Presented in Italian to XIV Congresso Nazionale dell'Associazione Culturale Pediatri
(14th National Congress of the Cultural Pediatrics Association)
Rome, October 10, 2002
Thank you. Thank you very much for your very warm and generous introduction. You know, when Dr. Sarno first proposed this presentation to me earlier this year we debated whether it should be simultaneously translated which would be slower and more expensive than my giving the speech in Italian. I have a background of seven years of highschool and college French and then I studied Italian seventeen years ago when I last came to Italy with my wife. We spent seven weeks in your country. We had a wonderful time and speaking Italian made the trip so much more enjoyable.
But when contemplating giving a formal presentation in Italian I was hesitant. But then I remembered I had some previous experience with a formal presentation in another language when I was thirteen years old. When a Jewish boy reaches that age he must sing a lengthy portion of the bible written on parchment paper scrolls in the original Hebrew language without any vowels or musical notation before his family, friends and the entire congregation. I realized compared to that presentation, today's presentation in Italian will be easy. At least I don't have to sing today (and you don't have to hear me sing either). Excuse me then while "Io mastico l'italiano" and go on.
A Personal Journey
I have practiced behavioral-developmental pediatrics in America for nearly twenty-five years. I was initially trained as a pediatrician but right out of my residency I spent an additional three years studying child development and behavior and family therapy. In the 1970s there were only three fellowships in the U.S. teaching behavioral-developmental pediatrics. Now there are nearly sixty. There are probably two thousand such trained pediatricians in the U.S. There is a Society for Developmental and Behavioral Pediatrics and a similarly titled Journal.
By the early 1990s nineties I already had been evaluating and treating children for behavior and performance problems and prescribing Ritalin for fifteen years when I began to experience an entirely new phenomenon. Much less disabled children with less severe problems were being brought to me by their parents often at the urgings of their teachers for an evaluation of attention-deficit/hyperactivity disorder or ADHD. These children were both younger and older than the previous generation of mostly elementary school age boys I had seen before. Oh, and there were many more girls too, being brought in for evaluations.
I found myself prescribing more and more Ritalin. I began to feel uncomfortable with my role. My efforts to address my own professional ethical dilemmas ultimately led to the publication in 1998 of my first book, Running on Ritalin: a Physician Reflects on Children, Society and Performance in a Pill. I was surprised by the response to my book. Apparently I wasn't the only one concerned about what was happening in the United States over ADHD and Ritalin. I found myself in the center of a maelstrom of debates, national TV appearances, even appearing before the U.S. Congressional House of Representatives as an expert witness testifying about Ritalin.
Now the ADHD/Ritalin issue has traveled beyond the borders of America. In 2001 I wrote an article entitled "Coca-Cola, McDonalds and Ritalin," which appeared in the French Journal, Enfances et Psy. The article was subsequently translated into Finnish and then into Italian for the Italian journal, Informazioni sui Farmaci, by your own Dr. Bonati. It is because of him and the officers of the Associazone Culturali Pediatri that I appear before you today.
The Prevalence of Stimulant Use in America
I would like to trace briefly the history of the diagnosis of ADHD and the use of stimulants for its treatment. But first I want to share with you some statistics to get a sense of just how rapidly the diagnosis and treatment grew in the nineteen nineties in the States. It is actually difficult to know just how many children have been diagnosed with ADHD in America. However a reasonable marker for the disorder is its treatment -- stimulants -- since the other indication for these drugs, narcolepsy, is only rarely diagnosed in America.
Between 1992 and 2000 the legal production of methylphenidate (Ritalin) increased by 730 per cent to over fourteen thousand kilograms annually. The increase for amphetamine (which is marketed primarily as the drug, Adderall) was an astounding 2500 percent (this was in part because of the massive advertising campaign promoting Adderall to doctors and patients). Over ten thousand kilograms of legal amphetamine are produced annually in the U.S. I emphasize legal, because there are vast quantities of illegal stimulants also produced in the U.S., mostly methamphetamine and sold on the streets as "speed or crank." As you will see America loves stimulants (legal or otherwise). The current legal market for Ritalin and similar drugs in the U.S. is estimated at one billion dollars a year for the pharmaceutical industry.
