Are we medicating a disorder or treating boyhood as a disease?
From Tuesday's Globe and Mail
Last year, more than two million prescriptions for Ritalin and other ADHD drugs were written specifically for children under 17, and at least 75 per cent of them were for young males
Last year, more than two million prescriptions for Ritalin and other ADHD drugs were written specifically for children under 17, and at least 75 per cent of them were for young males. Part 3 of a 6-part series.
For school children across the country - most of them boys - taking a drug for attention deficit disorder each morning has become as commonplace as downing a vitamin. But the daily ritual has been quietly growing in Canada, year after year - a trend that's dwarfing rates in other countries and raising disturbing questions about the forces driving it.
Figures compiled for The Globe and Mail by IMS Health, an independent firm that tracks pharmaceutical sales, show prescriptions for Ritalin and other amphetamine-like drugs for Attention Deficit Hyperactivity Disorder shot up to 2.9 million in 2009, a jump of more than 55 per cent in four years.
More than two million were written specifically for children under 17 - a leap of 43 per cent since 2005 - and at least 75 per cent of them were for young males - a ratio some see as evidence that society is making a malady of boyhood itself.
"What if we were drugging girls at the same rate?" asks Jon Bradley, education professor at McGill University. "What if [the majority] of these prescriptions were being written for girls? There'd be a march."
The figures seem to suggest a spike of epidemic proportions. But an analyst with IMS Brogan, a division of IMS Health, says the four-year snapshot is emblematic of a drug category that for more than a decade has surged annually in Canada by 10 to 13 per cent. While total prescriptions, worth $249-million, do not represent the number of people taking the drugs, a per capita breakdown of daily doses shows a similar escalation.
"It certainly suggests the drugs are being abused," says Gordon Floyd, president and CEO of Children's Mental Health Ontario. "There's a desire for the quick fix ... the idea that - 'oh, we'll fix this with a pill' - rather than spend a few months in counselling, is pretty appealing."
Our penchant for the pills has pegged Canada - after Iceland and the U.S. - as one of the world's top three consumers of methylphenidate, including Ritalin and similar drugs, according to the 2009 Annual Report of the UN International Narcotic Control Board, which based rankings on per capita consumption. A 2007 U.S. report on global use of ADHD drugs also singled out Canada for "higher than expected" consumption, and suggested our exposure to American advertising and "cultural norms" play a role.
ADHD is one of the most commonly diagnosed disorders of childhood, with core features that include an inability to focus, and hyper and impulsive behaviour. Increasingly, it's seen as a chronic condition that 60 per cent of kids never outgrow and one that experts estimate affects five per cent of children worldwide.
But the diagnosis rates in North America are notoriously higher. In Canada, research suggests that seven to 10 per cent of children have ADHD - most often, boys.
To some extent, the medical gender gap simply exposes the biological bias of Mother Nature: Boys' brains, perhaps due to chromosomes and hormones, are more vulnerable than girls to several neurological disorders. Boys are four times more likely to develop autism, three times more likely to suffer dyslexia, and two to three times more likely to be diagnosed with ADHD.
But some see a system of harried parents, school officials and general practitioners too ready to label rambunctious young males. While boys might be three times more likely than girls to develop ADHD, research suggests they are nine times more likely to be sent for a clinical assessment and five times more likely to be medicated for it.
IMS figures show ADHD prescriptions for males have increased 50 per cent since 2005.
The decline of male teachers in primary schools, Prof. Bradley suspects, is partly to blame for ballooning drug use - "What are we drugging? Female teachers who don't understand boys like to run and jump and shout - that's what boys do."
Medications are definitely needed in some cases, he says, "but definitely not in the quantity that we are seeing them."
Diagnosing ADHD has been a medical minefield ever since the rise of the so-called Ritalin Generation in the 1980 and 90s. With no blood test or any other biological means to confirm an ADHD case, psychiatrists, psychologists or a general practitioner diagnose children after a clinical assessment or, often, with behavioural reports from parents and teachers.
But evaluations are subjective and the distinction between ADHD symptoms and standard childhood traits can be quite subtle - such as forgetfulness, and fidgeting.
"We don't have a biological test to rule out ADHD and that gives rise to the possibility that ADHD may be misdiagnosed, or missed," says Rosemary Tannock, a psychologist at Toronto's Hospital for Sick Children who studies children with the disorder.
Dr. Tannock says biological signs of the syndrome exist. Imaging studies show brain development in children with ADHD lags two to three years behind a normal brain, particularly in the prefrontal cortex, an area involved with self control. The less mature a brain looks, she says, the more severe the symptoms, though kids with ADHD score average and above average in IQ tests.
Yet because males with ADHD tend to be boisterous and disruptive and females with the disorder tend to be distracted and daydream, boys are more likely to be identified and girls are more likely to be missed, she says.
