, www.justice.gov/dea/ 28 “Types of ADHD: Making the Diagnosis,” 13 Randy Dotinga, “Youngest Kids in Class More concern/methylphenidate.html. WebMD, May 15, 2012, www.webmd.com/add- Apt to Get ADHD Diagnosis: Study,” Health- 21 “Warnings on Packages and Advertising,” adhd/guide/types-of-adhd. Day, Healthfinder.gov, March 2012, http:// Article 10, Convention on Psychotropic Sub- 29 Allen Frances, “Attention Deficit Disorder Is healthfinder.gov/news/newsstory.aspx?docID= stances, 1971, p. 7, www.unodc.org/pdf/con Over-diagnosed and Over-treated,” Huffington 662425; Richard L. Morrow, et al., “Influence vention_1971_en.pdf. Post, March 5, 2012, www.huffingtonpost.com/ allen-frances/attention-deficit-disorder_b_120 6381.html. About the Author 30 Ibid. 31 op. cit. Staff writer Marcia Clemmitt is a veteran social-policy re- Rasmussen, , p. 3. 32 “Benzedrine-soaked Crammers May Wind porter who previously served as editor in chief of Medi- Up Behind an ‘E,’ Bock Warns,” The Harvard cine & Health and staff writer for The Scientist. She has Crimson, Jan. 24, 1948, www.thecrimson.com/ also been a high school math and physics teacher. She article/1948/1/24/benzedrine-soaked-crammers- holds a liberal arts and sciences degree from St. John’s may-wind-up-behind. College, Annapolis, and a master’s degree in English from 33 Rasmussen, op. cit., p. 3. Georgetown University. Her recent reports include “Trau- 34 Ibid., p. 4. matic Brain Injury” and “Sleep Deprivation.” 35 Lara K. Akinbami, et al., “Attention Deficit Hyperactivity Disorder Among Children Aged

