Running Head: THE PREVALENCE OF ADHD AND USE OF RITALIN

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The prevalence of ADHD and use of
Ritalin among young children



Stephanie Janzen
University of Calgary
EDPS 635
Prof. Mueller
Aug. 13, 2013







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The early diagnosis and medication for children with behavioral problems is a prevalent
and often controversial development within the field of School Psychology. Due to
improvements in diagnostic criteria and processes, as well as advancements in the
pharmaceutical industry, more and more children are being placed on medication in order to
control their symptomatic behaviors at the recommendation of parents, teachers, and physicians.
Attention Deficit Hyperactive Disorder (ADHD) is of special concern today due to its
controversial nature as being the most commonly diagnosed mental disorder among minors.
Consequently, School Psychologists are working with more and more young children that have
such a diagnosis and have been prescribed psychostimulants as a result.
Although many young students are helped through diagnosis and treatment of ADHD,
there is substantial concern due to the subjective nature of the diagnostic criteria and popular
pharmaceutical treatment of this disorder. Many wonder if such a dramatic rate of diagnosis
within the last twenty years might have resulted in over diagnosis, which may have consequently
resulted in many children being unnecessarily prescribed psychostimulants as a treatment option.
If you have a hammer Other concerns include the use of medications for such a young
population in the absence of studies measuring the long-term side effects. Therefore, should we
be more cautious in our evaluations of children who seem overly rambunctious and inattentive?
Or has our knowledge of ADHD progressed to the point that we can be confident in the
diagnosis? And should pharmaceutical treatments be looked with a cautious eye, or have they
proven to be a safe and effective treatment for all ages?
Although the biggest increase in diagnosis for ADHD didnt occur until the 1990s,
children have been diagnosed for similar behaviors since the 1930s. Although the basic
symptoms have remained unchanged, the disorder has gone though many different labels since
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this time, including: organic driveness, minimal brain damage, hyperkinetic impulse disorder,
minimal brain dysfunction, hyperkinesis, hyperactive child syndrome, and attention deficit
disorder (Mayes et al., 2008). The use of psychostimulants for treatment of this disorder is also
not new. Methylphenidate was introduced in 1955 and then was approved by the Federal Drug
Administration (FDA) in 1961 for children with severe behavior problems. The controversy
surrounding children using prescribed psychoactive drugs also stretches back four decades. In
the 1970s people became more vocal about their concern regarding the drugging of
problematic children which led to a rash of negative media that extended into the 1980s. There
also occurred a wave a lawsuits against physicians, school staff and the American Psychiatric
Association in the late 1980s as well. All of which had the effect of curbing the rate of
diagnosis and pharmacotherapy (Mayes et al., 2008).
At the beginning of the 1990s, schools had very few students with ADHD, but by 2000
every class had at least one or two students diagnosed with the disorder. What accounted for the
great surge of ADHD diagnosis was, according to Mayes et al. a confluence in trends . . .
alignments in incentives . . . and growth in scientific knowledge of ADHD and stimulants that
occurred between 1990 and 1995 (pg. 151, 2008). The authors contend that during this time in
the United States, the child welfare advocates were gaining strength as a broad collection of
medical professionals, antipoverty activists, and disability and childrens health and welfare
advocates began to successfully lobby in Washington for greater resources and affordable
services. As a result, congress gave low-income children diagnosed with ADHD access to
financial assistance, and amended the Individuals with Disabilities Education Act which now
included ADHD as a protected disability. They also expanded the number of children eligible
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for Medicaid, which consequently fueled increases in Medicaid spending on psychotropic drugs,
from $0.6 billion in 1991 to $6.7 billion in 2001.
At the same time, insurance companies were looking to find less expensive ways of
treating mental disorders with decreased hospitalizations, greater use of primary care physicians
and increased used of psychotropic drugs. This also coincided with changes in the
pharmaceutical industry, as during this time Prozac was introduced as a treatment for Depression
and was commonly being prescribed to minors, which did much for the decrease in stigma
associated with mental health disorders. For all of these reasons, people were now more
accepting and accommodating with the ADHD diagnosis (Mayes et al. 2008).
