Why Johnny Can't Sit Still

There's at least one in every classroom--the child who can't sit still, won't follow instructions, annoys fellow students, and spends more afternoons than not in the principal's office. Is this kid just plain obnoxious, or exhibiting signs of a neurological problem?

Within the last five years, the ranks of children diagnosed with attention deficit/hyperactivity disorder, or ADHD, has nearly doubled. The trend worries child health experts who say tests for the disorder are wholly subjective and often misinterpreted. Misdiagnoses are especially troubling in light of the powerful stimulant drugs routinely prescribed as treatment. Therefore, parents should not accept a hasty diagnosis of ADHD nor rely on a single type of therapy should ADHD truly be the cause of their child's difficult behavior.

SQUIRMY. ADHD is characterized by an inability to focus or pay attention, impulsivity, and hyperactivity. But 20% of the estimated 2- to 3 million children with the disorder may have only the inattentive (known as ADD) or hyperactive components. According to the American Psychiatric Assn.'s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), a child has symptoms--which must appear before age 7--if he or she is easily distracted, often interrupts, and fidgets or squirms. Sounds like your basic kid. But "with ADHD, these behaviors are over and above what is acceptable for the child's age group," says Dr. Deborah Pearson, associate professor of psychiatric behavioral medicine at the University of Texas Medical School in Houston. For example: an 8-year-old who shouts out disconnected thoughts and cannot stay seated at school or during movies.

The causes of ADHD aren't known, but because it often runs in families and is more common among boys, a genetic abnormality may play a role. Or, something could have gone wrong in utero. "Exposure to alcohol, smoking, and stress during pregnancy may be the culprit," says Dr. James M. Swanson, professor of pediatrics and director of the Child Development Center at the University of California at Irvine. Such conditions affect fetal development and might lead to a malformed brain that is insensitive to the neurotransmitter dopamine, a brain chemical that prompts restraint.

Some studies using magnetic resonance imaging (MRI) have showed that children with ADHD often have slightly smaller right brains. This makes sense in that the right side of the brain is responsible for self-control. Other research using positron emission tomography--PET scans--indicates that youths with ADHD may not utilize glucose (i.e. energy) in areas of their brain that moderate behavior as readily as children without the disorder. Although many people swear that sugar and additives exacerbate the symptoms, no studies have confirmed a dietary connection.

Since there are no reliable physical markers for ADHD, specialists rely on a battery of behavioral, psychological, and aptitude tests to make a diagnosis. Interviews with parents, teachers, scoutmasters, and anyone else who has sustained contact with the child should also figure into the evaluation. "This is not something that can be determined with a quick assessment," says Dr. Peter Jensen, chief of the Child and Adolescent Disorders Research Branch at the National Institute of Mental Health in Bethesda, Md.

Days are needed to eliminate the multitude of other causes of ADHD-like symptoms, such as learning disabilities, depression, hearing loss, sleep disorders, and epilepsy. Public schools often conduct ADHD screenings upon request using specially trained child-study teams or outside consultants. Parents who prefer to have a private assessment should brace themselves for the bill. A single day of testing can cost as much as $1,000. Insurance helps only when coverage extends to mental health.

Yet even after a comprehensive examination, a diagnosis of ADHD is still subjective. "It all depends on the biases of the diagnoser," says Dr. Lawrence Diller, a behavioral pediatrician in Walnut Creek, Calif., who recommends parents ask specialists for their definition of ADHD to understand "where they're coming from." Attitudes range from denial of the disorder's very existence to certitude that ADHD lurks behind every childhood misadventure.

BLAME THE BRAIN. While he does not deny ADHD exists, Diller, also a clinical professor of pediatrics at the University of California at San Francisco, is among many experts who worry that ADHD is a label too often applied to children whose distracted behavior may stem from environmental factors like an overcrowded classroom, pressure to excel, or lack of discipline at home. "There's a great appeal to placing all the blame on Johnny's brain," says Diller, rather than circumstances that have "pushed Johnny beyond his ability to cope."

Misdiagnoses are especially disturbing in light of the frontline treatment for ADHD--the amphetamine-like stimulant called methylphenidate. It produces dose-related increases in blood pressure, heart rate, respiration, and body temperature that provoke corresponding gains in alertness and ability to focus. Appetite suppression and stunted growth are common side effects. "You don't want to treat normal childhood behavior with a stimulant," says Dr. Swanson.

Many do, however, because methylphenidate--sold most often under the brand name, Ritalin--helps anyone to settle down and concentrate, whether they have neurological problems or not. Known as "vitamin R" in schoolyards, Ritalin is coveted as a means to enhance academic and social performance. Indeed, the Drug Enforcement Administration issued a report in 1995 citing widespread methylphenidate abuse by adults as well as children and advised greater caution in its dispensation. The DEA said that since 1990, there has been a "sixfold increase in U.S. production and utilization of methyl-phenidate" which is five times more than what the whole rest of the world manufactures and consumes. "There's either a strange plague of hyperactivity in the U.S., or we've got a lot of folks prescribing Ritalin as a psychopharmacological nanny," says Arthur Caplan, director of the Center for Bioethics at the University of Pennsylvania in Philadelphia.

However, assuming ADHD is accurately diagnosed, methylphenidate can be an important part of treatment. Dr. Edward Hallowell, child psychiatrist and author of Driven to Distraction (Pantheon, $23.50), says stimulants like Ritalin help children pay attention long enough to respond to psychological treatment and behavioral therapies that teach them how to avoid distractions and control their impulses. He recommends that children "come off the drug once a year to see if they've learned what they need to get along without it." Methylphenidate alone will do nothing in terms of long-term management of ADHD. "It may calm kids down, but drugs aren't going to teach them how to function in society," says Natalie Elman, a certified learning consultant who teaches a course in basic social skills for ADHD children at the Summit School for Learning in Summit, N.J.

Parents and teachers also need to be involved. Their job is to reinforce and amplify what children learn in behavioral training and counseling. A common strategy for dealing with ADHD children is to use charts. Charts influence conduct by delineating expected behaviors and keeping track of whether or not the child meets those expectations. Good behavior is rewarded with tokens or points, which can be traded for something the child values, such as staying up late to watch TV or a trip to the zoo.

Teachers may find it helpful to seat ADHD children in the front of the classroom and away from distractions. Structuring schoolwork into a series of short assignments rather than large, time-consuming projects is another recommendation. Although most children with ADHD grow out of it, treatment may prevent lasting effects such as low self-esteem. When a child has an attention deficit, it's best to attend to it.

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