688 CQ Researcher 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. FOR MORE INFORMATION 36 Rasmussen, op. cit., p. 236. ADDitude 37 Quoted in “Leading ADHD Researcher Blows , www.additudemag.com/adhd/about-additude.html. Advertising-supported website that provides information about ADHD. Whistle on Concerta and Chadd,” Alliance for Human Research Protection website, Dec. 3, American Academy of Child and Adolescent Psychiatry, 3615 Wisconsin Ave., 2004, www.ahrp.org/infomail/04/12/03.php. 38 N.W., Washington, DC 20016-3007; 202-966-7300; www.aacap.org. Membership Quoted in Gardiner Harris and Benedict group for psychiatrists that monitors legislation and policy activities related to Carey, “Researchers Fail to Reveal Full Drug children’s mental health. Pay,” The New York Times, June 8, 2008, www. nytimes.com/2008/06/08/us/08conflict.html? Centers for Disease Control and Prevention, Attention-Deficit/Hyperactivity pagewanted=all. Disorder, 1600 Clifton Rd., Atlanta, GA 30333; 800-232-4636; www.cdc.gov/ncbddd/ 39 “CHADD Ethical Principles for Acceptance adhd. Federal website that posts data and medical information on ADHD. of Corporate and Foundation Support,” www. chadd.org/AM/Template.cfm?Section=Home& CHADD (Children and Adults with Attention Deficit Hyperactivity Disorder), section=Privacy_Policy&template=/CM/Content 8181 Professional Place, Suite 150, Landover, MD 20785; 800-233-4050; www.chadd.org. Display.cfm&ContentFileID=1334. Nonprofit membership group that provides information on ADHD; hosts the Na- 40 Quoted in Kelly Hearn, “Here, Kiddie, Kiddie,” tional Resource Center on ADHD, a federally funded national clearinghouse for AlterNet, Nov. 29, 2004, www.alternet.org/ evidence-based research on the condition. story/20594?page=entire. 41 Quoted in Harris and Carey, op. cit. DSM-5 Development, American Psychiatric Association, 1000 Wilson Blvd., Suite 1825, 42 Xi Yu, “Three Professors Face Sanctions 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 Mental Following Harvard Medical School Inquiry,” Disorders. The Harvard Crimson, July 2, 2011, www.the crimson.com/article/2011/7/2/school-medical- Feingold Association of the United States, 11849 Suncatcher Dr., Fishers, IN harvard-investigation. 46037; 800-321-3287; www.feingold.org. Membership group for parents who try to 43 Nicola Berkovic, “Urgent Review to be Un- control hyperactivity in children by eliminating food additives from the diet. dertaken of ‘Tainted’ ADHD Guidelines,” The Australian, Nov. 24, 2009, www.theaustralian. Multimodal Treatment of Attention Deficit Hyperactivity Disorder Study, com.au/news/urgent-review-to-be-undertaken- National Institute of Mental Health, 6001 Executive Blvd., Room 8184, MSC 9663, of-tainted-adhd-guidelines/story-e6frg6n6-122 Bethesda, MD 20892-9663; 866-615-6464; www.nimh.nih.gov/trials/practical/mta/ 5802595063. multimodal-treatment-of-attention-deficit-hyperactivity-disorder-mta-study.shtml. 44 Grace Chai, et al., “Trends of Outpatient Federal information website for the largest study of ADHD treatments. Prescription Drug Utilization in U.S. Children, 2002-2010,” Pediatrics, July 2012, http://pediatrics. Russell A. Barkley: The Official Site, www.russellbarkley.org. Website of a pro- aappublications.org/content/130/1/23.full.pdf+ fessor of psychiatry and pediatrics at the Medical University of South Carolina who html. spearheaded movement to gain recognition for ADHD as a serious affliction with 45 Erin White, “Diagnosis of ADHD on the biological causes. Rise,” press release, Northwestern University, March 19, 2012, www.northwestern.edu/news Why?” WebMD, Jan. 3, 2012, www.webmd. chicagotribune.com/2012-06-06/news/ct-met- center/stories/2012/03/adhd-diagnosis-pediatrics. com/add-adhd/news/20120103/adhd-drug- accommodations-folo-20120606_1_disabled- html. shortages-why. students-time-or-other-accommodations-poorest- 46 “Resident Population by Sex and Age: 1980 50 Ibid. schools. to 2010,” Table 7, Statistical Abstract of the 51 “S. 2020: Keeping All Students Safe Act,” 54 Ibid. United States, 2012, U.S. Census Bureau, www. govtrack.us, www.govtrack.us/congress/bills/ 55 “DSM-5: The Future of Psychiatric Diag- census.gov/compendia/statab/2012/tables/12s 112/s2020. nosis,” American Psychiatric Association, www. 0007.pdf. 52 “Statement for the Record: Beyond Seclu- dsm5.org/Pages/Default.aspx. 47 Quoted in White, op. cit. sion and Restraint: Creating Positive Learning 56 “Rationale for Changes in ADHD in DSM-5,” 48 Quoted in “American Academy of Pediatrics Environments for All Students,” National School American Psychiatric Association ADHD and Expands Ages for Diagnosis and Treatment of Boards Association, July 12, 2012, www.nsba. Disruptive Behavior Disorders Workgroup, ADHD in Children,” press release, American org/Newsroom/Spotlight-On/NSBA-Statement- May 3, 2012, www.dsm5.org/ProposedRevisions/ Academy of Pediatrics, Oct. 16, 2011, www. for-the-Record-on-Senate-Committee-Hearing- Pages/proposedrevision.aspx?rid=383#. aap.org/en-us/about-the-aap/aap-press-room/ on-Keeping-All-Students-Safe-Act-July.pdf. 57 Allen Frances, “DSM 5 Continues to Ig- pages/AAP-Expands-Ages-for-Diagnosis-and- 53 Diane Rado, “Special Help Starts as Early as nore Criticism From Petitioners,” Huffington Treatment-of-ADHD-in-Children.aspx. Grade School — but Only for Select Students,” Post, June 20, 2012, www.huffingtonpost.com/ 49 Daniel J. DeNoon, “ADHD Drug Shortages: Chicago Tribune, June 6, 2012, http://articles. allen-frances/dsm-5-petition_b_1610569.html.

