TIME neuroscience

How Air Pollution Affects Babies in the Womb

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A new study finds evidence that prenatal exposure to common pollutants can contribute to hyperactivity, aggression and more in kids

It makes sense that an expectant mom’s exposure to pollutants in the air can affect her still-growing baby’s lungs and respiratory system. But there’s increasing evidence that such compounds can also harm brain development and contribute to behavioral and cognitive problems later in childhood.

In the latest study on the subject, published in JAMA Psychiatry, researchers for the first time pinpointed exactly which areas of the brain are affected if a baby is exposed to car exhaust and the byproducts of burning home heating oil. These polycyclic aromatic hydrocarbons (PAHs) have previously been linked to developmental delays, lower verbal IQ. signs of anxiety depression and problems with attention. But researchers haven’t been able to identify which areas of the brain are most vulnerable.

MORE: Children Exposed to More Brain-Harming Chemicals Than Ever Before

In this study, they recruited 40 mothers and their children living in the inner city who were participating in an ongoing study of pollution’s effect on development. They were selected because they had low exposure to environmental factors other than PAHs that could affect development, such as tobacco smoke, lead, insecticides and other chemicals. Based on measurements of PAH in their surroundings, about half of the mothers had PAH exposures below the median of those in the larger group, and half had PAH exposures higher than the median.

“The effects were extraordinarily powerful,” says Dr. Bradley Peterson, director of the Institute for the Developing Mind at Children’s Hospital Los Angeles and lead author of the study. “The more prenatal exposure to PAH, the bigger the white matter problems the kids had. And the bigger the white matter problems, the more severe symptoms of ADHD, aggression and slow processing they had on cognitive tasks.”

MORE: Mom’s Exposure to Air Pollution Can Increase Kids’ Behavior Problems

White matter is made up of the fibrous connections between nerve cells and is critical to helping neurons from one part of the brain communicate with their counterparts in other regions, and the babies with the highest exposure to PAH in the womb showed a dramatically lower volume of white matter in the left side of their brains. The entire left hemisphere, from the front to the back, was affected. “You would assume that an environmental exposure brought in by the blood and circulating to the brain would affect both sides of the brain,” says Peterson. “But the adverse effects of PAHs is located on one side; that’s surprising.”

The asymmetrical effect speaks volumes about how PAHs target brain tissue. Like other neurotoxins, they may preferentially seek out actively developing tissue. During gestation, the left side of the brain, which houses language capabilities, may be undergoing more intense structural changes in preparation for birth. This was supported by the fact that in the larger group of children in the study, those who were exposed to PAHs around age five didn’t show the same left-sided bias; in the older children, the pollutants affected both sides equally because the right hemisphere of the brain is undergoing active development at that time as well.

MORE: ADHD Linked to the Air Pregnant Women Breathe

Peterson suspects that the connection between PAHs and later behavioral and cognitive symptoms such as inattention, hyperactivity and slow processing speed may be due to how PAHs disrupt the normal communication between nerves in the left side of the brain and elsewhere.

The problem, he admits, is that moms-to-be can’t easily change where they live or work. And most people aren’t aware of how many PAHs they absorb on a daily basis. There are ways to minimize the risk of exposure, however. Expectant mothers can avoid secondhand smoke, a major source of the compounds. Not directly inhaling exhaust from cars on busy streets or smoke from fireplaces can also help, as can spending as much time as possible in parks or other areas free of burning fuels. It won’t eliminate the risk from living in an inner city and being surrounded by car emissions, but it can help, Peterson says. “Even if you can reduce your exposure from moderately high to moderate levels, it’s going to have a beneficial effect on the developing fetus,” he says.

TIME

There’s a Promising Pill For Binge Eating Disorder

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Correction appended, Jan. 15, 2015

A drug typically used to treat ADHD in adults and kids may also be an effective treatment for binge eating disorder, a new study shows.

In the study, published in the journal JAMA Psychiatry, researchers tested the safety and effectiveness of the drug lisdexamfetamine dimesylate on people with binge eating disorder—those who repeatedly eat an excessive amount of food, accompanied by a sense of having no control. When people took the drug every day for 11 weeks, half of them stopped binge eating entirely, which was more than the placebo group.

