As a preschooler, Cherrish Slaymaker was a tiny tempest — at times defiant, other times bouncing distractedly from toy to toy at daycare, while other children were absorbed in play.
Amanda Slaymaker hoped her daughter's troubling behavior was just a phase, but a medical evaluation showed otherwise — Cherrish had Attention Deficit Hyperactivity Disorder, which afflicts Kentucky children at the highest rates in the nation.
Meanwhile, Tennessee ranks 11th highest among all U.S. states.
The latest statistics from the U.S. Centers for Disease Control and Prevention show 19 percent of Kentucky children ages 4-17 have been diagnosed with ADHD at some point, compared with 11 percent nationally and 16 percent in Indiana. Nearly 15 percent of Kentucky children currently have the diagnosis.
The figures, based on parent reports in a 2011 national survey, also showed that ADHD levels have risen steeply in the past decade across the nation, with 6 million children diagnosed at some point in their lives.
"We're probably over-diagnosing it to a certain extent," said Dr. Christopher Peters, a psychiatrist and assistant professor in the University of Louisville's pediatrics department. "But these numbers indicate a problem. There are many kids in need."
Doctors aren't sure why Kentucky's rates are so high. Some theorize the numbers reflect the state's rampant poverty, since ADHD is identified more frequently in the poor. Others say more children here may be genetically prone to the disorder or face other risk factors.
And some say overworked primary care doctors who aren't experts in the disorder may be over-diagnosing — and possibly over-prescribing — both locally and nationwide. Roughly 8 percent of of school-aged boys nationally and nearly 4 percent of girls took ADHD medications in 2012, according to data from the pharmacy benefit management firm Express Scripts.
But experts say the higher numbers may also indicate greater awareness of the disorder, meaning the truly needy are getting the medication, therapy and support they deserve.
Slaymaker, whose daughter was diagnosed three years ago at UofL's Weisskopf Child Evaluation Center, said she initially resisted putting her child on medication. But with a mild stimulant and counseling, Cherrish is doing well as an 8-year-old second-grader at Schaffner Traditional Elementary School.
"Her focus has been a whole lot better," Slaymaker said. ADHD "doesn't hold her back."
Kentucky kids at risk
Dr. Carmel Wallace, chairman of the pediatrics department at the University of Kentucky, describes ADHD as "an inborn biochemical issue" that causes inattentiveness, hyperactivity and impulsiveness.
Genetics also plays a big role. Studies show that at least a third of parents who had ADHD as children have kids with the diagnosis.
Jillian Greene, a 13-year-old eighth-grader at Highland Middle School, was diagnosed with ADHD last year, and her mother, Lynn, said her 16-year-old son also has been diagnosed. Lynn Greene believes she may have it too, though she's never been evaluated.
Jillian said she often forgot to turn in assignments and got failing grades before being treated for ADHD. "I couldn't concentrate," she said. "I couldn't just grasp one thought."
Scientists also have linked ADHD to alcohol and tobacco use during pregnancy — although doctors said it's unclear whether smoking is a cause or simply occurs more often in families with afflicted children. Kentuckians smoke at the nation's highest rate and also have high rates of substance abuse overall.
Researchers are looking into whether babies born dependent on drugs because of their mothers' addictions — a burgeoning problem in Kentucky — are more likely to develop ADHD. Since the problem of dependent newborns is relatively new, doctors said there's not enough research to say whether there's a true link.
"We do know that any adverse substance use during pregnancy is not good for babies," said Eva Markham, a psychologist at the Weisskopf center.
Diagnosing too often?
Doctors said another possible explanation for Kentucky's high rates is that doctors are falling back on an ADHD diagnosis too often, particularly in areas short of doctors and specialists. The federal government designates 49 Kentucky counties, and parts of other counties, including Jefferson, as "health professional shortage areas" for primary care.
To the inexperienced eye, experts said it can be tough to differentiate ADHD from problems such as anxiety, depression and certain learning disabilities.
There's no single test for ADHD; screening involves a medical exam to rule out other problems, symptom-rating checklists for parents and teachers, and thorough histories of the child.
Peters said some doctors may misinterpret behavior problems that stem from other issues — such as poverty or abuse. And teachers in schools with fewer resources and larger classes might be quicker to refer disruptive children to be evaluated for ADHD. But research hasn't shown poverty to be a definitive cause of ADHD.
Wallace also acknowledged financial incentives associated with the disorder.
A diagnosis may translate into disability payments if a child has measurable and serious problems, and students with ADHD can get extra help in school. But Wallace, who has treated many children with ADHD in Corbin and Lexington, said parents rarely push for a diagnosis to get a disability check. And the threshold for disability is high.
Whatever the reason for Kentucky's top-in-the-nation rates, diagnoses are higher than they've ever been across the nation. CDC statistics show 8 percent of American children in 2003 had been diagnosed at some point, jumping to 11 percent in 2011. In Kentucky, those percentages grew from 10 percent to 19 percent during that period.
Some doctors question the accuracy of those numbers, since they're based on parent reports. But no one disputes the clear upward trend.
"There could be a lot of reasons why the numbers are" rising, said Dr. Jonathan Posner, an ADHD expert at the Columbia University Department of Psychiatry in New York.
For instance, there's been rising awareness of the disorder that may have gone under-diagnosed in the past. Greene said she doesn't ever remember hearing about ADHD as a child, but now knows many other families dealing with it and finds reams of information about it online and in books.
But experts said more troubling trends also likely contribute to the rise. For example, they said, doctors may be pushed into making a diagnosis by parents who see ads on ADHD stimulants and believe the medications can boost academic performance — although Posner said this is "rather uncommon."
For children who don't have the disorder, doctors said treatment is never the answer. But those with ADHD often respond well to medication, behavioral therapy and accommodations at school. Doctors said some children seem to grow out of ADHD and can stop treatment, while others take stimulant medications past middle age.
Experts said the best treatment is medicine plus behavioral therapy. But Markham said, "if you're only going to do one treatment, medication is by far the most robust."
Cherrish Slaymaker takes a medication called Focalin, is monitored every four or five months at the Weisskopf center, and gets counseling at Seven Counties Services. Slaymaker said the Weisskopf staff also asks Cherrish's teachers to fill out forms about her behavior every four or five months.
Jillian, who also has been diagnosed with depression takes the antidepressant Prozac and the ADHD medication Concerta. She recently completed behavioral therapy, sees another therapist weekly for counseling, and has a plan in place at school to help her succeed.
Greene said it was a tough decision to start Jillian on medication, and she tried two other types before settling on Concerta. But she said treatment has resulted in "a mind-blowing change," with her daughter earning A's and B's and finally able to concentrate.
"Now, I can think about so many things, but I can think about them in an organized way," Jillian said. "The medicines are helping me focus and learn and be a better person."