The following essay is a reply to inquiries after reading and analysis of the following two NY Times reports: the Risky Rise of the Good-Grade Pill, June 2012, and now A Pill for Education, October 9, 2012. Pediatricians may conclude that public policy shapes the ADHD treatment choices available to each unique set of a student, the parents, their teacher, and physician.
Up to 10% of grade-schoolers visit a doctor requesting an evaluation for Attention Deficit Hyperactivity Disorder (ADHD).[i] Before ever arriving at the doctor a number of these families already presume their children have ADHD, worried over its dire consequences.[ii] Apparently many families have read the manual that defines ADHD as a dysfunctional mismatch between individuals and their environments.[iii] The following authority counts the number of children affected:
“Attention-deficit/hyperactivity disorder (ADHD) is the most common neurobehavioral disorder of childhood and can profoundly affect the academic achievement, well being, and social interactions of children…”[iv]
A disorder with 7% to 10% U.S. prevalence may not qualify as a quantitative abnormality.[v] Other reports suggest a link between rising student-to-teacher ratios and rising numbers of children treated for ADHD.[vi] Ironically, ADHD treatments remain highly-focused on adjusting patients’ biology; notwithstanding an alternative of adjusting those reciprocal environments.[vii] Only by a family’s limited resources and ADHD’s difficult prognosis may families decide to treat their young children with medications the US Department of Justice considers as highly-addictive.[viii]
Nevertheless, the path to treatment begins for many when a school, or family friend, suggests that a child needs “ADHD testing.” The family may receive some “check-box-form” rephrasing the Manual with scientific-like style.[ix] Doctors then examine children, review histories, search for another cause, and verify the form documents. Doctors may claim such forms have less usefulness than their scientific appearance.[x] Curiously, however, if doctors do not use these forms, then they may face government penalties. Perhaps these forms serve to dress-up the apparant increasing number of children requesting amphetamines merely to pass grade school.[xi]
Parents may conclude that treatments other than medications appear less effective, less affordable, less private, and even socially harmful to children.[xii] The following are accepted guidelines:
For elementary school-aged children (6-11 years of age), the primary care clinician should prescribe US Food and Drug Administration-approved medications for ADHD (quality of evidence A/strong recommendation) and/or evidence-based parent and/ or teacher-administered behavior therapy as treatment teacher-administered behavior therapy as treatment for ADHD, preferably both (quality of evidence B/strong recommendation).[xiii]
When parents determine no other effective or available treatment choice remains for their child, they see the following choice: (1) abide the risk of further school failure with its known long-term perils, or (2) accept medications with potential, yet unproven, long-term harm.
Some community pediatricians may believe that by treating ADHD (even according to accepted guidelines), they may attract unwelcome attention, criticism and perhaps even regulatory scrutiny.[xiv] Thus, some of these pediatricians face an ethical dilema to refer all ADHD inquiries to the waiting rooms of subspecialists; who welcome those with private payer insurance, leaving the Medicaid population with fewer choices still.[xv] Here we are holding steady to evaluate and manage our patients appropriatly.
History will eventually judge this apparent epidemic, its subjective diagnostic criteria and awkward logic. For the present, families and doctors may tolerate amphetamines as the practical option of last resort. Conceivably, future changes to our education policy priorities, decreasing classroom size, may at least slow the growing number of children who find the ADHD dysfunction and receive uncertain help from the pharmaceutical industry, for better or worse. The opportunity to stem any epidemic begins by wanting to know how it came to this.
Without Its knowing, the inspiration and a self-imposed challenge came after reading a report by the New York Times titled as Risky Rise of the Good-Grade Pill, by Alan Schwartz, NY Times, p.A1 (10 Jun 2012), and more so after reading the same analysis applied to families regardless of financial resources in the Times (10 Oct 2012). These NY Times reports generated the energy necessary to overcome personal inertia and driving the expression eventually submitted as The ADHD Dysfunction. The author also respectfully denies significant conflicts-of-interest, and has no financial motivation, interests, activities, and relationships, affiliations, funding or other. Endless appreciation is due to that medical-practice partner (and life-time, best-friend and partner for 27 years) Stephanie H. Anderson, DNP, RN, APRN, as she sacrificed twith this project.