What followed these developments was a dramatic rise of diagnosis of ADHD and
prescription of stimulants. In fact, between 1991 and 2005 the number of prescriptions for
children with ADHD rose by 700% in the US. By 2006, 4.5 million kids under the age of 18
were diagnosed with ADHD, and 2.5 million children were regularly using prescription
medication (Elder, 2010). The advances in information about ADHD and diagnosis did much
for those students demonstrating those problematic behaviors, yet at the same time, the rate of
increase also resulted in a public backlash. Many believed that such a large upsurge during a
short amount of time must surely be the result of misdiagnosis, (profiteering?) and so
allegations arose that children were not being diagnosed properly or were prescribed medication
for non-medical reasons. They questioned the legitimacy of the ADHD disorder and wondered
whether such symptomatic behavior necessitated medication.
Much of the debate during this time centered on the issue of subjectivity in diagnosis. As
ADHD cannot be objectively confirmed, for example, with a blood test, there is indeed a large
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amount of subjectivity that is involved in the diagnosis process. Behavior ratings are based on
comparisons to the normal behavior of age-appropriate peers, therefore many physicians, teacher
and parents might have competing definitions as to what is considered normal (Mayes, 2008).
For instance, a student with ADHD is identified by behaviors such as fidgeting, running,
climbing, failing to sit still, acting impulsively, interrupting others, having trouble waiting for
their turn etc. MYet many kids have an excessively high level of activity and meet many of
these criteria, but should not qualify for such a diagnosis. In fact, many, if not all kids at some
point demonstrate inattention, hyperactivity and impulsivity. Therefore, many critics claim that
parents and teacher are turning to medication as a solution to problem children stemming from
inadequate discipline, overcrowded classrooms, boredom or resistance to authority. They state
that ADHD may just be the invention of incompetent and over burdened parents and teachers
who turn to medication based on how much they are able to tolerate (Ezell Powell et al., 2003).
Due to the legitimacy of these concerns, researchers do admit that over-diagnosis has
probably occurred in some areas, especially among those physicians who may not have been as
rigorous with the criteria for ADHD as perhaps they should have been. (or as familiar with
children in general?) This may often be the case due to economic or time constraints that many
of them may face in their practices. Physicians may also lack the training pertaining to mental
disorders. Furthermore, it is not self-evident how hyperactive or inattentive a child has to be in
order to warrant a diagnosis, because the benchmark is normal (Mayes et al., 2008). Thus, it is
very likely that many children may have been misdiagnosed. Yet those that place the blame on
physicians fail to understand the breadth of criteria and evidence needed before a diagnosis can
be made. If they only focus on those 18 behavioral symptoms listed in the DSM-IV, it is easy to
see why the public might be concerned about the accuracy of the diagnosis, but a diagnosis is not
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simply made as a result of teacher and parent observations, but rather must follow the strict
guidelines set forth in the DMS-IV.
The DSM-IV requires five criteria for an ADHD diagnosis. The first is specific
symptoms that must occur at a level that is developmentally inappropriate and must be evident
for six months, therefore the symptoms must be persistent and chronic. The symptoms must also
cause significant difficulty for the child in at least two settings (most likely school and home),
thus the symptoms must be pervasive. They must also cause significant impairment in
functioning such as in their relationships or with their academics. The onset must occur before
the age of seven. And lastly, the symptoms and impairments must not be explained by another
disorder (Mayes et al., 2008). These five criteria or not lax or vague, thus a diagnosis is not or
should not be made quickly or easily.
Although the symptoms of ADHD are persistent and chronic, is important to note that
there can be some variability. For instance, a child with ADHD might display different
behaviors at different times of the day or during different activities, or even due to different
situational demands. For instance, they may perform better in the morning as opposed to the
afternoon, or they might be better behaved during recess as opposed to class time. Their
symptoms are also most likely to emerge in situations that are boring or repetitive, which is why
teachers are usually the ones to suggest ADHD as an explanation. But these children may also
act out in play settings or even in organized sports. For instance, a child with ADHD may be
playing in a soccer game yet is easily distracted by an insect or pedestrians walking nearby.
