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Who Needs Stimulants for ADHD?

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Ritalin. Courtesy of en:User:Sponge via Wikimedia Commons.

In 1970, 150,000 U.S. children were taking stimulant medications. By 2007, that number had risen to 2.7 million, according to pediatrician Sanford Newmark of the University of California, San Francisco. In the video embedded in this post, titled “Do 2.5 Million Kids Really Need Ritalin?” Newmark analyzes the reasons behind the rise in prescriptions, which follows the sharp climb in diagnoses for attention-deficit hyperactivity disorder (ADHD). He also makes a case for fewer scripts, detailing the downsides of these medications and suggesting alternative remedies for ADHD, including changes in diet, supplements, as well as parenting, school and lifestyle interventions. Here are some highlights of Newmark’s talk, along with time stamps indicating when to watch.

2:30- The use of stimulants and the number of kids diagnosed with ADHD have both exploded in recent years; the diagnostic rate and percentage of kids medicated for the disorder differs from state to state, indicating variability in criteria for diagnosing ADHD.

5:02 – What is ADHD? Its defining features are hyperactivity, inattention and impulsivity. In a correct diagnosis, a patient’s symptoms cause impairment in more than one setting—both home and school, for example. Significant deficits should be evident; concentration and impulsivity levels vary normally across the population. If a kid is hyperactive and impulsive but she’s getting great grades and everything is going well, that is not ADHD, Newmark says.

Twin studies show that 70 percent of the incidence of ADHD can be traced to genetics, but no one has identified a specific gene or set of genes responsible for the disorder. Certain environmental influences can also trigger or worsen the condition.

10:33 – The rise in stimulant prescriptions for ADHD could result from four factors.

  • Many children with ADHD went unrecognized in the past. We are better at spotting the disorder today. Newmark believes this is true. Some of the kids who were labeled “stupid” or delinquent decades ago might have had ADHD.
  • We have loosened the definition of ADHD. This is true, says Newmark. In the past, the only kids who received an ADHD diagnosis were so hyperactive they essentially tore apart the doctor’s office as soon as they arrived. Today, kids who can’t focus qualify for the diagnosis as does the preschool kid who can’t sit still at story time.
  • Even with loosened definition, we are diagnosing too many children. Often diagnoses are handed out cavalierly after a brief evaluation, Newmark says. He says that the diagnostic procedure should include an hour visit with the child and an hour follow-up, including interviews with parents and teachers.
  • More people now have ADHD. Our genes haven’t changed but our environment has. Newmark argues that toxins in the prenatal and postnatal environment along with increased TV exposure and stressed parents can spawn symptoms.

22:50 - Why don’t we just take a pill? Stimulants are effective about 70 percent of the time, in the short term, at least. Some kids need them. But they have side effects, principally slowed growth. One in 100 individuals also experience hallucinations while on the drugs. In Newmark’s experience, the drugs seem to sometimes lead to personality changes, too. Over the long term, the drugs’ effects are unclear, although animal studies suggest possible additional harms.

29:30 – What is an integrative approach to ADHD? A doctor considers a child in the context of his or her home, friends, school and community—and not just as a set of symptoms. From that vantage point, a physician can often find nondrug interventions involving changes in diet, lifestyle, schooling and family dynamics.

30:34 – Diet is important. A lot of kids are sensitive to certain foods. In some cases, eating these foods cause behavior changes. Studies have shown that restricted diets can lead to improvements in ADHD symptoms that are comparable to those achieved by taking stimulants. Processed sugar and red food die are common culprits.

What kids eat for breakfast can make a big difference in their thought and behavior. Breakfasts composed of white flour or simple sugars (think, waffles and syrup) have a high glycemic index, which means that they cause blood sugar to rapidly rise--and later plummet, making kids jittery and inattentive around 10am. Fat and fiber slow down this process, so breakfast should include unprocessed cereal with some fat, such as low-fat milk or peanut butter. Kids perform better when they eat a breakfast that has a low glycemic index.

Some studies also suggest that supplementing a child’s diet with omega-3 fatty acids, iron (when it is deficient) or zinc can diminish symptoms.

45:16 – Parenting and school interventions can help. Many parents do not know how to parent a child with ADHD. One behavioral approach focuses on positive feedback and consequences given without emotion. At school, Newmark recommends reasonable modifications such as more time to take tests, abbreviated tests or seating changes.

49:12 - Alternative therapies may include herbal remedies, yoga, hypnosis and exercise. Among herbs, valerian and lemon balm can have a calming effect on children, though they do not improve focus. A computer program called Cogmed trains working memory in kids with ADHD, boosting their cognitive capacity. Newmark strongly recommends decreasing the use of electronic media and adding exercise to a child’s daily routine.

54:10 - How does Newmark treat ADHD? He cleans up the diet, checks for deficiencies in iron and other nutrients and suggests parenting, school and lifestyle changes. Then, if necessary, he prescribes stimulants. Yet if kid has real problems—say, he’s about to get kicked out of school—stimulants may have to come first.

For more about alternative therapies for ADHD, see "Can ADHD Be Prevented?." >>

Video Credit: University of California Television (UCTV)

The views expressed are those of the author and are not necessarily those of Scientific American.

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