I guess between four and five million children under eighteen take stimulants today in America out of population of about eighty million youngsters. This represents approximately five to six per cent of all children but as we will see in a moment there is wide variation in use geographically and ethnically within the U.S.
America uses eighty per cent of the world's stimulants, down from ninety percent just four or five years ago. That's because other countries are beginning to catch up. Most notably Canadian rates are very similar to those of the U.S. (it is said "Culturally, when the U.S. catches a cold, Canada develops pneumonia."). But rates are climbing in Australia, New Zealand and Great Britain. In other countries, like France and Italy rates of Ritalin use appear to be one twentieth those of the States. In all of Finland only a few dozen children take stimulants.
Even in the U.S., rates vary widely. The more prosperous homogeneously white states (like in New England or the mid-west) use five times more Ritalin per capita than Hawaii. African Americans use Ritalin at one half to one quarter the rates of their economically equal white counterparts. However there are pockets of extreme use also. In at least two communities in the southeast U.S. (Virginia and North Carolina) between one in four and one in five ten year old white boys use Ritalin. Even the most vigorous proponents of medication admit this is way too high and are perplexed and worried by such reports. In the United States, the ADHD/Ritalin epidemic is primarily a white middle/upper middle class phenomenon.
Finally one must look beyond simply the overall number of children taking Ritalin to explore just who is taking the medication and why. Perhaps the most telling survey was the largest to examine community use (not academic center) of the drug. In over three thousand children the study found the overall use of Ritalin to be about five per cent which is about the estimated prevalence of the disorder at least as defined in the U.S. However a closer inspection of these children on medication found that about seventy five percent of those children with clearly defined ADHD were getting medication but over half of the entire group who were prescribed Ritalin did not meet criteria for the ADHD diagnosis. Conclusion: in the real world of office pediatrics and psychiatry many children for a variety of problems are being given performance enhancing stimulants with or without a clearly defined diagnosis of ADHD.
The roots and causes of the American ADHD/Ritalin epidemic are worth exploring because they say much about American culture and the way we view and treat our children's problems of behavior and performance. Whether other countries will find our example worthy of emulation remains to be seen but for the moment let me briefly outline some early history of this problem and its treatment.
Notable Dates in the History of ADHD and Ritalin
The English physician, George Still, in 1902 wrote the first modern description of the condition we now call ADHD. Even back then he highlighted problems of impulsivity, distractibility and hyperactivity in children; symptoms called by Russell Barkely, the American intellectual guru of ADHD, the holy trinity of this disorder. Still felt the causes to be primarily neurological but offered no treatment other than good discipline.
Then next major event took place in 1937 in America when Charles Bradley accidentally discovered the concentration effects of stimulants on children. He was a doctor in charge of a foundling home for children with neurological and behavioral problems. In the course of his evaluations the children were often given spinal taps and later complained of headaches. He thought stimulants might ameliorate their headaches. The headaches didn't get better but the teachers and the kids themselves noted remarkable improvements in their hyperactivity and schoolwork. The stimulants, Bradley wrote, "appear" to have a paradoxical effect on these children in that the amphetamine seemed to calm them down. Bradley was quite clear with the knowledge that stimulants in low doses have this similar effect on everyone. However, soon an incorrect myth developed that is still held in even many professional circles that the stimulants work differently on the brains of hyperactive children to calm them down.
In fact they don't work differently. But soon doctors were using a trial of stimulant medication to "prove" a child had hyperactivity or ADHD. To disprove this absolutely false proposition, Judith Rappoport of the National Institute of Mental Health in Washington DC in the late 1970s first gave amphetamine to normal adult volunteers and found their performance improved on repetitive boring tasks. It was technically ethically dubious to give stimulants to normal subject children so Rappoport sidestepped this issue by given stimulants to her children and the children of her colleagues, none of whom had ADHD. All their performances improved by rates equal to those children who were compromised by ADHD. The normal children's performance became simply supranormal. These studies should have finally destroyed the myth of the paradoxical and diagnostic effects of stimulants on ADHD children. But unfortunately, still today, even in the U.S. (and probably more in Europe where there is less experience with these drugs) the myth continues even with doctors and psychologists that the stimulants work paradoxically on hyperactive children
The next major historical date is 1980 when the third version of American psychiatry's bible, the Diagnostic and Statistical Manual of Mental Disorders or DSM Three (III) was published. This document was originally designed primarily for psychiatric research purposes. It quickly garnered use as a clinical diagnostic manual and even more importantly it became the sole instrument for the financial reimbursement of psychiatric services in America. With the publication of the DSM Three American psychiatry culminated nearly fifteen years of inner turmoil and ultimately revolution from Freudian dogma and organizational control which had ruled American psychiatry for the previous fifty years.
