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Safer Child encourages you to make sure that before you accept a diagnosis of ADHD and especially before you fill a prescription for medication, your child has undergone a complete physical exam to rule out other any other possible causes of the behavior (such as hearing or vision problems, insufficient sleep, chronic dehydration, snoring or sleep apnea, lead poisoning, giftedness, sexual abuse, poor discipline, etc.). According to the experts: ADHD should not be diagnosed in a 15-minute visit. If your doctor doesn't want to do a complete exam, consider finding another doctor. Symptoms should be present for at least 6 months BEFORE diagnosis. It is not recommended that children younger than 6 years old take stimulant medications such as Ritalin or Adderall, since their safety and efficacy in young children has not been determined. And, if medication isn't working, or if it's making your child's behavior worse, consider obtaining a second opinion. Besides the fact that ADHD medications can have a negative effect on children who don't need them, it's also possible for medications to conflict with each other or for medications to improve one symptom while worsening another.
Professional concern is growing over the drugs commonly prescribed to treat Attention Deficit Disorder and Attention Deficit/Hyperactivity Disorder. Some of the concerns:
Overprescription? Although The National Institute of Mental Health estimates the number of American children with ADD/ADHD at 3 to 5 percent, the number of American children actually diagnosed with the conditions - and prescribed Ritalin - often is much higher (sometimes up to 10 percent of a classroom). Meanwhile, The American Academy of Child and Adolescent Psychiatry has said that up to 10 percent of boys and 5 percent of girls might suffer from ADD/ADHD. And Safer Child has heard teachers comment that up to 75 percent of their class have ADHD and should be on Ritalin. Does this mean Ritalin and other ADD/ADHD drugs are being overprescribed? Maybe, maybe not. The sudden increase in prescriptions (and the tender age of the children -- sometimes as young as 3) is alarming, however. It's possible that there is overprescription and underprescription going on. Only dedicated and professional investigation will uncover the truth.
Does this mean that some parents, physicians and educators are too quick to drug children -- just for being children? Maybe, maybe not. ADD/ADHD experts say that these symptoms are just the tip of the diagnosis, and that ADD/ADHD children do not behave like other children. Perhaps, however, the astoundingly high diagnosis of this condition in the United States -- as compared to the rest of the world -- is worthy of professional discussion.
Misdiagnosis? The American Academy of Sleep Medicine says that some children who suffer from obstructive sleep apnea syndrome (OSAS) might be misdiagnosed as having ADHD because the daytime symptoms are similar. Other conditions that reportedly mimic some symptoms of ADD/ADHD are: giftedness (an exceptionally bright child), lead poisoning, pesticide poisoning, vision problems or disorders, hearing problems, dehydration, allergies, chronically poor diet, insufficient sleep, or inadequate or abusive caregiving. Does this mean ADD/ADHD is a myth, as some claim, or that all cases should be viewed with skepticism? Safer Child respects expert opinion on the reality of ADD/ADHD. However, we have heard and read complaints that many ADD/ADHD diagnoses get made over the course of a single doctor's visit, and this causes us to wonder if the possibility of these other conditions gets adequate consideration.
Overdiagnosing boys? According to The National Institute of Mental Health (NIMH), boys constitute about 75 percent of all American children diagnosed with ADD/ADHD. Does this mean that because more boys are diagnosed than girls, they're all being misdiagnosed? Probably not. But perhaps such a lopsided rate of diagnosis, again, is worthy of professional investigation.
