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FAMILIES THE SEDUCTIVE DIAGNOSIS

ADHD is the disease of the hour for thousands of Dallas area kids. Ritalin is the drug of choice. But the "disease" may not exist. And the cure can make matters worse.
By Glenna Whitley |

MADLY TWIRLING THE KNOBS of an Etch-a-Sketch like they’re the controls of a Nintendo game, Daniel Jacobs* reclines on a love seat in Dr. Warren Weinberg’s office, his back on the seat cushions and his jiggling feet propped on its arms. A healthy looking boy, his curly brown hair cut in a bowl shape, Daniel wears high-top basketball shoes and a “Slam Daddy” T-shirt nearly down to his knees. He is constandy on the move. The only thing in the office that has held Daniel’s attention for more than a few moments is the Sega Genesis game attached to a television stationed in a comer of Dr. Weinberg’s office, beneath a large bulletin board showing I0 dramatic diagrams of the human brain.

Now 10, Daniel was a prototypical “supermarket toddler.” His mother Anna*’ couldn’t take him to the grocery store without the tot attempting to climb out of the cart or pull down everything his chubby little arms could reach. Daniel had such difficulty with school skills in kindergarten he had to repeat that grade. He couldn’t sit still in class, chewed on his shirt, and impulsively touched the other children after being told to stop. Testing showed that Daniel had no learning disabilities and had a high IQ. But he couldn’t seem to learn to read or focus long enough to finish bis math. When he was six years old, doctors diagnosed Daniel as suffering from Attention Deficit-Hyperactivity Disorder (ADHD) and prescribed Dexedrine.

Now in the third grade in a Piano elementary school, Daniel benefited from the medication for a while, but his hyperactivity and problems at school began to get worse. In recent months, he’s become more agitated, and acts bored, morose, and frustrated in school. Daniel often cries at night, saying he wishes he wasn’t so hyperactive.

He complains that he’s worthless, no good.

Another doctor who specializes in treating children with ADHD recommended that Mrs. Jacobs take Daniel to Dr. Weinberg, an associate professor of neurology and pediatrics at University of Texas Southwestern Medical Center who specializes in treating such children. Dr. Weinberg is Mrs. Jacobs’ last resort.

He asks Daniel to hop up on an exam table, where the boy immediately begins to manipulate a rolling step-stool with his feet-back and forth, back and forth. Weinberg smiles at him, appearing not to notice the constant motion of Daniel’s legs. Daniel’s mother, a beauty in her 30s with long blond hair, tells her son to “Stop that!” Seeing that Weinberg isn’t bothered, she catches herself.

The doctor banters pleasantly with the boy for a while. Daniel says the hardest thing for him in school is reading. It makes him fall asleep. And there’s writing. “I’m not good at that either.” Daniel says thoughts constantly race through his mind. “The only tiling is to get my hyperactivity out-I got to be wild.”

Dr. Weinberg asks Daniel about his feelings. “Do you have mostly good days, mixed days, or bad days?”

“Mostly bad.”

“And on a good day, how do you feel?”

“Bad.” He begins systematically shredding the paper covering the exam table.

While the doctor takes Daniel’s blood pressure and listens to his heart, he asks Mrs. Jacobs about her education, her medical history, then about her husband s history. Both of Daniel’s parents are well-educated. A nurse, Mrs. Jacobs has been separated for two years from her husband, a physician.

A visit to Dr. Weinberg’s office for a new patient lasts up to three hours. Before Mrs. Jacobs came to the office, she and her estranged husband filled out extensive questionnaires. Daniel’s teacher answered another set of questions, The boy answered his own survey and drew several pictures at the doctor’s request. Daniel’s questionnaire indicates that along with the hyperactivity, he’s having bad moods and thoughts about death. Before Dr. Weinberg examines the child, one of his associates takes an extensive verbal psycho-social history of Daniel and his family.

Dr. Weinberg considers family histories vital in treating children with ADHD symptoms. By the time they are finished, he knows Mrs. Jacobs has taken Prozac for depression. Her sister, hyperactive as a child, was treated for narcolepsy. Her father was an alcoholic and her mother once was hospitalized for mental problems, first with a diagnosis of paranoid schizophrenia, later changed to manic-depression. Daniel’s father was an “underachiever” who did poorly in class until high school, then became “obsessive-compulsive” and made great grades. As an adult, he has experienced depression. Both his parents and one of his sisters suffers from depression.

Dr. Weinberg asks Daniel to perform a few simple tasks. The boy quickly touches his fingers to his thumb in succession, then holds his hands up and wags them from side to side. He tries to touch the doctor’s outstretched index finger with his own. Daniel then lies down on the floor and lets his legs fall apart as if he’s asleep. Dr. Weinberg nods. Daniel’s performance on these simple neurological tests indicates a weakness on his left side; according to Dr. Weinberg, this signals a problem in the right brain, where the doctor believes a number of learning disorders and mood disorders are seated.

Then the doctor does something he’s done hundreds of times before. He writes a prescription for Ritalin (methylphenidate), but tells the startled mother that despite another doctor’s previous diagnosis, Daniel does not have ADHD. In fact, Dr. Weinberg says, ADHD does not exist.

“ADHD is a myth and a scam,” he says, handing her copies of his published papers on the subject. Dr. Weinberg says that Daniel is actually suffering from a complex layering of “co-morbid” disorders, all probably genetic: a learning disability undetected by the school, a mood disorder called cyclothymia (a form of manic-depressive illness), and a brain disorder Dr. Weinberg has named “primary disorder of vigilance,” which he often treats with Ritalin.

Dr. Weinberg dismisses ADHD as a myth, but a powerful myth. So he has to engage in a small charade to get Daniel Jacobs the help he needs in school, For the Piano Independent School District, Dr. Weinberg fills out a form stating that Daniel suffers from ADHD, which federal law defines as a health impairment, thus making Daniel eligible for special classroom assistance. In Daniel’s case, he tells Mrs. Jacobs this should include: “No homework, no reading aloud, allow busyness, use calculators, use computers. ” He recommends that Daniel stay in a regular classroom rather than go to a special education class.

