Paying Attention Public Acceptance Of ADD Has Been Slow, Doctors Say

When it comes to fashionable labels, kids returning to school want to wear them on their clothes — not on their medical records.
Yet hundreds of thousands of school-age children went back to school this fall being treated for attention deficit disorder (ADD) — and it’s a label many parents continue to question, in fashion though it may be.

“It’s still very controversial, but the scientific and medical communities have a very strong conviction that ADD is a very common disorder, and that it’s real,” said Dr. Barry Sarvet, chief of Child Psychiatry at Baystate Medical Center.

Common is the right word, if statistics from the American Psychiatric Association (APA) are correct. The organization estimates that between 1.6 million and 2 million Americans suffer from ADD or its counterpart, attention deficit disorder with hyperactivity (ADHD) — and that 3{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} to 5{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of school-age children have the disorders.

“There are some people who say that it’s not real, but that it’s basically a normal variation on how children act,” Sarvet told The Healthcare News. “They say it only becomes a problem when children are expected to fit into the same mold, particularly when boys are expected to sit still. Then when we put very high expectations for achievement on them, it makes it look like these kids are really messing up.”

Most of the medical community believes that’s a false, and perhaps dangerous, assumption. Children and teen-agers with ADD, if left untreated, are more prone than others to accidents, depression, and poor performance in school and in life, Sarvet said.

In short, he said, if the problem is ignored, a little acting up in class might turn out to be the least of the child’s — and parents’ — concerns.

Gender Gap

A nationwide survey suggests that parents of girls with ADHD are more likely to be initially concerned about the disease than parents of boys. Here are some of the results of the study, conducted by Harris Interactive:

Parents of Girls Parents of Boys
Were ‘very willing’ to seek a medical opinion regarding ADHD 92{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} 73{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5}
Were initially reluctant to treat the child with medication 39{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} 59{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5}
Have felt pressure from family or friends not to medicate the child 31{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} 67{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5}
Have felt pressure not to treat because of a perceived stigma 47{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} 59{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5}
Believe that treating ADHD with medication has helped the child 96{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} 94{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5}

Label Shock

ADD is a condition characterized by difficulty concentrating, a tendency toward distraction, and impaired visual and spatial coordination. The symptoms of ADHD may also include inattentiveness, impulsiveness, and hyperactivity.

These are signs parents may notice but be unwilling to share with a physician, said Dr. Dennis J. Rosen, a developmental pediatrician at Wing Memorial Hospital who specializes in treating children with special needs, both physical and emotional.

“There’s a tendency for parents to not want to share this information because they’re nervous about labels,” Rosen said. “I recommend just the opposite. I recommend that they seek out advice.”

Rosen, who serves as the staff doctor for 20 schools, stresses that attention is closely connected with learning, making it vital that learning evaluations are performed on children.

“Kids who have ADD or ADHD, according to the diagnostic criteria we use, have all kinds of problems and bad life outcomes,” Sarvet added, starting with antisocial behavior and delinquency stemming from poor school achievement and constant clashes with teachers and parents trying to steer them correctly.

The negative interactions can spread outside of the classroom, he added, leading to low self-esteem and possibly drug addiction, as ADD sufferers may attempt to “self-medicate” to relieve their symptoms. “These are real outcomes,” Sarvet said. “We’re not just trying to label these kids.”

The problem is, with so many children suffering from ADD — and with the causes still vague — doctors face the challenge of distinguishing ADD from look-alike disorders that may also manifest in anger, anxiety, or depression. Diagnosing the condition is by nature a subjective process, Rosen said, measuring only behavior.

But within five to 10 years, he expects the diagnostic process to be like that of a blood-sugar test or an X-ray, with more clear-cut results.

Boys and Girls

For a condition that breeds such confusion among many parents and doctors, that would be a welcome development, especially since new studies reveal that ADHD may be more severe — and perhaps more difficult to detect — in girls than in boys, adding a gender twist to an already touchy subject.

