“Mommy knows best” is a popular expression but it’s not a universally accepted truth. Several months ago, Jacqueline Howard refused to believe that her eight-year-old son Oliver had attention deficit hyperactivity disorder. Oliver’s teachers, however, “just wanted him medicated and to be very compliant and quiet in class. And the psychologists [wanted] to engage my son in huge amounts of counselling and programs,” recalls Howard.
But she had her own explanation for Oliver’s supposed bad behaviour in school. Born in mid-December, he was the youngest student in a split class of third and fourth graders, making some of his peers up to three years older than him. “So of course he’s noticeably immature. Of course he’s noticeably unfocused,” says Howard. “My gut instinct was that there’s not much wrong with my son. He’s just stressed out and people are setting really high expectations for him at a really young age, which he can’t fulfill.”
Howard’s view—as seemingly logical as it was maternal—was nonetheless largely dismissed, even after groundbreaking research published in the March issue of the Canadian Medical Association Journal showed that, yes, in fact, the youngest children in a class are much more likely to be diagnosed with ADHD. “It seemed that a lack of maturity was, in some cases, being misinterpreted,” explains Richard Morrow, lead author of the study and health research analyst for the PharmacoEpidemiology Group at the University of British Columbia in Vancouver. The findings “are definitely of concern,” he says. “We want to avoid medicalizing a normal range of childhood behaviour. Children mature naturally at different rates.”
Rather than acquiesce to the pressure to put Oliver on medication for a disorder that Howard was unconvinced he actually had, she opted for another, similarly drastic solution. Two months ago, Howard, a single mother, left her job of 12 years as a geophysical technologist in Calgary earning $150,000. With no work lined up, she moved with her son and 10-year-old daughter to Pender Island, B.C., population 2,500. There, they attend a small public school so accepting of “kids being kids” that there are exercise balls inside the classrooms for fidgety children to sit on during lessons. Since then, “Oliver has turned around hugely. He is doing incredibly well. And he’s happy too, which is really important,” says Howard. For her, this is vindication: “I don’t think I’m a parent in denial. I think he’s a child who needs to be given an opportunity to grow up and relax.” In his own way, and at his own pace.
Howard’s solution is extreme, no doubt, but her situation as a parent trying to chart the right course for a child suspected of having ADHD is all too common. Today, ADHD is the most prevalent mental disorder in children around the world, affecting more than five per cent. And there are no signs of the trend slowing down. “I’m afraid it will continue to increase,” says Montreal sociologist Marie-Christine Brault. “We live in a society that favours diagnosis and medication intake. I don’t know why it would stop.”
Especially given the deluge of scientific evidence published over the last few months pointing to the rising prevalence of ADHD diagnoses and the use of medication. Brault’s own work in the February issue of the Canadian Journal of Psychiatry revealed an almost twofold increase in the percentage of school-aged children diagnosed and treated for ADHD between 1994 and 2007. In the United States, a paper published in the March-April issue of Academic Pediatrics discovered a 66 per cent rise in the number of visits to the doctor for ADHD diagnosis or treatment between 2000 and 2010. “If we’re seeing this increase, there are important questions to ask,” says lead author Craig Garfield, a pediatrician and professor at Northwestern University in Chicago. First among them, “Why are we seeing this increase?”
Unfortunately, neither Garfield nor anyone else has the answer, just lots of theories: improved awareness about ADHD, effective pharmaceutical marketing of newer and apparently better drugs, a broadening of the diagnostic criteria for the disorder, higher expectations placed on children, a growing intolerance for immaturity—for “kids being kids.” Now, amid these bewildering theories and trends, a growing chorus of researchers and parents are asking out loud another important question—an unsettling one that could ultimately be life-altering for those families affected: to what extent are we over-diagnosing and overmedicating our kids?
“Everybody is so eager to say your son has ADHD,” says Howard, recalling her own experience with Oliver. “But you can’t just go, ‘Oh, how convenient, I’ll just put my kid on a pill and his school report card will get better.’ ” In her family’s case, as with many others in this situation, there was more at stake than grades, after all. “Oliver wasn’t being given the opportunity to be Oliver.”
As a mental health nurse for 15 years near Miramichi, N.B., Ann Tozer Johnston has seen many youth struggle with ADHD. But it wasn’t until her own son was having problems at school that she began to wrestle with the issue. Last year, when Bram was nine and in Grade 4, Tozer Johnston began getting phone calls about her son’s behaviour. “The teacher would say, ‘I asked him to sit down and he took the long way around. He sharpened his pencil without permission. He was moving about the class. He wasn’t raising his hand,’ ” recalls Tozer Johnston. The offences amounted to 14 detentions. “That really started a nasty ball rolling.”
