Teachers Usually First to Report ADHD

Many Advocate ADHD Medications Merely to Keep Classroom Peace, Experts Say

From the WebMD Archives

Sept. 30, 2003 -- Teachers and other school personnel may largely be responsible for the surge in the use of medications to treat attention deficit hyperactivity disorder (ADHD) in children, a new study shows.

Among children who received ADHD medications, more than half were initially recommended for drug treatment by their teachers or other school officials, researchers found. By comparison, parents first suspected the condition and asked for ADHD medications such as Ritalin and Adderall in 30% of cases, and doctors made the initial call only 11% of the time.

These findings, based on surveys of nearly 500 family physicians, pediatricians, and child psychiatrists treating children with ADHD medications, are published in the current issue of Annals of Family Medicine. Although doctors ultimately prescribe the ADHD medications -- now taken by at least 2 million American kids -- one of the study's researchers tells WebMD that it's not always by their choice.

"What we are being told is that many doctors feel they are strongly being pushed to prescribe medications, sometimes in children who don't really have attention deficit disorder," says Leonard Sax, MD, PhD, a family practitioner in Maryland who heads the Montgomery Center for Research in Child and Adolescent Development. "We don't want to be prescribing these medications willy-nilly to children who really don't need them, he says"

So why do they?

Sax says that school personnel may innocently confuse restlessness, fidgeting, or inattentiveness with ADD or ADHD, but often purposely pressure parents and doctors to prescribe ADHD medications to certain children in order to ensure order and focus in the classroom. "There is no question that if you put children on these medications, they will do better in tests."

Since 1991, ADHD has been classified as a "handicap" worthy of special education funding and initiatives, resulting in some educators to actively look for symptoms in their students. Perhaps not by coincidence, in that time the use of stimulants such as Ritalin and Adderall has increased 20-fold among school-aged children, he says. Use of these ADHD medications among preschoolers has also tripled in the last decade.

"And now we're seeing a similar 20-fold increase in prescribing antidepressants in school-aged children, and many are being given to the same children on the stimulants," he tells WebMD.

When a teacher suspects ADHD in a child, parents are called in. "At that meeting, it's not uncommon for several teachers, the psychologist, and the principal to push for getting that child on medication, and it can be very intimidating for parents," says Sax. "The schools also know which doctors will rubber-stamp their recommendation. And when the parents want to go to another doctor, they may say, 'he's not a specialist.'"

Sax cites some of his own experiences, including one in which a second grader was suspected of having ADHD because he was inattentive in class. "The school wanted him on medication, but upon an examination, it turns out the child had obstructive sleep apnea and couldn't focus in class because he was sleep deprived. The teacher was correct that he was inattentive, but it wasn't because of ADD."

Another expert not involved in Sax's study says that while many schools indeed "overdiagnose" attention deficit disorders, others don't recommended ADHD medications enough for those who need it.

"Some schools and teachers definitely use medications as a form of behavioral control, so they overcall it, and some doctors prescribe the drugs more than they should to keep patients satisfied," says Edward Hallowell, MD, a Harvard psychiatrist who wrote Driven to Distraction, a best-selling book about ADD in children. "But there are other places where the mere mention of medication sends people through the roof, so they undercall it.

"Everybody wants to put an "either/or" label on this debate, but in reality, attention deficit disorders are both being overdiagnosed and underdiagnosed," Hallowell tells WebMD. "It all depends on where your child happens to go to school."

Both experts recommend that you get your own second opinion if your child is suspected of having ADD or ADHD -- either by you, school officials, or your family doctor. "And get it as far away from the school as possible -- ideally from a child psychiatrist," says Hallowell.

"You want what is best for your child, but many schools want what is best for the entire classroom," Sax cautions. "And family doctors, who are faced with a waiting room full of sick kids, may not have the time to do a careful evaluation or may not want to refer children to outside specialists because it puts a black mark by their names with HMOs. It really comes down to you."

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SOURCES: Sax, L. Annals of Family Medicine, September/October 2003; vol 1: pp 171-174. Leonard Sax, MD, PhD, director, Montgomery Center for Research in Child and Adolescent Development; private practitioner, Poolesville, Md. Edward Hallowell, MD, clinical Instructor, psychiatry, Harvard Medical School, Boston; founder, Hallowell Center for Cognitive and Emotional Health, Sudbury, Mass.
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