Advocate illustration by John Gipson -- Nearly 16 percent of Louisiana children have been diagnosed with attention deficit hyperactivity disorder, placing the state third behind Kentucky and Arkansas, according to the CDC. When it comes to medication, Louisiana leads the nation.

Childhood attention disorders have gone up dramatically nationwide in the past decade, but few states have seen their rates climb as high as Louisiana.

Nearly 16 percent of Louisiana children have been diagnosed with attention deficit hyperactivity disorder, placing the state third behind Kentucky and Arkansas, according to the latest statistics from the federal Centers for Disease Control and Prevention, gleaned from a 2011 phone survey of parents. The national average is 11 percent, up from almost 8 percent in 2003.

However, when it comes to medication, Louisiana leads the nation, with 10 percent of the state’s youngsters ages 4 to 17 on ADHD drugs.

?Dr. Steven Felix, a Baton Rouge developmental pediatrician, said children with ADHD can “have issues with school failure, low self-esteem, early drug use and higher rates of juvenile delinquency. So it is a major problem.”

The rising population of children and adults living with ADHD has led doctors, researchers and lawmakers to ask questions: What is causing the spike? What are the best ways to treat children diagnosed with the disorder?

And the high rate of children medicated for ADHD in Louisiana has even drawn the attention of the state Legislature, where, in the current session, state Sen. David Heitmeier introduced a resolution asking the state Department of Health and Hospitals to study ways to ensure ADHD medication isn’t abused.

No easy explanation

A brain disorder that affects behavior, ADHD can be diagnosed in children by the age of 4, Felix said.

Symptoms include difficulty completing long tasks, impulsiveness and being restless and compulsive. Many of those diagnosed are also hyperactive.

“Most people at some point in time have these” symptoms, said Claire Advokat, a retired LSU psychology professor and drug researcher. “That’s what makes it so difficult to be sure where the line is drawn.”

While there are no definitive explanations for why Louisiana outpaces the nation in ADHD cases, many theories connect high rates of ADHD diagnoses with poverty. Four of the top five states for ADHD diagnoses are also among the 10 most impoverished states. Louisiana ranks third in its poverty rate, according to U.S. Census Bureau data. Yet New Mexico, which ranks second in poverty, has a rate of ADHD diagnosis only half as high as Louisiana.

Other factors may account for the rising numbers of diagnoses.

“A lot of people in the field are concerned that these are valid,” Advokat said. “When you get into the double digits … they’re questioning whether there is an accurate diagnosis.” Doctors question whether the CDC survey is completely accurate because it relies on parents’ recollections of a doctor’s diagnosis.

Felix, who has treated developmental issues for two decades, said more parents may be aware of the disorder, causing numbers to rise.

Also, environmental factors, including television and computer usage, neglect and abuse, and exposure to alcohol and drugs, could make children appear to have ADHD, he said.

“Kids that have been exposed to drugs and alcohol have those classic ADHD behaviors,” Felix said. “So, I think the same impact can happen from excessive TV, computer, video use.”

‘Lost in her own world’

Emma Shupe was diagnosed with the disorder in first grade.

She was “lost in her own world, sometimes a little bit hyper,” said her mother, Kara Shupe. “One of the biggest symptoms for Emma was that she was so socially behind. Kids with ADHD are usually one to two years socially behind their peers.”

While Shupe “had a gut feeling,” it took Emma’s teacher pointing out her symptoms for Shupe to realize her daughter needed help.

“It just kind of all adds up,” said Shupe, who now counsels parents of special-needs children at the nonprofit Families Helping Families of Greater Baton Rouge.

Emma couldn’t follow two-step directions, and, when playing with other kids, she would often take things a step too far.

“She thought she was being funny, but she was being aggravating and did not know the difference,” Shupe said.

No one knows what causes ADHD, and because no blood tests or brain scans can diagnose it, doctors rely on a series of questionnaires from teachers and parents to create a history of behaviors, Felix said.

Many children who show symptoms of the disorder must deal with other issues. About 40 percent have learning disabilities, he said, and many have high anxiety, sleep disorders or oppositional defiant disorder, a condition that includes a pattern of tantrums and arguing.

These issues can prevent children from reaching their full potential.

“We’re not talking about an IQ problem,” Advokat said. “I want to make that clear. This is not an intellectual deficit of any sort.”

Most diagnoses are made by primary care doctors, who may not spend as much time with children as needed, said Dr. Rochelle Head-Dunham, the interim assistant secretary and medical director for the Office of Behavioral Health for the state Department of Health and Hospitals.

“Prescribers are often pressured by parents, as a result, in order to keep their kids in school,” she said.

Treating the disorder

The Shupes’ primary care doctor placed Emma on a medication that helped right away. Later, Emma began seeing a psychiatrist who tried multiple medications before finding one that fit her best.

Drugs commonly used to treat ADHD, such as Ritalin and Adderall, are stimulants. In large doses, they are similar to drugs abused for a “high,” Advokat said. But in low doses — and Advokat said doctors are unsure why — the medications can cause people who are hyperactive to focus.

“It makes things less effortful,” Advokat said. “Things don’t seem so difficult, less unpleasant. Those are real phenomenon. Maybe it’s like having glasses mentally.”

The medication works reliably, Head-Dunham said.

“It’s always the simplest, in some ways, approach to take because medications act pretty rapidly,” she said. “They really do reduce symptoms fairly quickly in the ADHD population, if, in fact, the diagnosis is accurate.”

In concert with the medication, Emma saw a behavioral therapist who helped model appropriate behaviors and social interaction with other children, which Head-Dunham said is the best way to diagnose and treat childhood ADHD.

“We never did the medication without doing the social skills therapies,” Shupe said. “I’m a firm believer you have to have those.”

Today, Emma is a straight-A student in the eighth grade. Shupe works with her teachers to ensure they understand the accommodations Emma needs to succeed, extra help such as written instructions and extra time on tests.

“She owns her issues,” Shupe said. “She’s not afraid to tell people, ‘I have ADHD.’ She also knows not to use it as a crutch.”

Living with ADHD remains difficult. Many adults with the disorder have more marital problems, said Advokat, whose research at LSU showed that medications do not quite help the ADHD students’ gpas catch up with others who have similar intelligence levels.

And many teachers and parents refuse to believe in the diagnosis, Shupe said.

“There’s still a majority population who feel like it’s not real, it’s just laziness,” she said. “There are a lot of people close to it who just don’t think it’s real. It’s a hard situation to deal with.”