Yesterday a letter of mine was published in the print and Web editions of the New York Times. I had read an op-ed over the weekend, "Raising the Ritalin Generation," which had stimulated my letter. Click here to read the letter.
I thought it was a pretty good letter. Still the chances of getting a letter in the Times are pretty low. So when I received the call on Tuesday from the Times editor doing some fact checking on the letter and me, I was pretty pleased that a forum as prominent as the Times was willing to air my opinion.
But as I reflected on the process and read some of the other letters the next day I had more mixed feelings about my "success." I've been trying to raise consciousness and effect change about the ADHD/Ritalin scene for children since the early 1990s. I had become professionally uncomfortable about the increased number of families with children who were much less impaired with ADHD/ADD coming for evaluations and expecting treatment with stimulant medications like Ritalin, Adderall and Concerta.
Early in my efforts to raise alarm, I attended a conference hosted by the Hastings Center for Bioethical Research in New York on the ethics of enhancement. A woman sociologist talked about the ethics of plastic surgeons who enlarge women's breasts because it makes the woman feel better about herself, because in a society that values larger breasts, breast augmentation may actually improve a woman's power (in terms of attractiveness). The sociologist made the point, however, that while the surgeon improves the situation for that individual woman, both of them are actually complying with and reinforcing sexist and potentially-oppressive societal values that place a higher value on women's looks than other more meaningful attributes like intellectual and emotional intelligence.
Sitting there at the conference in 1996, I was struck by the very similar situation I was facing in treating minimally-impaired children for ADHD. I could help the individual child where aspects of culture, politics and economics have parents and teachers worried about their children's behavior and performance (read Running on Ritalin or the Last Normal Child for a full description of the ecosystem of ADHD and Ritalin). But if I only medicated these children, which could assist them on the short term, without trying to address the larger social factors that was influencing my decision, then I, like the surgeon, would become complicitous with values that I thought were bad for children and families.
So since the early 1990s I've attempted to address my ethical quandary by helping individual children with Ritalin while steadfastly maintaining my efforts to raise the alarm and influence with quixotic zeal the environment of children. I am under no illusion that I have been or will be successful in my public endeavors to change children's environments, but I feel I must continue as long as I medicate children in order to avoid full complicity.
I've been criticized by both sides in the debate on children's psychiatric medication. The right criticizes me for raising questions that might make parents or children feel badly about the choice to use medication (read the letter in the Times by the parent who is using medicine with her child). The left challenges my use of any medication with children who truly do not have a psychiatric disorder. I am reassured that my position must be reasonable when attacked from both groups on a regular basis.
Which gets me to my letter. As a doctor, I engage with the media with full awareness of a Mephistophelean arrangement. I appreciate the opportunity to influence a larger audience when in print, online (like The Huffington Post), or on television. Yet inevitably a more complex message about the pros and cons of diagnosis and medication gets oversimplified or biased toward a more anti-medication stance than I actually promote. Partly, this is simply a matter of the number of words allowed (150 in a Times letter, 750 in an op-ed) or the time permitted on a TV appearance (typically 4-5 minutes maximum, often shared with another "expert"). Even with more time, a basic message to an audience can get lost with too many qualifiers and "howevers." I've seen too many of my colleagues attempt to "get it right" on TV or in a presentation only to lose the audience entirely.
So when given the 150 words or four minutes, generally I will present a more challenging view of ADHD and medication treatment than in the real world I practice as the doctor. So to be clear: ADHD is real! -- in that for a minority of kids the neurological/temperamental/biological/biochemical component of behavior predominates. I've estimated that only about 10 percent of the kids being treated with medicine in our country fit that picture. That's not to say personality or the brain doesn't affect the other children who take Ritalin drugs, but it's only one component (and generally not the major one) affecting their behavior and performance.
Medicine works! And it is generally safe in children if used properly. I've never been against using medication in children (I wrote my first Ritalin prescription in 1978). I am against a first and only use of medication in children who are minimally impaired. I believe first one must try to employ effective non-drug interventions of behavior modification and special education. Medicine is efficient and less costly than non-drug interventions that call for engagement with the child. Drug and non-drug interventions both work. However, they are not ethically equivalent. Medical and educational systems prioritize efficiency and value the drugs. Parents and families (and most teachers) value the engagement.
I am not under any illusion that my letter, the op-ed and the subsequent feedback will change much when it comes to children and psychiatric medications. In my nearly 20 years at the barricades, I've become jaundiced and skeptical that anything short of children dying -- as in the publicity over Prozac and children's suicides in 2004 and 2005 -- leads to substantive change. In that case, the FDA hearings began a long overdue tectonic shift in the relationship between doctors and the drug companies.
I am also not pleading for sympathy. I'm actually very fortunate that I continue to have an audience for my viewpoints, simple or complex. So my letter was published in the Times. Already I'm receiving positive and negative feedback from the willing and unwilling soldiers of the Ritalin Wars -- that hyperbolic debate in the media about Ritalin as manna from heaven or Ritalin as poison for the brain. It is frustrating to know in advance that I will be misunderstood and vilified by some. But I will continue to speak out until our society provides a more just and ethical way of dealing with our children's behavior and school problems.
For more by Lawrence Diller, M.D., click here.
For more on ADHD, click here.