Dr. Weinberg is regarded as a brilliant but controversial researcher whose views rankle those with more traditional psychiatric views of behavior disorders. The pediatric neurologist contends ADHD does not exist as a definable medical disorder with its own cause, development, and symptoms. He believes that children diagnosed with ADHD are stamped with a label that lacks scientific validity and given treatment that may be not only totally inappropriate for their real conditions, but in some cases may actually make their problems much worse.

“ADHD is a fashionable diagnosis,” says Dr. Roger A. Brumback, professor of neurology and neuropathology at the University of Oklahoma College of Medicine, who has published numerous scientific papers with Dr. Weinberg on the subject. “It’s used to explain lots of things that are a problem, whether it’s real or not. If the parents are alcoholics and beat up the kid, they can say the kid has ADHD. If a teacher doesn’t like a kid, they call him ADHD and it obviates the teacher’s guilt. It cakes it out of the realm of real medical involvement, It also hampers the physician from making a real medical diagnosis.”

And that, says Dr. Weinberg, is the crux of the problem.

“If you don’t go after the cause of ADHD, you miss the diagnosis,” he says,

Ritalin: The Magic Bullet

THIRTEEN-YEAR-OLD JOEL* HAS BEEN TAKING RITALIN FOR FIVE YEARS, since he was a third-grader diagnosed with ADHD after the teacher at his North Dallas elementary school complained he was disruptive in class and never finished his work. The médication helped him calm down and get his work done. But lately, the Ritalin has not been working. He’s been complaining of headaches and rarely wants to play basketball, a sport he loves. He’s failing all his classes hut RE. and art. A teacher has warned his parents that if he doesn’t improve, he may have to repeat the eighth grade.



EVERY SCHOOL DAY ACROSS DALLAS, THOUSANDS OF CHILDREN IDEN-tified as ADHD line up at their school clinic to receive doses of medication, usually Ritalin. The ’90s has seen the proliferation of private school programs designed to educate children with ADHD. Public schools now are required by federal law not only to dispense medication, but to provide appropriate classroom resources for children designated as learning disabled by the disorder.

In the Piano Independent School District, children can qualify for special education if they are designated as having a learning disability or “other health impairment,” which includes ADHD and other medical disorders. In the last four years, the number of Piano students designated as suffering from “other health impairment” has increased by 275 percent. Though they haven’t broken the numbers down, one hypothesis, says Kathy Seei, special education director for Piano, is that the number of children diagnosed with ADHD has increased dramatically This fall, a psychotherapist named Steven Steen plans to open in Piano the area’s first private school for children diagnosed with ADHD,

Knowing where a child lives is important in recommending education strategies for children identified as ADHD. Dr. Weinberg says that in his experience, most middle-class districts try to accommodate these children’s needs; the level of response varies from district to district, from principal to principal within districts, and from teacher to teacher. “But many parents [in affluent communities] don’t want the child accommodated,” he says. “They want the child ’fixed. ’They want their genes re-engineered.”

Attention Deficit Disorder, or Attention Deficit-Hyperactivity Disorder ( the two terms are used interchangeably) now represents between one-third and one-half of all referrals for child mental health services, according to the National Institute of Mental Health. That has prompted some to dub ADHD “the disorder of the 1990s,”

In the 15 years since it was first defined in the diagnostic manual used by psychiatrists, ADHD has emerged as possibly the most commonly diagnosed childhood disorder in the United States. The number of prescriptions written for the three main stimulant drugs used to treat ADHD-Ritalin, Dexedrine, and Cylert-tripled from 1990 to 1994. The popularity of Ritalin led to a shortage of the drug in 1994, prompting the Drug Enforcement Administration to increase the manufacturer’s quota to more than four times its 199Q allotment, An estimated 2 million American children-4 to 6 percent of all elementary school children-have been diagnosed with ADHD. The vast majority are treated only with Ritalin.

Some parents regard Ritalin as a near-miracle drug, allowing their children for the first time to achieve success in school. Others worn’ that too many children are unnecessarily taking drugs, which can have side effects lor long periods of time, and wonder if that is setting them up for later drug abuse. They fear that children are being tagged as disabled when they have a condition once simply known as childhood.

Tom Sawyer and Huck Finn certainly would have been diagnosed as ADHD. A 1994 New York Times story, “The Debilitating Malady Called Boyhood,” dubbed ADHD “the disease of the hour,” an attempt to “pathologize what was once considered the normal range of behavior for boys. ” The story pointed out that in England, Ritalin rarely is used- one estimate puts the number of children in that country taking stimulant medication at 300, probably tar less than the number of children on Ritalin in a single American town the size of University Park.

Many parents with a child who constantly fidgets and can’t seem to concentrate in school don’t consider the behavior simple boyish high spirits. But there is no lab test for ADHD, no way to diagnose the disorder the way diseases such as polio or diabetes are identified. There’s only a group of criteria symptoms (listed on page 88), but these symptoms can cover an enormous range of behavior.

“Diagnostic terminology is very nice and you’ve got to do it,” says Dr. Peter C. Ray, a Park Cities behavioral and developmental pediatric physician who specializes in treating ADHD children. ” But it does little good to label someone as having ADHD. “

Affluent, successful parents whose children are failing in school worry that it could set up a pattern of failure for lite-making it hard to get into good high schools, and thus good colleges.

They hear the horror stories: Children with ADHD have a 75 percent chance of becoming school failures or dropping out, a 50 percent chance of being arrested for a felony, and a 25 percent chance of being hospitalized or jailed during adolescence. Some experts say these young people are at a higher risk for depression, low self-esteem, teacher and peer rejection, and antisocial behavior, although Dr. Weinberg disagrees. So their parents seek out doctors who will write a prescription for Ritalin, hoping that it will help their offspring academically.

Adults are also streaming into their doctors’ offices, seeking prescriptions for Ritalin after reading an article about ADHD and becoming convinced they suffer from the disorder. Dallas Cowboys head coach Barry Switzer has said he suffers from attention deficit. A Time magazine commentator suggested, perhaps with tongue in cheek, that President Bill Clinton, clearly attention-challenged, was only a “pill away from greatness.”

