I've prescribed Ritalin type drugs to children for 33 years. In the early 1990s I began feeling ethically uneasy about my professional role. I went public with my concerns in a book called "Running on Ritalin." In the process I was involuntarily enlisted into what has been called, "The Ritalin Wars," an often-polemical public debate about whether psychiatric drugs are good or bad for children.
Recently I published an article on The Huffington Post called "The United States of Adderall." I mentioned that we are 4 percent of the world's population but produce 88 percent of the world's legal amphetamine (Ritalin, Adderall, Concerta, etc.) virtually all for the treatment of attention deficit/hyperactivity disorder (ADHD) in children and adults. I tried to maintain a balanced view on ADHD and medication. The article generated over 200 mostly extreme comments from my point of view.
Over 80 percent of the responders expressed a negative view of prescribing psychiatric drugs to children. Another 10 percent or so, primarily parents and a few doctors, defended the practice -- basically saying that "until you've walked in my shoes as a parent watching my child's suffering improve with these meds you don't know what you're talking about."
Only about one in 10 understood and supported my position. Children with extreme degrees of impulsivity, distractibility and hyperactivity are easy to diagnose with ADHD. ADHD is real. However because these behaviors vary (from none to many) in a bell shaped distribution curve, most of ADHD diagnosed in this country is of the mild variety. The prestigious Hastings Center for Bioethical Research, in a report on children's psychopharmacology, concluded that even experts will regularly disagree on psychiatric diagnoses in children with mild symptoms.
The stimulant drugs like Adderall and Concerta (all amphetamine or variations) do work on ADHD to improve focus and decrease activity (as they will for anyone, child or adult ADHD, or not). They work more quickly and are relatively less costly than the other effective non-drug interventions of behavior modification and special education. The pills are efficient but are not the moral equivalent to non-drug interventions which value engagement with the child.
I am not trying to proclaim which approach is "better." I'm only trying to make clear that in their effectiveness, the different approaches prioritize different values. My own approach with most of the children I treat for ADHD is to first make certain that a reasonable effort has been made to help parents become more effective. I also make sure the school has attempted to address any of the children's underlying learning or processing problems. If problems are continuing, it makes sense then to utilize the medications which are effective in 80 to 90 percent of the children I treat and have a track record of over 70 years of relative safety.
But I am curious and worried about a society that relies so heavily (compared to others) on drugs for coping. However, just raising questions about the frequency of ADHD diagnosis and its treatment in our country stimulates another round of the "Ritalin Wars," which I propose we now call the "Adderall Wars". Since the mid 1990s, Adderall has overtaken Ritalin as the most commonly prescribed, misused and abused trade name prescription stimulant in our country.
The critics of Adderall basically say, "It's not our children that are sick, it's the (fill in the blank) of society." The list is very long: sugar, additives, toxins, allergens, TV, video games, permissiveness, competition, materialism, doctors, drug companies, teachers, parental anxiety. ADHD and its treatment become a tabula rasa for those unhappy with our culture to promote their particular chosen evil as the cause for this multi-faceted condition.
The response of those critical of Adderall seem angry and lacking compassion. They blame parents and teachers for the not doing their jobs. I wonder how stressed the critics are, themselves, by the current economic, occupational and educational problems our country faces today. With regards to the myriad reasons offered for the ADHD epidemic, some seem more cogent than others. But I believe as the social commentator, Gary Cross, said in 2004, "Modern ideas about the innocent child have long been projections of adult needs and frustrations. Instead of projecting all our mental confusion onto children, we should aim to find a more mature resolution to the contradictions of modern life."
Many of the defenders of ADHD and Adderall were also critical of my point of view, which raises questions about both. Some of their defensiveness is understandable in light of the majority opinion's overwhelming hostility. If I were a parent treating my child with Adderall I think I would just keep quiet in light of the general public's overt animus. But the defenders of ADHD/Adderall criticize me just for raising questions. It's as if asking questions is tantamount to challenging whether ADHD exists at all.
I've often wondered about this hypersensitivity. It's not easy for any parent to reach the decision to use a psychiatric drug for his/her children, especially because the Adderall War critics exaggerate the bad and blame parents for poor discipline, etc.. So once that decision has been made and the drug is helpful, the last thing a parent wants to hear is another doctor raising questions about Adderall's use in America -- especially if there's a hint of critical thinking or worry attached.
If the Adderall Wars cause certain defenders to close their minds to these questions it's unfortunate. I raise the broader questions about our use of Adderall to challenge the very economic, educational and social factors that may have pushed their children over the line from simple liveliness to problematic over activity. The Adderall Wars make it difficult for parents to get an even-handed view of ADHD and medication treatment. It's Adderall, either as brain poison -- or -- the essential treatment for ADHD as insulin is for diabetes. Both positions, in my opinion, are gross distortions of fact.
A number of the Adderall critics say I, too, am to blame because I prescribe these medicines to children. It's true that on the individual level I prescribe these medications because I believe they can be helpful (especially after non-drug efforts have been tried or are ongoing). But by writing about the U.S. of Adderall nation I try to address my potential complicity with values and factors that I believe are bad for children by raising alarm about those very factors.
Every society and culture has its strengths and weaknesses. It's a fact that we are unique in our high use of legal stimulant drugs. While the French may use far less stimulants, they use far more sedatives (especially with their elderly) [UN International Narcotics Control Board. Report of the UN International Narcotics Control Board, No. 4 (February 23, 1999) (New York, UN Publications)]. Adderall, as a treatment for ADHD, is virtually absent in most third world countries. However, there's a much higher prevalence and acceptance of corporal punishment.
My particular theory on why we are the U.S. of Adderall leans towards our worry about our children making it in an economically shrinking materialist meritocracy -- but I may just be projecting. However, I think restrained, sensitive discussion about the ADHD/Adderall epidemic is important and should continue. How else will we come together to make some sense of this phenomenon and if necessary change the way we address our children's needs? Perhaps the vehemence and vitriol of the Adderall Wars are but a reflection of a broader loss of comity and civility in today's public discourse. Yet for the moment, Adderall Wars continue. But for the sake of our children, why can't we all just get along?