Eventually, Bram’s presence in the class was deemed so distracting that, with Tozer Johnston’s approval, he was moved to an “intervention room,” essentially an isolation area. But that didn’t help. The calls came again: Bram was opening drawers, standing on chairs. So, in March of last year, the school suggested to Tozer Johnston that her son be moved again—to a room where there would be even fewer distractions. “In their defence and in my stupidity, I did not ask more questions,” she says in hindsight. She was desperate to find a solution, anything that would help her son. “I said, ‘Well, you know, if you think that’s the best thing for him, then okay.’ ”
When, a month later, Bram was “in crisis” at home—“He was crying and saying, ‘What’s wrong with me?’ ”—Tozer Johnston visited the school unannounced. “I found him in the storage closet. On the outside of the door it said, ‘Storage.’ He was in there with a teacher’s assistant, all alone, no education materials on the walls, no teaching materials, nothing. There was a desk in the corner with a chair. And there was a big vent that went through the ceiling. My son said, ‘When that would turn on I couldn’t hear myself think,’ ” recalls Tozer Johnston. She was stunned: “I pretty much lost it. I took him home for a week, and I said, ‘He will not be returning until this gets worked out.’ ”
The ordeal was reported to the school district, says Tozer Johnston, and after a long meeting, Bram was put back into the classroom where all his problems had begun. The teachers were more tolerant of him, and Bram was understandably happier. But for Tozer Johnston, the matter was far from over. She had been inundated with requests to have Bram treated for ADHD. “They would constantly ask me, ‘Have you had him checked? What does the doctor say? Are you going to medicate him?’ That was the big question,” says Tozer Johnston. When she resisted bringing her son for testing so he could have time to recover from the trauma, she was called “medication resistant.”
Tozer Johnston saw the situation differently. For starters, Bram had long battled low self-esteem and anxiety, and she believes that was at the heart of his acting out last year. “These strategies, or whatever you want to call them that they were using, were only making it worse.” What’s more, Bram, born in mid-November, has perpetually been among the youngest students in his class. “I’ve said that for many years, ‘This child is immature,’ ” says Tozer Johnston, but that point was never taken seriously, in her view. After learning of Morrow’s study, Tozer Johnston felt affirmed. Had she known this when Bram was just starting school, “I would have held Bram back a year,” she says. “Instead he went at age four, but the expectations were the same for him as they were for every other child, even if they were born in January.”
Of course, there are many kids for whom a birthday late in the year appears to have no negative effect. And experts emphasize that in many, if not most, cases where an ADHD diagnosis is made, it is correct—and medication is warranted. “There are children in high need of help. And these medications can be effective in alleviating symptoms,” says Morrow. But it’s not always easy to make the right call, says Brault. “ADHD is a complex phenomenon. Some children are really suffering, and the consequences have a significant impact on their life,” she explains. “What’s difficult is making the distinction between normal and pathological behaviour—answering the question, is it really ADHD or not?”
Part of what makes that so hard is the wide-ranging symptoms that, when present for six months and in at least two settings such as school and home, can lead to an ADHD diagnosis: “loses objects” and “does not seem to listen” and “excessively loud” and “acts without thinking,” according to the latest Diagnostic and Statistical Manual of Mental Disorders. What’s more, the age range for diagnosing ADHD has recently been expanded by the American Academy of Pediatrics from ages six to 12 to four to 18, thereby casting a wider net for diagnoses. Next year, the new DSM will likely feature a broader diagnostic criteria as well. “The prevalence rate of ADHD increases with each new version,” says Brault. “You can diagnose more people than ever.”
For parents such as Howard and Tozer Johnston, making sense of what’s best for their children—what behaviour is acceptable or “normal” and what’s not—is a personal challenge, the likes of which they’ve never encountered. For Howard, moving to a small community where Oliver can run around in the woods during recess and after school, and even bounce on a ball in the middle of class without judgment from teachers or other students, has been a risky but rewarding solution. At least so far. “My gut was that this would be better,” she says, “and it has been.”
For Tozer Johnston, getting to a better place has been complicated. Since starting Grade 5, Bram has had “a wonderful year,” she says, crediting supportive teachers as well as self-esteem building strategies. Still, earlier this year, Tozer Johnston did have Bram checked for ADHD. The results indicated that he does have the disorder, and since February, he’s taken medication every school day.
There have been side effects: Bram has lost seven pounds, and he has trouble sleeping. Tozer Johnston is conflicted about taking him off the medication. “I feel that he doesn’t need this stuff. But I do feel pressure to do it because there’s so much on the line—his education, the tolerance, being involved in school activities,” she says. “I’m afraid that if I don’t do this, will he still be treated the same way?”
For now, both she and Bram are looking forward to one thing: summer, when he will be out of school, and off the meds, says Tozer Johnston. “I can hardly wait.”
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