American kids are now much more likely to be diagnosed and treated for ADHD than kids in any other country. For example, a teenager in the United States is now nearly 14 times more likely to be on medication for ADHD than a teenager in the United Kingdom. In my book The Collapse of Parenting, I explore some of the reasons why. One is that in the U.S., medication has become the first resort for almost any child who is struggling in school. Outside of North America, medication is usually a last resort. That’s especially of concern because of research showing that these medications for ADHD may affect the developing brain in significant ways.
Here are some questions to ask yourself before your start filling prescriptions for your child:
Am I sure my child really has ADHD, rather than some other problem which is causing him to be inattentive?
Not all problems with attention are due to attention-deficit disorder. If a child is bored, that child won’t be paying attention. The same is true of a child who is sleep-deprived, or depressed. Justin isn’t paying attention because he has ADHD. Jason isn’t paying attention because he stays up late playing video games and he’s sleep-deprived. Jennifer isn’t paying attention because she is gifted, and the material covered in class is material she mastered two years ago; she’s bored. A skilled clinician who takes the time to ask the right questions will determine that Justin has ADHD, but that Jason and Jennifer do not. However, I have found that some doctors do only a cursory evaluation, look at an automated report, and then say, “Let’s try medication and see whether it helps.” Stimulant medications such as Vyvanse and Adderall may be dramatically ‘effective’ for Jason the sleep-deprived gamer. Vyvanse and Adderall are amphetamines, powerful stimulants; they will compensate for his sleep deprivation and improve his performance in class. But the appropriate remedy is really for Jason’s parents to unplug the video games and turn off the lights so he can get some sleep. The best treatment for sleep deprivation is sleep, not stimulants.
Has my child had problems in elementary school, or did teachers only start talking about attention in middle school?
ADHD hardly ever emerges after a kid turns 12. Prior to 2013, the official guidelines for the diagnosis of ADHD required significant impairment prior to age 7. The 2013 guidelines changed that to age 12, in part to accommodate the fact that ADHD appears to present in girls later than in boys. But ADHD seldom presents in anybody after 12 years of age. If your child didn’t have a problem in 5th grade, but now in 8th grade is having issues, there is likely to be some other explanation. Maybe it’s anxiety, or depression, or sleep deprivation. Maybe your son has decided that it’s uncool for boys to care about school. Or your daughter is more concerned about texting and Instagram than about spanish grammar. Those are major problems, but they’re not ADHD. Bottom line: if your child didn’t have major problems prior to age 12, then ADHD is probably not the correct diagnosis.
Is my doctor suggesting we try medication even though he or she is not 100% that ADHD is the problem?
It’s reasonable to prescribe a medication on a “let’s try it and see” basis, even if the diagnosis is not certain, IF the risks of the medication are known to be low. But the stimulant medications most often prescribed for ADHD—Vyvanse, Adderall, Concerta, Metadate, Focalin, Daytrana, and Ritalin—have been linked to damage to the motivational center of the brain. This evidence is not conclusive. In view of the uncertain risk, these medications should be prescribed only as a last resort, after other, safer alternatives have been tried.
Am I comfortable with the risks of giving my kid ADHD medication?
The most serious potential risk is damage to the nucleus accumbens, the motivational center of the brain. In my own practice, I have seen many children and teens—mostly boys—who took these medications for a number of years, and who seemed to lose their motivation and drive as a consequence. (I describe this phenomenon at greater length in chapter 4 of my book Boys Adrift.)
Is it my child who needs to change, or the way he or she is taught?
In my experience, many kids who meet criteria for ADHD can be treated successfully with accommodations in school, if the school is understands how to work with these kids. Sometimes, switching to a different school—often with a more hands-on, experiential approach to learning—can make a big difference, reducing or eliminating the need for medication.
Are we using the safest form of the medication?
If you and your child’s doctor believe that medication is essential, start with a safer medication for ADHD such as Strattera, Intuniv, and Wellbutrin. No medication is risk-free, but these medications have not been linked to damage to the brain in the way that the stimulant medications have. They are much less popular than medications such as Adderall and Vyvanse for two reasons. First, they may require weeks to months to start working while Adderall and Vyvanse, like all amphetamines, work on Day 1. Secondly, stimulant medications such as Adderall and Vyvanse boost concentration and attention in almost everybody, regardless of whether they have ADHD or not; non-stimulants are less likely to be beneficial for kids who don’t really have ADHD.
It's unlikely that American kids are really 14 times more likely than British kids to have ADHD. The differences in prescriptions between the USA and the UK more likely reflect the increased tendency of American doctors to prescribe medication and the increased willingness of American parents to administer those medications to their children. But this column is no substitute for the advice of your healthcare professional. If your provider recommends medication and you're convinced it's the right thing to do, then go ahead. If you're not persuaded, then ask questions, seek a second opinion, and read the chapter in my book The Collapse of Parenting titled "Why are so many American kids on medication?" Administering powerful medications which affect the developing brain may have serious consequences down the road, so it's worth trying other measures before putting medications into your child's brain.