At the risk of ridiculous simplification the Freudian model posited that problems developed as a result of inner conflicts generated by experience and particularly by a failure of the child's mother to adequately meet the psychological needs of her child. The DSM Three avoided any etiological basis for diagnosis and returned to descriptive lists of symptoms similar to the work of Emil Kraepelin of Germany in the late nineteenth century. Unbeknownst to most readers was a last minute deletion from the DSM Three text where the authors (the current leaders of American psychiatry) stated their belief that the causes of most of these disorders were biologically based. Indeed, within just a few years after the publication of the DSM Three, American psychiatry declared that Luigi's mother was no longer responsible for Luigi's problems. In fact Luigi, himself, wasn't responsible either. It was Luigi's brain, his genetic heritage and biochemistry caused his poor behavior, including ADHD.
However, the DSM Three alone did not cement this notion of biological culpability with the American public. The introduction of Prozac, or fluoxetine, in 1988 did it. Prozac was not especially more effective than the older versions of tricyclic anti-depressants it eventually replaced. But Prozac was far easier and safer to take so that many more adults with only minor depressive symptoms were willing to take the drug and felt better. As less disabled citizens benefited from Prozac, the stigma of taking a psychiatric medication lessened. Since the drug lessened the symptoms of depression soon the notion that it was correcting an inherent "chemical imbalance" in the brain became a fashionable way of looking at all behavioral disturbances including ADHD.
The Illogic of Biological Reductionism: Blaming the Brain
A moment's digression to address the fallacies of biological reductionism (to use a fancy term) regarding psychiatric disorders in children and adults -- somehow the response to Prozac led to the conclusion that sufferer's of depression had an inherent brain chemical imbalance that was relieved by the addition of Prozac. However, we take aspirin or Tylenol for headaches, but no one says headaches are caused by an "aspirin deficiency." As yet no biochemical abnormality has been proven to cause a psychiatric disorder. Furthermore, the focus on biological causes misses the critical interplay between genetically derived constitution and the environment.
For instance with PET, MRI and SPECT scans, we are getting increasingly good real-time pictures of the brain in operation. In ADHD, the prefrontal cortex is often implicated when there are problems of impulsivity and hyperactivity in children and adults. The brains of the ADHD children are said to be different anatomically or function differently as documented by these brain scans. However, these scans cannot distinguish between an association and causation. The brain is a plastic organ. There are also now many brain function and brain scan studies that show the brain changing as a result of experience or psychological treatment. No one can say whether the differences in the brain scans of ADHD children are the cause of their problems or the result of several years of experience with the problems of their behavior associated with ADHD or its treatment. In fact, with nearly all these children on stimulants, one might say (and there are radicals anti-drug advocates who do say it) that the changes in the brain are the result of the drugs being given to treat the condition and not the condition itself.
Along similar lines much has been made about the genetic origins of ADHD. Both Joseph Biederman of Harvard and the aforementioned Russell Barkely have promoted extensive pedigrees of well-screened individuals purporting that the heritability factor of ADHD is nearly the same as that for adult height. What the researchers fail to acknowledge is that the line between behavior which is merely an extreme of normal temperament and that, which is deemed pathological, is culturally determined. Of course biological susceptibility in the form of personality may make one child more prone to develop the symptoms of ADHD, but genes are not destiny and who has or hasn't got ADHD is still culturally determined.