But Dr. Weinberg says treating a child or adult with Ritalin could help-or it could exacerbate the underlying problem. He contends that ADHD is not only a myth but a “scam,” because the presumed existence of the disorder has spawned a vast cottage industry of books, videos, learning programs, workshops, therapeutic games, computer testing programs, even T-shirts. Parents can buy books for their kids such as Shelley the Hyperactive Turtle, or You Mean 1 ’m Not Lazy. Stupid or Crazy? Parents can join the advocacy group Children with Attention Deficit Disorder (CH.A.D.D.), which has grown to more than 600 chapters in 49 states and lobbied in 1993 for the DEA to increase Ritalin quotas after a shortage of the drug loomed. Doctors can take seminars-one takes place on a Caribbean cruise-that show them how to develop a lucrative ADHD practice, in which they can diagnose patients after spending as little as 15 minutes with them.

Dr, Weinberg is not the only expert claiming ADHD is a myth, California educator Thomas Armstrong. Ph.D.. in his 1995 book The Myth of (he ADD Child, also contends that Attention Deficit- Hyperactivity Disorder does not exist as a discrete psychiatrie disorder, as described in the Diagnostic and Statistical Manual.

Dr. Armstrong maintains ADD/ADHD was invented in university psychology laboratories and given life by frustrated activist parents, the American Psychiatric Association, the U.S. Department of Education, and the world’s pharmaceutical laboratories.

These children are being diagnosed with a medical condition because of behavior that bothers adults, Dr. Armstrong says, behavior that can appear in one setting and disappear in another, especially when children are allowed to choose their activities. ADHD symptoms are subjective, he says, and answers on commonly used rating scales of a child’s behavior can vary widely from one observer to another. He points to a study of 5,000 elementary school children in which three groups of parents, teachers, and physicians were asked to identify the ADHD children. About 5 percent were considered hyperactive by at least one of the groups; only 1 percent of the children were considered hyperactive by all three groups.

Other tests for ADHD, like “continuous performance tasks”-for example, matching identical figures or remembering random digits-resemble little that children are asked to do in real life and have yet to be validated by objective measures. Dr. Armstrong contends. And about 50 percent of kids labeled ADHD reach adulthood and discover die symptoms disappear, he says. Though they’re labeled “disabled ” and given drugs to treat their disability, most such children don’t need medication, he says, only “nurturing, stimulating, encouraging interventions good for all kids.”

Dr. Armstrong and Dr. Weinberg differ in their explanations of what lies at the bottom of the ADHD phenomenon. And while many doctors don’t agree with the assessments of either, they are quick to admit that many ADHD children may lie misdiagnosed. “The bad news is that ADHD has become a very seductive diagnosis that is unfortunately easy to confuse with the symptoms of daily life,” Dr. Edward M. Hallow-ell, the author of the ADHD best-seller Driven to Distraction,, told a trade journal.

Most doctors treating ADHD children agree on at least one thing: Physicians must make careful diagnoses and prescribe treatments that rely not just on medication, but also on counseling and alternate teaching methods, techniques that involve giving more individual attention and changing instructional methods.

Some parents spend thousands of dollars on testing for their ADHD-diagnosed children, only to find few answers. In frustration, many turn to treatments outside mainstream medicine. One Highland Park parent, whose 13-year-old son is now attending Episcopal School of Dallas, says that after taking her impulsive, overly aggressive child to various psychologists, psychiatrists, and other “experts.” she found an answer at The Block Center in Bedford.

As an osteopath, Mary Ann Block refuses to prescribe Ritalin and other controlled drugs, believing that the natural chemicals in the human body can be adjusted to make the changes needed. She contends that among the underlying causes for ADHD behavior are low blood sugar, thyroid dysfunction, and sensitivities to foods like dairy products, wheat, com. and sugar. Dr. Block treats the symptoms with dietary changes, injections of food “antigens” to “neutralize” the reactions, and supplements of various vitamins, minerals, and fatty acids. The Highland Park mother says that her seventh-grader, who in the past has taken Ritalin and an antidepressant, is off all medication and passing all but one of his classes at ESD, though he still occasionally gets into difficulties with impulsive behavior, Other researchers say there’s no scholarly evidence that these treatments are beneficial. ’Whatever the cause, the problem can be very real. Three or four students with ADHD symptoms-which inevitably distract the other students-can tax the average teachers abilities to the breaking point.

Indeed, much of the ADHD dispute might be confined to .the lab and the ivory tower were it not for the impact on schools. In September 1991, the U.S. Department of Education recognized children with ADHD as eligible for special education in public schools. After receiving such a designation, the parait takes it: to the school, which sets up ameeting of an Admission. Review, and Dismissal CARD) committee- parents, teacher, special education teacher, and counselor-to come up with an Individualized Education Plan HEP) far the student

For example, among Dr. Weinberg’s “bypass strategies” for Daniel Jacobs are: Use talking books and films to gather information. Don’t make him read aloud. Tests should be taken orally, if written tests are necessary, provide a reader and recorder, Test: should be by multiple-choice with no time limits. Provide a calculator and computer. Offer “random organization.” dividing larger tasks into 10- or 15-minute increments and shuttling subjects to maximize attention. Allow “busyness.”

Tin saying reading is unhealthy for him.” Dr. Weinberg says. “Pencils are unhealthy for him.” In most cases, Dr. Weinberg prefers regular classrooms for most children with learning disabilities, “Special classes can lower self-esteem,” he says.

Some of Dr. Weinberg’s patients have had few problems getting teachers and principals to comply* But some districts haw actively resisted, though such IEPs are mandated by law. A mother at a Dallas public school had a mixed reaction. After the child was designated ADHD (Dr. Weinberg’s actual diagnosis was primary disorder of vigilance, a learning disability, and mild mood disorder), the teacher said that she would make the changes the doctor requested. But in the middle of the meeting to formulate the plan, the teacher walked out. complaining that they were giving the fifth-grader a crutch instead of making him take responsibility.

