A local mom shares her journey of putting her adolescent son on medication to treat attention deficit/hyperactivity disorder.
As I sat erect on the worn sofa in the doctor’s office, facing the pediatric psychologist, the tension in the room was palpable.
My sixth grade son was in the midst of undergoing an extensive psychoeducational evaluation, a fancy term that involves upward of eight or more hours of testing intended to uncover learning disorders. I hoped the tests would shed light on why he worked at a slower pace than many of his classmates, and why it was so hard for him to memorize definitions and organize his thoughts to write clearly—why, in essence, school was a struggle for him at the competitive, academically rigorous Baltimore private school he attended.
When I picked up my son from his second or third two-hour testing session, the physician asked him to step into another room while she spoke privately to me. She got right to the point, saying she suspected my son had attention deficit hyperactive disorder (ADHD) and suggesting he undergo a medication “trial” of Concerta, a widely prescribed psychostimulant used to combat the symptoms of ADHD, a commonly diagnosed disorder marked by one or more of the following symptoms: difficulty sustaining attention, hyperactivity, and impulsive behavior.
Admittedly, I was shocked. I was pretty sure my son had a reading disorder that was preventing him from decoding multi-syllabic words, and his forgetfulness—whether school work or sports equipment—strongly suggested problems with executive functioning (the cognitive processes having to do with memory, planning, and execution). But I wasn’t prepared for a diagnosis of ADHD. Nor was I eager to place him on a stimulant medication, primarily because I was wary of the drug’s hallmark side effects – appetite suppression and sleep disturbances, especially as he approached puberty, a period known for increased sleep and caloric needs.
When I shared my concerns with the doctor, she responded, in an admonishing tone: “What I’m worried about are these test scores.” She pointed to the assessments she’d given my son thus far. As she continued her lecture, I quietly fumed, angry that she had so curtly dismissed my concerns. But her final words of persuasion were what stuck with, and scared, me. “Everybody could benefit by these drugs,” she murmured. The words were so quiet that I wasn’t sure whether she intended for me to hear them outright.
An alarming rise in diagnoses
That doctor’s cavalier attitude toward ADHD medication stunned me. Given the alarming increase in ADHD diagnoses among U.S. children in recent years, it probably should have come as no surprise.
While the well-reputed American Psychiatric Association places the rate of children with ADHD at 5 percent, 13.2 percent of all boys living in the U.S. today receive a diagnosis of ADHD at some point during childhood, according to the Centers of Disease Control and Prevention. The CDC also notes that in just eight years, between 2003 and 2011, the percentage of children (including both boys and girls) diagnosed with ADHD climbed from 7.8 percent to 11 percent.
It follows that as the diagnostic rate of ADHD has risen, so too has the use of psychostimulants, the drug used to treat the disorder. In the 1990s, a 700 percent increase in psychostimulants occurred in the U.S. The graph below, courtesy of IMS Health, a healthcare analytics company, shows the dramatic rise through the 1990s.
Some blame pharmaceutical companies’ pervasive advertising of psychostimulants for ADHD —directed at healthcare professionals and parents—as one reason for the uptick in prescriptions for the drugs. Even the name of one of the most popular drugs used to treat attention deficit, Adderall, was named to suggest “ADD for all.”
Roger Griggs, the executive who introduced the drug, admits as much.
“It was meant to be kind of an inclusive thing,” he told the New York Times in an article entitled “The Selling of Attention Deficit Disorder” published in 2013.
Ubiquitous, and sometimes irresponsible, advertising led pharmaceutical company Shire, a leader in the multi-billionaire dollar ADHD drug industry, to pay last year nearly $60 million in fines to resolve allegations of improper sales and advertising of five ADHD drugs.
A magic bullet
For some children diagnosed with ADHD, psychostimulant medication seems to work wonders. Consider a local 9-year-old boy whom I’ll call Jack. Almost from birth, his parents noticed that he had considerably more energy than his older brother, as well as most other kids they knew.
“He had a hard time settling down and doing anything at a regular pace,” said Jack’s mom.
By kindergarten, Jack’s highly energetic nature was getting him in trouble, and annoying the other children in his class, according to his mom. He was being singled out frequently by his teacher for his behavior, and it was having negative ramifications on his self-esteem. Jack began calling himself stupid, and even hitting himself in the head.
Jack’s kindergarten teacher suggested he receive a psychoeducational evaluation. The diagnosis? ADHD. “It was hard to hear, but, at the same time, we sort of knew it too,” said Jack’s mom.
She and her husband didn’t hesitate to put Jack on Concerta, a commonly-prescribed psychostimulant used to treat ADHD. She describes the positive effects as near magical. “The first day we tried it, an hour later we were like ‘Oh my gosh,’” recalled Jack’s mom.