Another way of putting it, draws from our next speaker's subject. A better tape measure will not necessarily help determine who does or doesn't have a problem with their short stature. Except with extreme ADHD, whether impulsivity and hyperactivity are problems will be determined within the context of family, school, neighborhood and culture. In their prodigious efforts to jettison the Freudian model, American psychiatry seems to have forgotten these fundamental notions. The dangers to children and the society of these illogicisms and reductionisms will be elucidated shortly.
A final word on the ADHD diagnosis as per now a revised fourth generation of the DSM published in nineteen ninety-seven called DSM Four. We still have two lists of symptomatic behaviors. One is a form of ADHD that includes hyperactivity and impulsivity and one is a type of ADHD that includes only inattentive and distractible behaviors. Some examples from either list are, "often has difficulty sustaining attention in tasks or play activity," "often does not seem to listen when spoke to directly," "often fidgets with hands or feet," or "often talks excessively." If you meet six of nine symptoms from either list of hyperactivity or inattentive symptoms then you technically meet the criteria for the disorder or "have" ADHD.
Couple of problems though -- just how many fidgets is too much? What does "often" mean exactly, or "excessively"? Who determines this? Where? And Why? While two doctors on a university research team may agree on standards we find over and over again in real life not only with doctors but also with parents and teachers that there is a wide range of opinions and differences over these observations. One then finds both under and over diagnosis of ADHD and stimulant use depending on the community you assess and your own standards and prejudices. The reality is that except in extreme cases, ADHD remains a diagnosis in the eye of the beholder.
Social, Cultural and Economics Factors Associated with the Ritalin Boom
So returning to the theme of why this explosion of ADHD diagnosis and stimulant treatment in the U.S. during the 1990s, a growing host of combustible social factors were in place when an event in 1991 lit the match which detonated the explosion. First the educational and social demands on children had been increasing since the 1970s. Younger and younger children are asked to learn more and at an earlier age. Today three and four year olds are expected to know their letters and numbers and five-year-olds are expected to read. America's leadership in technology age has led to a premium placed upon a technological education. All children are expected to attend a four year university and maybe more. The competition for spots at the university is intense and often the cause for much stress in high-school age children. Of course the rat race doesn't end there.
Because at the same time America's parents are working more and not available to their children. The most telling statistic is that in 1970 only one in three mothers of children under five were working full time. By 1998 more than eighty per cent of mothers were working in addition to the fathers working longer hours. In other words despite America's economic boom of the nineties, the standard of living in this country actually declined over thirty years because it now takes both parents' incomes to maintain living standards where it used to take only one. For American children, this meant not only more and earlier structured childcare but no one to supervise Luigi's homework or behavior after school. And when they are home Luigi's parents were more tired and less likely to follow through with discipline and also fun activities.
Discipline is a touchy subject in America (no pun intended -- corporal punishment is increasingly frowned upon even within the home). But discipline in America has been eroding for one hundred and fifty years since families left the farm and children first entered the industrial work force and then school (especially when high school became nearly universal). But American parents urged on by "experts" in child psychology in recent years have become particularly leery to just say "no" without some explanation to avoid conflict with their children. But this form of cognitive parenting is especially poorly suited for the personality of our friend Luigi. Just try talking to ADHD Luigi. Why he's halfway down the street before you've finished your first sentence. But in twenty first century America, it seems parents are more ready to give their kids pills for behavior rather than giving them a swat on the rear.
The spark that ignited all these building social factors was a change in the federal educational disability laws in 1991. Under pressure from citizen self-help groups (later we learned they had major financial support from the drug industry -- more on that in a moment), the government added ADHD as an eligible diagnosis for special services in school to a list which included vision and hearing impairments, cerebral palsy and dyslexia. Once parents learned their children could get extra help at school for this condition they flocked to their doctors for the diagnosis. Teachers also found that difficult, poorly motivated or unruly kids improved on stimulants and they too urged parents to get the diagnosis for their children. In this way the ADHD epidemic and boom in Ritalin began in the United States a little over ten years ago.
Other economic factors have played a role. During the nineteen nineties major efforts to reign in the cost of health care in the U.S. led insurance companies and employers to adopt managed health care insurance plans which many referred to cynically as managed "health cost" plans. These plans ostensibly offered doctors a regular supply of patients if the doctors could keep their patients' health costs down. These arrangements only exacerbated the economic pressures on doctors to see patients quickly. And it's faster to offer a pill for ADHD than to explore family dynamics or place a call to the teacher at school.