A drug that can treat both ADHD and an eating disorder may seem like an odd pairing, but lisdexamfetamine dimesylate works by acting on the dopamine and norepinephrine systems in the brain, which are two pathways that help control rewards and control. People with binge eating disorder can experience reward dysfunction and be very impulsive, similar to symptoms in people with ADHD. Norepinephrine helps with focus and concentration, while the dopamine helps recalibrate the rewards system—so the drug may help binge eaters feel more in control and able to avoid mindless eating.

“This study adds to our toolbox in that we have another treatment to potentially offer to people suffering binge eating disorder,” says study author and eating disorders and obesity expert Denise E. Wilfley of Washington University School of Medicine in St. Louis. “What we really want is a comprehensive treatment plan. There is a lot of loneliness and isolation needs to be met.” (Pharmaceutical company Shire, which has a version of lisdexamfetamine dimesylate, funded the trial and has supported prior research performed by Wilfley as well).

Another drug called topiramate has been used similarly to treat eating disorders, but has been shown to have some serious side effects, including cognitive problems. But in the new study, lisdexamfetamine dimesylate caused side effects similar to those in people with ADHD who take the drug, none of them serious, the results showed. One patient in the new study died, but the cause of death was determined to be methamphetamine overdose. The study authors do not believe it was related to the study.

Other treatments like cognitive behavioral therapy and interpersonal psychotherapy have already proven to be successful at treating binge eating disorder—which was only formally recognized as a disorder in 2013—but this study didn’t compare the effectiveness of the drug to the other treatments. Another question researchers want to explore is whether the drug wears off at night, a common time for people to binge, so more research is needed.

Even so, the fact that the drug succeeded because it was able to give a person more cognitive control opens the door to other non-pharmacological treatments, some of which show impressive results. Meditation, for instance, has been shown to help enhance executive function, as has exercise. Given how recently binge eating disorder was formally recognized as a problem, researchers hope there will soon be a variety of ways to treat it.

Correction: The original version of this story misstated the relationship between the pharmaceutical company Shire and the trial’s research. The company funded the study.

TIME Parenting

The 5 Trends Driving the Surge in ADHD

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Researcher says it's less to do with brain chemistry and more to do with money

Until recently, 90% of all Ritalin takers lived in the U.S. Now, America is home to only 75% of Ritalin users. But that’s not because Americans are using less of the drug, says a Brandeis professor. That’s because ADHD diagnoses, and treatment via pharmaceuticals are growing in other parts of the world.

In a recent paper in the journal Social Science and Medicine, sociologists Peter Conrad and Meredith Bergey looked at the growth of ADHD in the United Kingdom, Germany, France, Italy and Brazil and found that prescriptions for Ritalin-like drugs have risen sharply, particularly in the U.K. and Germany.

Attention Deficit Hyperactivity Disorder, or ADHD, is a controversial subject among many parents, educators and medical professionals. Some doctors insist it’s a genuine neurological condition, if occasionally over-diagnosed and not treated properly. Others believe parents are giving their children drugs unnecessarily. (For a look at what it’s like to be, or parent, an ADHD child, read TIME’s special report, Growing Up with ADHD).

Conrad and Bergey, while not doctors, fall into the second camp. They list five possible reasons for the jump in ADHD diagnoses that have little do with medicine.

1) Pharmaceutical companies are well-resourced and determined lobbyists, and have coaxed some countries to allow stimulants, such as Ritalin and Adderall to be marketed more directly.

2) Treating patients with counseling and non medical therapies is becoming less popular than treating them with medicine. (Many insurers, including Medicaid, will pay for drugs but not for psychotherapy, for example.)

3) The Diagnostic and Statistical Manual (DSM), the bible of mental disorders, is gaining more traction in Europe and South America. The DSM has slightly broader standards for diagnosing ADHD than the system used by many other countries, the International Statistical Classification of Diseases and Related Health Problems (ICD), hence more folks are falling within the standard.

4) ADHD advocacy groups are raising awareness of the condition.

5) Because everybody is occasionally fidgety and distracted and nearly everybody despairs of not getting enough done, people turn to the internet for answers and find checklists put up by drug companies, with overly general questions like: “Are you disorganized at work and home?” and “Do you start projects and then abandon them?” and encourage people to ask their doctors about medication.