The educational strategies don’t end at high school. For 22-year-old Spring Foster, an Arlington patient who recently graduated from college, Dr, Weinberg wrote an “accommodations request” for the law school admittance test (LSAT) asking that she be given additional test time, additional rest time, and a computer with a thesaurus and spellchecker for the writing segment.

Dr. Weinberg, who was involved in creating the federal law mandating IEPs for such students, applauds schools willing to implement such changes. But he believes that doctors are doing little more than guesswork unless .they know the answer to a complicated question: What is really going on in the brains of these children who just can’t seem to pay attention?

Why Johnny Can’t Focus

NORTHDAUAS\iOWERSHERRYCOSRAD*WQ\T)ERSJUSTmk\TDALLAS parents are doing to their kids. When she took Noah* to summer camp m the Hill Country last-year, she took along a bottle of Rob it us sen for his cough. At the infirmary, Mrs. Conrad was the only mother checking in a medication other than Ritalin.

Mrs. Conrad has vigorously resisted pressure to put her son on Ritalin. After several teachers at his private school expressed concern that Noah was not paying attention and couldn’t follow instructions, she took him to an educational psychologist who did a number of tests. The psychologist said Noah was above average in intelligence, with no hyperactivity, but he needed more direction. In the third grade, Noah had a teacher new to the profession. “I don’t know what’s wrong with this child, ” the teacher told Mrs. Conrad. “He’s so far behind. He doesn’t look at me; he doesn’t understand me. I think he has Attention Deficit Disorder. ” The teacher recommended that the Conrads take Noah to Scottish Rite Hospital to be tested for ADHD. “They’ll give you medication, ” the teacher said.

Other mothers voiced their agreement, raving about how well their children-almost always boys-did in school after taking Ritalin. Skeptical, Mrs. Conrad thought there were other ways to help her dreamy child, who could spend hours concentrating on his toy soldiers. In October 1994, she and her husband flew with Noah to the school evaluation program at Boston Children’s Medical Center. In the waiting room, she saw 25 sets of parents with little boys ages H toll. After two days of testing, 10 doctors found Noah to be a normal 9-year-old with horrible handwriting. They did not recommend Ritalin, just common-sense ways for his teacher to handle Noah’s problems, such as forge/ting his books and assignments.



DR. REKHA POLE, A CHILD PSYCHIATRIST WITH SOUTHWESTERN CHILD & Family Associates in Dallas, hears stories like this all the time. “The parents show up and say the teacher says the children can’t come back to school until they are on medication.’’ For successful, affluent families, this verdict can be frightening. “It’s almost narcissistic,” Dr. Pole says. “My child’s not doing well.”

Much of the pressure to identify kids as ADHD is related not only to teachers’ abilities to cope with various students’ behavior, but to parents’ high expectations of academic success. “My son Noah is only in the fourth grade, ” Mrs. Conrad says, “and already I’m hearing about pressure to get in the right high school.” Conflict can erupt in families where one parent wants the child to take medication and the other doesn’t.

Teachers often misdiagnose ADHD because some children with normal development have a hard time adapting to the requirements of the modern classroom, says Dr. Weinberg, who considers most schools- public and private-poorly designed for optimal learning. “Learning ceases at 8:30 in the morning and begins again at 3 o’clock in the afternoon, if there’s no homework,” he says with a smile. “I see no evidence that learning those kinds of skills needs so much labor. A lot of it is simply maturation.”

Those students whose attention problems don’t affect their ability to function don’t necessarily need medication, doctors say; their academic performance can be improved by better time management skills and other education strategies. When students are referred either by parents or teachers to the Campus Assessment Team in a Piano school, the team looks at each child’s individual needs and makes recommendations to the classroom teacher, says Ms. Seei at Piano ISD. The recommendations might be as simple as having a child sit at the front of the room or calling her name when the teacher notices the student daydreaming. If the changes in teaching methods don’t help, then the team might refer the child for special education.

Benjamin J, Albritton, a psychologist with Southwestern Child & Family Associates, thinks ADHD is “overdiagnosed but under-treated,” meaning that some children who don’t have it get the diagnosis while others who clearly do go untreated because parents are reluctant to admit they have a problem. “1 see kids in private schools, highly intelligent kids from high-functioning families just give up,” Albritton says. “The big question is this: Is something wrong with the kids or is something wrong with die schools?”

Often, attention problems do not surface until children are in the third or fourth grade and face greater demands that they sit still and produce more challenging paperwork. As a neurologist, Dr. Weinberg believes that requiring developing brains to perform boring, repetitive skills is guaranteed to fail, especially with a small group of children with learning disabilities like dyslexia and dysgraphia (writing problems), whose brains do not perform such tasks easily, “If you ask kids with learning disabilities to do repetitively what they cannot do, their brains will become inattentive,” he says.

Dr. Weinberg first got interested in attention disorders in children as a pediatricneurologist at Washington School of Medicine at St. Louis University in the early ’60s. He started the school’s Hyperkinetic Behavior Syndrome Clinic to study why children with epilepsy didn’t function well when they were free of seizures. That led to his study of the biological basis of behavioral disorders.

Throughout this century, the hallmark symptoms of ADHD-inattention, impulsivity, and hyperactivity-have been given various labels, including “organic brain dysfunction” and “malignant attention syndrome.” Some researchers believed children exhibiting these symptoms were emotionally disturbed, the products of neglectful or abusive homes. Others felt it was a physical problem. The discovery in the 1930s that children with impulsive, aggressive behavior could be controlled by amphetamines added fuel to the controversy.

In the 1940s, attention problems were dubbed “Strauss syndrome” after a doctor whose young patients with seemingly normal intelligence had trouble learning. “Cerebral malfunction” was the catchword for the ’50s. Throughout the ’60s, the disorder was variously labeled “hyperkinetic behavior syndrome.” “hyperkinetic impulse disorder,” and “minimal brain dysfunction.” The 70s brought a flurry of books on the “hyperactive child syndrome,” with admonitions to keep children away from foods containing sugar and artificial ingredients like red food coloring.