www.cqresearcher.com Aug. 3, 2012 689 Bibliography Selected Sources

Books Articles

Barkley, Russell A., Taking Charge of Adult ADHD, The Harris, Dan, and Lana Zak, “Supermom’s Secret Addiction: Guilford Press, 2010. Stepping Out of Adderall’s Shadow,” ABC News, June 26, A clinical professor of psychiatry and pediatrics at the Med- 2012, http://abcnews.go.com/Health/adderall-rise-mothers/ ical University of South Carolina describes the relatively new story?id=16622475. diagnosis of adult ADHD along with drug and non-drug Middle-aged women, including a mother of four and a strategies for managing it. nurse, say they became addicted to the ADHD drug Adder- all after taking it to enhance their performance in their jobs Brown, Richard P., and Patricia L. Gerbarg, Non-drug and as homemakers. Adderall use has risen quickly among Treatments for ADHD: New Options for Kids, Adults adult women, and experts believe many users are obtaining and Clinicians, W.W. Norton & Co., 2012. the drug illegally, such as by “doctor shopping” among physi- An associate clinical professor of psychiatry (Brown) at Co- cians to get multiple prescriptions. lumbia College of Physicians and Surgeons, in New York City, and his wife, an assistant clinical professor of psychia- Rabin, Roni Caryn, “Drugs to Treat ADHD Reach the try at New York Medical College, describe a variety of com- Preschool Set,” The New York Times, Oct. 24, 2011, www. plementary treatments such as dietary changes, herbs, vita- nytimes.com/2011/10/25/health/25consumer.html. mins and mind-body techniques such as breathing exercises, The American Academy of Pediatrics has revised its ADHD to help manage ADHD. treatment guidelines, approving the addition of drugs to preschoolers’ ADHD treatment if behavioral techniques don’t Diller, Lawrence H., Remembering Ritalin: A Doctor and quell their symptoms. The recommendation makes some par- Generation Rx Reflect on Life and Psychiatric Drugs, ents and medical professionals leery, however. Perigee, 2011. A developmental pediatrician and assistant clinical profes- Thurm, Wendy, “Is There an ADHD Epidemic in Major sor of pediatrics at the University of California, San Francis- League Baseball?”SBNation, June 29, 2012, http://mlb.sb co, recounts the stories of 10 young adults he treated for nation.com/2012/6/29/3104332/is-there-an-adhd-epidemic- hyperactivity as children. Diller reflects on whether ADHD in-major-league-baseball. is overdiagnosed and says the long-term prognosis for children Eight percent of major league baseball players have been with the disorder is better than many believe. diagnosed with ADHD and prescribed stimulant drugs. But the National Institutes of Health estimates that only 4 per- Rasmussen, Nicolas, On Speed: The Many Lives of Am- cent of adults have ADHD, and skeptics wonder whether phetamine, New York University Press, 2009. players are being diagnosed illegitimately. The drugs would A professor of the history and philosophy of medicine at otherwise be off-limits to them under baseball’s rules for- Australia’s University of New South Wales chronicles the 100- bidding performance-enhancing drugs. plus year history of stimulant drugs as medicines, perfor- mance enhancers and intoxicants. Reports and Studies

Reiff, Michael I., ed., ADHD: What Every Parent Needs “Monitoring the Future: National Results on Adolescent to Know, 2nd Ed., American Academy of Pediatrics, 2011. Drug Use,” National Institute on Drug Abuse/University Authors from a pediatricians’ professional group describe of Michigan Institute for Social Research, February 2012, the current medical thinking on ADHD. www.monitoringthefuture.org/pubs/monographs/mtf-over view2011.pdf. Smith, Matthew, An Alternative History of Hyperactivity: The latest edition of a long-running national survey on drug Food Additives and the Feingold Diet, Rutgers University use by high school students describes trends in abuse of the Press, 2011. ADHD drugs Ritalin, Concerta and Adderall. A research fellow at Britain’s University of Exeter says the emergence of ADHD as a diagnosis in the post-World War II “Teaching Children with Attention Deficit Hyperactivity era made it almost inevitable that some would ascribe its Disorder: Instructional Strategies and Practices,” U.S. origins to the presence of chemical additives in food. Skep- Department of Education, 2008, www2.ed.gov/rschstat/ tics and supporters of that hypothesis continue producing research/pubs/adhd/adhd-teaching-2008.pdf. dueling — but ultimately inconclusive — research studies The Education Department describes how teachers can on the question. identify children with ADHD and employ the best classroom strategies to manage their behavior and help them learn.