Their behavior and task performance can also be inconsistent as they might have a good day one
day, and then a bad one the next (Mayes et al., 2008). Therefore it is imperative that physicians
are provided with a detailed history in combination with clinical interviews, behavior rating
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scales, other tests and observations (such as an IQ test), medical tests, information from parents,
teachers, the child, and any others who might be familiar with the child in question.
It is important to note that the symptoms must also have a significant impact on their
academic, social and emotional development. Thus, their inappropriate behavior must interfere
with their functioning in all three important life domains school, family and peers.
Consequently, a child cannot be diagnosed for simply being inattentive. He must be inattentive
to the point where he cannot concentrate in class and consequently does not learn the material
causing him to fall substantially behind in school. Or their hyperactivity causes them to bounce
around to the point that they cannot play effectively or establish friendships with their peers.
Thus, a diagnosis would not be appropriate for those problem children who may act out but do
not suffer major developmental delays.
Despite the rigorous DSM-IV criteria, some skeptics still note that the rate of diagnosis
in the United States is much higher than any other country, and that the USA consumes three
times more psychiatric medications than children in the rest of the world combined (Mayes et al.,
2008). Although these statistics might indicate over diagnosis, it should be noted that most
European countries have different rules about how ADHD is diagnosed. For instance, in many
countries only a Child Psychologist can prescribe medication, while in other countries they
require three individual professionals to agree before a diagnosis can be made. And despite the
American statistics, research has found that the prevalence of ADHD is the same across the
different western countries (Mayes et al., 2008).
Some critics also still maintain that ADHD is socially constructed, meaning that these
behaviors are the result of interactions in our social ecology. Though this argument has faded
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out in time as scientific evidence has made it difficult to argue that that it was the invention of
schools and parents, or was a product of the environment, diet or parenting style. General
acceptance of ADHD as a real disorder also was aided by the increase use of antidepressants for
minors, as there is little controversy about the legitimacy of depression. Consequently, there
were fewer debates about whether ADHD was a real disorder. Brain scans have also proven
that ADHD is a product of biological mechanisms, as children with ADHD tend to have a higher
ratio of theta and beta waves than children who dont have the disorder. In fact, the Food and
Drug Administration has just approved the first medical scan that can help diagnoses in ADHD
in children aged 6 to 17 (Associated Press, 2013). This is an exciting development in the field of
School Psychology as it will decrease or perhaps even eliminate the subjectivity in the diagnostic
process. Currently, such scans have only been approved in several states, therefore further
research and study will be needed before such techniques will be permitted in more states and
even Canada.
Much of the controversy regarding ADHD not only stems from over diagnosis and its
origins, but also the concept of medicating children for behavioral problems. For even though
many children are debilitated by their inappropriate behaviors (such as the aforementioned
academic failure, rejection by peers, conflict with parents and difficulty participating in social
events), many are concerned that millions of children are using potentially harmful medications
to treat disorder with inherently subjective symptoms. They resist the idea of medicating for the
purpose of changing their behavior and fear that the costs of medication outweigh the benefits
(Elder, 2010). In short they believe that young children should not be given stimulants merely
for behavioral problems. Yet much of these objections fail to take into account what we know
about the medication for ADHD and the progress that has been made in the last 20 years.
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The drug most commonly used to treat ADHD is methylphenidate. This is a
psychostimulant drug that has been prescribed to treat this disorder since the 1960s. Its
primary intent is to increase dopamine levels in the brain as someone with ADHD will suffer
from a dopamine imbalance or deficiency. Methylphenidate acts primarily to inhibit the
reuptake of dopamine thereby retaining these hormones longer, which increases the levels of
these neurotransmitters in the brain, which affects ones attention regulation and control of
impulsive behavior (Ezell Powell et al., 2003). The most popular market brand of
methylphenidate is Ritalin.
