December 30, 2013

My Uneasy Marriage to Ritalin

Posted first: 12/23/2013 12:44 pm on the Huffington Post (

I've been uncomfortably married to Ritalin for 35 years. That's how long as a behavioral pediatrician I've been prescribing stimulant drugs like Ritalin, Adderall and Concerta to children and adults in my suburban private practice outside of San Francisco.

Prescription stimulants, which are all a version of amphetamine, have been controversial since their introduction in 1929. They are front-page news again. This Sunday's New York Times offers a detailed report on the role of drug companies' influence through advertising, medical education and research on attention deficit disorder (ADD) and its treatment. Today one in seven American children have been told they "have" ADD.


The pharmaceutical industry did not come up with the idea of using drugs to treat children's problems of behavior and performance. Doctors did. But several large drug companies in the mid-1990s grabbed this ideological football and ran with it. Five years later, these companies had become the dominant influence in the way we Americans think about children's mental health and school performance.

The "f" word in my practice is not four letters -- it's five for "focus." Parents and teachers attribute virtually every type of children's misbehavior or underperformance (especially in school) as a problem of focus or attention. Does he or she "have" ADD is the daily question. The ADD diagnosis is technically categorical -- either you have it or you don't. But in reality the qualities of distractibility and inattention fall across a spectrum of ability/disability that follows a bell-shaped curve.

There are no blood or brain scan tests for ADD. At one extreme are children whose personalities and behavior are so shaped by neurological and biochemical factors that there is little question they meet the behavioral criteria for ADD and benefit from medication. However, by virtue of the bell-shaped curve, the vast majority of children receiving the ADD diagnosis are of the mild variety. There, abnormal behavior blends into variations of normal and controversy rages on whom should be treated with drugs.

Relatively speaking, the stimulant medications when used properly are safe and improve short-term performance in behavior and grades potentially for everyone (child/adult, ADD or not) who takes them. However, for mild or moderate ADD, non-drug interventions like parenting strategies, behavior modification techniques and special education also work. The drug approaches prioritize efficiency and cost. Non-drug interventions prioritize engagement with the child. School systems and insurance companies value the former. Parents and most teachers prefer the engagement strategies. But too often when parents are offered only drugs or no other treatment for their child, they'll try the drug approach.

However, we cannot just blame the drug companies for our ADD/stimulant epidemic. We are 4 percent of the world's population but in 2011 produced 70 percent of the world's legal stimulant drugs. In any epidemic, there are host factors that make the population particularly susceptible to the infection.  Ritalin and Adderall are like the jeweler's chisel that has exposed the cracks and faults in our society's view of our children. We have lost our place as the predominant manufacturing power in the world. Jobs are either technical or service oriented. The gap between the rich and the middle class has grown enormously. There is real fear in the air.  We've come to expect more from our children (and teachers) educationally at an earlier and earlier age. Everyone now is expected to go to college in order to be "successful." Our ideas about discipline are very confused. Children are expected more than ever to perform and self-regulate their behavior. And when many, especially boys, don't, we medicate them because they "have" ADD.

But at the core of this epidemic, the drug companies exploited a key shift in our thinking about feelings in general and especially the importance of children's feelings of self-image and self-esteem. We are so concerned about our children's immediate and continuing happiness, that we have become paradoxically intolerant of minor differences in their behavior and performance that temporarily might have them feeling badly about themselves.

Of course, we love our children and want them to feel good. However, we worry so much about our children's feelings (and how they will do in the future) that we then take them to our doctors who diagnose them with a mental disorder and treat them with psychiatric drugs. It is a curious, unique and sad way our society is handling children's differences.

Large Fortune 500 companies now earn $9 billion a year treating and exploiting this worry. The glare of publicity on drug company influence along with the increasing reports of Adderall misuse, abuse and addiction may give pause to some. But the social and economic factors that have fed this epidemic will continue into the foreseeable future. Fifteen years ago I suggested we might become a nation "running on Ritalin." I continue to worry about our country's use of prescription stimulants because a society that copes by using drugs does so at its own peril.

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