January 5, 2001

Hear No Evil, Speak No Evil

As a behavioral pediatrician in California for over twenty years I have evaluated children for ADHD and prescribed Ritalin. Beginning in the 1990s the great growth in rates of the diagnosis and treatment of ADHD led me to question my own role as a physician. To address my own professional ethical dilemmas I analyzed the social, cultural and economic factors involved in Ritalin use in America. My efforts became the basis for a book Iíve written on the subject.

Along the way sympathetic colleagues warned me that I risked offending various groups that had a vested interest in viewing ADHD as a biological disorder and Ritalin as the treatment of first choice. While I strongly believe that biology (heredity, brain chemistry and medication) plays a crucial role, I also think that biology isnít the only important factor contributing to the problems of living an ADHD life.

Despite my careful effort to avoid blame and offense, there are those who have been hurt and are angry with my attempt to explore the larger world of ADHD. I feel badly about these upset feelings and Iíve tried hard to understand why asking questions about ADHD and Ritalin is so difficult. Hereís my best guess.

Iíve never met parents who when initially presented with their childís difficulties immediately embraced an ADHD diagnosis and Ritalin. Virtually all parents decide to medicate their child only after a good deal of ambivalence and reluctance. Most parents have persevered with other avenues and efforts for months or years before deciding upon Ritalin. Yet a stereotype of parents who abdicate their responsibility and demand Ritalin for their child continues to exist especially when ADHD is discussed in the media.

All the parents I know (professionally and socially) love and feel responsible for their children. When their children do not perform well or misbehave parents feel responsible. With persistent difficulties they (and their children) feel like they have failed and some feel guilty. Freudian psychological theories which dominated American thinking until the1980s added a professional stamp of science to the notion that it was the parentsí fault.

In the last twenty years the biological basis for behavior has become the reigning ideology in American psychiatry. Doctors no longer blame Johnny or his mother for his misbehavior; they blame Johnnyís brain. Apart from the common sense that personality plays a role in behavior, many parents are attracted to a view of child behavior that fits their perceptions. Parents and grandparents knew intuitively long before temperament researchers proved in the 1950s that every child is born with a unique personality. But psychiatryís shift to the biological view did much to distribute or alleviate some of the parentsí sense of responsibility and guilt for their childís situation.

Yet even as researchers and CHADD declared ADHD a neurobiological disorder, the larger society continues to have its doubts. The view has been attacked mostly in an either/or, nature vs. nurture way and once again parents, teachers and doctors are blamed. Some critics suggest a conspiracy that employs drugs to control American children. It is easy to understand, given these attacks, how a defensive, even bunker mentality can evolve as a protection against such challenges.

The truth is that parentsí sense of responsibility and sadness continues even when they adopt the view that ADHD is biological. Iíve tried very hard not to blame anyone in my quest to answer my own questions about my role. I realize that when I raise questions about the large rise in Ritalin use in our country I may stimulate a reaction that is an attempt to protect hurt and raw feelings about family and parenting. Some people respond angrily.

It would be unfortunate if the questions couldnít be asked nor a dialogue developed for fear of offending. Potentially important aspects of having ADHD and treating it might not be addressed to the detriment of those particular families suffering with the condition. Indeed, some important issues may be missed for all the children of America because the conditions that fuel Ritalin use in America say a great deal about how we view childrenís problems and how we allocate resources to them, their families and schools. I believe the leaders and parents of CHADD are strong enough to entertain a dialogue on ADHD and Ritalin which considers other views. I look forwards to the process.


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