Although other drug treatments exist (such as antidepressants, clonidine, and
antipsychotic medications), it was the rate of prescription for Ritalin that tripled during the
1990s (Setlik et al., 2009). This was primarily due to its effectiveness in treating ADHD
symptoms. Not only has there been no evidence of serious harm or long-term health risks but
studies also showed significant improvements in social behavior and academic performance. For
instance, after only just starting on medication, parental conflicts, school disruptions, peer
rejections have improved dramatically. During the 1990s, pharmaceutical companies also
created a new once-a-day form of Ritalin, which meant that children could now take their pill at
home, rather than at school thereby risking embarrassment. This made Ritalin treatment an
easier and more attractive choice (Mayes et al., 2008).
Although Ritalin is considered to be safe, its pharmacological effects do resemble closely
those of cocaine and amphetamines. Therefore despite its therapeutic low dosage, it does have
properties potential? for eliciting dependence and abuse. Abusers can experience euphoria if the
pill is crushed and then snorted so that it is quickly released into the blood stream. It can also be
injected, which produces effects somewhat similar to cocaine. But if taken orally, Ritalin does
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not reach peak concentration in the brain until 60 minutes after ingestion so patients dont easily
achieve a high. It is the quick peaks that lead to addiction, and so proper? therapeutic use of
Ritalin does not cause addition nor does it lead to psychosis if taken properly for treatment of
ADHD (Ezell Powell et al., 2003).
That being said, there is still the potential for these prescription drugs to be used for non-
medical purposes. According to Setlik et al., prescription medications are the most common
drugs teens use to get high, of which Ritalin is included (2009). This is because they believe it is
safe, and because it can relieve pain and anxiety, aid with sleep, and increase concentration
levels or increase alertness. Thus it can commonly be found in schools and college campuses as
a study aid. There is little known about Ritalin abuse and diversion for non-therapeutic use,
though studies have shown that with the surge of Ritalin prescriptions?, there was also a sharp
increase of poison center calls that was out of proportion to other calls. The authors contend that
this does suggest a rising problem with teenaged ADHD stimulant medication abuse (Setlik et
al., 2009). They claim that case severity has increased over time and that the call volume has
also risen 76%, while sales of these medications have increased by 80% but that the percentage
of calls related to amphetamine is rising fast than sales. Thus they believe that this indicates
rising levels of abuse for these types of drugs. That being said, it is important to note that
production levels of Ritalin are not only attributed to rising ADHD diagnoses; it is also
prescribed to geriatric patients. And those unexplained deaths that some attribute to Ritalin
could have resulted from a combination of Ritalin and other drugs, not Ritalin alone (Ezell
Powell et al., 2003).

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Because therapeutic use of Ritalin has proven to be safe for children suffering from
ADHD, it has now been prescribed to approximately 90% of children who take medication for
this disorder. Although there is no evidence of harm or long-term risk related to Ritalin use, the
side effects of Ritalin do include memory loss, growth disruption, tics, sleep disruption,
nervousness, hypersensitivity, anorexia, nausea, dizziness, palpitations, headache, drowsiness,
angina, cardiac arrhythmia, abdominal pain, and weight loss. There have also not been any
studies done measuring the long-term side effects of Ritalin use, therefore we do not know if
future issues will arise for chronic users. And if taken inappropriately, such as in crushed form,
this stimulant drug can cause seizures, psychosis or strokes (Ezell Powell et al., 2003).

Although the public now generally accepts the prescription of Ritalin to primary school
students, new research is investigating whether such treatment is acceptable for preschool school
students as well. Although most with ADHD are not diagnosed until after seven years of age,
the symptoms of hyperactivity may appear in very young preschoolers and are almost always
present before the age of seven. In very young children, their symptoms may include fidgeting,
squirming when seated, having to get up frequently to walk around, and behaving in an
inappropriate and inhibited manner (Arons et al., 2002). Many of these symptoms appear in
normal children, but for those with ADHD they occur more frequently, in several setting, and
greatly interfere with the childs functioning. Such problem behavior can be detected as early as
age three. Therefore it leads many researchers to believe that if children can be prescribed
medication when symptoms first appear, it may help them avoid those issues caused by their
hyperactivity and inattentiveness. (Mostly boys?)
