January 4, 2001

A Chat with Dr. Lawrence Diller

Moderator at 12:01pm ET Welcome Dr. Diller. Thank you for joining us today!
Dr. Lawrence Diller at 12:02pm ET I'm happy to address people's questions or comments. I understand that this is a sensitive subject, and feelings run strong on both sides of the question of ADHD (Attention Deficit Hyperactivity Disorder) and Ritalin. I hope that I can project a notion of a balanced view on the subject.

Moderator at 12:04pm ET
Our first question comes from jchecco. He asks: What causes ADHD? Can ADHD be diagnosed without a neurological examination? If so, what factors determine ADHD?

Dr. Lawrence Diller at 12:06pm ET
Despite years of study, no one knows exactly what causes children to act in an impulsive, distractible and hyperactive way. Surely the brain plays a role, but that can't explain the wide variation in the incidence in the diagnosis of ADHD and the use of Ritalin in this country. Rates vary as much as 5-1 between the highest per capita Ritalin-using state and the lowest, and America uses 85% of the world's stimulants (which include Ritalin). While a neurological exam is often part of a diagnostic workup, in fact most children have a normal neurological examination and even more subtle signs of neurological dysfunction do not correlate well with the real-life problems these children have.

Among the important issues to be evaluated in an ADHD assessment, include aspects of the child's personality (that's the neurological brain component from my point of view); the child's emotional status (happier children focus better and delay gratification better than unhappy children); the child's learning abilities (children who are challenged educationally often have attentional problems and vice versa). Medication alone will not remediate a learning disability. Those are factors just of the child.

Any evaluation must also include some understanding of the parent/child relationship, especially how the parents set limits for their children. Some direct contact with the child's teacher is necessary, not only to obtain her viewpoint of the child's performance at school, but also to assess how this teacher approaches and teaches this child or other children in the classroom. There are also larger cultural issues involved in both the widespread and disparate use of this diagnosis which I might bring up in a short while.

Moderator at 12:11pm ET
Rob asks: Can depression in boys sometimes be misdiagnosed as ADD?

Dr. Lawrence Diller at 12:12pm ET
Rob brings up a critical issue of emotions and focus. There's a problem in general with psychiatric diagnosis in that we have no specific tests, and symptoms of one condition often blur into another. However, a disturbing trend in child psychiatry is when a child does not improve sufficiently on one medication (say Ritalin for ADHD) and another diagnosis is invoked (for example, depression) in order to justify adding a drug like Prozac to the child's program.

Bill Thompson from brooks.af.mil at 12:13pm ET It is sometimes suggested that children grow out of ADD. If this is true how does one assess this growth and subsequent removal from drug therapy?

Dr. Lawrence Diller at 12:15pm ET Any child on medication should be assessed about every 6 months as to the continuing need for the drug. Sometimes it is very clear, but sometimes a 3 day trial on no medication is a worthwhile, albeit unpleasant, experience. However, the future for many of the children (the Tom Sawyers and Huck Finns) who come into my office and may wind up on Ritalin is far rosier than the descriptions of the more severely impaired, highly screened, university-diagnosed children that are often the subjects of studies that project a far gloomier picture for these children.

tmbassist at 12:16pm ET I was diagnosed with ADD, but none of the medications seemed to work. My doctor said that if the meds don't work, I don't have ADD. Is it possible to have ADD/ADHD that is not treatable with Ritalin or other ADD drugs?

Dr. Lawrence Diller at 12:18pm ET I think it's a very good question and brings to mind whether or not our psychiatric categories are actually drug-driven more than anything else. Certainly, you can have problems of impulsivity and inattention, and not respond to a stimulant (but 70%-80% of people do, and 90% improve in my practice). However, everyone should know that the response to Ritalin is not unique to the ADHD person. All people, child or adult, ADHD or not, will stick with things they find boring and difficult when they take a stimulant in low doses.

Moderator at 12:19pm ET A number of our online readers are asking about the drug Adderall ...

