Sir George Still was the first to describe ADHD-like symptoms in 1902. It’s also been called mental brain dysfunction, hyper-active disorder, brain damage syndrome and hyper-kinetic impulse disorder.
In its 61-year history, the Diagnostic and Statistical Manual of Mental Disorders (DSM), the so-called bible of the mental health profession, has been significantly updated five times, most recently in May of this year. It wasn't until the second edition was published in 1968 that a disorder resembling ADHD appeared.
In the third edition of DSM, published in 1980, the disorder became Attention Deficit Disorder. In 1987, ADD became Attention Deficit Hyperactivity Disorder — ADHD.
“Attention deficit has been around for more than 100 years,” says Diana DuFriend, a licensed marriage and family therapist who, as a counselor at the Southwest Alabama Behavioral Healthcare Systems in Grove Hill, has been studying the disorder since 2001. “But it’s definitely been getting a lot more attention in the media in recent years ... and for good reason.”
Today, nearly one in five high school-age boys in the United States and 11 percent of all school-age children have been diagnosed with ADHD, according to the Center for Disease Control and Prevention. That’s a 16 percent increase since 2007 and a 41 percent rise in the past decade.
“Those are astronomical numbers. I’m floored,” Dr. William Graf, a pediatrician and professor at Yale School of Medicine recently told The New York Times. “Mild symptoms are being diagnosed so readily, which goes well beyond the disorder and beyond the zone of ambiguity to pure enhancement of children who are otherwise healthy.”
Anniston clinical psychologist Lucile Bodenheimer says that in her 35 years of practicing psychotherapy she’s “actually met less than 10” people who truly have ADHD.
The rest can attribute their behavior to insufficient sleep, a diet of sugary foods and beverages, and “parents who don't know how to be or want to be parents,” she says. “So, in the past five years alone, I have gotten a couple hundred off meds and only recommended meds for three in that same time. But everyone in this fast food age wants a simple and quick solution.
“The drug industry even puts the check lists on the Internet. Take one. You'll find that you are also ADHD.”
Diagnosing ADHD is problematic because symptoms typically appear between ages 5-7, making it difficult to distinguish actual symptoms from what could be considered normal behavior in young children.
Children mature at different ages, though on average most kids settle down between the ages of 5-7, when they begin to show more control, can plan ahead, understand the consequences of their actions and avoid inappropriate behavior, explains Anniston pediatrician Angela Martin.
“The child with ADHD cannot do this. It’s not about wanting to ... they simply cannot,” Martin explained. “But diagnosing ADHD can be tricky. It takes time and certainly more than one visit to make the right assessment.”
Though she won’t say it is necessarily misdiagnosed, Martin is concerned that ADHD is often seen as the first option.
“But we’ve got to be certain before putting children on any kind of medication,” she said. “There cannot be a rush to judgment.”
The number of ADHD cases may continue to rise given the changes in the most recently published DSM.
Among the changes, DSM-V requires clear evidence that ADHD symptoms “interfere with, or reduce” the quality of functioning in different environments. In the earlier version, the symptoms had to show “clinically significant impairment” in those environments. The new parameters also allow for ADHD to be diagnosed when symptoms are present prior to 12 years of age, an increase from the previous manual’s age of 7. And there is no longer the requirement that the symptoms create impairment by age 12, just that they are present.
One of the most outspoken critics of these changes is Dr. Allen Frances, who chaired the DSM-IV Task Force prior to its publication in 1994. In his book “Saving Normal: An Insider's Revolt Against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life,” Allen argues that these changes will lead millions of essentially healthy people to be diagnosed as having a mental disorders, including ADHD.
“ADHD is spreading like wildfire,” Allen writes. “It used to be confined to a small percentage of kids who had clear-cut problems that started at a very early age and caused them unmistakable difficulties in many situations. Then all manner of classroom disruption was medicalized ... ADHD is becoming an explain-all for all sorts of performance problems in adults as well.”
According to Allen, pharmaceutical companies played a large role in “selling ADHD,” conspiring to create an “unexpected epidemic.”
Until the mid-1990s, ADHD was largely ignored by the drug companies. Things changed around 1997 when newly patented and expensive ADHD medications hit the market and the companies were allowed to advertise them directly to the consumer via TV commercials and magazine ads with the slug line, “ask your doctor.”
