What accounts for the huge increase in the number of children diagnosed with attention deficit hyperactivity disorder (ADHD) and the use of Ritalin? Dr. Lawrence Diller analyzes the explosive growth of the ADHD diagnosis and Ritalin use.

I've practiced behavioral pediatrics in an affluent San Francisco suburb for over twenty years. In that time I've evaluated and treated nearly 2500 children for a variety of behavior and performance problems. I never imagined during my early years of practice that one diagnosis would so come to dominate not only my work, but America's children in general.

That diagnosis is attention deficit hyperactivity disorder, or ADHD.

A Diagnosis on the Rise

I had always encountered hyperactive children or kids who performed poorly at school. Stimulant drugs, the best known of which is Ritalin (methylphenidate), have always been one of the interventions I used to help these children and their families. These children were mostly boys, aged six to thirteen. But in the early 1990's, I began to see with increasing frequency a new type of ADHD candidate. These children were both younger and older than the previous group that met my criteria for ADHD and received Ritalin. There were also many more girls. Some of them weren't even kids. Older teenagers and adults (initially the parents of the children I evaluated for ADHD) wondered whether they too had ADHD.

But most strikingly, these new candidates for the ADHD diagnosis were far less impaired in terms of behavior and performance than my earlier patients. Many of these children behaved quite well in my office. Many were getting passing grades, even B's, at school, but were not "meeting their potential." Most of these children tended to have their biggest problems at school, or only at home when it came to doing homework.

Did Tom Sawyer have ADHD?

Boys still predominated over girls in the number presenting for evaluations for ADHD. But their problematic behaviors could just as well be viewed as an extreme of the normal variations one attributes to the male gender. Indeed, I began to wonder if boyhood, at least in my community, had become a disease. I mused if Mark Twain's Tom Sawyer walked into my office in the late 1990's whether or not he too after several visits might also leave with a prescription for Ritalin.

I became interested in the ADHD epidemic I was witnessing and quickly learned that my experience wasn't unique. Stimulants are, by far and away, the predominant medical treatment for ADHD and are prescribed overwhelmingly for only that indication. In that sense, they serve as a marker for how much ADHD is being diagnosed in the population. Because stimulants are abusable, the Drug Enforcement Administration (DEA) tightly monitors and controls their legal production and distribution in the U.S. The DEA's records showed that between 1991 and 2000, annual production of methylphenidate rose by 740 percent, or over fourteen tons produced per year. Production of amphetamine, the active ingredient of Adderall and Dexedrine, two other stimulants used for ADHD, multiplied twenty-five fold during the same period. In the year 2000, America used eighty percent of the world's stimulants.

Most of the other industrialized countries use Ritalin at one-tenth the American rate. Only Canada, which uses half our per capita rate, comes close to using stimulants the way we do.

Many have hailed the increase of Ritalin use in our country as simply a treatment catching up to a previously under-diagnosed condition. Others are alarmed at this unprecedented rise in the diagnosis of ADHD and Ritalin use in America. Whether good or bad, this large rise in Ritalin use tells us a great deal about the way we view and address problems of children's behavior and performance at the beginning of the 21st century.

Patterns of Prescription

The answer to the question "Is Ritalin over-prescribed or under-prescribed?" is "Yes". It depends on the community you assess, and its threshold for the ADHD diagnosis and Ritalin use. Ritalin use rates from DEA data (reported in several research studies and most recently by the Cleveland Plain Dealer's county-by-county national survey) widely vary within the U.S.—from state to state, community to community and even school to school.

For example, Hawaii perennially is the state with the lowest per capita Ritalin use in the nation. Hawaiians typically use Ritalin at one-fifth the rate of the highest using states, which tend to be eastern states like Virginia or Midwestern states like Michigan. There are various "hot spots" of Ritalin use. The best documented is a three-cities cluster in the southeast corner of Virginia, where one in five white boys was taking Ritalin at school (G.Lefever, ET AL, American Journal of Public Health, September, 1999). Overall rates were probably higher than twenty-five percent since many children only take medication at home before the start of the school day. The DEA maintains that virtually every state has pockets of high use rates that are centered near a college campus or clinic that specializes in the evaluation and treatment of ADHD.