The Influence of the Pharmaceutical Industry
Finally, the role of the pharmaceutical industry cannot be underestimated in its influence on the way American's think about themselves and their children. While I doubt there was any real conspiracy between doctors, the self-help groups and the drug companies, you don't need to have a conscious plan when, as the eighteenth century English economist Adam Smith wrote, the "invisible hands" of capitalism and profit are at work.
I already mentioned how the makers of Ritalin secretly funded the main patient self-help group as they successfully lobbied their government to change the status of the ADHD diagnosis. This same organization, CHADD (Child and Adults with Attention Deficit Disorders) again with the assistance of drug company money was nearly successful in eliminating the governmental controls on the production of Ritalin. In the U.S. Ritalin production is tightly regulated by the Drug Enforcement Administration (DEA) because it along with all of the stimulants is highly abusable. CHADD backed off (the DEA was prepared to fight) only when the news of the drug company money came to light in a TV news documentary and a potential scandal of conflict of interest and hidden advertising surfaced.
The drug companies have exerted their influence in other ways. Most of the money for ADHD research comes from pharmaceutical companies who are more interested in short term symptom and pill counting rather than exploring quality of life issues. Studies rarely last beyond two to three months. There is no systematic long-term follow up for positive changes or side effects. Researchers whose drug studies yield no positive changes or reveal potential side effects are discouraged or prevented from publishing their findings. Research studying psychosocial effects and interventions on ADHD suffer from a relative dearth of funds dependent primarily on the government money.
You should also be aware, as Western Europe has been targeted as the next major stimulant market by the drug industry, that virtually every ADHD expert in the United States has some financial affiliation with one or several drug companies. This conflict of interest has become so ubiquitous in the States that academic institutions and journals have resigned themselves to the situation because otherwise there would be no one to give the presentations or write the articles. The collapse of the U.S. stock market has brought to our attention news of repeated corporate financial scandals. One cannot avoid the parallel between the discredited accountants and stock analysts with their close ties to the very companies they were assigned to scrutinize and the doctors who do research for the drug companies. The work of ADHD experts and researchers with major financial links to the drug companies should face similar questioning.
But perhaps the most alarming and pernicious drug company influence comes in the form of advertising and promotion. For years doctors in the U.S. have been inundated with professional magazine ads, drug salesman visits, free samples for patients and more recently monetary inducements to attend "educational" seminars or act as consultants for meetings that aren't anything more than promotional events for a new drug. A recent relaxation of advertising rules has allowed the drug companies to advertise their products directly to the consumer, the patients. Ads for anti-depressants or anti-anxiety agents regularly appear on television (as do ads for Viagra, the male potency drug). The drug companies that market stimulants for children were planning a major television campaign but it was suspended after adverse publicity appeared in two national newspapers (I modestly admit a role in these reports).
Here's what I'm worried about. Take a look at these two ads that appeared in women's magazines in the States. In the first, you see this picture of the smiling boy holding the pencil. His parents are on either side of him beaming. In the background his sister is also all smiles. Why are they smiling? Because as the caption reads, "Homework is no longer a problem at the Williams' family home." Why? Because they've learned their son has ADHD.
So what's my problem with this ad. It reduces a fairly complex developmental-social undertaking, homework, to solely a problem with the boy's brain to be solved by taking a pill. It diminishes the importance of other non-drug interventions by parents, teachers, school counselors or family therapists. Look at the next ad. Here we see the picture of a costumed super-hero saying "Look kids, I'm here to save you," touting the virtues of a new long acting stimulant drug. It was this ad that aroused the U.S. citizenry. It is very reminiscent of a highly criticized -- now defunct -- cigarette smoking campaign directed to teenagers and children using a cartoon character, Joe Camel for the cigarette brand of the same name.
But you can see how the efforts to promote a broader biopsychosocial view of the ADHD problem are dwarfed by the economic clout of the pharmaceutical industry. Unfortunately there are no stock dividends or equity for promoting special education teachers or family therapists. The drug companies now spend nearly twice as much on their advertising budget than they do on new drug research which has been their main justification for the high prices they charge for the new drugs.