According to the study, fewer than 1% of kids in the U.K. had been diagnosed with ADHD in the 1990s, but about 5% are today. In Germany, prescriptions for ADHD drugs rose 500% over 10 years, from 10 million daily doses in 1998 to 53 million in 2008. Conrad, author of The Medicalization of Society, worries that we may be addressing a sociological problem with a chemical solution.

“There is no pharmacological magic bullet,” says Conrad, who suggests that the one-size-fits-all compulsory education system might be more to blame for kids who can’t sit still rather than a flaw in brain chemistry.

“I think we may look back on this time in 50 years,” writes Conrad, “and ask, what did we do to these kids?”

TIME Developmental Disorders

ADHD Linked to the Air Pregnant Women Breathe

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Alan Hicks—Getty Images Heavy traffic can pollute the air with compounds that can contribute to ADHD

Everything an expectant mother does can have an impact on her baby’s development—including the air she breathes

Research has long connected what a mom-to-be eats and drinks to the health of her baby, and recent studies have even linked behavioral experiences such as stress, sleep and mood to the growing fetus’s development.

Now, scientists reporting in the journal PLOS ONE have pinpointed one exposure that could contribute to a baby’s higher risk of developing attention deficit hyperactivity disorders (ADHD), which the latest data from the Centers for Disease Control show affects around 11% of children aged four to 17 years.

MORE: Early Exposure to Air Pollution Tied to Higher Risk of Hyperactivity in Children

Frederica Perera, director of the center for environmental health sciences at the Mailman School of Public Health at Columbia University, and her colleagues focused in on how the pollutants in the air that pregnant women breathe can affect their babies’ cognitive development. Perera previously found a correlation between polycyclic aromatic hydrocarbons (PAHs) emitted by burning fossil fuels (such as in car exhaust and some forms of residential heating) to developmental delays by age three, reduced IQ in kindergartners and attentional problems by age six. So the team looked specifically at symptoms associated with concentration and evaluated how these effects connected to PAHs might be contributing to ADHD.

The scientists measured the level of PAHs in both the cord blood retrieved when the mothers gave birth and the mothers’ blood following delivery. They also collected urine samples from the children at age three or five years and analyzed them for PAH levels. The children born to mothers with higher levels of PAH during pregnancy had five-fold increased odds of showing symptoms of ADHD than those who were born to mothers with lower levels. The effect remained strong even after the researchers adjusted for the babies’ exposure to air pollution and smoking after birth.

“This is a new finding, and if the PAHs are identified as a contributor to ADHD, that opens up new avenues for preventing ADHD,” says Perera.

MORE: Study Links Exposure to Pollution with Lower IQ

PAHs, says Perera, circulate in the body for a long time, so even brief exposures could contribute to changes in the body. And each person processes the chemicals differently. Some may be more prone to breaking down the compounds into their potentially toxic elements, while others are less affected by the exposure.

While mothers may not be able to control some exposures, such as those from traffic and heating sources, there are some ways that expectant women can reduce their risk. Pushing local legislators to adopt clean air laws is one way to improve air quality, and on a more personal level, families can make sure that cooking areas have proper ventilation, avoid burning candles and incense and other sources of PAHs, and most importantly, ensure that they aren’t exposed to tobacco smoke. “Air quality is a policy problem, but individuals can be empowered to take steps,” Perera says.

MORE: Mom’s Exposure to Air Pollution Can Increase Kids’ Behavior Problems

Women who are pregnant can also eat more antioxidants from sources like fresh fruits and vegetables, since these can counteract some of the oxidative damage that PAHs wreak on fetal cells.

Perera stresses that limiting exposure to PAHs isn’t the only answer to reducing the increasing rate of ADHD in the country. Genetic and other environmental factors all contribute to the disorder, but identifying as many potential factors as possible could start to reduce the effect that the chemicals have not just on mothers, but on their developing babies as well.

TIME Mental Health/Psychology

Why Schools Should Screen Their Students’ Mental Health

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Two new reports argue for in-school mental health screenings

Schools should be a first line of defense for catching young people at risk for mental health issues from depression to ADHD, a pair of new reports says.

Kids and adolescents spend a significant amount of their time in school, yet providing mental health screenings and care is not an overarching requirement for many schools. “We need to think about how to embed mental health services so they become part of the culture in schools,” says study author Dr. Mina Fazel, a child psychiatrist at the University of Oxford. “It will take a commitment from health and education.”

