What is clear across the board is that assessment, diagnosis and the use of stimulant medication such as Ritalin for children with Attention-Deficit/Hyperactivity Disorder (ADHD) have become increasingly common.
The Weekly Morbidity and Mortality Report from Sept. 2, 2005, showed that approximately 4.4 million children ages 4-17 had a history of ADHD diagnosis; of those, 2.5 million (56 percent) were reported to be taking medication for the disorder. The same report showed 2.5 percent of California children as "diagnosed and currently taking medication."
Pleasanton Unified School District's Kevin Johnson, senior director of pupil services, said 183 of its 14,900 students have a "Section 504" plan, which provides for special accommodations under the Americans with Disabilities Act, and most of those students have ADHD. Johnson said this represents an almost 50 percent decrease from four years prior; however, some area doctors say there has been a slight uptick in the number of ADHD cases.
This trend is also visible in special education, said Kent Rezowalli, senior director of special education for PUSD
"There has been an increase statewide as students in special education are categorized as 'other health impaired.' Most of those kids are attention deficient students," he said.
"People became a lot more aware of the diagnosis," said Dr. Peter Levine, a pediatrician at Kaiser Permanente in Walnut Creek who has worked with ADHD patients for more than 20 years. "Having attentional problems also got kids school support where it didn't before, and that put pressure on doctors."
Developmental Pediatrician Deborah Sedberry said the relatively low number of diagnoses pre-1980 could be due to a lack of awareness of the "quiet, inattentive bunch," those kids that lack the hyperactive portion of ADHD.
"People are more aware of that now just like they are more aware of milder versions of autism," she said, noting that in the 1960s, ADHD was called Minimal Brain Dysfunction.
The notion of increased awareness is part of a larger promotional campaign by drug companies, said Robert Whitaker, a medical journalist and author of "Anatomy of an Epidemic" and "Mad in America," which discuss the rapid increase of mentally disabled adults and children, and the treatment of the severely mentally ill, respectively.
"The average practicing doctor isn't dirty or malicious, but the problem is there's some influencing by thought leaders, and those men and women are often on the payroll of the drug companies," he said. "There's no question that that corrupts the story that's being told. Next thing you know the doctor is in a context where the standard of care is to prescribe."
Sedberry estimates that three-fourths of her ADHD patients are currently taking medication, with a 70 to 80 percent positive response rate.
Whitaker takes issue with this treatment because studies have shown no long-term efficacy for children taking stimulants for ADHD.
The 1994 edition of the American Psychological Association's "Textbook of Psychiatry" echoed this notion and stated, "Stimulants do not produce lasting improvements in aggressivity, conduct disorder, criminality, education achievement, job functioning, marital relationships or long-term adjustment."
Additional studies cited in Whitaker's book showed that medicated children are often "less happy and ... more dysphonic"; have higher delinquency scores; and perhaps are more likely to develop bipolar disorder.
Donna Love, a member of the Northern California chapter of CHADD (Children and Adults with Attention-Deficit/Hyperactivity Disorder) has facilitated support groups for ADHD adults for 13 years. She called Whitaker's research "a crock" and "really irresponsible."
"Stimulant medication is amazing. For someone who is hyperactive, it tends to normalize their activity and normalize their inattention," she said.
Interestingly, NPR reported in 1995 that CHADD had received funding from Ciba-Geigy, the company that makes Ritalin, since 1988.
"Since then, CHADD has received close to $1 million in grants and its membership has grown from 800 to over 35,000," the report read. "CHADD has used Ciba-Geigy's money to build its membership and promote awareness of ADD."
This information hasn't necessarily fazed Nancy Vandell, one of the co-founders of the San Ramon Valley Unified School District PTA Special Needs Committee. Her 20-year-old son has been on stimulant medication since fourth grade and has since excelled in school.
"There's a lot of harm that is done by these so-called studies that aren't peer reviewed that give parents the information that stimulant medication does harm," Vandell noted. "Sometimes parents go through months or years of delay because of the controversy that surrounds them, and it harms the child because they don't get the education they deserve."
Still, CHADD, local doctors and parents who have children on stimulants advocate for a multimodal approach in which "multiple interventions work together as part of a comprehensive treatment plan." CHADD associates said stimulants are usually used as a last resort because parents are often wary of medicating their children.
Pediatrician Levine said 50 to 60 percent of people will try alternative treatments such as dance therapy, herbal treatments and neurofeedback.
"Finding something that the child is good at and getting them involved in it to be successful works best," he said. "Parents are probably the biggest factor."
Similarly, the bulk of Sedberry's medicated patients are those who came to her after "trying everything."
"Many are children that have other issues as well, and by controlling the ADHD, we're trying to get the child in the position where they can take better advantage of the social and educational opportunities regarding their disease," she said.
The education system certainly plays a role in the number of children being assessed and diagnosed. Both Levine and Whitaker said most requests for assessment come from parents who have been referred by teachers.