In the early L980s, a committee of the American Psychiatric Association created the diagnostic terms “attention deficit disorder” and “attention deficit disorder with hyperactivity.” Both were later lumped under the label “attention deficit-hyperactiviry disorder.”

When children exhibit six or more of the symptoms of ADHD- such as excessive talking, inability to listen, risky behavior-lor at least six months to a degree that interferes with their functioning, they can be diagnosed as ADHD. Dr. Peter Ray says everybody with ADHD has problems with “side-tracking,” or staying on tasks. They can focus on things that are novel, very visual, or stimulating, but rote activity loses their attention quickly. Typically, they have trouble managing time. As adults, they’re the ones who are always late or always early.

The cause has been attributed to everything from neglectful (or overbearing) parenting to vitamin deficiency’ to lead poisoning. In 1990, when a report linking hyperactivity to poor metabolism of glucose in the brain appeared, an ADHD advocate wrote: “Finally…we have an answer to skeptics who pass this off as bratty behavior caused by poor parenting.” (Their relief was premature; further study of the glucose connection cast doubt on the report.)

But children are often diagnosed as ADHD without meeting the full criteria, with only a few symptoms. Doctors know that attention problems can be situational, such as the short-term anxiety created when a parent loses a job, a clash between a teacher’s style and a child’s personality, or even the emotional fallout from sexual abuse. These symptoms also occur in a wide range of medical disorders.

And it’s becoming increasingly obvious to many doctors that ADHD rarely stands alone. “There’s no question in my mind that ADHD exists,” says Dr. Ray. “Do I believe ADHD exists as a solitary condition? No. Most of these children have multiple things going on. Very few people have pure ADHD,”

Thomas Armstrong, the California educator, sees ADHD as a catchall diagnosis that removes the stigma from teachers, parents, and children for puzzling, irritating behavior. Dr, Armstrong advances non-biological explanations for ADHD behavior, including:

Normal gender differences. Most children diagnosed with ADHD are boys.

A “bad fit” among the temperaments of parents and child; tor example, a laid-back, easy going parent and an aggressive, forceful child.

Learning differences within the normal range.

The collision of traditional classrooms and kids raised on fast-paced media, which teaches them to scan information presented in short, vivid bursts. (Think channel surfing).

Where biological factors do come into play, Dr, Armstrong considers them subordinate to other social, cultural, educational, and psychological influences. Among his “50 strategies to improve your child’s behavior and attention span,” Dr. Armstrong includes trying the Feiflgold diet, which eliminates additives and preservatives; limiting television and video games; getting biofeedback therapy; and enrolling your child in a martial arts class.

Unlike Dr. Armstrong, Dr. Weinberg definitely believes that something is biologically wrong with many of these children. But it is not, he says, ADHD. In October 1992, the prestigious Journal of Child Neurology published his paper, “The Myth of Attention Deficit-Hyperactivity Disorder,” as part of a series of controversial “position papers.”

As a neurologist, Dr. Weinberg believes that genetic factors present at birth manifest themselves in the behaviors described as ADHD, though they may be triggered or aggravated by cultural factors. He contends that many of these children do suffer from neurological and developmental problems, but that inability to pay attention is not the disorder, It is simply a symptom, not the disease.

The Bipolar Hypothesis

DEBBIE DAWSON* AND HER FAMILY MOVED FROM RICHARDSON TO PLANO about the suffit time that her middle child Heather* one of four kids, was beginning third grade. Heather had never been able to spell, hut in Richardson,Mrs. Dawson never felt pressured to have her tested. Heather began to struggle in school. Her teacher expected her students to function independently and Heather, though bright, couldn’t make the adjustment. She couldn’t seem to get her homework done, her handwriting was horrible, and she was constantly losing things.

Mrs. Dawson decided to allow consequences to run their course, letting Heather reap the bad grades her lack of focus created. But when Heather’s report card showed failing grades, her parents finally gave up. They took her to a series of professionals for testing: a psychologist, an ophthalmologist, and an occupational therapist, who examined Heather’s fine motor skills. The tests found no learning disabilities, but did find-Heather had “zilch internal organization skills” and a large gap between her “performance 1Q” and “verbal IQ “-the difference between what she knew and how well she could express it.

Heather is now in the fifth grade. So fat; the Dawsons have resisted putting her on medication. “I have seen friends struggle with that decision, ” Mrs. Dawson says. “It bothers me to see people do that without much agonizing. “



But Heather still has trouble organizing her thoughts, and seems to support the Piano library with all the fines from her lost library hooks. Mrs. Dawson says that if the academic demands increase and Heather cannot stay afloat, they will consider putting her on Ritalin.



WHEN A CHILD WAKES UP INTHE MIDDLE OF THE NTGHT WITH A FEVER, a parent typically takes out the thermometer. If the child’s temperature isn’t too high, the parent usually provides a dose of acetaminophen and waits to see what happens.

Dr. Weinberg compares ADHD to a fever that indicates a child has an underlying medical problem-perhapsa cold, chicken pox, measles, an ear infection, pneumonia, or meningitis. But the fever is not the disease. Giving a child Tylenol for fever caused by a cold or chicken pox wall make the child feel better and the problem eventually will go away by itself. If the disease is meningitis, Tylenol may make the fever go down, but the child could still die of the underlying viral infection.

Doctors must perform thorough examinations and investigate family histories when patients come in with ADHD symptoms, Dr. Weinberg says, noting that is difficult to do in the length of the typical visit to a doctor-30 minutes or less-especially in these days of managed care, New patient evaluation for most doctors who specialise in ADHD takes at least one-and-a-half hours. Psychologist Thomas Armstrong points out that in his field it costs an estimated $1200 to diagnose a child suspected of having ADHD. Dallas area physicians charge anywhere between $150 and $350 for new patient evaluations.

Only a detailed examination can tease out which underlying medical problems are causing the attention symptoms. Dr. Weinberg says. Heather’s condition is mild. But many children with pronounced attention deficit symptoms, he believes, have several inherited developmental and chemical brain disorders that interact together.

