This article is from the WebMD the Magazine -- Feature Archive

At age 4, Jeremiah Ryans routinely refused to wait in line at the water fountain at his summer day camp. Sometimes he'd get so cranky he would hit his classmates. But an alarm bell went off when he grabbed a pair of children's scissors and cut his teacher's hair.

Just a kid being a kid -- or extreme behavior that may need medical help? The answer isn't clear-cut, and it's different for every family.

"He was on the verge of being expelled from day care," remembers his mother, Mimi, of Columbia, Md., who, with her husband, Richard, adopted Jeremiah when he was 16 months old.

As the father of a teenager from a previous marriage, Richard did not consider Jeremiah's behavior typical. So he and Mimi took Jeremiah to a therapist, who diagnosed separation anxiety. The Ryanses were unconvinced.

Then, after the scissors incident, they opted for a complete physical examination for Jeremiah. A pediatric and neurological specialist independently confirmed that it was attention deficit hyperactivity disorder (ADHD). Mimi's reaction? Fear of putting her child on drugs. "I didn't want Jeremiah to be one of those kids who was misdiagnosed and overmedicated."

Mimi's concerns about ADHD drugs are well-founded. Parents, physicians, and educators are questioning the rising numbers of kids under 18 now on ADHD medication. According to a recent report in the journal Psychiatric Services, ADHD-related doctors' office visits by children ages 3 to 18 more than doubled, from 3.2 million to 7.4 million, between 1993 and 2003. The number of visits that included a prescription for an ADHD medication also more than doubled, from 2.7 million to 6.6 million.

Drug Warnings

And experts are currently debating whether these same medications, which are used widely in children, should carry a warning label about the risk of heart attackheart attack or even suicide. Other experts argue that these frightening side effects are extremely rare and that the drugs' benefits outweigh the risks.

The jury remains out. In February 2006 an FDA advisory committee recommended that stimulants prescribed for ADHD carry a "black box" label -- the FDA's strongest warning -- informing consumers about the risk of heart attack, sudden death, and strokestroke. The committee reviewed 25 cases of sudden death, 19 of them in children who were 18 and younger, associated with ADHD drugs. Because some of these people had previously had underlying heart diseaseheart disease, the reviewers did not think the data were definitive in proving cause and effect.

The recommendation for the black-box warning created controversy, with some FDA consultants maintaining that the label was especially important for adults (increasingly being prescribed ADHD medications), who might have high blood pressurehigh blood pressure. Many calling for the warning label concede that the drugs have important benefits but say that increasing the awareness of the potential risks is crucial.

"The real question is whether there is any risk for children without heart problems," says Andrew Adesman, MD, chief of developmental and behavioral pediatrics at the Schneider Children's Hospital, Lake Success, N.Y.

As for the possible link to suicides, the ADHD drug Strattera is under special scrutiny. In late 2005, the FDA issued a public health advisory after reports of suicidal thoughts in five kids and a suicide attempt by one child in a clinical trial involving 2,200 participants. The advisory cautioned doctors and parents to watch for any behavior changes in children who were on the drug.

Parents such as the Ryanses worry about misdiagnoses and overprescribing, and experts concede that both can happen. But, Adesman says, overprescribing and misdiagnosis are more likely to happen if the evaluation is not thorough and is not done by a health care professional experienced in diagnosing and treating the condition.

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