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Ritalin debate: Are we over-medicating?

Prescriptions for ADHD drugs have been incresing, leading some to believe U.S. children are overmedicated
Prescriptions for ADHD drugs have been incresing, leading some to believe U.S. children are overmedicated  

By Rhonda Rowland
CNN Medical Unit

ATLANTA, Georgia (CNN) -- It's part of the routine for at least one child in every classroom across the country: starting the school day with a dose of Ritalin or other stimulant drug.

"We know that they're effective, we know they're safe. And there's been some very large government-funded studies that have established this," said Dr. Peter Jensen, a child and adolescent psychiatrist at Columbia University.

Medications such as Adderal, Concerta and Ritalin are used to treat attention-deficit hyperactivity disorder, or ADHD. It's a brain disorder characterized by inattention and impulsive behavior.

Government studies suggest approximately 4-million school-age children suffer from ADHD. Yet, about 20-million prescriptions were written last year for stimulant drugs, according to IMS Health, a health care information company. The number of prescriptions written for the drugs has steadily increased since 1996 when about 14-million were written.

CHADD:  Children and Adults with ADHD

"We know there's better recognition of ADHD, and we also know that when children are treated nowadays, they're more likely to be treated over a longer period of time," said Jensen. "If you go back five, seven, eight years ago, it was very rare that an adolescent with ADHD was treated. And usually it'd just be a child in elementary school was treated, but nowadays prescriptions have probably risen because adolescents are getting treated, there's better recognition for girls and they tend to be treated more throughout the school year."

This month, for the first time, drug companies are using print and television ads to sell their products directly to the public.

"I think it's a big mistake," said Lenny Winkler, a state representative in Connecticut. "I believe we are over-medicating our children."

Winkler is an emergency room nurse by training.

"I think we're aiming the information to the wrong people. They should be targeted to the physician. The physician is the one that writes the prescription," explained Winkler.

Jensen, an ADHD researcher formerly with the National Institute of Mental Health, disagrees.

"I am actually very pleased that there are responsible, carefully prepared, factually based advertisements," he said. "They inform parents and others about the condition of ADHD. That it's a true medical disorder, that it has serious long-term consequences for children if they're not treated."

There is currently no objective diagnostic tool for the disorder, so the diagnosis often comes down to a judgment call. Last year the American Academy of Pediatrics published guidelines recommending that children suspected of ADHD have at least 2 to 3 visits with a physician, and that the physician solicit additional information from parents and teachers.

But Winkler says, in reality, too often it's the teacher who's making the diagnosis.

"In some situations, even parents were told if they didn't place their child on a psychotropic drug, their child wouldn't be able to attend school. And I just found this horrendous," she said.

She supports a Connecticut law that would, starting October 1, prohibit schools and teachers from recommending psychotropic medications. A teacher could recommend a visit to a doctor.

"If a child is appropriately diagnosed with ADD, ADHD, the child would definitely benefit from the medication, and I am not opposed to that at all," said Winkler. "But I am opposed to somebody making the recommendation to a parent (that) their child needs this drug and the physician sits down and writes it out without doing the necessary work on the child."

Medication with counseling

Evelyn Green, president of Children and Adults with ADHD (CHADD), says the group supports such legislation, but adds that critics shouldn't be too hard on schools.

"Teachers are very much a part of the team, as well as the doctors and the parents, so they need to be able to relay information, but they certainly have no business making a recommendation for medication. ADHD is a medical diagnosis," added Green.

CHADD supports the use of stimulant medications, with behavioral modification and counseling.

"That may include things like social skills training. It may include family counseling, individual counseling, behavioral therapies, behavior modification," explained Green. "Medication is a piece of the picture. It works for lots of kids; it certainly worked for my child and it works for a lot of adults, but it doesn't work for everybody and it's not a magic bullet."

A study published two years ago that included 600 children found combination therapy was the most effective way to treat youngsters with the disorder.

While much of the public debate has focused on over-diagnosis and over-medication of children, some doctors say a bigger problem is children being missed.

"Here in the United States, there is a tendency to over-prescribe in some instances. But it pales in comparison to the under-prescription or under-recognition of these problems in children," said Jensen. "We know from a variety of epidemiologic and other related studies, that as many as half of the children with conditions such as ADHD are not being treated at all."

Much of the stigma associated with psychotropic drugs for the treatment of ADHD comes from their potential for abuse. The introduction of new, less-addictive drugs over the next year could alter the Ritalin debate.

• American Academy of Pediatrics: New Guidelines for Diagnosis of ADHD
• CDC: ADHD Home Page
• NIH: Methylphenidate (Ritalin)
• Concerta

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