Controversies in the Diagnosis and Treatment of ADHD: One Doctor's Perspective

What accounts for the huge increase in the number of children diagnosed with attention deficit hyperactivity disorder (ADHD) and the use of Ritalin? Dr. Lawrence Diller analyzes the explosive growth of the ADHD diagnosis and Ritalin use.

I've practiced behavioral pediatrics in an affluent San Francisco suburb for over twenty years. In that time I've evaluated and treated nearly 2500 children for a variety of behavior and performance problems. I never imagined during my early years of practice that one diagnosis would so come to dominate not only my work, but America's children in general.

That diagnosis is attention deficit hyperactivity disorder, or ADHD.

A Diagnosis on the Rise

I had always encountered hyperactive children or kids who performed poorly at school. Stimulant drugs, the best known of which is Ritalin(methylphenidate), have always been one of the interventions I used to help these children and their families. These children were mostly boys, aged six to thirteen. But in the early 1990's, I began to see with increasing frequency a new type of ADHD candidate. These children were both younger and older than the previous group that met my criteria for ADHD and received Ritalin. There were also many more girls. Some of them weren't even kids. Older teenagers and adults (initially the parents of the children I evaluated for ADHD) wondered whether they too had ADHD.

But most strikingly, these new candidates for the ADHD diagnosis were far less impaired in terms of behavior and performance than my earlier patients. Many of these children behaved quite well in my office. Many were getting passing grades, even B's, at school, but were not "meeting their potential." Most of these children tended to have their biggest problems at school, or only at home when it came to doing homework.

Did Tom Sawyer have ADHD?

Boys still predominated over girls in the number presenting for evaluations for ADHD. But their problematic behaviors could just as well be viewed as an extreme of the normal variations one attributes to the male gender. Indeed, I began to wonder if boyhood, at least in my community, had become a disease. I mused if Mark Twain's Tom Sawyer walked into my office in the late 1990's whether or not he too after several visits might also leave with a prescription for Ritalin.

Ritalin production up 740 percent

I became interested in the ADHD epidemic I was witnessing and quickly learned that my experience wasn't unique. Stimulants are, by far and away, the predominant medical treatment for ADHD and are prescribed overwhelmingly for only that indication. In that sense, they serve as a marker for how much ADHD is being diagnosed in the population. Because stimulants are abusable, the Drug Enforcement Administration (DEA) tightly monitors and controls their legal production and distribution in the U.S. The DEA's records showed that between 1991 and 2000, annual production of methylphenidate rose by 740 percent, or over fourteen tons produced per year. Production of amphetamine, the active ingredient of Adderall and Dexedrine, two other stimulants used for ADHD, multiplied twenty-five fold during the same period. In the year 2000, America used eighty percent of the world's stimulants.

Most of the other industrialized countries use Ritalin at one-tenth the American rate. Only Canada, which uses half our per capita rate, comes close to using stimulants the way we do.

Many have hailed the increase of Ritalin use in our country as simply a treatment catching up to a previously under-diagnosed condition. Others are alarmed at this unprecedented rise in the diagnosis of ADHD and Ritalin use in America. Whether good or bad, this large rise in Ritalin use tells us a great deal about the way we view and address problems of children's behavior and performance at the beginning of the 21st century.

Patterns of Prescription

The answer to the question "Is Ritalin over-prescribed or under-prescribed?" is "Yes". It depends on the community you assess, and its threshold for the ADHD diagnosis and Ritalin use. Ritalin use rates from DEA data (reported in several research studies and most recently by the Cleveland Plain Dealer's county-by-county national survey) widely vary within the U.S.—from state to state, community to community and even school to school.

For example, Hawaii perennially is the state with the lowest per capita Ritalin use in the nation. Hawaiians typically use Ritalin at one-fifth the rate of the highest using states, which tend to be eastern states like Virginia or Midwestern states like Michigan. There are various "hot spots" of Ritalin use. The best documented is a three-cities cluster in the southeast corner of Virginia, where one in five white boys was taking Ritalin at school (G.Lefever, ET AL, American Journal of Public Health, September, 1999). Overall rates were probably higher than twenty-five percent since many children only take medication at home before the start of the school day. The DEA maintains that virtually every state has pockets of high use rates that are centered near a college campus or clinic that specializes in the evaluation and treatment of ADHD.

Racial/ethnic disparities

At the same time, there are areas where Ritalin is hardly used at all, especially in rural areas (the Cleveland Plain Dealer featured a county in New Mexico) and within the inner city.

Socioeconomic differences or unequal access to care are not the only reasons for differences in diagnosis and stimulant use rates. There are clear ethnic differences between who does and doesn't use Ritalin. African American children are conspicuously absent in the ADHD/Ritalin epidemic. Missing too are children from Asian American families, though the reasons for the under-representation are different for both groups.

On average, neither group tends to trust or utilize mental health services as frequently as white Americans. Many Asian American families simply raise their children differently in the early years, employing stricter standards and techniques compared to their white American counterparts. Many African Americans seem especially suspicious of a neurological label of ADHD to account for their children's problems, which may be partly attributed to poor schools and neighborhood environments. African Americans in urban communities are also uneasy about what they perceive to be similarities between Ritalin and crack cocaine, which devastated black communities in the 1990's. These opinions were expressed by the NAACP Legal Defense Fund when public hearings were held by the DEA over decontrolling Ritalin in the mid-nineties.

Indeed, the ADHD/Ritalin epidemic appears to be a primarily white middle-upper middle class phenomenon. The best demonstration of these ethnic-racial disparities comes, ironically, from HealthCanada, a federal department responsible for helping Canadians maintain and improve their health. The data and its conclusions were debated in an article and a series of letters in the Canadian Journal of Medicine. They examined Ritalin use rates in two large cities in British Columbia separated only by a short ferry ride. Victoria, a highly homogeneous white middle class community, used Ritalin nearly four times as much as Vancouver, a far more cosmopolitan, polyglot city with large numbers of people of Asian descent. All families were enrolled in a national health plan, which covered visits for ADHD, so access to care cannot explain this striking difference.