“Armies of eager sales reps filled the offices of pediatricians, family doctors and psychiatrists peddling a pill that would magically prevent classroom disruptions and solve home meltdowns,” Allen writes. “Parents, teachers and physicians were recruited in an all-out effort to identify and aggressively treat ADHD.”
Since 1936, when the Food and Drug Administration (FDA) first began studying the effects of Benzedrine on children with psychological and behavioral disorders, stimulants have been the leading treatment for ADHD.
Of the more than six million children diagnosed, roughly two-thirds are given powerful prescription stimulants such as Ritalin and Adderall.
“The drug company rush to diagnosis and mindlessly prescribe-the-pill message has dominated the conversation,” Allen writes, “turning many normally immature kids into prematurely medicated mental patients.”
Kameron Butler was diagnosed with ADHD at 5 years old. One of her earliest memories is of leaving class and walking up to the office of her elementary school for her medication.
“Before that I just remember being really, really hyper all the time,” says the now-15 year old. “The medication helped ... I’m still really hyper, but now I can function. I don’t know where I’d be without it, but it wouldn’t be good.”
Kameron does more than function. She’s a straight-A student in the gifted program at Oxford High School.
“I’ve learned to live with it,” she says. “It’s not something I’ve ever wished I didn’t have.”
While it might sound counterintuitive to treat hyperactivity with stimulants, “these medications actually activate brain circuits that support attention and focused behavior, thus reducing hyperactivity,” according to the National Institute of Mental Health.
There’s no such thing as a one-size-fits-all approach to medicating children. Often several different medications and dosages are needed to find the right balance. It’s understandable that parents are hesitant about putting their children on powerful medications like Ritalin and Adderall, says Anniston psychiatrist Glenn Archibald.
“A lot of what I do with the parents is to try and relieve their guilt,” he said. “In the media, there’s a lot of talk about overmedicating our children, and there’s no doubt that this does happen, but for a child who is legitimately diagnosed with ADHD, medication is really the best option.”
DuFriend welcomes the debate, believing such attention helps remove the stigma associated with ADHD.
However, of the dozen families with ADHD children contacted for this series, only those featured agreed to be identified.
“I don’t believe ADHD is being over-diagnosed,” DuFriend said. “There are people out there who don’t believe ADHD is real. The more it’s talked about, the more aware people become.”
Education breeds understanding, particularly among parents. There has long been a misconception that some children are being willfully disobedient — that if they really wanted to, they could behave, or that they are simply lazy and unmotivated in school. Or worse, that they’re stupid.
“The worst thing is when parents won’t believe that there’s such a thing as ADHD, that there are just bad kids and if you whip ‘em enough they’ll straighten up,” DuFriend said. “Sadly, I run into that a lot.”
The concern that ADHD is an overreaction deserves consideration, but what about the flip side of the coin? ADHD is a lifelong condition. The failure to provide appropriate treatment for certain disorders, including ADHD, poses a threat to the brain itself.
“A child who cannot pay attention and who cannot learn is at risk of having his or her brain and development adversely affected,” according to the NIMH. “Many children with ADHD who are untreated may be at increased risk for some medical and social problems such as reckless driving, drug and alcohol abuse, smoking, academic failure, difficulty in maintaining relationships, keeping a job and trouble with the law.”
In addition to his medical practice, Archibald works in prisons and methadone clinics where he says at least half of those he counsels have untreated ADHD.
“Think of all the future problems we could avoid,” he said. “Treating these kids has the potential of keeping them from the behaviors and actions that could cause real problems.”
It’s a difficult position for parents with hyperactive or unfocused children. Allen, the chairman of the DSM-IV Task Force, believes that any problem with misdiagnosis and overprescription of drugs is the actions of a “few doctors in each community.” The best approach to ADHD, he says, is a graduated “stepped diagnosis” rather than a “shoot first, aim later” mentality.
“Diagnose early and begin medication quickly only when the ADHD symptoms are very severe, pressingly urgent and classic in presentation,” Allen writes. “Whenever symptoms are mild or equivocal (as often is the case), it is best to sit back and have a period of watchful waiting.”
Contact Brett Buckner at email@example.com.