690 CQ Researcher The Next Step: Additional Articles from Current Periodicals

Drugs Wen, Patricia, “ADHD Rates Low Among Latinos,” The Boston Globe, Sept. 26, 2011, p. B1, articles.boston.com/ Bankston, Amanda, “Students Faking ADHD to Get Drugs,” 2011-09-26/news/30205138_1_adhd-medication-latino- Star Tribune (Minneapolis), Feb. 17, 2012, p. A1, www.star children-latino-youngsters. tribune.com/local/139491333.html?refer=y. Fewer Latino children are diagnosed with ADHD compared University of Minnesota students reportedly are faking ADHD to white and black children, according to the Centers for symptoms to obtain prescriptions for Adderall. Disease Control and Prevention.

Ellison, Katherine, “Mother’s New Little Helper,” Los Ange- Symptoms les Times, Jan. 13, 2012, p. A17. Experts say some young mothers are taking their children’s Gerhart, Jacqueline, “Steps to Diagnosing ADHD,” Wis- prescription ADHD drugs to boost their productivity. consin State Journal, Dec. 13, 2011, p. C3, host.madison. com/wsj/news/local/health_med_fit/dr-jacqueline-gerhart- Martin, Richard, “ADHD Drugs Dwindle and Parents how-can-a-parent-know-if-child/article_0ef24598-2514- Scramble,” St. Petersburg (Fla.) Times (now Tampa Bay 11e1-bbd8-0019bb2963f4.html. Times), Dec. 3, 2011, p. A1, www.tampabay.com/news/health/ Children should display symptoms for at least six months adderall-shortage-has-adhd-patients-parents-scrambling-for- in two different settings — such as at home and at school answers/1204576. — before being diagnosed with ADHD. Doctors say growth in the number of ADHD cases is caus- ing a shortage of a generic form of Adderall. Johnson, Tim, “Inside a Teenager’s Brain,” Burlington (Vt.) Free Press, April 30, 2012, p. A1, www.burlingtonfreepress. Non-Drug Treatments com/article/BT/20120430/NEWS0213/120429012/uni versity-of-vermont-teenage-brain-research. Andazola, Matt, “Struggling to Focus,”Albuquerque (N.M.) Behavioral scientists generally agree that ADHD is associated Journal, July 25, 2011, p. C1, www.abqjournal.com/main/ with impulsivity but are unsure whether the impulses make 2011/07/25/health/struggling-to.html. people more prone to drug or alcohol use. Alternative ADHD therapies often are preferred to drugs because they don’t have side effects such as appetite loss. Mascarelli, Amanda, “Profile of ADHD Sharpens in Each School Year,” Los Angeles Times, Aug. 13, 2011, articles. Manziello, Evelyn Gilbert, “New Approach to ADD, ADHD,” latimes.com/2011/aug/13/health/la-he-adhd-20110813. Poughkeepsie (N.Y.) Journal, Sept. 16, 2011. ADHD symptoms can become clearer as children enter Diet, exercise and acupuncture are several ADHD treat- classes requiring more attention and organizational skills. ments that don’t involve drugs.

Yim, Michael, “ADHD — Can the Disorder Be Treated Without Medication?” The Explorer (Tucson, Ariz.), Feb. 29, CITING CQ RESEARCHER 2012, explorernews.com/northwest_chatter/article_33e0bf Sample formats for citing these reports in a bibliography 8c-6250-11e1-abcd-0019bb2963f4.html. Many parents of children diagnosed with ADHD prefer al- include the ones listed below. Preferred styles and formats ternative treatments. vary, so please check with your instructor or professor. Prevalence MLA STYLE Jost, Kenneth. “Remembering 9/11,” CQ Researcher 2 Sept. Hellmich, Nanci, “ADHD Seen As Early As Age 4,” USA 2011: 701-732. Today, Oct. 17, 2011, p. D4, www.usatoday.com/LIFE/usa edition/2011-10-17-Attention-Deficit_ST_U.htm. APA STYLE ADHD can be diagnosed in children as young as 4, ac- Jost, K. (2011, September 2). Remembering 9/11. CQ Re- cording to updated diagnostic guidelines from the American Academy of Pediatrics. searcher, 9, 701-732. CHICAGO STYLE Midey, Connie, “Women and ADHD,” Arizona Republic, Nov. 11, 2011, p. H1, www.azcentral.com/health/news/ Jost, Kenneth. “Remembering 9/11.” CQ Researcher, September articles/2011/11/03/20111103adhd-diagnosis-women.html. 2, 2011, 701-732. ADHD estimates are low among adults because many af- fected women haven’t been properly diagnosed. www.cqresearcher.com Aug. 3, 2012 691 In-depth Reports on Issues in the News

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