The reports, published in The Lancet Psychiatry, looked at programs already implemented in both high-income schools and middle- and low-income schools. The authors made suggestions for both education systems. For instance, schools could conduct school-wide screenings by asking teachers to identify at-risk kids for further evaluation, or health counselors could be trained to spot both physical and mental issues by looking for visible signs like weight fluctuation or bullying. If treatments like cognitive behavioral therapy were included in a school’s health offerings, Fazel believes mental health problems could be caught early and treated.

“If we made mental health part of the usual health system of a school, then it becomes more normal…and hopefully it will then be easier to access it,” says Fazel. According to data presented in the reports (which is UK-specific but also looks at U.S. programming), about 75% of adults who access mental health treatment had a diagnosable disorder when they were under age 18, but in high-income countries, only 25% of kids with mental health problems get treatment.

Stigma is largely to blame for a lack of participation in mental health care. “[Mental health] is the service that people seem to know least about, seem to fear accessing most, and think they will be negatively viewed by their peers or their teachers or their families if they access those services,” says Fazel.

Some schools in the U.S. and abroad have had success with mental health screenings and programs, but implementation still hasn’t been made a standard, which Fazel thinks is a lost opportunity. By prioritizing mental health in a child’s early years, more people will get the treatment they need early on.

TIME Parenting

ADHD in Adulthood: To Prepare for a New Baby, I Had to Prepare My Mental Health

The author with his son Jack.
Courtesy Timothy Denevi The author with his son Jack.

Soon enough we’ll find ourselves short on sleep and patience—in anticipation I’ve been trying to make the necessary preparations

This fall I’m expecting the birth of my second child, a daughter. Over the past months she’s grown from the size of a kumquat, to the size of a banana, and recently achieved the esteemed gradation of cabbage. From what I can tell the final step is cantaloupe—and then, having triumphed through the full prenatal catalog of produce, Sylvia Denevi, the newest member of our family, will be here.

For now the focus is on preparation. My wife and I live in a suburb of Washington, D.C., with our seven-year-old son, Jack. Together we’ve begun to make the expected adjustments. The guest room is now a nursery. The garage has been searched and reorganized, its assortment of baby gear emerging again like relics from a previous life.

I see my preparation for Sylvia’s arrival as love: the first opportunity I have to tell her I love her, that she’s precious to me, that I’ll do whatever it takes to be the best father I can be. I’ve also been taking the steps to prepare myself, within the context of mental health, for the change that’s about to come.

Growing up in the 1980s and 90s, I was part of the first generation of Americans to be diagnosed with Attention Deficit-Hyperactivity Disorder. There was never really a question of whether or not I had ADHD, and after years of being the most active, over-sensitive, and impulsive person in the room—after a childhood of psychiatric and psychological treatments, some of which helped, others making things worse—I graduated from college and entered the workforce, at which point my personality no longer seemed as exaggerated and out-of-whack as it had once been. In the end I figured that whatever ADHD was, it was a part of the past.

That understanding changed when Jack was born. At the time I was 27. All at once I found myself surrounded by an enormous amount of conflict—the same kind I used to experience, growing up, when my behavior would drive the people around me crazy. It was uncanny: my wife would say something, and I’d overreact, and she’d say something else, and then I’d be shouting, and glaring, and shouting again. We argued constantly over the new demands: diaper changes, midnight feedings, who got to take a midday nap and who had to do the grocery shopping. Soon enough our lives began to resemble a ledger. I did this and you didn’t do that. My time is just as important than yours! You want to go to the gym for an hour but I can’t play softball tomorrow night? Instead of finding a way to share the new amount of work that was required of us, we spent hours fighting.

My wife is a scientist, thoughtful and logical, traits that have always fit well with my more energetic demeanor, and up until Jack was born our relationship was steady. But now it seemed as if our personalities had switched; at the end the day she’d be yelling at me and I’d turn sullen and depressed.

I felt overwhelmed. Like I couldn’t do the simplest things. It was as if I was underwater, gazing up toward a normal reality—one in which every other new parent seemed to deal well enough—while I was the abnormal one, a failure, once again a problem for the people who loved me. It was the most distant I’d felt from my wife since we’d been together.

“You’ve never been like this,” she told me. And while there were other variables involved—we’d moved across the country right after Jack was born, were at precarious points in our careers, and didn’t have extended family around to help—it was clear that if I didn’t act soon I’d run the risk of damaging my relationship with my family in a way that couldn’t easily be undone.