Why America?
Now I'd like to spend a few minutes discussing why the American culture, in particular, is vulnerable to an epidemic of stimulant use in their children and increasingly in the adult population too. Listen closely, because what follows is a primer of the best and worst America has to offer you. Why does America use eighty per cent of the world's stimulants?
One theory I reject I call the "presto-tempo" theory of ADHD. It posits that it is the fast paced over stimulating life in America -- the constant TV, video games, the commercials, and fast cars -- that produce an overabundance of children with ADHD who then need stimulants to settled them down. But why then are there not similar rates of children on Ritalin in Tokyo, London and Milan -- not exactly backwaters when it comes to sensory and psychological stimulation.
America is unique in how it rewards work effort with monetary success. There is much more economic class mobility in the States than anywhere else. Everyone potentially can be the next Bill Gates. Ironically this creates a tremendous pressure on all children and their parents to aim high for the four-year university even though many are neither temperamentally or intellectually suited for this path.
Then there are consistent and inconsistent cultures. A consistent culture demands across the board self-sacrifice for the sake of group conformity and group adhesion. An inconsistent culture promotes self-interest, spontaneity and freedom of self-expression while demanding conformity at school. The best example of consistent cultures are the westernized Asian countries like Japan, Hong Kong or Singapore where Ritalin use are virtually non-existent. As you might guess, the most inconsistent culture is that of America. Western Europe falls somewhere in between the two extremes. But in the States we deliver a mixed child rearing message to parents and teachers especially about discipline and the results for the temperamentally borderline ADHD child is to push him into overt symptomatology.
But perhaps the most profound and central cultural factor influencing the ADHD/Ritalin epidemic in the U.S. is our state religion. In Italy, you have Roman Catholicism. You didn't know we have a state religion in America? Why it's corporate consumer fundamentalism. It's the belief that through material acquisition (buying stuff) you will achieve emotional and spiritual satisfaction. This credo is announced from the electronic pulpit every twelve minutes with each television commercial a person sees from a very early age. Our state religion has led us to have an obsession with performance at all costs for monetary gain. Performance at work, performance at school, performance at home. This performance can be achieved if necessary by taking a pill, whether it's Ritalin, Prozac or Viagra. This vision to me, personally, is an empty promise, morally bankrupt and ultimately dangerous to society -- but in the near term it prevails with the help of vested economic and political power interests. Unfortunately, I see no changes in sight, short of another major catastrophe like September Eleventh or another Vietnam War. Ritalin will remain popular at least until then.
A Complete and Ethical Evaluation of and Treatment for ADHD
So what is the ethical American physician to do? Children with problems will continue to present to the doctor -- and changing American society in the short term is highly unlikely. I would briefly like to run through what I feel constitutes a complete and ethical evaluation of ADHD in children. I am nearly done with my talk. I will go through this section quickly -- for a full description I urge you to try to read Should I Medicate My Child? which is only in English.
I am interested to help the child. I am also interested in the child's brain like so many of my bioreductionistic colleagues. However, this brain does not operate in isolation. A child's brain becomes a problem when the expectations for that brain or the responses to it are out of sync with what that brain can deliver. So I am interested in both the child's brain and his or her world.
I like to meet the parents first for an hour without the child present. I emphasize meeting with both parents by which I mean especially having the father involved from the beginning. I make a big point of this because too often it is only the mother who is interviewed in the studies we read about in ADHD. But the fathers obviously play a critical role and have an important point of view to hear about. I cannot go into all the other reasons right now why it's so valuable to have the dads involved except to say it's my experience that I use far less medication with children when the fathers are involved in any treatment plan. And when I do decide to prescribe medication it is also more successful because the father fully supports that intervention also.
After I meet the parents, I like to meet the child the first time with his entire family. I cannot overemphasize the value of this type of meeting for me. It is probably the single most useful encounter I have with the child (meeting him with his family) but unfortunately such meetings rarely take place in the typical ADHD evaluation mostly because of logistical and ideological barriers.