In the early ’90s, Dr, Weinberg studied 100 successive patients (mostly boys, with an average age of 10.3 years), referred for attention problems to his Pediatric Behavioral Neurology Program at Children’s Medical Center of Dallas. Eighty percent fulfilled the criteria for ADHD and probably would have been labeled that way by other examiners. But Dr. Weinberg says all the ADHD children’s symptoms could be explained by other diagnoses-important because appropriate treatment is different for the various disorders.

Dr. Weinberg says that among the most prominent causes of ADHD symptoms are: mood disorders (affective illness), learning disabilities, and “primary disorder of vigilance,” a term he created to describe one type of attention problem caused by a brain disorder. (Other causes are conduct disorders, narcolepsy, or brain damage. Dr. Weinberg believes that most children labeled with conduct disorders have an underlying mood disorder that, if not recognized and treated, could lead to antisocial behavior.)

Vigilance is a state of arousal, maximum alertness. Its opposite is drowsiness, sleepiness, lethargy. According to Dr. Weinberg, the loss of attention or vigilance has been implicated in major industrial and engineering catastrophes, like the explosion of the space shuttle Challenger, In the context of an air traffic control tower and a schoolroom, the same behavior can have vastly different consequences.

Dr. Weinberg defines disorder of vigilance as a decreased ability to stay alert if not allowed to move, fidget, daydream, or be free of tasks demanding continuous mental performance-like writing 20 spelling words five times. Children with primary disorder of vigilance are quick to start new activities but also quickly tire of them. Their brains keep their bodies moving in order to stimulate vigilance or keep themselves awake. According to Dr. Weinberg, these children have a sweet and compassionate temperament, and their viligance problems do not begin to manifest themselves until formal schooling starts.

But primary disorder of vigilance is not the same as hyperactivity. Some children with PDV may daydream or look out the window. If they’re not allowed to move, they complain of being bored, tired, or sleepy. (As adults, these are people who drink lots of coffee to stay awake in lectures and in old age may be described as “sleeping their lives away.”) Dr. Weinberg says Ritalin works for these children because it stimulates their brains enough to keep them alert without the fidgeting and hyperactive behavior.

Another large set of ADHD kids are those whose primary attention problems appear as they hit school age. Most often, Dr. Weinberg says, those problems are caused by one or more learning disabilities combined with primary disorder of vigilance. Dr. Weinberg’s theories have raised the question: Do the attention problems exist along with the learning disabilities, or does the child have problems paying attention because he has difficulty learning? Careful diagnosis and treatment is the only way to know, Dr. Weinberg contends.

But the main medical condition underlying most cases of ADHD, Dr. Weinberg believes, is some type of bipolar disorder, commonly known as manic-depressive illness. In most ADHD children he sees, the doctor diagnoses three conditions that interact: vigilance disorder, learning disabilities, and depression. He’s well aware that it’s far easier for a doctor to tell a parent his son or daughter has ADHD than a mental illness like depression.

A Family Affair

AS A FIVE YEAR OLD, DREW WEATHERBY WAS A LOVABLE, SWEET CHILD. Bright and constantly busy, be easily finished his kindergarten work and then pestered the other children. But that busyness could turn quickly to aggression. When be got mad, Drew hit his classmates. Then he’d berate himself. “I want to die, ” Drew told his teacher. His mother Marsha was shocked. She’d just had a new baby and Drew clearly was jealous of the infant. Maybe that was the problem. Heeding the teacher’s advice that Drew must be hyperactive, she took him to an Irving doctor who specializes in ADHD.

The doctor, aware of Dr. Weinberg’s work, performed extensive tests and diagnosed Drew not as ADHD, but as suffering from depression. That forced Mrs. Weatherby to remember her own experience as a child, when she’d been tested at Scottish Rite Hospital for learning disabilities. None were ever found, but in years since, she’s been diagnosed as manic-depressive and now takes medication.

Drew began taking an antidepressant called Tofranil. His sweet nature returned and the aggression subsided. But Mrs. Weatherby was not satisfied with medication alone. “Children need to learn coping skills as well, ” she says. She and Drew went for counseling together; then she began looking for a child therapist. One psychiatrist wanted to test Drew again for ADHD, he could do complicated math problems in his head, hut couldn’t seem to get them down on paper. But Mrs. Weatherby resisted. “I knew he wasn’t hyperactive, she says. A Fort Worth psychologist helped Drew learn to recognize his irritating behavior and control it.

When the psychologist moved, Mrs. Weatherby felt lost. Two years ago, she took Drew to Dr. Weinberg, who diagnosed Drew as suffering from several disorders: depression, a learning disability, and primary disorder of vigilance.

“Dr. Weinberg has been the only one that has truly put it all together. ” Mrs. Weatherby says. The depression-a mood disorder that comes and goes-has disappeared, so Drew now takes only Ritalin daily to treat the loss of vigilance. But both he and his mother know to watch for the signs of a recurring depression, which Ritalin can mask.



WHEN DR. WEINBERG BEGAN HIS CAREER AS I a pediatric neurologist, the conventional wis-dom among psychiatrists was that children couldn’t suffer from depression. According to the Freudian-based theories prevalent at the time, depression didn’t manifest itself until people were in their 30s. In 1973, Dr. Weinberg and his associates published the first criteria for diagnosing depression in pre-pubescent children, That was followed three years later by his publication of the criteria for childhood mania.

“These were heretical, unacceptable concepts,” says Dr. Weinberg, “that children could manifest depression, mania, or manic-depression. Now depression in children is widely recognized and treated. ” But mania, he contends, continues to be poorly recognized and treated. “Most children with manic symptoms are mislabeled AD1 ID,” he says.

Some hyperactive children with mood disorder-impulsive, aggressive behavior- were hyperactive “in the oven” or womb. These children, in Dr. Weinberg’s opinion, are manic.

The classic hallmark of mania is euphoria, combined with hostile anger or rages. “Hypomania” sounds remarkably like ADHD: persistent hyperactivity; inordinate ! silliness, giddiness, and intrusiveness; and interruptive or disruptive behavior, From age 3 to 8, these children may have racing thoughts and gushing speech. They bounce from one topic to the next with lightning speed. They’re irritable and show a decreased need for sleep. They may shock their parents with provocative sexual behavior outside die realm of normal curiosity.