Eventually I went to see my family doctor, and then a psychiatrist. When I explained my moodiness and agitation they said the same thing: ADHD, even in adulthood, tends to make you much more sensitive than other people to your surrounding environment. If you’re constantly feeling restless and impulsive, you might react to demands in a disproportionate way—and there are few things more destabilizing than the birth of a child.

There wasn’t one thing I could do to magically make things better, they told me—that’s not how mental illness works. Instead, they recommended a series of steps. For the first time I started exercising regularly; I paid careful attention to my sleeping and eating habits; I even went on a low dosage of Adderall, which helped to make everything seem less drastic and overwhelming.

Eventually things improved, but not right away. It was a genuinely hard stretch for my wife and I—part of the reason, no doubt, we’ve waited a while to have another baby. But now, seven years later, as the summer turns to fall and Sylvia continues in her ascension through an aisle at the grocery store, we can take solace in the fact that we both have a much better idea of the changes to expect.

Soon enough we’ll find ourselves short on sleep. And time. And stamina. I’ll be less resilient in terms of mood and patience. In anticipation I’ve been trying to make the necessary preparations.

I started psychotherapy, visiting a psychologist regularly both by myself and with my wife. I’ve set up my exercise schedule with an emphasis on cardiovascular activities like running and tennis, the most beneficial to mental health. I’m trying to cut down on social events and alcohol—two things I very much enjoy. And I find myself making observations about my own sleeping and eating that are usually directed at seven-year-olds: Do you really think it’s a smart decision to start another television show this close to bedtime? If you’re sweating and your stomach already hurts, maybe that fifth piece of pizza isn’t the best decision…

I’ve also talked with my psychiatrist about the possibility of making a medication adjustment. (I hate being on medication anyway, and prefer to take as low as dose as possible.) The Adderall I’m on is the instant-release kind; my current approach is to take it ahead of time when I know I’m about to find myself in situations that are especially overwhelming or agitating—a birthday party for one of Jack’s friends at Chuck E. Cheese; driving through an unfamiliar snarl of D.C. traffic—but what happens when the foresight necessary for such an approach is already eroded by a lack of sleep and/or a screaming infant? I can try a time-release version, or a new medication.

One of the most difficult aspects of mental illness, especially within the context of parenthood, is finding a way, when it comes to your life and its influence on the people you love, to do more good than harm. In the end you can’t possibly predict what’s really coming: the moment in the future that will dislodge you from the balance you’ve worked so hard to achieve. It might be a random calamity, or one you’ve personally brought about. But the incredible truth is that it’s already on the way. And against such a prospect, what good can something like a therapist or exercise or a low-dosage pyschostimulant actually do?

This isn’t to dismiss the idea of effort. In fact it’s the opposite: imagining all the things that could go wrong or right for my family, I can’t help but find solace in action. I’m lucky that there are steps I can take, and that often enough they do tend to help. What matters is the act itself: an expression of love for the most important people in my life. After all, there are many ways to show how you feel; is it so terrible that one of mine happens to take the form of self-preparedness?

A few weeks ago, when Jack was looking through the toys in his closet and trying to guess which, if any, his future sister might enjoy, he turned to me and said, “Daddy, I have a question.”

I could tell by the line of his mouth that it was something he’d been considering for a while. “Yeah?”

“What do you think Sylvia will be like?”

Briefly the image of a pumpkin with very long eyelashes flashed into my mind, but in the next instant was something outside the parameters of size and shape: an emotion similar enough to anticipation. “A little like you,” I said. “And like Mommy. A little like me, too, I think.”

He nodded.

“That’s the exciting part,” I added. “Whoever she’s going to be, she’ll be herself.”

Courtesy Simon & SchusterHyper, by Timothy Denevi

Timothy Denevi is the author of Hyper: A Personal History of ADHD, out this week from Simon & Schuster. He received his MFA in nonfiction from the University of Iowa. He lives near Washington, DC and teaches in the MFA program at George Mason University, where he’s a visiting writer.

TIME Developmental Disorders

Kids With a Parent In Jail Need Special Care, Research Says

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Lynn Koenig—Flickr RF/Getty Images

It's a greater influence than the death of a parent or having divorced parents

Having a parent in jail is associated with more behavioral problems and learning disabilities in kids compared to children of divorced parents or a parent who has died, according to a new study.