In the family meeting I see in real time how the child acts and how the parents respond. I also see the role of the siblings and can make better inferences on how the parents work or don't work together. How often in 25 years, have I seen a situation where the family comes in because eight year old Luigi is having trouble in school for supposed ADHD. I meet the family and watch four year old Louisa leave tracks on the ceiling while Luigi sits quietly on the couch as his mother chases his sister ineffectually around the room (father by the way is doing nothing except criticizing his wife for her ineffectiveness). Even more astounding is that I never would have learned of this situation from the parents' interview, because they never even mentioned Louisa as a problem. Luigi was their problem because he was in school and the school was complaining about his behavior.
Then I meet Luigi. Depending on his age -- actually for children five and under I might only perform a developmental assessment -- but for older children we talk for a while and often play with some toys or a game too (children show different behaviors while playing and also express themselves through play - I say this even though I am emphatically not a Freudian). I then do what I call academic/developmental/neurological screening. I take about thirty minutes to do this because learning and neuroprocessing disorders are so common a cause for becoming distractible or are simply associated with hyperactive behavior.
I do not use any formal intelligence test. This would take too much of my time. My job is to screen for learning problems and turn things over to the school psychologist for more testing if one appears. I check on the child's reading, writing, spelling and math abilities. A check of auditory processing is critical because so many children with a fundamental problem with auditory processing (following directions or understanding a lecture) are referred for an ADHD evaluation because they appear lost and distracted in the classroom.
I was trained to do a very detailed neurological examination with much attention paid to an elicitation of soft neurological signs. But over the years I found these signs to be less valuable. Indeed studies show they are not consistently related to the ADHD diagnosis. So my neurological exam focuses on gross and fine motor coordination which if weak can be a problem especially for boys in the playground.
All children should be tested for vision and hearing acuity. This is done routinely in our schools. A general physical exam is necessary only if one hasn't been performed on a routine basis or there is something else in the history to suggest a clear organic problem. There are no laboratory tests that yield useful results in an ADHD evaluation except if chronic lead intoxication is a worry based upon where the child lives. No blood test, electroencephalogram (EEG) or brain scan will be useful. A range of "alternative medicine" theories abound in the U.S. on ADHD encouraging families to obtain allergy testing or hair composition analysis (looking for rare metal deficiencies). None of these have proven valuable and are considered fringe practices in America.
It is critical to get information directly from the teacher. I prefer to call the teacher on the telephone and chat for ten to fifteen minutes learning about the child and the teacher, herself. I diverge from my academic colleagues in eschewing the use of parent and teacher questionnaires. The most popular in the U.S. were developed by Connors and Aschenbach. They are popular because they are fast, convenient and available for standardization. But I have two problems with the questionnaires. First they ask only negative questions about the child like: "How much does he fidget?" or "How much does he disobey?" It puts the respondent into a negative mindset to look for more problems with the child. I prefer to ask "Tell me about this child's strengths and weakness, academically and behaviorally."
My second problem with child problem behavior checklists is that you learn nothing about the people who are filling out the forms, especially the teacher -- how she runs her classroom, how she maintains discipline, whether or not she uses tangible rewards like stickers or candy in the classroom. Also what are her attitudes about ADHD and medication? You'd be surprised on the range - especially those teachers who are vigorously promoting the ADHD diagnosis and treatment often because they or their own children have taken medication.
In addition to inquiring about the child's strengths and weaknesses, I also ask the teacher about the child's peer relationships -- another important area of problems for kids with the ADHD personality. If there are other important figures in the child's life -- tutor, psychotherapist, even baseball coach I might also give them a call -- because I'm trying to get the broadest picture of this child in a multiple of settings.
After I've collected all this information I sit down with both parents without the child present and we talk for an hour where I share my ideas of what I think is going on and develop a plan with the family. If I think it is useful I will invoke the ADHD diagnosis. But often I find it is just better to describe the child in terms of his strengths and weakness, the optimal responses to him and come up with a comprehensive plan.
The plan virtually always includes advising the parents in their parenting approaches to the child. Here already I move into a bit of family therapy, for simply giving the parents suggestions without understanding their psyche and relationship is rather like giving advice through a book or the internet. I make myself available to them for further counseling if it seems necessary.