Four years from that initial diagnosis, Jack remains on Concerta. While many kids take “medication holidays” during weekends or in the summer, Jack does not. His mom says that, for the health of the entire family, it’s best that he maintains his medication regimen whether in school or out. He is a more manageable kid on the medicine and, to date, Jack seems to suffer from only one side effect.
“His appetite is completely suppressed on it,” explained Jack’s mom, who says she attempts to compensate by feeding him a hearty breakfast and late dinner at night, after the medication wears off.
While there is little dispute within the medical community that, for the right patients, psychostimulants can effectively treat symptoms of ADHD, a small but growing number of health professionals have begun to speak out about overuse of the drugs.
“ADHD drugs are over-prescribed for American children and adults. An estimated 75 percent of children currently medicated for ADHD could be successfully treated with behavioral interventions,” said Gretchen LeFever Watson, PhD, a Virginia-based clinical psychologist and president of Safety and Learning Solutions, an organization aimed at improving the safety of people in various public environments, including college campuses.
She, too, blames, in large part, the pharmaceutical industry for what she believes to be an overuse of the medication.
“A major factor [for overuse] relates to the pharmaceutical industry’s successful marketing of the notion that ADHD symptoms are synonymous with a neurological condition that can be effectively treated with stimulant drugs. Physicians, psychologists, teachers, parents, and policy makers have all assumed the message that the pharmaceutical industry promoted through its paid consultants was legitimate and backed by science.”
Watson says that message is oversimplified and misleading, and believes it has contributed to what she and other experts call an epidemic rise in ADHD drug abuse.
Shades of gray
While Jack appears to present an indisputable case of ADHD, others are not so cut and dry. There is no bio marker that unequivocally states whether a child has ADHD. Diagnoses are made based on reports of symptoms. Standardized surveys ask parents and teachers questions like: Does the child ever act impulsively? Does he or she have trouble sitting still for extended periods of time? Does X have trouble focusing on classroom discussions; does he or she ever appear to be daydreaming in class? Does X ever forget to bring home books needed for homework, or leave things at school?
Let’s face it. When asked these questions of a child, most parents would probably respond ‘yes.’ I did. After all, my child has been known to leave books he needs for homework at school and, after he’s completed one subject worth of homework, he needs to get up and move around before embarking on another. I’m guessing he’s spent his fair share of time daydreaming in class—I know I did when I was his age.
So, did these somewhat minor symptoms warrant medicating him with a stimulant known to cause a potential laundry list of common adverse effects, including sleep disturbances (primarily insomnia), decreased appetite, irritability or sadness when the medication wears off, physical tics, and irritability? Was ADHD truly at the root of his learning problems?
I wasn’t sure.
But unlike Jack’s mom, who expressed concern that placing her son on medication for ADHD would make it seem that she and her husband had somehow failed to manage their son’s behavior on their own, I felt the opposite pressure—to medicate my son. So I did place him on a low dose of an ADHD stimulant medication.
On my son’s first day taking the medication, I picked him up from school in the late afternoon. He got in the car and started talking loudly and non-stop—completely out of character for him. My son is generally pretty quiet and while he shares things with me about his school day, he never blathers on incessantly the way he did that day. It scared me. He acted like he was on speed. That night, he had no interest in eating dinner. Closer to bedtime, he became irritable. When I tucked him into bed, my son who was normally asleep in minutes lay completely rigid—his body actually felt stiff to the touch—and it took him a long time to fall asleep. I had heard the side effects would subside, so we soldiered on.
When my son was on the medication, I did notice an improvement in his mental stamina. One afternoon, he came home from school and whizzed through a detailed and lengthy science project, something that would have normally taken a lot of cajoling and re-directing. But he still had no appetite. He often had trouble falling asleep. And, unbeknownst to him, I noticed he’d developed facial tics. It was particularly unsettling to me that these symptoms occurred while he was on the medication’s lowest possible dose.
Academically, the medicine was not a slam dunk. Some of his teachers reported that he was more engaged in class. Others said they didn’t notice a difference. The test scores that the psychologist administered after he began to take Concerta were only mildly better than those before he took the medicine. After all the tests were administered, the psychologist acknowledged that he had a reading disorder and was slow to process certain types of information. She never confirmed any connection between his learning problems and ADHD.
The situation changed a few months later. My son confided to me that obsessive compulsive tendencies—feeling the need to continuously line up pencils and papers on his desk just so, for example—were taking over his school days, making him unable to focus on what his teachers were saying. My decision to take him off the medication was sealed. I had not known that paranoia, anxiety and obsessive compulsive actions were possible side effects of the medicine. When I explained my son’s symptoms to the psychologist, she confirmed that these were known side effects, and recommended he stop taking the medication.