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Currently, such early diagnoses are not made often as ADHD is not a well-defined
psychiatric disorder in this age group. Although controlled studies to evaluate medication for
preschoolers are rare, researchers are currently attempting to understand the disorder among
preschoolers. For instance, in 2000 a study was done to test the effects of Ritalin on preschool
ages children. Although Ritalin is not approved by the FDA for those under six year of age, in
this study 165 children age 3-5.5 participated in this 5 week, placebo controlled study. During
the five weeks, most of the preschoolers tolerated the drug well, but 11% did discontinue due to
adverse side effects. For those that did remain in treatment for the entire maintenance phase,
their behaviors continued to improve. The results then suggest that the maximum effect of
treatment of symptoms emerges early on, followed by slower improvement in functioning.
Persistence of some of the older symptoms did persist occur? , and so full normalization was not
achieved for most children in spite of careful treatment (Vitiello et al., 2007). But results were
promising, which indicates that more and more preschoolers may be more confidently diagnosed
with ADHD and placed on medication.
Although the FDA has currently not approved Ritalin for children less than six years of
age, doctors will prescribe the off-label use of the drug for those in preschool. Off-label use is
the prescription of pharmaceutical drugs for an unapproved age group, dosage or form of
administration (Arons et al., 2002). These guidelines are based on information from clinical
trials, which then dictate how the drug should be used. Although this type of use is generally
legal, it does carry health risks as different populations that are not studied may react
unpredictably. That being said, stimulant treatment in preschoolers increased approximately
three- fold during the early 1990s. In fact in 1994, Ritalin was prescribed 226,000 times for off-
label use and 94% (wow!) of all drugs given to preschoolers have been distributed in this
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manner. Doctors felt it appropriate to distribute Ritalin in this manner for several reasons. First,
there was now a larger pool of eligible youths due to expanded diagnostic criteria for ADHD
since 1980. There were more girls being treated which also increased rates of diagnosis, and
there was now greater acceptance of biological treatment for behavioral disorders (Zito et al.,
2000). Thus, the greater pool of children now being diagnosed with ADHD meant that more
preschoolers will also be included and thus receive medication.
The fact that doctors must prescribe Ritalin as off-label use does raise some red flags.
Should children be using medication that is not supported by clinical trials? And are diagnostic
processes accurate enough for such young children? Arons et al., the authors of Too young for
ADHD: The potential role of systems of care, contends that preschools can be too young for
ADHD if the diagnosis is the consequence of inadequate assessment, hurried use of medication,
lack of follow-up, and if there is a failure to use comprehensive family centered integrated
approach. But they also state that preschoolers are not too young if (big if?)early identification
of ADHD was made with thorough and complete assessment approaches, it involved the family,
school and the child in decision making and management of medication, and there is careful
evaluation of effectiveness of treatment and integration modalities (2002). They believe that if
done correctly, giving attention to the needs of young children can prevent adverse consequences
in their growth and development. That being said, further study and research needs to be done to
study the effects of medication for this age group, as well as improve diagnostic criteria for those
between three and seven.
Another area for further research is how a childs age-for-grade might affect a teachers
recommendations for an ADHD diagnosis. Although a teacher cannot make the official
diagnosis, their suggestions may do much to influence opinions about that child, which furthers
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the process toward a diagnosis. Accordingly, it is worth looking into what may affect their
decision making. A study done by Elder looked at this issue to determine if the kindergarten
eligibility cut off dates might affect the rate of diagnosis. For example, if the cut-off date for
kindergarten is the end of December, then those born in the month of December will be more
emotionally and intellectually immature as compared to most of the other children in the class.