Neurological factors

Neurological factors alone, felt to be the basis of the official ADHD diagnosis, do not account for the extreme variation in Ritalin use. While children with severe impulsivity and hyperactivity exist in all populations in every country of the world, these are not the majority receiving stimulant medication in America today. Rather, economic, social and cultural factors are strongly implicated in the real world diagnosis of ADHD and who does and doesn't get Ritalin.

An Explanation

Why this huge increase in the use of Ritalin during the 1990's? I propose a number of factors involved in the explosive growth of the ADHD diagnosis and Ritalin use. By the early 1990's we, as a society, accepted the notion that poor behavior and performance in children are caused by a brain disorder or chemical imbalance. American psychiatry over the previous twenty years turned 180 degrees from the previous Freudian model, which blamed Johnny's mother for all of his problems, to a biological model of mental illness, which blamed Johnny's brain and genes.

The Prozac connection

The success and popularity of the anti-depressant Prozac, which was introduced in the late 1980's, cemented the notion of the brain-behavior connection in the public's imagination.

Prozac made taking a drug for an emotional problem in adults more acceptable and paved the way for the increased use of a psychiatric drug, Ritalin, in children.

Living in a pressure cooker culture

In my mind, a "living imbalance" rather than a chemical one has fueled Ritalin demand. In general, academic standards among the middle class have increased, and children are expected to reach certain milestones earlier and earlier. Children at three are often expected to know the alphabet and their numbers, children at five are expected to know how to read, children in third grade are learning multiplication and division, and so on. These are the expectations middle and upper middle class children face today.

The expectation is also that every child attains at least a four-year college degree in order to compete in the marketplace and survive economically in a post-technological world. By talent or temperament, many children are found wanting, and wind up taking Ritalin.

Changing parental habits

Nearly eighty percent of mothers now work outside the home, leaving many more young children in full-day childcare and many more school age children alone at home in the afternoons. Both parents are working longer hours to maintain their economic position, leaving them exhausted, and perhaps guilty at the end of their day when they finally get to see their kids.

Parents are further handicapped by current styles of American discipline of children.

"Politically correct" parenting practices propose that by effectively talking to children, conflict and punishment can be avoided. The fear of damaging a child's self image by even short-term immediate punishment is a significant handicap for parents today, as this type of direct, immediate discipline is a major motivator for children, especially for children with ADHD-type personalities. Of course ineffective discipline alone does not explain the explosion of ADHD diagnoses, but it is one piece of the puzzle. When children's behavior continues to be out of control, and punishment is not an option, then using a medication becomes very appealing.

Managed care, media, and the pharmaceutical industry

Until the last few years, average class sizes were increasing even as curricula demands rose for the general classroom teacher. No wonder teacher complaints are often the catalyst that leads to an ADHD evaluation. Managed health care only exacerbated economic pressures, especially on pediatricians and family doctors, resulting in less time in evaluations and treatment and a rise in the "quick fix" of Ritalin. Media tended to exaggerate the ubiquity of the ADHD diagnosis ("Does your child have this hidden disorder? Do you?"). Testimonials that recount the power of the Ritalin intervention belie the often complex courses and treatments necessary for myriad children's problems that get lumped under ADHD diagnosis.

The pharmaceutical industry's influence has been profound, both in determining the kinds of ADHD studies funded and published and in their drug promotions, advertising first to doctors (Adderall) and most recently directly to consumers (Concerta).

Federal educational disability law

All these factors were in place by the early 1990's and Ritalin production in the U.S., which has remained stable throughout the 1980's, took off beginning in 1991. The spark that set off all these socially combustible materials and led to the Ritalin boom was the change in the Federal educational disability law, IDEA. In 1991, IDEA was amended to include ADHD as a covered diagnosis for special educational services at school. Once parents (and teachers) learned that they could get help for their kids at school, they flocked to their doctors seeking the ADHD diagnosis and along the way received Ritalin for their children.

Nothing surprising about the effectiveness of stimulants

Ritalin "works." Stimulants in one form or another have been used for treating children's behavior for over sixty years. But the effects of Ritalin are not specific to treating ADHD.

Ritalin improves everyone's ability—child or adult, ADHD or not—to stick with tasks that are boring or difficult. Ritalin decreases everyone's impulsivity and therefore decreases motor activity. There is nothing paradoxical about low dose stimulants' effects on "calming" hyperactive kids. Higher doses "wire" both ADHD kids and normal adults: except children tend to dislike the experience of the higher doses while teens and adults can abuse the drug.

Conclusion

I'm not against the use of Ritalin in children. I am against Ritalin as a first and only choice for a wide variety of children's performance and behavior problems. Ritalin works but it is not a moral substitute for, or equivalent to, better parenting and schools for children. My role as a physician is to ease suffering. After a proper evaluation and an attempt to address issues of family and learning as best as possible, I will prescribe Ritalin if the child continues to significantly struggle.

But as a physician who prescribes medication for children, it is also my role to alert others about the economic, social and cultural factors that are involved in the ADHD diagnosis and Ritalin use in our country. To not raise alarm would make me complicitous with values and factors I feel are harmful to children and their families.

The huge rise in Ritalin use in our country is telling us we should reexamine our demands on our children and the resources we offer them, their families and their schools. It is a message we should heed not only for children with the ADHD diagnosis who take Ritalin but for all of America's children. We should be paying attention.

Originally published at Healthology.com, August 20, 2001
Copyright © 2001 Healthology, Inc.

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