“Children of incarcerated parents, compared with their counterparts, are a vulnerable population who are disadvantaged across an array of health outcomes,” the authors write. “The correlation between parental incarceration and children’s health means that physicians serving poor and minority communities may consider screening children for parental incarceration and that social workers in these communities should pay special attention to children’s health.”

The study, published in the Journal of Health and Social Behavior, used data from the 2011-2012 National Survey of Children’s Health and compared kids with similar socioeconomic, demographic and behavioral characteristics. The results showed that kids with a parent in prison were associated with a greater likelihood for ADD or ADHD, behavioral problems, speech and language problems, learning disabilities and developmental delays.

Among black children with fathers without a high school diploma, the data showed 50% experienced a parent in jail by the time they were 14 years old compared to only 7% of white children. The rate of developmental and behavioral disorders in kids was higher in those whose parent went to jail versus kids who experienced a parent death or divorce.

Since the incarceration rate in the U.S. continues to increase—researchers estimate that 2.6 million kids have a parent in the jail at any given time—the study authors believe it’s important to remember that having a parent in jail has a serious impact on the people they leave behind.

 

 

TIME Parenting

Audra McDonald: Why I Thanked My Parents for Not Putting Me on ADHD Medication

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Walter McBride—Getty Images Audra McDonald attends American Theatre Wing's 68th Annual Tony Awards at Radio City Music Hall on June 8, 2014, in New York City.

The decision of whether or not to medicate a child is a personal, difficult and subjective one, the Tony winner writes in response to a TIME article

In response to an open letter to me, titled “Sorry, Audra McDonald — My Kid Needs His ADHD Meds.”

Dear Ms. Luscombe,

I would like first to congratulate you and your son, both on coping with his ADHD diagnosis and on coming to a solution that works for you.

If my speech in any way offended you, I do apologize. However, it was in no way, shape or form intended as a platform for me to denounce the use of medication for ADHD or any other psychological disorder. I myself have benefited from psychotropic drugs to help combat depression in my youth.

The decision of whether or not to medicate a child is a very personal, difficult and subjective one. What works for one child doesn’t necessarily work for another. But in the end, as a parent, all that matters is that you do everything within your power to help your child. You sound like a mother who is fiercely dedicated to your child and his well-being. My mother is also someone who was — and still is — quite fiercely dedicated to her children and their well-being. (In fact, she very much wanted to be the one to respond to your letter.) In the 1970s, when the term ADHD hadn’t even really been coined yet, and Ritalin was still a relatively new drug being prescribed for hyperactive children, my mother and late father were struggling with their very sensitive, overdramatic, hyperactive 8-year-old daughter, who was having serious issues in school. Growing up in my house, “Audra-induced anxiety,” as you put it, had quite a different connotation.

After months of increasingly frustrating, painful moments watching their child struggle, and after talking with psychologists and my teachers — but not yet having the benefit of decades of research, media and social discourse on what was still a relatively new medication — my parents happened to attend a performance at a local dinner theater. Although my family was a very musical one — my dad was a high school music teacher, my grandmothers both taught piano, and, as you yourself were kind enough to bring up in your letter, my aunts used to sing at various black churches in California in the ’50s and ’60s — we were not theatergoers. That night, at that theater in Fresno, Calif., my mother and father saw a troupe of young children performing in a pre-show cabaret. A lightbulb went off in their heads and they decided to encourage me to audition to be a member of this troupe, in hopes that it might be a good outlet for my energy, an oasis for my emotions and possibly a place for me to build some desperately needed confidence. That moment, that decision, that “lightbulb” was what put my feet on the first tiny bricks of the yellow brick road that led me toward the Oz that is my life in the theater. All because they were struggling with the question of how best to help their struggling, unhappy, hyperactive child.

If that moment had not happened — if they had decided to try another tactic (medication or anything else), and I had stayed on what had been my path up until that point — I have no doubt that while my life might have been a fantastic one, it would not have been one in the theater. I have my parents to thank for making what was ultimately a life-changing decision for me.

