Steve is an 11-year old European American boy who is being evaluated for attention deficit hyperactivity disorder (ADHD). He reportedly has been increasingly disruptive in school, has difficulty completing homework assignments and daydreams a lot. At the insistence of his mother, Steve was recently prescribed Ritalin by his family physician. I am completing the initial intake for Steve. He will be evaluated by a psychologist for ADHD and a psychiatrist for medication.

DSM diagnosis

Steve is presented as if a diagnosis has already been determined by his teacher, his parents and by the family physician. Over the past year, Steve has developed behavior in the school that is difficult to manage. He fidgets in his seat, has difficulty remaining in his seat during classes, seems to be constantly ‘on the go’, and talks excessively, even after the teacher asks him to quiet down, and has a difficult time waiting his turn, often blurting out answers to questions asked by the teacher. Steve’s behavior had been of some concern to his teacher and she had strongly encouraged that Steve be put on Ritalin. His symptoms have noticeably worsened in the past year. Steve’s symptoms suggest a DSM diagnosis of ADHD, hyperactivity/impulsivity type, though its manifestation has, by history, been relatively mild and manageable.

Discussion

Given his history, Steve probably meets the criteria for ADHD. Though his symptoms are relatively mild, they appear to have worsened in the past year. An in-depth assessment reveals external factors that may help to explain Steve’s increase in psychomotor activity and other behaviors typically associated with ADHD, as well as his lack of focus in class. 

First, Steve’s diet may be partially to blame for the increase in his energy level. Steve’s parents started him on an allowance this past year, and he is able to spend his money as he chooses. He chooses caffeinated soda and sugar. When probed about his diet, Steve states that on his way to school every day he buys two 16-ounce sodas from a corner market , drinks one caffeinated soda during lunch, and finishes the day with the second caffeinated soda. Joe supplements this with an average of 2-3 candy bars each day, again from the corner market. He has been throwing away most of the lunch his parents make him each day, and usually purchases french fries for lunch. At home, Steve is allowed a snack, usually chips and a large soda, caffeinated. 

Another external factor influencing Steve’s classroom behavior has to do with the increase in class size this year from 20 to 28 and the fact that there is no student intern assigned to the class as there has been in years past. The teacher to student ratio, therefore, has shifted from 1:10 to 1:28. The end result is that Steve receives very little individual attention from his teacher and, being easily distracted, does not participate in class as he has in the past. 

Steve needs to eliminate caffeine from his diet and greatly reduce the amount of sugar that he ingests. This will likely have a dramatic impact on his classroom behavior. He also needs an environment that is more closely supervised and in which he receives more individualized instruction. 

Commentary

Steve is victim in several ways. First he is a victim of an educational system that is non-supportive of children with milder manifestations of ADHD. Second, he is a victim of the pharmaceutical and the managed care industries that support medicating rather than providing behavioral treatment for children with a diagnosis of ADHD. Finally, Steve is a victim of corporate food producers that sacrifice children’s heath to cultivate profitable young customers. And, the economic cost of ADHD in the United States is estimated to be between $143 and $266 billion (Doshi 2012).

Educational system. While Steve appears to have a mild manifestation of ADHD, it appears that his behavior did not become an issue until the student to teacher ratio shifted in his classroom and he experienced a subsequent loss of structure and individual attention. Steve’s ‘problem’ really appears to be more a problem of the inability of the school system to meet his individual educational needs. The school’s interest in medicating Steve for ADHD appears to be motivated by their interest managing his behavior in a classroom that is inadequately staffed, and prescribing a stimulant for Steve is perhaps seen as the most efficient and cost-effective method of controlling energetic children with mild ADHD in increasingly large classes.   According to the Centers for Disease Control and Prevention (CDC), ADHD diagnosis by a health care provider increased by 42% between 2003 and 2011, The percentage of children 4-17 years of age taking medication for ADHD, as reported by parents, increased by 28% between 2007 and 2011.  Results from the 1987 National Medical Expenditure Survey, and the 1997 Medical Expenditure Panel Survey indicate that during the years between 1987 and 1997 there was a nearly 400% increase in the rate of outpatient treatment for ADHD from 0.9 to 3.4 per 100 children. Among children who received treatment for ADHD during these 10 years, there was a significant decrease in the number of treatment visits and a corresponding increase in the number of stimulant prescriptions (Olfson et al., 2003). The Diagnostic and Statistical Manual-5 (2013) reports rates of ADHD as high as 5% among children and adolescents. 

Pharmaceutical companies. The lower the bar can be set for labeling a child with ADHD the greater the numbers of children on pharmaceuticals and the greater the profits for the producers of Ritalin and other pharmaceutical for ADHD. Many children labeled with ADHD, particularly those with milder manifestations, take drug holidays during the summer months and the weeks away from school, suggesting a correlation between presence in school and taking Ritalin. Olfson et al. (2003) reports that treatment for ADHD is increasingly relying on pharmaceutical intervention; their report shows that among children who received treatment for ADHD between 1987 and 1997, there was a significant decrease in the number of treatment visits but an increase in the number of stimulant prescriptions. These changes occurred during a period of growth of managed behavioral healthcare (which tends to favor more cost-effective pharmaceutical intervention over treatment visits), and increased promotion of effective psychotropic medications by pharmaceutical companies (Olfson et al., 2003). 

Diet and ADHD. Children taking medication for ADHD need to be nutrition and diet conscious. Caffeine ingestion is on the rise among children and should be closely monitored (Temple, 2009).  And since there is a  link between nutrition and chronic disease, school and community policies should ensure a healthful food environment for students. 

Students are encouraged to debate and discuss Steve’s challenges in the classroom as a function of his ADHD. We explore the unwitting collusion (perhaps) of school systems; food and beverage industry; pharmaceutical and managed care industries; and even the mental health professionals to diagnose and manage even the mildest forms of ADHD with stimulant prescriptions.