A study released in August, conducted by Harris Interactive on behalf of Novartis Pharmaceuticals Corp., shows that a higher percentage of ADHD girls than boys — 14{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} to 5{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} — were taking anti-depressants before their ADHD diagnoses. Part of that trend may simply be the way girls express emotion, said Dr. Patricia Quinn, director of the National Center for Gender Issues and ADHD and an adviser to the study.

“Unfortunately, all too often, girls with ADHD are missed altogether or misdiagnosed with depression because girls tend to internalize their symptoms,” Quinn said.

“Therefore, the unique difficulties that girls with ADHD encounter are often prolonged.”

Indeed, girls with the disorder are less likely than boys to show hyperactivity and aggression, even though they are just as likely to display the symptoms of the ADHD-inattentive subtype, such as forgetfulness, timidity, difficulty listening, anxiety, and being easily distracted. Research suggests that children with these symptoms but not obvious hyperactivity are accurately diagnosed only about half the time.

Ironically, while many girls might fall through the cracks, the Harris study indicates that more parents of girls than parents of boys believe that untreated ADHD has a serious long-term impact on their children’s self-esteem and family life.

“Survey results suggest that girls’ parents are more willing to seek medical assistance for their children’s symptoms than boys’ parents,” Quinn said. “This may be due to a number of factors, including the impact ADHD has on girls’ social development, the fact that the problem tends to go unaddressed longer in girls, and the misperception that the chronic and pervasive hyperactive symptoms of ADHD in males is just a case of ‘boys being boys.’”

While the study showed that 73{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of boys’ parents were “very willing” to seek a medical opinion on ADHD, 92{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of girls’ parents feel the same way. At the same time, more parents of boys than of girls report feeling pressured to treat their children with medicine, indicating that teachers and doctors may be focusing more on boys.

Pills, Patches, and Pumps

For those children who are being treated, stimulants in the Ritalin family continue to be the most common medication. According to Sarvet, these drugs stimulate the parts of the brain that are responsible for organizing cognitive functions and bring more alertness and self-control to the user.

While some parents have questioned the safety of such drugs — another obstacle some have to accepting ADD treatment — the medical community strongly feels that the treatments are safe if used correctly, he added.

Other medications that are not stimulants are still being developed, but until then, the stimulants are far and away the most effective treatment available — “no bones about it,” Sarvet said. “If people are afraid of the medications and concerned about side effects and risks, they might try other treatments. Ritalin is an amphetamine-type compound, but if it’s used as described and monitored, there is not a greater incidence of future drug abuse than in people who don’t use them.”

Of greater concern is the fact that, ground into a powder, such drugs may be snorted to obtain a high of sorts, creating a type of playground drug trade at some schools. That’s why non-grindable pills are being developed, Sarvet said — and why parents need to monitor their children’s use of the medications.

To avoid overmedication, Rosen advocates a prescription delivery method called “the pumps, the patches, and the beads.” By way of pumps, the medication is contained in a pill that includes an osmotic pump, which forces the medicine to be released slowly. Patches may also distribute medication systematically while attached to the patient’s back. Meanwhile, the beads are capsules that can be opened and sprinkled on foods.

Simply put, Rosen said, parents don’t have to fear their perceived dangers of commonly used medications. And for many children struggling with ADD, ignoring those medications could prove costly down the road.

Spreading the Message

Still, Sarvet said, some parents frankly ask whether all the emphasis on ADD is just a way of stifling — and unnecessarily medicating — children who simply don’t fit the “mold” of what teachers expect in the classroom. That’s why doctors still have a ways to go in convincing the public that attention deficit disorder is a real problem, he added.

Of course, not everyone who displays symptoms will be diagnosed with ADD, Rosen said, but it doesn’t hurt to get the proper advice from doctors.

“Children can be paranoid about something without being paranoid-schizophrenic,” he said. “They can be anxious about some aspects of their world, but it doesn’t mean they have an anxiety disorder. They can be inattentive and easily distracted, but that doesn’t necessarily mean they have ADD.

“Go through the process of getting help,” Rosen said in issuing advice to parents. “Don’t make the diagnosis before understanding the process.”

For many parents who fear medical labels, it can be a scary process to begin — but perhaps, in the long run, a crucial one.