Controversies in the Diagnosis and Treatment of ADHD: One Doctor's Perspective - Growth of ADHD Diagnosis

Written by Lawrence H. Diller, M.D.

Parents are further handicapped by current styles of American discipline of children.

"Politically correct" parenting practices propose that by effectively talking to children, conflict and punishment can be avoided. The fear of damaging a child's self image by even short-term immediate punishment is a significant handicap for parents today, as this type of direct, immediate discipline is a major motivator for children, especially for children with ADHD-type personalities. Of course ineffective discipline alone does not explain the explosion of ADHD diagnoses, but it is one piece of the puzzle. When children's behavior continues to be out of control, and punishment is not an option, then using a medication becomes very appealing.

Until the last few years, average class sizes were increasing even as curricula demands rose for the general classroom teacher. No wonder teacher complaints are often the catalyst that leads to an ADHD evaluation. Managed health care only exacerbated economic pressures, especially on pediatricians and family doctors, resulting in less time in evaluations and treatment and a rise in the "quick fix" of Ritalin. Media tended to exaggerate the ubiquity of the ADHD diagnosis ("Does your child have this hidden disorder? Do you?"). Testimonials that recount the power of the Ritalin intervention belie the often complex courses and treatments necessary for myriad children's problems that get lumped under ADHD diagnosis.

The pharmaceutical industry's influence has been profound, both in determining the kinds of ADHD studies funded and published and in their drug promotions, advertising first to doctors (Adderall) and most recently directly to consumers (Concerta).

Federal educational disability law

All these factors were in place by the early 1990's and Ritalin production in the U.S., which has remained stable throughout the 1980's, took off beginning in 1991. The spark that set off all these socially combustible materials and led to the Ritalin boom was the change in the Federal educational disability law, IDEA. In 1991, IDEA was amended to include ADHD as a covered diagnosis for special educational services at school. Once parents (and teachers) learned that they could get help for their kids at school, they flocked to their doctors seeking the ADHD diagnosis and along the way received Ritalin for their children.

Nothing surprising about the effectiveness of stimulants

Ritalin "works." Stimulants in one form or another have been used for treating children's behavior for over sixty years. But the effects of Ritalin are not specific to treating ADHD.

Ritalin improves everyone's ability—child or adult, ADHD or not—to stick with tasks that are boring or difficult. Ritalin decreases everyone's impulsivity and therefore decreases motor activity. There is nothing paradoxical about low dose stimulants' effects on "calming" hyperactive kids. Higher doses "wire" both ADHD kids and normal adults: except children tend to dislike the experience of the higher doses while teens and adults can abuse the drug.

Conclusion

I'm not against the use of Ritalin in children. I am against Ritalin as a first and only choice for a wide variety of children's performance and behavior problems. Ritalin works but it is not a moral substitute for, or equivalent to, better parenting and schools for children. My role as a physician is to ease suffering. After a proper evaluation and an attempt to address issues of family and learning as best as possible, I will prescribe Ritalin if the child continues to significantly struggle.

But as a physician who prescribes medication for children, it is also my role to alert others about the economic, social and cultural factors that are involved in the ADHD diagnosis and Ritalin use in our country. To not raise alarm would make me complicitous with values and factors I feel are harmful to children and their families.

The huge rise in Ritalin use in our country is telling us we should reexamine our demands on our children and the resources we offer them, their families and their schools. It is a message we should heed not only for children with the ADHD diagnosis who take Ritalin but for all of America's children. We should be paying attention.

Originally published at Healthology.com, August 20, 2001
Copyright © 2001 Healthology, Inc.

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