January 3, 2001

Medicating Pippy

(First Appeared in the Los Angeles Times, December 27, 1999)

Pippy Longstocking just left my office on Ritalin. Of course thatís not her real name. Her name could be Kayley, Anna, Natalie or that of a half-dozen other girls I saw this week at my behavioral pediatrics practice in an affluent suburb east of San Francisco.

Eleven year old Pippy was not performing up to her potential at her private school according to her teacher. She daydreamed and when called upon was often not prepared to answer. She could be silly in the classroom. This girl in my office demonstrated academic skills two grade levels above average. She spoke to me cogently and thoughtfully about her life. She dreamt about living on a ranch with many animals. She did act a bit nervous and giggly with her parents and more serious younger brother. But she did not seem to me like a serious case of Attention Deficit Hyperactivity Disorder (ADHD) and I told her parents so. I didnít think she needed medication at this time. I suggested that we work on making consequences more immediate for Pippy at home and at school and if she still was struggling a few months from now perhaps Ritalin could be tried then.

Pippyís mom asked me if there was really anything bad about taking Ritalin and if not, why not do it now so that Pippy could do better in school immediately. I said that most children and adults have little problem taking Ritalin and that it was probably pretty safe. It works the same on children and adults, ADHD or not, to improve focus and attention on tasks found boring or difficult. Pippyís dad, uneasy about using a drug that also had abuse potential, thought they should wait.

The family came back to see me a week later. Dad had changed his mind. Another doctor felt Pippy had mild ADHD and gave them a prescription. Pippy apparently felt okay about taking it. The prescribing doctor had only left the instructions on the bottle, 1 to 3 tablets per day. They asked me to tell them more about using the medication. I internally shrugged and started to tell them how to titrate the optimal dose and frequency using a teacher feedback sheet. They left happy. I felt strange.

I find myself evaluating and prescribing medication for more and more Pippys and Tom Sawyers. These seemingly normal children are inattentive or disinterested in school and bit slow to finish their chores at home. Concerned and loving parents bring them in because the children arenít performing up to their potential or are disruptive in their classrooms. Ritalin production is up 700% in the decade. Dexedrine and Adderall production, the other two stimulants used for ADHD, has tripled in the past three years. America uses 85% of the worldís stimulants. While school age boys remain the largest users of Ritalin, girls and adults are the most rapidly increasing groups taking the drug. The Colorado State Board of Education, concerned about too many Pippys on medication, recently passed a resolution which made national headlines, discouraging teachers from referring children to doctors for evaluations and prescriptions.

Russell Barkley, arguably the leading theorist and researcher on ADHD, has said that the use of stimulants for ADHD will be seen as one of the great discoveries of the late 20th century. Iím not so sure. Even as I prescribe more and more Ritalin to help round and octagonal peg children fit into square educational holes, I know that Barkley, himself, is worried about the trivialization of the disorder. While several surveys say we are still under treating ADHD, regional variations in treatment widely vary. In some rural areas virtually no children get Ritalin. Yet in Virginia Beach one in five white fifth grade boys receive Ritalin at school.

Ritalin fits our current biological model of ADHD. Training parents and modifying classrooms also help but some say these interventions are too costly and less effective than medication. That may be so in which case I wish to offer a Swiftian Modest Proposal of my own. With classroom sizes now averaging about 30 kids per class and about four million children taking Ritalin I propose we increase the number of children taking Ritalin to seven million and we could probably increase class size to 45 children and save a lot of money. Ritalin works but I donít see it as the moral equivalent or substitute for better parenting and schools for our children. Currently, our country has an intolerance for temperamental diversity in our children. I worry about an America whereís thereís no place for an unmedicated Pippy Longstocking.


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