Some symptoms of depression in children include sadness, pessimism, moodiness, and i frustration. A child may express negative thoughts about himself, like “I’m ugly,” or “I’m stupid. ” Depression also results in symptoms similar to ADHD: agitation, restlessness, 1 and irritability.

Because depression comes out of the right hemisphere of the brain, where certain abili-ties like writing and organization are seated, depression can make learning disabilities worse. Dr. Weinberg says. Typically, he is asked to see children with ADHD symptoms caused by mild manic-depressive illness when they are in the sixth or seventh grade, the Ritalin is no longer working, and they are failing in school “It’s common to see an adolescent girl who gets depressed with the onset of puberty and her math goes to zero,” he says.

Vital to any diagnosis of bipolar disorder is an extensive family history. Many parents of Dr. Weinberg’s patients report that they experienced depression in their childhood years. I His associates ask parents whether any other I family members experienced depression, whether treated or not. What about substance abuse, which is often associated with mood disorders? Did any relatives go on shopping binges and run up huge credit card bills (a sign of maniat or suffer from migraine headaches (a sign of depression)?

While conflict and anxiety at home may aggravate various disorders. Dr. Weinberg believes that ultimately everything comes down to genetics. Obtaining a family history that shows a tendency toward vigilance disorders or affective illness (mood disorders) can help parents make decisions about treatment and allow them to watch for changes in symptoms.

A child may inherit the tendency for depression, but it can lie dormant for years; Dr. Weinberg says that during puberty, children with bipolar disorders begin to show more depressive symptoms. As a child taking Ritalin moves into adolescence, he may say that die drug doesn’t make him feel good anymore and complain of headaches and stomach aches, Dr. Weinberg says that may mean that the Ritalin is “promoting” or bringing to the forefront the physical symptoms of depression.

Parents unaware of the underlying depression may attribute their child’s complaints of migraine headaches, stomach aches, and other somatic problems to side effects from the Ritalin. In extreme cases, if the depression goes unrecognized and untreated, it could lead to death wishes and suicidal thoughts. “These are the children who may kill themselves and everybody wonders why,” he says.

Dr. Weinberg says genetics explains why 15 to 20 percent of the children he sees are adopted, far higher than the 1.2 to 1.6 percent of children who are adopted in the general population. Often, those parents who give up their children for adoption have histories of mood disorders, substance abuse, and impulsive behavior.

Four years ago, an adopted adolescent from Texarkana came to Dr. Weinberg after being diagnosed as ADHD. He diagnosed the 14-year-old boy as suffering from a vigilance disorder and recurrent bouts of depression. A family history revealed that the boy’s biological father had committed suicide.

Now 18, the teenager has just come out of a major depression during which he became preoccupied with suicidal thoughts. Because Dr. Weinberg prepared the boy’s parents for the potential depression, they were able to recognize the signs and get their son to a doctor, who prescribed an antidepressant. The depression has receded; he’s now doing fine. “These diseases have a natural history,” he says. “We can anticipate these problems.”

When treating pre-pubescent children, if the primary problem is a vigilance disorder or manic symptoms, with no prominent signs of depression. Dr. Weinberg usually prescribes Ritalin or another stimulant medication first. If the depressive symptoms are most prominent, then he puts the child on an antidepressant like Tofranil (imiptamine) or Elavil (amitriptyline). Weinberg believes that it is important for doctors and parents to monitor the child’s response to the drugs and make changes if needed. He prescribes Lithium, a primary drug used for adult manic-depressives, only il other medications fail.

Though children abusing Ritalin have gotten attention in the press, Dr. Weinberg says he has never seen it. Sometimes, children refuse to take their medication. In fact, they may actually be less likely to abuse drugs later. “There is still some stigma attached to taking Ritalin,” says psychiatrist Dr. Pole.

Dr. Graham Emslie, a child psychiatrist at Children’s Medical Center who often collaborates with Dr. Weinberg, says he rarely sees children abuse their medications. More often, he says, it’s the parents who sneak the child’s Ritalin or antidepressant. But Dr. Emslie points out that children with ADHD symptoms may be more at risk for drug abuse than others because of their family history.

Dr. Weinberg often refers patients to psychiatrists or psychologists. “Therapy and medication together work better than either alone, ” Dr. Pole says. “The therapy helps educate the child not to fall back on his condition as an excuse tor his grades or his behavior, You help them unlearn bad habits and teach social skills.” Sometimes, the parents also need therapy to cope with their child’s mood disorder- and, in some cases, their own.

Dr. Weinberg stresses that while it’s important for physicians to ferret out what is causing a child’s ADHD symptoms, the milder the problem, the less a physician can do. But for those with severe problems, like 11-year-old Tony of Wichita Falls, the doctor can prescribe medication and recommend other strategies that can make an enormous difference in the child’s life. During a December office visit, Tony brings Dr. Weinberg a Christmas card that reads, “You’re my friend.” The doctor gives the smiling boy a hug.

As a toddler, Tony wouldn’t participate in preschool. Afraid of group situations, he got angry and threw things. A change to a more structured environment made him worse. Clearly very bright, in the first grade Tony was reading at the sixth grade level, But his school problems escalated. Diagnosed as ADHD at age 6, he was put in special education, tucked away in a cubicle where he slept all day. A trial on Ritalin at age 9 made him go haywire, staying awake for three days.

Diagnosed with autistic tendencies, ADHD, and motor skills problems by a doctor in Wichita Falls, Tony was given an antidepressant, It helped his attention disorder, but made his anger more intense. The doctor prescribed Clonidine to help ease the anger.

In second grade, Tony did better. But he still had occasional flares of anger and couldn’t seem to make friends. Third grade started well, but when Tony threatened to bring a bazooka to school, he was suspended for seven weeks.

Tony returned to a mainstream school with modifications allowing him to do his assignments orally and cutting back on the writing he was required to do. But at age 10, his behavior disintegrated: He couldn’t get through class assignments and frequently exploded in anger. At his doctor’s recommendation, his mother Debbie brought Tony from Wichita Falls to see Dr. Weinberg.