Faye Caplan at 12:19pm ET My son, age 11 1/2, has been put on Adderall as an alternative to generic Ritalin. What is known about Adderall when used in place of Ritalin for ADHD and is it considered a safe(r) alternative?

Lisa Nicholls from dhcp.missouri.edu at 12:20pm ET Please discuss the differences between Adderall and Ritalin for treating ADD. Donna Isele from proxy.aol.com at 12:21pm ET Adderall has not been tested for carcinogenic effects--even on animals. Is it safe to administer to children?

Dr. Lawrence Diller at 12:24pm ET Oooooooh! You've touched a raw nerve. Adderall represents a triumph of American marketing know-how. Adderall was introduced about 4 years ago as a new drug option for ADHD. Adderall is simply an old drug Obertral that was taken off the market in 1981, because at that time the FDA ruled that an amphetamine (which is what Adderall is) could no longer be prescribed for weight control because it was ineffective and too many people (women) became addicted to it. Dexedrine (which is also an amphetamine) has been available for 40 years in this country. The Medical Letter, the most respected newsletter on drugs and therapeutics, reviewed Adderall and stated it adds nothing new to the choices for ADHD. The only remarkable thing about Adderall is the amount of promotion and advertising directed at physicians. It has reached new levels of hype activity in terms of its assault on doctors. That said, the amphetamine group represents a reasonable alternative to Ritalin. But as you can tell, I'm not a fan of Adderall because of the disingenuousness of their campaign.

Julie Lewis from nsba.org at 12:24pm ET I have heard that the proliferation and over-prescribing of Ritalin was driven by the pharmaceutical industry. Is this true?

Dr. Lawrence Diller at 12:27pm ET Ritalin is both over-prescribed and under-prescribed, depending upon the community you assess. The threshold for both the diagnosis and need for medication are compared to your standards. There are community-wide rates of Ritalin use where 1 in 5 boys are receiving this medication at school. There are other other communities, especially rural, where Ritalin rates are near zero. I don't believe that there is any plot between pharmaceutical companies, doctors, teachers and parents. Some drug companies, like Novartis, have actually behaved quite responsibly during this epidemic. As mentioned, there are others I do question. There is no doubt that the profit motive operates within the culture of the Ritalin nation. But that is true of virtually every other endeavor or phenomenon in this country.

There are ethical questions raised about this money issue. It costs money to do an adequate ADHD evaluation. It costs money to provide necessary special education, or decreased classroom size in schools. It costs money to offer brief behavioral management training for parents. Ritalin is much cheaper to offer. Some have said that we, as a country, can't afford to provide these services to our children. I have no doubt that Ritalin works on the short term, but I do not believe that Ritalin is the moral replacement for better schools and parenting for our children.

Dave O'Connor from proxy.aol.com at 12:30pm ET Why are boys more prone for ADD than girls?

Dr. Lawrence Diller at 12:32pm ET Good question. By the way, once children reach late adolescence, girls and women are identified more than boys. What I think, though, about the elementary school years, where boys are receiving Ritalin 4 to 1 compared to girls, has to do with biology and culture. At the risk of some stereotyping, when girls are stressed and uncomfortable at school, they respond by trying to please; when boys are stressed, they attempt to take over or punch someone. Elementary school was designed for girls. We've become more comfortable as a society to offer a pathological diagnosis and a drug to a boy, rather than the combination of freedom and firm discipline that he needs.

sw from nscs.com at 12:33pm ET How long do you recommend taking Ritalin? Is there a certain age that a young adult should be able to handle the ADD on their own or should they remain on Ritalin while still continuing treatment with a doctor?

Dr. Lawrence Diller at 12:35pm ET There's no magic age. Typically, children at 13, 14, 15 want to try life without medication. For virtually everyone, the hyperactivity disappears around that time. Not untypically, though, at 17, 18, 19, some people return to Ritalin because they cannot meet the demands (often academic) on their lives. Another group goes ahead and finds the niche that meets their developmental and temperamental qualities. They may go on to have quite successful lives without any medication or treatment.