"Everything we knew about ADHD was based on behaviour of 11 year old boys," said Dr. Tannock, who also works with the Ontario Institute of Studies in Education, training teachers to teach children with the disorder.
"The imbalance of medications comes because girls are not seen as having serious behavioural problems - they're not hyperactive."
A growing awareness that girls also suffer ADHD has added to the increase in drug use, experts say and IMS data show prescriptions for females rising by more than 60 per cent since 2005. But prescriptions for males still account for the vast majority.
Prof. Bradley, who taught elementary school before joining McGill to teach prospective teachers some 40 years ago, believes that schools have removed "the time to be male." Shorter recesses, and lunch and gym periods, and the decline of metal and woodworking classes all contribute, he says, to boys' restlessness in the classroom and the likelihood of being picked out for acting up.
In his home province, the story is particularly striking. Quebec, where boys drop out of school at a rate of nearly 40 per cent - the highest in Canada, and one of the highest in the western world - also leads the country in ADHD drug use.
IMS data show ADHD drug use rising in all provinces, but Quebec's rate of more than 10 doses a day for every 1,000 people in the population, tops the list. Nova Scotia follows with 9.2 daily doses, while consumption in B.C., the lowest user in the country, is half that amount.
Prescription rates for ADHD drugs, which like cocaine, are psycho-stimulants, can also vary by school board, says Wendy Roberts, a developmental pediatrician at Sick Kids and Toronto's Bloorview MacMillan Children's Centre.
In certain boards, Dr. Roberts says, teachers are more likely to say to parents - "I'm having a problem with [your] child, and so you should go and see Dr. So-and-So," confident the doctor will recommend drugs, says Dr. Roberts. "Some parents have certainly told me that they have felt they could not take their child back to school unless he was taking a medication ...I think we're jumping to medication too quickly.
"There's no question if you have a child that's going to sit quietly in your classroom, you're going to be a happy teacher."
A study of three Ontario school boards in 2000, which Dr. Roberts co-authored, suggests ADHD diagnoses and drug use can vary wildly. At the East York Board of Education, the proportion of kindergarten to Grade 6 children taking drugs after an ADHD diagnosis was 13 per cent - boys nearly three times more than girls. At the Metropolitan Toronto Separate School Board it was three per cent and girls and boys had nearly equal drug use. At the more rural, eastern Ontario Hastings County Board of Education, it was 43 per cent of children with ADHD who were medicated, and boys seven times more than girls. The survey, published in the Pediatric Journal of Child Health, also found that 27 per cent of boys with ADHD were medicated for the condition compared to five per cent of girls.
Other reasons cited for the increase in ADHD medications, include their illicit use among college and university students who treat the stimulants like brain steroids to improve their studies.
Part of the drug increase is thought to reflect the fact that new and longer-lasting ADHD medications have hit the market. It may be, says Mr. Floyd at CMHO, that those who didn't tolerate the older drugs have signed up for the next generation - which are also more costly than the last. IMS statistics show spending on ADHD drugs surged 104 per cent - from $122-million in 2005, to $249-million in 2009.
Any time new medicines become available, drug companies facing more competition ramp up their marketing efforts, he says. This includes dispatching legions of drug representatives to doctors' offices to promote their use - "So their drug is top of mind for the doctor when kids come in."
Drugs to treat ADHD, with common side effects that include insomnia and headaches, have been better studied than most psychiatric medications used in children. But questions linger about their long term safety - a U.S. study last year suggested that Ritalin, or methylphenidate, could have unknown consequences on crucial brain systems. As well, Health Canada, and later, the U.S. Food and Drug Administration, warned a few years ago that the stimulant drugs may be dangerous for those with underlying heart problems - and those who do not actually have ADHD.
Mr. Floyd feels counselling stands a better chance of getting to the root of problem with children, rather than using drugs for years to dull symptoms. Research shows, he says, that talk therapy can be very successful for kids with ADHD.
But with wait times of six months or more in Ontario for behavioural therapies for children, many don't wait. "There's a desire for quick fix....the idea that "oh, we'll fix this with a pill' rather than spend a few months in counselling is pretty appealing."
As well, he notes, "the kid with ADHD is going to be bumped to the back of the line...ADHD doesn't stack up against a kid who is suicidal."
In the meantime, general practitioners with little training in the disorder will prescribe drugs for ADHD and not even make a referral for counselling, he says, because of the wait times - "So a kid might get a drug and nothing else."
In Ontario, the numbers of children coming through provincially funded mental health services and assessed as having ADHD remain fairly stable, says Mr. Floyd. But kids seeking help elsewhere seem more likely to be diagnosed and to receive drugs. "When we see a high energy youngster, we jump to put the label on. An assessment would look much deeper."
With files from Celia Donnelly