"Often parents come in after the school suggests. There's a lot of pressure on the schools because of the cutbacks, and schools don't want to give extra services," Levine said.
But PUSD officials said schools aren't advocating for assessment as much as addressing performance-based issues.
"The reality is teachers are not saying your kid should be tested for ADHD, they're raising a concern for a student's performance with the family," said Johnson. "There are students who can benefit from extended time on tests, testing in a quite environment, or preferred seating in class."
"Society has changed and what they now teach in kindergarten, they taught in third grade," said Judy Marshall, who teaches an ADHD parenting class and sits on the board of directors at CHADD. "(Children are) not developmentally ready to learn, and that's what creates the anger and concern and more people having their kids diagnosed."
PBS reports that schools often prefer that a child be served under Section 504 because it allows "more latitude in determining what services must be offered, and the necessary administrative procedures aren't as extensive."
Sedberry also said that parents come to her as their teens prepare to take their SATs, hoping she will diagnose them with ADHD so they will be given more time for college entrance exams. She no longer accepts high school seniors as first-time patients.
Celeste Winders, whose 7-year-old son Nasir has a 504 plan for his ADHD, said she still feels pressured by her school district in Sonoma to medicate her son.
"(Medication) gets brought up at every single (individualized education plan) meeting. They always make a point of saying, 'Mom's chosen not to medicate,'" she said. "There's a lot of pressure to medicate and when you choose not to medicate it's almost like you're not cooperating."
Winders said she's had great success controlling Nasir's ADHD with a carbohydrate- and dye-free diet as well as activities such as Tae Kwon Do.
"School is cut out for kids to sit quietly at their desk and fill out bubbles; tests are very high pressure for kids with ADHD. Then the tests tell (Nasir) that he can't do things that I know he can do at home," said Winders, who has had to advocate for her son not to be "ostracized" in class. Winders said she would put her son in private school if she could afford it.
Winders said Nasir keeps her on her toes and she likes him just the way he is -- hyperactive as heck.
"To me there's something endearing about him hanging from a tree -- and it gives me a few heart attacks -- but I like him like this. If I took that away from him, would I be taking away from him being great?"
While Winders and Nasir are exemplary of a family who chose not to medicate, others said they'd be lost without stimulant medication. Debbie Wayne-Daniels, 39, and her father, John Wayne, said Ritalin has changed Daniels' life, comparing the drug to insulin for diabetes.
Daniels has been on methylphenidate (Ritalin) extended release for about 15 years, which "was a blessing that allowed all of us to keep our sanity -- a wonder drug -- there was peace in the house again," Wayne said.
Daniels was put on Ritalin as a 3 - or 4-year-old but was taken off shortly because it made her zombie-like. She was unable to concentrate in high school, making poor grades and graduating with a 1.17 GPA. She also acted impulsively, self-medicating with alcohol and drinking at least one six-pack of soda a day.
After starting Ritalin again in 1995, Daniels said she noticed "almost an instant difference." She graduated from a Firefighter 1 Academy in 1996 with a 4.0.
"My life is so much more controlled, normal and happy now. I think about the consequences of actions whereas before Ritalin, I thought about -- and knew -- the consequences of my activities, behavior and actions and didn't care," Daniels said. "The Ritalin is not a cure-all or the answer to all the problems, it just allows and/or helps me to have more control over my life."
Sedberry said she's seen similarly positive results in patients, though not as long-term. She described a bright young man who came to her as a high school sophomore with dismal grades. After taking medication for his ADHD, he became an A student and was given early acceptance to Lehigh University.
But Whitaker stands strong behind the notion that, while stimulant medication can help children and adolescents, "If you want to do evidence-based medicine, you can't prescribe by anecdotes."
"Are there kids that fidget and can't concentrate? Yes. Do I think there's an identifiable pathology behind that? No. There's a spectrum of brain functioning out there and kids operate in different manners," Whitaker said. "ADHD-identifying behaviors are clearly annoying to some people but the biological causes are unknown."
Whitaker said that society should be more tolerant of diverse behaviors, noting that when he was in grade school, a normal day felt like six years.
"Societies have raised kids for centuries without putting them on stimulants, why can't we raise kids today without medicating them? A certain percentage of kids don't adjust to the school environment well, so maybe it's the environment and not the kids," he said.
One thing everyone can agree on, however, is that parents need to do serious research before putting their child on stimulant medication for ADHD.
"In my opinion, as a journalist, all the information needs to be known," Whitaker said. "Given all the risks and lack of long-term benefit, you'd want to be quite cautious of starting children on this medication and using it for a short period of time and in a small group of children."
Levine said that while there are certainly side effects, many studies show that medication is helpful.
"But it's still unclear how helpful it is long-term and that's why you need to jump in and have interventions. It's very important for parents to learn and get support for ADHD," he said.