Last Sunday night, I was overwhelmed with gratitude and love for my parents, who put me on the path that somehow, miraculously led to my standing on that stage, clutching that Tony. I am ashamed to admit that I don’t think I had ever truly thanked them for that before. Unfortunately my father is now deceased, but my mom was there, and I’m so grateful that in the 90 seconds allotted a winner to say thank you — and as the completely addled wreck of an emotional mess that I was at that moment — I was able publicly, from that stage, to look into her tear-filled eyes and acknowledge her struggle and thank her for making that decision. Not for driving me to rehearsals, helping me with my lines or keeping me calm, as you suggest I should have said to her, but for the actual decision she made. That is exactly what I wanted to thank her for, and I did. It was a decision that was very personal, and it ended up being the right one for me. It was a moment for and about my parents and their love for me: nothing else and no one else.

Every parent, when faced with a decision like that, makes it on the basis of real, personal and specific circumstances relating to their child. For some, the right decision is to medicate, for some it is not. For some it is a bit of both, and for some it is any one of a million other variations on the treatment options available. The only common factor that goes into making that decision, which is indisputably true for almost all parents, is the indescribable amount of love they have for their child.

I’m positive that your son will someday recognize that he has a mother who is fiercely devoted to him and that every decision she ever made was out of love for the child he is and the adult he will become. My best wishes to you both.

Audra McDonald is a mother, activist and a six-time Tony Award–winning singer and actress.

TIME Parenting

Sorry, Audra McDonald — My Kid Needs His ADHD Meds

Kevin Mazur—2014

Isn't being awesome enough? Do you have to start prescribing as well?

Dear Ms. McDonald,

I love your work. Who doesn’t? Clearly nobody, since you just won a record-obliterating sixth Tony for your performance as Billie Holiday in Lady Day at Emerson’s Bar & Grill. Congratulations. That’s an incredible feat.

And don’t get me wrong, I love that you thanked your parents before anyone, the folks who got you your start in the theater. “I want to thank my mom and dad up in heaven,” you said in that seriously kick-ass red-and-white gown, “for disobeying the doctors’ orders and not medicating the hyperactive girl and finding out what she was into instead and pushing her into the theater.”

I have kids too. Should they happen to ever achieve a modicum of success, I’d like to think they might thank me one day. Not publicly from a podium or anything, but maybe just from their desk, or whatever place of work they happen to land upon. Here’s the thing, though: I really want them to have jobs. Unlike your family, of whom you once joked that if you were “tone-deaf they would have kicked me out,” I’m not musical. Unlike you, my kids do not have five aunts in a professional gospel-singing group. (My brothers did have a band. If memory serves, my mother called them the Unlistenables.)

But here’s the thing: one of my kids doesn’t learn very well without the meds. We’ve tried the theater, sports, music, wearing him out, getting him more sleep, meditation, diet, being super-disciplinarian, being not too disciplinarian, art, bribery and shouting. We even tried chewing gum for a while. Oh, man, that stuff is hard to remove. We tried a lot of techniques, some of them more seriously than others, because we are human and have jobs and other children. But the thing that worked best, that enabled him to learn to read and stopped him from getting into trouble at school, was medicine.

Since completing school and getting a job are pretty tightly linked, our options are limited. Since employment and having a family, or a home or a healthy mental attitude, have also been linked, the parent of a child who has trouble learning can begin to get very anxious. Nobody, as I’ve said before, is thrilled to medicate their child. It’s not what anybody considers a huge parental triumph. We have no trophy cabinet for the expired bottles of methylphenidate. But if you don’t have a child whose talents are as prodigious and obvious as yours, it can be tough to figure out what’s best for them. So you’re left with trying to avoid what’s worst; and clearly not being able to learn is pretty high on that list.

I’m sure that you were not personally judging me and other concerned parents when you thanked your parents for not putting you on Ritalin. I’m sure you weren’t trying to prescribe from the podium. And obviously, you have thrived, against some serious odds. But damn it, you’re not making it any easier to live with our hard decisions. There’s anxiety and then there’s Audra-induced anxiety, which is more dramatic and accomplished than the regular sort. I’m equally sure your parents also drove you to rehearsal a lot, or ran lines with you, or calmed you down if you had stage fright, or told you not to chew your nails. You couldn’t have mentioned that instead?

The chances of anybody winning six Tonys are extremely slender (again, bravo). If by giving my child medication, I have reduced his chances of getting that gong even further, so be it. He may not be Audra-level awesome, but he’s going to get through school. I’m O.K. with that.

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