It was then that we began exploring plan B in earnest. What our son really needed, my husband and I eventually decided, was a learning environment that was slower paced and would provide him with specialized reading and writing instruction. Perhaps not coincidentally, the psychologist who tested our son had suggested initially that if we had him repeat a grade in school, he probably wouldn’t need ADHD medication. To me, that raised a red flag.
Had we given him a drug solely so that he could keep up with his peers in an academically rigorous environment where many of his classmates were 12 or more months older than him? If he truly had ADHD, shouldn’t he benefit from a prescribed stimulant regardless of his learning environment? I never had any intention of administering my son a psychostimulant simply so that he would be better equipped to compete in a challenging school environment. But, in retrospect, that seems to have been what happened. Unfortunately, I don’t think that set of circumstances is too unique in the ultra-competitive bubble in which many of us live.
A case of addiction
Consider, for example, the story of a young woman I’ll refer to as Lindsay. Growing up in Baltimore, Lindsay attended an exclusive all-girls’ school. Initially, she thrived academically. But in middle school, as the volume of school work and the organizational demands increased, Lindsay began to struggle.
“She started to feel stupid,” her mother said.
In ninth grade, Lindsay was diagnosed with ADHD and placed on a psychostimulant. “It was life-changing for her,” said her mother. “She found [academic] success again; she got into a really good college.”
When Lindsay went off to college, she took her ADHD medication with her.
Around that time, Lindsay stopped taking the psychostimulant Adderall (it caused her to clench her teeth to a damaging degree) and was prescribed another psychostimulant: Vyvanse. Scores of anecdotal reports from Vyvanse users describe experiencing severe “crashes”—a side effect of psychostimulants that can occur when the drug wears off. Effects range from feelings of sadness and depression to insomnia, anxiety, and irritability.
According to her mother, Lindsay was plagued by these crashes when she began to take a “bump,” or additional dose, of the medicine to stay sharp for night classes at college. “She got to where she was taking [Vyvanse] all the time. She had become addicted, and would lose days and days,” her mother said, a haunting tone in her voice.
At her peak usage, Lindsay was taking 120 mg. of Vyvanse daily, according to her mother. The highest prescribed dosage typically is 70 mg. “She’s very beautiful, and she’s winning. She would convince every doctor she saw that she just needed this medication,” her mother explained.
Eventually, Lindsay’s drug use expanded to include prescription pain killers, obtained by friends, and cocaine. She is currently in an inpatient drug treatment program.
Lindsay’s mother was not told of the medication’s potential for addiction when her daughter received her initial prescription for it. Of all the adverse effects I was worried about when my son took this medication, addiction wasn’t one of them. I wasn’t warned about it, and I didn’t even know it was a possibility. But, according the U.S. Drug Enforcement Agency, it is a real concern. A fact sheet on the website of the U.S. Drug Enforcement Agency states:
Methylphenidate, a Schedule II substance, has a high potential for abuse and produces many of the same effects as cocaine or the amphetamines… The primary legitimate medical use of methylphenidate (Ritalin®, Methylin®, Concerta®) is to treat attention deficit hyperactivity disorder (ADHD) in children…”
The more I discovered about psychostimulant medications through personal experience, research, and discussions with other parents, the more questions I had. Why has the rate of ADHD diagnosis and subsequent medication usage skyrocketed in recent years? Which of the children diagnosed today would have qualified for that same diagnosis 20 years ago, and what is the effect of treating a much broader population of children with psychostimulant drugs? How do we as parents know when ADHD medications are being prescribed responsibly and in the best interests of our children? What about long-term effects?
It’s too late for Lindsay’s mother to ask these questions. But I did ask her what she thought would have happened to her daughter had she not taken the psychostimulant medication as an adolescent. She paused for a moment before replying: “She probably wouldn’t have gotten straight A’s. (Lindsay was a B-plus student before she went on the medication.) Maybe she wouldn’t have gotten into the college of her choice.”
Although I felt pretty certain of the response to this next question, I nonetheless asked Lindsay’s mother if, knowing what she knows now, she would have placed her daughter on psychostimulants back in ninth grade. “I would never have allowed her to be medicated,” she said.
Clearly, statistics on psychostimulant use for ADHD have been climbing since the 1990s. But vocal voices within the medical community such as Watson’s, plus well-publicized media stories such as the 2013 New York Times article demonstrating the potentially tragic effects of ADHD drug abuse, may start the pendulum swinging in the other direction. Already, chatter among parents increasingly includes a cautionary tone when it comes to the decision regarding whether or not to medicate one’s own child for ADHD, and for good reason.