The teacher might notice that they are relatively more hyperactive and inattentive and mistake
this for symptoms of ADHD. In fact, their research shows that students with ADHD born just
prior to the states kindergarten eligibility cut off date are more than 60% prevalent than those
born immediately after. If these are incorrect diagnoseis due to this bias, they estimate that 20%
of 2.5 million students have been misdiagnosed. If this is indeed correct, authors postulate that
$320 million to $500 million is spent annually for inappropriately diagnosed children (2010).
Further policy research is also being done in the area of mandated medication for children
with ADHD. If a child with ADHD does indeed display those behavioral characteristics that
impede their development, and if medication can help manage those symptoms so that they can
succeed in their relationships and in school, should medication be mandatory? This is the
question that Australia is currently grappling with. The National Health and Medical Research
Council (NHMRC) is Australias peak funding body for medical research, and in 2001 they
drafted guidelines for ADHD in children, which stated consideration should be given to the
ability of the child/adolescent and their caregivers to implement strategies. As with any medical
intervention, the inability of parents to implement strategies may raise child protection concerns
(Dunlevy, 2012). .
For those children who do suffer from ADHD, they may indeed encounter many serious
problems throughout their lives. As mentioned previously, they may have a hard time
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establishing relationships with their parents and peers, they may not be able to participate
effectively in activities, and they might suffer academically. Thus some people may believe that
medicating children with ADHD is imperative so that they might function normally and avoid
those issues. But should legislative bodies mandate medication? Proponents of this movement
believe that this situation should not be seen as being unique to ADHD, but should be likened to
other medical ailments. For instance, it should be compared to parents who fail to manage
serious conditions such as their childs asthma or diabetes, as they are considered to be failing
their duty as a parent (Dunlevy, 2012).
Although there are several strategies that can be used with regards to ADHD (such as
classroom tactics and strategies), the NHMRC advises that for children and adolescents
diagnosed with ADHD, stimulant medications like Ritalin can reduce core ADHD symptoms and
improve social skills and peer relations in the short term, and that a combined behavioral-
pharmacological treatment is most effective in normalizing child behavior (Dunlevy, 2012).
Despite their good intentions, these guidelines have caused much controversy over the last
several years. Most, if not all parents believe that medicating their children should be a choice,
especially when the child is too young to give informed consent and when the symptoms are
behavioral rather than medical. Others are worried that these guidelines may lead to a situation
similar to that in the US, where some US states have had to legislate to prevent schools and child
protection authorities from telling parents they must put their children on drugs. Yet at the same
time, the consequences of not placing a child with ADHD on medication should be considered
with gravity as it does (may?) seriously affect their development. Although Australia has yet to
mandate the use of medication for children with ADHD, these guidelines has have served as a
topic of debate and consideration for other countries.
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Many School Psychologists who have been working in the field for any considerable
length of time has have undoubtedly noticed the increased number of children that who? are
diagnosed with ADHD. Many parents have questions and concerns about the sharp rise in
diagnosis throughout the last 15 years or so, and so it is important to understand why such an
increase has taken place. As developments happen in behavioral psychology and as
improvements are made in diagnosis, it will also be imperative for School Psychologists to
understand ADHD both in primary- school children as well as preschoolers so that they can give
informed opinions to parents and teachers alike. It will also be useful to understand the benefits
of medications as well as the risks involved, which includes off-label use for younger children.
Yet although ADHD is present in every school, there is also much we still dont
know. Any recommendations made to parents of preschoolers should be made with caution
given the limited number of studies available on this topic. Observations from teachers should
also be studied for bias or influencing factors such as the students birthday in relation to cut-off
dates. Many of these limitations and warnings are due to the subjective nature of the diagnostic
process, and so we can take solace in advancements in more scientific processes of diagnosis
such as measuring brainwaves. Hopefully advancements like these will resolve much of the
controversy around this disorder and that more children will be helped as a result. The three
officials recommending may not be overkill?
Good treatment, touchy area . 47/50
15+35+47 = 97 = A+


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