The doctor diagnosed Tony as suffering from “juvenile rapid cycling bipolar disorder,” both manic and depressive moods on a day-to-day basis, with increasing symptoms of depression as he got older. Tony also has two communication disorders caused by dysfunction in his right brain: dysgraphia, and a mild Asperger’s syndrome, which causes over-expressiveness. For Tony, a little bit of sadness comes out as gloom, a little bit of anger as rage. This problem makes it difficult for Tony to make friends.

Under the management of a doctor in Wichita Falls, Tony is now taking Prozac, Clonidine, and Tegretol, drugs that have helped him control his extreme mood swings and outsized anger, He’s made a friend and is doing well on shortened days in a regular classroom. As part of Tony’s Individualized Education Plan, the public school provided a teacher’s aide to work primarily with him.

“How are you doing, Tony?” Dr. Weinberg asks.

“I’m doing good, but I get sleepy,” Tony says. Drowsiness is a side effect of the Tegretol and Clonidine Tony is taking. “You don’t get sleepy playing the Sega Genesis, ” Dr, Weinberg says, jousting with Tony, then gathering him up in a gentle headlock. “This was an angry, depressed, irritable child,” the doctor says, “Now he’s a sleepy, lovable child.”

II one is the worst and perfection is 10, Dr. Weinberg says that sometimes the best doctors can do is get a child functioning at the level of seven or eight. That’s where Tony is now. He had perfect attendance last semester and for the first time, he received an A in conduct this year. The doctor tells Tony his goal for spring is to get the boy off the Clonidine and attending school full-time.



The Search Continues

Dawn Reesing first took her son Chris to Dr. Weinberg in (he summer of 1984, when the three-year-old was kicked out of daycare. Disruptive, he wouldn’t sit down and wouldn’t listen to the teacher.

And she was beginning to get frightened. A daredevil, Chris was afraid of nothing. One Christmas, the toddler had dashed away from her in a crowded mall; after a search, security guards found him with a sales clerk in a store’s linen department, playing with (he cash register. Mrs. Reesing had to put Chris in his room when she cooked dinner. One late afternoon she discovered that while she had been cooking, he had snuck out the window of his bedroom and dashed down the street.

Mrs. Reesing couldn’t understand it; she has an older child who isn’t like Chris at all. Her friends kept saying, “He just needs discipline; he’s a normal, wild little boy. ” She tried to discipline him, hut he didn’t respond to anything, even spankings. Therapy through the Dallas Child Guidance Clinic brought no relief

Mrs. Reesing took Chris to Dr. Weinberg after hearing about him through a psychologist. Dr. Weinberg diagnosed him as suffering primary disorder of vigilance and hypomanic/manic symptoms. He first tried Ritalin, which had no effect on Chris. A trial on antidepressants simply sped up his hyperactivity. Cylert, a stimulant medication like Ritalin, worked for about three years. Chris’ underlying angelic nature was again at the forefront. Mrs. Reesing was amazed, hut after three years, the Cylert stopped working. In 1987, Dr. Weinberg changed his medication to Ritalin SR, a variation of Ritalin that releases the drug over a longer time period.

Since then, Chris has been an extremely healthy, normal, upbeat child, bis mother says. He’s now 15 and has been on Ritalin nine years. “It doesn’t bother him to take his pills, ” she says. “Nothing bothers him. I was worried about the Ritalin at first, wondering what repercussions it might have. But he’s had absolutely no side effects at all. “

Dr. Weinberg has warned her to look for signs of depression in Chris. She suspects there may be some depression in her family history. But she’s never seen its signs in Chris. He makes straight A’s in school and is involved with athletics. “He just couldn’t sit down and absorb things before, Mrs. Reesing says.



PHYSICIANS WHO DISAGREE WITH Dr. Weinberg contend that as a pediatric neurologist, he sees a skewed population, children with problems that don’t respond to Ritalin. They maintain that a small group of children have “pure” ADHD, what Dr. Weinberg would call primary disorder of vigilance, and nothing else.

Dr. Weinberg’s response is that some children may have only primary disorder of vigilance, but if they still are not functioning well as they reach puberty, they probably have an underlying mood disorder that needs treatment as well. But he believes the underlying mood disorder eventually will reveal itself, either in adolescence or adulthood.

As more is known about how the brain leams, Dr. Weinberg thinks it will get easier to educate doctors, parents, and educators. A colleague points out that Dr. Weinberg’s ideas about ADHD were once regarded as renegade; now, because of his work, many pediatricians know to look for mood disorders in children with ADHD symptoms.

“I’m sure in the next century all this will be understood biologically much better,” Dr. Weinberg says. Until then, doctors’ abilities to decipher such symptoms can mean the difference in a life of success or a life of failure for a child, according to Dr. Weinberg,

“Learning disabilities get better over time, but they do not go away,” he says, Mood disorders are genetic; symptoms can emerge at any time. “The only thing you outgrow,” Dr. Weinberg says, “is your shoe size. “

SYMPTOMS OF ATTENTION DEFICIT-

HYPERACTIVITY DISORDER

These behavioral symptoms often

lead parents, teachers, and doctors to

conclude a child has ADHD:



● Often fidgets with hands or feet or squirms in seat.

● Has difficulty remaining seated when required to do so.

● Is easily distracted awaiting turn in games or groups.

● Often blurts out answers to questions before they’ve been completed.

● Has difficulty following through on instructions from others (not due to oppositional behavior or failure to understand)-for example, finishing chores.

● Has difficulty sustaining attention in tasks or play activities.

● Often shifts from one uncompleted activity to another.

● Has difficulty playing quietly.

●VOften talks excessively.

● Often interrupts or intrudes on others-for example, butts into other children’s games.

● Often does not seem to listen to what is being said to him or her.

Often loses things necessary for tasks or activities at school.

● Often engages in physically dangerous activities without considering possible consequences (not for the purpose of thrill-seeking), like running into the street without looking.

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