Risks of addiction/dependence/criminal activity/adult depression? The NIMH says that addiction to Ritalin can occur if the drug is misused. This is true of many drugs. But advocates say that, when it comes to ADD/ADHD medications, it's rare to see (the all-important) careful monitoring of dosages and prescriptions. Meanwhile, the U.S. Drug Enforcement Administration, Department of Justice lists Methylphenidate (Ritalin) as a "Drug of Concern" and adds this: "Methylphenidate, a Schedule II substance, has a high potential for abuse and produces many of the same effects as cocaine or the amphetamines. The abuse of this substance has been documented among narcotic addicts who dissolve the tablets in water and inject the mixture. Complications arising from this practice are common due to the insoluble fillers used in the tablets. When injected, these materials block small blood vessels, causing serious damage to the lungs and retina of the eye. Binge use, psychotic episodes, cardiovascular complications, and severe psychological addiction have all been associated with methylphenidate abuse. "Methylphenidate is used legitimately in the treatment of excessive daytime sleepiness associated with narcolepsy, as is the newly marketed Schedule IV stimulant, modafinil (Provigil®). However; the primary legitimate medical use of methylphenidate (Ritalin®, Methylin®, Concerta®) is to treat attention deficit hyperactivity disorder (ADHD) in children. The increased use of this substance for the treatment of ADHD has paralleled an increase in its abuse among adolescents and young adults who crush these tablets and snort the powder to get high. Youngsters have little difficulty obtaining methylphenidate from classmates or friends who have been prescribed it. Greater efforts to safeguard this medication at home and school are needed." The U.S. DEA and the NIDA say that Ritalin is being increasingly traded, bought and sold illegally, by not just children, but also parents and educators. A 2004 Harvard Medical School study indicated that pre-adolescent rats given popular ADHD drug Ritalin are more likely to show signs of depression as adults. The study indicates that Ritalin might have unintended effects on a developing brain. It also underscores the need for accurate diagnosis and treatment of Attention Deficit/Hyperactivity Disorder (ADHD). The study's findings were presented at a December meeting of the American College of Neuropsychopharmacology in Puerto Rico. Additionally, in April 2004, a British analysis of available data indicated that four popular antidepressants used to treat American children for depression might actually be unsafe and/or ineffective in treating that disorder. The four are Paxil, Zoloft, Effexor and Celexa. The findings of the analysis, published in The Lancet, found an increased incidence of suicide among children taking these drugs. The analysis also indicated that the drugs are not as effective for depression as previously suggested by others. In 2003, Britain banned use of Paxil for depression in children, and the FDA also issued a recommendation against using it for that purpose. Also in April 2004, a study indicated that stimulants like Ritalin may stunt children's growth. The study, led by University of California at Berkeley researcher Stephen Hinshaw and published in the April 2004 issue of Pediatrics, did not address whether that effect is permanent. Weight loss is another known potential side effect from long-term stimulant use. If all of this is so, does it mean that all prescriptions for Ritalin and other ADD/ADHD drugs should cease immediately? Some children seem to be benefiting from the drugs. Does it mean that children prescribed Ritalin or other ADD/ADHD drug will wind up as junkies? Some studies don't confirm that. But in light of the criminal activity witnessed with respect to illegal trading and handling of Ritalin, for example, perhaps more investigation and more public and government oversight is needed. More and more, we are hearing about adults who become hooked on Ritalin and about children who abuse it for its high. See the U.S. Drug Enforcement Administration article on our Expert Voices page that discusses the growing problem of stimulant abuse.
New trend in marketing prescription drugs to parents: A new trend in medications for attention-deficit disorder is to market them to parents in several popular parenting and women's magazines. It's logical to assume, then, that the drug manufacturers believe it's the parents who make the decisions about which ADHD medications their children should be taking. We're greatly concerned about this trend and wonder if it best suits a child's interests and medical needs. Reportedly, the U.S. Drug Enforcement Administration also is concerned about the advertisements and is moving to limit such advertising.
An intriguing silence -- but new AAP Recommendations: Interestingly, searches of various health and child advocacy organizations has provided Safer Child with minimal or no information at all on the debate, and further investigations turned up "no comment" kind of responses. However, in October 2001, the American Academy of Pediatrics issued a new policy on Ritalin and on how to diagnose attention deficit/hyperactivity disorder (ADHD). Ritalin is approved by the AAP for treatment of ADHD as long as the treatment goals are clear and the children are properly monitored. The AAP already had issued recommendations for doctors to diagnose ADHD only by using the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR Fourth Edition. Perhaps this new policy indicates the beginning of a more public professional debate. We'll keep you posted on anything else we find out.
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