Jay Maran from new-york-43-44rs.ny.dial-access.att.net at 12:35pm ET What alternatives are used in Europe? I hear their Ritalin use is much lower than USA.

Dr. Lawrence Diller at 12:38pm ET Jay is correct, Ritalin use in Europe and industrialized Asia, are 1/10th ours. Families and physicians in those countries prefer to continue to intervene with psychosocial treatments. Other values and parenting styles also explain some of the differences. We are an inconsistent culture. On one hand we prize individuality and expression of self, then demand conformity at school. A consistent culture expects group adherence at all ages, in all settings. We are the best example of an inconsistent culture. A country like Japan is a consistent one, and western Europe is somewhere in between.

Kim at 12:39pm ET My husband has ADHD and has taken Ritalin and Zoloft for about 6 years with BIG improvement. My son age 7 is very bright and exhibits a lot of the same traits of ADHD as my husband (e.g. things have to be perfect and explodes when say a Lego won't fit perfectly). Is ADHD genetic? I wonder if life is so much better for my husband, should I consider drugs for my son so the quality of his life is better?

Dr. Lawrence Diller at 12:41pm ET There's no doubt in my mind that aspects of behavior we ascribe to personality is genetic. Studies show qualities of impulsivity are transmitted from one generation to the next. Those same studies show that the whole spectrum of impulsivity (meaning those children who focus well to those who have ADHD) are transmitted at the same rate. What's different is where each community and each society draws its line between abnormality and normal variations of temperament. Finally, one's genes are only a tendency or proclivity toward a behavior.

Dr. Lawrence Diller at 12:43pm ET They are not mandates or blueprints. There is much evidence that states a child's brain is very plastic for the first several years. Except in extreme situations, environment can make a difference. Once again this is neither nature or nurture, it's both.

JL Brown, RN at 12:44pm ET Dr. Diller, I am a school RN. During the last several years I have seen a dramatic rise in the numbers of psychoactive medications prescribed for the behavior and attentional difficulties children seem to be having in school, at home, and in the community today. As a school nurse, I find myself playing a somewhat hypocritical role. I recognize that these stimulants and other medications have potential to cause harm, and that there is no scientific evidence that there are any long-term benefits,yet it is extremely difficult to go against the popular wisdom of the medical profession and speak out against this process of drugging children. What advice would you offer to school nurses who find themselves in this very uncomfortable position?

Dr. Lawrence Diller at 12:48pm ET I wrote Running on Ritalin to address a very similar professional, ethical dilemma. At least with Ritalin we have some evidence of its efficacy and safety. Virtually every other psychoactive drug now being used in children has no evidence for either. But even with Ritalin, if I only prescribe the drug and not speak up about the larger social and cultural factors involved in the diagnosis, then I become complicitous with forces and values that are harmful to children and families. The Ritalin phenomena is only the tip of the iceberg for what we expect from our children and what we offer them, their families and schools. As a society we seem to have decided the problems are only in their brains which can be corrected with psychoactive drugs. The solution to my ethical dilemma is to continue to prescribe medication to help round or octagonal peg children fit into square educational holes, but to also speak out about the social conditions that have led to this situation.

Moderator at 12:49pm ET Thanks for your time today Dr. Diller. Any final thoughts?

Dr. Lawrence Diller at 12:52pm ET I appreciate everyone's interest about ADHD and Ritalin. Realistically however, I think Ritalin and other psychoactive drugs for children will remain popular in this country until the values of our society change. There is an intolerance of temperamental diversity currently, yet it is that very diversity that has made our culture rich and worthy. Thank you again for your interest and if you would like to be in touch with me further please check my website: www.docdiller.com. And thank you ABC for this opportunity.

Moderator at 12:54pm ET Dr. Diller is the author of Running on Ritalin. Thanks for all the great comments and stay with ABCNEWS.com for more chats as we look at America's Sons. Copyright ©1999 ABC News Internet Ventures.


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