[i] See Increasing Prevalence of Parent-Reported Attention-Deficit/Hyperactivity Disorder Among Children in United States, 2003 and 2007, CDC Morbidity Mortality Wkly, 59:44 pp 1439-43 (12 Nov 2010).
[ii] Z. Chen, School Failure in Early Adolescence & Status Attainment in Mid. Adulthood, Sociology of Edu., 76:2, p.110 (2003).
[iii] Diagnostic & Statistical Manual of Mental Disorders, 4th Ed.,TR, Am. Psych. Association, 2000, (“DSM IV-Tr”). Here presents twenty behaviors observed in ADHD and the rules as they apply to the “Diagnostic Criteria.” This criterion asks evaluators to identify any six from either the first or second group of ten behaviors. Next these must cause difficulty in two environments (commonly home and school), and all before seven years old and not be the result of another ailment.
[iv] See Subcommittee on ADHD, Clinical Practice Guidelines for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents, Pediatrics, 128:5 at 1007, Nov. 2011, hereinafter “AAP Guidelines”.
[v] More than 2.5% of a population may not qualify as an outlier. See, Atkinson. A.C. Fast Very Robust Methods for the Detection of Multiple Outliers, Journal of the Am. Statistical Association, 89(428):1329-1339 (1994).
[vi] See Loe, & Feldman, Academic & Educational Outcomes of Children with ADHD, J. Ped. Psychology, 32:6 p.643-54 (2007).
[vii] See Id.
[viii] See Thom Mrozek , WEST HOLLYWOOD PSYCHIATRIST, OFFICE MANAGER ARRESTED ON CHARGES OF WRITING HUGE NUMBER OF PRESCRIPTIONS FOR ADDICTIVE DRUGS WITHOUT EXAMINING CASH-PAYING ‘PATIENTS’, Release No. 10-065, 13 April 2010, U.S. Dep. of Justice, U.S. Attorney Central Dist. of California (Here law enforcement describes .… “Schedule II drugs, which include the highly addictive substances amphetamine salts ‘Adderall’ .…”) notably such is a common medication used to treat ADHD in children.
[ix] See also, BR Collett, et. al., Ten-year Review of Rating Scales Assessing Attention-deficit/hyperactivity disorder, Am. Acad Child Adolesc Psychiarty 42:9, pp 1015-37 (2003); DJ Purpura, ADHD Symptoms in Preschool Children: Examining Psychometric Properties using IRT, Psychol Assess. 22:3, pp 546-58 (2010).
[x] See Reid, How many fidgets in a pretty much: A critique of behavior rating scales for identifying students with ADHD, Journal of School Psyc., 32:4, pp. 339–54 (1994).
[xi] See Alan Schwartz, Risky Rise of the Good-Grade Pill, NY Times, p.A1 (10 Jun 2012).
[xii] See Mayes, R., Suffer the restless children: the evolution of ADHD and pediatric stimulant use, History of Psych. 18, pp. 435-57 (Dec 2007).
[xiii] See supra, AAP Guidelines at 1008.
[xiv] See Thaddeus Mason Pope, Legal Briefing: Conscience Clauses and Conscientious Refusal, The Journal of Clinical Ethics 21, no. 2 (Summer 2010): 163-80.
[xv] See Anderson, Michael G., et. al. A Case of Severe Monkeypox Virus Disease in an American Child; Emerging Infections and Changing Professional Values, PEDIATR. INFECT. DISEASE; 22(12):1093-96 (December 2003); and, Pellegrino, E, MD, Patient and Physician Autonomy: Conflicting Rights and Obligations in the Physician-Patient Relationship, J. Contemp. Health Law and Policy, 10:47 (1994).