There is always a plan for the school too. Very often there is a need for further testing to delineate the learning problems or justify the need for special services, educationally or behaviorally. The school is bound by law to provide them but fiscal limitations and the parents' lack of knowledge about their rights often leads to under treatment unless the doctor is actively involved.
I prepare a short summary report of my evaluation and recommendations but far more valuable is a visit to the school, if necessary, to meet with the school personnel and the parents together to develop a plan for the child. I don't do this with every child but probably attend about thirty of these meetings a year. Parents have repeatedly told me the sixty minutes at the school was the single most valuable hour I spent for the family.
And I prescribe medication. In extreme cases I may recommend using medication immediately along with the other interventions. But most of the time I feel it's worth giving the behavioral/educational plan a good try -- often for at least three to four months. At that point if the child continues to struggle behaviorally or academically I will then consider a medication trial. My guess is about one third of the children who see me (and I see a more difficult population than the general pediatrician) end up taking medication. This compares to the ninety per cent of children who wind up on drugs when they go to the average child psychiatrist in America today.
The Ethics of Ritalin and the Intolerance of Temperamental Diversity
It's not that I don't believe that Ritalin and the stimulants work. Study after study has shown that they improve focus and reduce impulsivity on the short term. Behavior and grades often improve. Actually, my concern is that stimulants DO work -- on everyone non-specifically to improve performance. However, that Ritalin works, does not make it a moral equivalent of or substitute for better parenting or teaching. But Ritalin is certainly faster and cheaper and makes for an attractive choice.
Long term results from Ritalin are another story. Despite nearly seventy years of use we still aren't sure if using Ritalin makes a difference. Studies from the 1970s and 1980s concluded it was less important that special education and family counseling but these conclusions were criticized because the patients followed until late adolescence were not randomized. Such a study can no longer be done in the States because withholding Ritalin for a control group at this time would be considered unethical medical practice by American standards. Perhaps some courageous and determined European doctors will answer the questions over the long-term value of stimulants. Personally I have my doubts.
Returning to the ethics of Ritalin, Dr. Biederman of Harvard questions whether the U.S. has the resources to address all the educational and behavioral needs of America's children without the increased use of Ritalin. To that I have a "modest proposal" along the lines of Jonathan's Swift's eighteenth century satiric essay which suggested the answer to the Irish famine was to feed the children to the adults simultaneously reducing the population and providing food. My modest proposal goes as follows. With about four million children taking Ritalin in the U.S. and classroom size averaging twenty-nine kids per class why not increase the number of kids taking medication to seven and half million and we could probably increase classroom size to forty children per class and in the process save a lot of money? So far no one in the States has taken me up on my offer.
But perhaps it's only a matter of time. In America today, I have little doubt that if Mark Twain's folk heroes of the nineteenth century, Tom Sawyer and Huckleberry Finn presented to a doctor's office, they would eventually leave with prescriptions for Ritalin. Huck Finn might actually leave with two or three drugs. But I've wondered what if Huck took his medication? Would he have helped the runaway slave, Jim, escape as he does in the Further Adventures of Tom Sawyer? Or would he have been sitting in class dutifully copying his alphabet, saying "Yes, ma'am." or "No, ma'am." to his teacher.
Indeed, in America today we have an intolerance of temperamental diversity. Every child's personality, whether round or octagonal peg, must fit into the same square educational hole. Ritalin will help squeeze that child in. What we've lost is an appreciation for the differences of personalities and talents that have made American culture the envy of much of the world. On the short term I will continue to medicate children who are being crushed by a combination of rigid demands and waning social supports. But if I medicate and do not I continue to speak out about the social and economic factors working against children and their families then I become complicit with values and forces that are harmful to children.
In America today, I feel very much like the prophetess, Cassandra, of the Greek and Trojan Wars who had the gift of foretelling the future and the curse that no one believed her predictions. So, to you Italian professionals who will be manning the gates of Europe and making decisions in the next years as to who should and shouldn't receive Ritalin -- Remember, I warned you. Beware of Americans bearing gifts.
Thank you, thank you all for inviting me and listening to me today.