Josiah Simons has just finished eating lunch at Ridgeview Elementary School and he's on his way to the nurse's office to take a pill for his Attention Deficit Hyperactivity Disorder.
Along with daily doses of reading, writing and arithmetic, Josiah, 7, gets a daily dose of Adderall, a stimulant that allows the second-grader to sit still and pay attention in class.
“You can immediately tell whether a child has taken it or not,” said Debbie Johnson, health services administrator for Oklahoma City Public Schools and the mother of a son with ADHD. “Typically they're more attentive and they can stay on task longer. There's less anxiety.”
About one in 10 school-age children in Oklahoma — and the nation — has ADHD, according to figures provided by the Centers for Disease Control and Prevention. It's a condition that makes it hard to focus and pay attention and can make it difficult for a child to do well in school or behave at home.
“You watch children struggle with not being able to get all of the successes that other kids get because they are always in trouble,” Johnson said. “They're the ones who can't sit in their chairs or get their homework done.”
Dr. William Graf, a pediatric neurologist and a professor at the Yale School of Medicine, said that over the last 20 years the percentage of people diagnosed with this disease has doubled.
He said that while it is a complicated question, he feels ADHD is probably diagnosed too frequently and too many people are taking medication to combat it.
“It's a condition that has a treatment and the treatment has helped many people,” he said. “But it's also a treatment that has the potential to be abused or misused and needs to be closely scrutinized.”
Some children with ADHD may be hyperactive or have trouble being patient. Others have trouble controlling impulsive behaviors and act without thinking about consequences.
“ADHD does not just interfere with learning, but the symptoms can also cause problems for children socially with their friends and at home with their families,” said Anne Jacobs, an Edmond-based psychologist who treats children and adolescents with ADHD. “The inability to wait your turn in a game or stop yourself from interrupting peers can gradually cost children some friendships.”
About 5.2 million children ages 2 through 17 have ADHD, including about 72,000 in Oklahoma, according to recent CDC data.
Many more go undiagnosed because they don't have access to medical care or because of the stigma attached to the disorder, said Dr. Mark Wolraich, medical director for the OU Children's Physicians child study center.
“Clearly, from past studies, there are a number of children who have the condition but are not identified or treated,” he said. “Clearly, there remain children who would benefit from treatment.”
While the Oklahoma City School District doesn't specifically track students with ADHD, Johnson said about 2 to 3 students take ADHD medication at each of the district's 55 elementary schools.
“We've got quite a few children receiving ADHD medication,” she said. “It's become more of a norm than not.”
Johnson was a school nurse for 19 years. The youngest of her three grown children was diagnosed with ADHD in elementary school and “still has a lot of issues.”
“We couldn't take him to church or go out to dinner and try to sit at a table,” she recalled. “And forget about trying to take a trip somewhere in the car. It was impossible.”
Some parents of children with ADHD are conflicted because they don't want to medicate their child but don't want to see them singled out for negative behavior that often leads to isolation, Johnson said.
“Their child is the one that others are going to stay away from,” she said. “The negative reinforcement leads to low self-esteem, which of course, causes them to lash out or they get really depressed.”
Josiah, whose father and two brothers were diagnosed with ADHD, began taking Adderall in the first grade. He takes a short-acting pill twice a day, after breakfast and lunch.
“He was restless. He couldn't sit still,” recalled Melodee Simons, Josiah's grandmother and a longtime parent liaison at Ridgeview. “If you gave him a list of three items to get, he could get two but he'd forget the third one every time.”
Josiah became an honor roll student after he started taking the medication, Simons said.
Wolraich, who specializes in pediatric development and behavioral medicine, chaired the committee that revised ADHD guidelines for the American Academy of Pediatrics in 2011.
He recommends behavioral therapy for young children diagnosed with ADHD, and a combination of therapy and medication for children ages 6 to 11 and adolescents up to age 17.
“Clearly, ADHD continues in many of these individuals into adulthood,” he said. “Certainly there are adults who continue to have the condition and continue to benefit from treatment.”
Wolraich said most people diagnosed with ADHD have an additional condition such as a learning disability or anxiety disorder, and can be extremely defiant. While some are easily annoyed by their peers, others can become bullies and thieves and eventually stop following social norms.
“There are certainly a number of people who suggest that it is not a real condition and that is clearly not the case,” Wolraich said. “It's not a condition that is inconsequential. Those with ADHD have a much higher rate of dropping out of school and getting in trouble with the law.”
Jacobs, the Edmond psychologist, does not prescribe medication, although she said it can be very helpful when children face failing school or dropping out.
“I've had some young clients who were starting to think that they hated school or that they were just dumb,” she said. “Referring out for a medication in those cases gave the children the hope they needed while the families were putting behavioral techniques in place.”
About two thirds of those diagnosed receive prescriptions for stimulants like Adderall or Ritalin, which can improve the lives of those with ADHD but can also lead to misuse and abuse, experts said.
“Some high school and college students will try to get a hold of the medication to stay up all night and study for exams,” Wolraich said.
Jacobs said she is meeting more and more teenage clients without ADHD who are taking a friend's medication to help them study.
“Sadly, in the past I have worked on cases where parents were selling their children's medications and everyone was wondering why the children were not doing better in school,” she said.
Jacobs works with prescribing physicians, sharing feedback about their clients' symptoms and side effects. She said whether children are treated with behavioral therapy or a combination of therapy and medication, it is important to note that children with ADHD cannot “pull themselves up by their bootstraps.”
“The playing field for children with ADHD is not level,” she said. “It takes much more than just a desire to pay attention or sit still.
“When I meet children with ADHD symptoms, they are trying the best they can to cope. It is not as though they are holding out their best efforts for later or are simply unmotivated.”
Besides being the most common neurobehavioral disorder among children, children with ADHD suffer more injuries than those without it, the CDC reported.
Between 2003 and 2007, the rate of parent-reported ADHD diagnoses among children 4 to 17 years of age increased from 7.8 percent to 9.5 percent, according to a CDC report. In four years, the number of children with ADHD had risen by 1 million to 4.1 million. Oklahoma was among the states with the most significant increases in ADHD prevalence, 35.8 percent.
A 2012 CDC-funded study of six school districts in two states, including Oklahoma, found an estimated 10.6 percent of children had enough symptoms to fit the ADHD diagnosis, and 7.4 percent were taking ADHD medication.
“I don't want to say it's being over-diagnosed,” Johnson said. “I think people are becoming more attentive to it.”
Teachers have become better at spotting ADHD in students and communicating their concerns to parents, she added.
“It doesn't take long to realize a kid's got a problem,” Johnson said. “There has to be good communication between the teacher and the parent.”
Johnson advises concerned parents to schedule a complete physical with their child's primary care physician.
Johnson oversees the district's 1,500 nurses, who are responsible for setting up and maintaining health care plans for children taking medication.
“You have to monitor the student's behavior because that's really the only way you know if you made the right choice,” she said. “Medically you want to monitor the child for any side effects, and you want to watch to see whether they're getting their assignments done.”
You watch children struggle with not being able to get all of the successes that other kids get because they are always in trouble. They're the ones who can't sit in their chairs or get their homework done.”
Health services administrator for Oklahoma City Public Schools and mother of a son with ADHD