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Journal of Developmental & Behavioral Pediatrics:
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Lessons from Three Year Olds

DILLER, LAWRENCE H. M.D.

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Department of Pediatrics, University of California, San Francisco, California

Address for reprints: Lawrence Diller, M.D., 2099 Mount Diablo Blvd., Suite 208, Walnut Creek, CA 94596; e-mail: diller@itsa.ucsf.edu

I have been a behavioral pediatrician evaluating and treating children for attention-deficit hyperactivity disorder (ADHD) for 23 years. Beginning in the early 1990s, I noticed a new group of children presenting themselves with their families for ADHD evaluations. They were both younger and older, more often female, and not nearly as disabled compared with the previous generation that I had treated in my practice, which was dominated by boys ages 6 to 13 years. As I wrote more and more Ritalin (methylphenidate) prescriptions, I began to wonder that, if Tom Sawyer or Pippi Longstocking showed up at my office, would they also leave, after a proper evaluation, with a Ritalin prescription?

My local experience was mirrored nationally by an ever-growing number of children taking Ritalin or an equivalent stimulant (unless otherwise specified, the use of “Ritalin” in this text is meant to include all the stimulant drugs used for ADHD). One marker of the growth of this diagnosis and treatment are annual rates of stimulant production as approved and monitored by the Drug Enforcement Administration (DEA). Methylphenidate production in this country remained relatively stable throughout the 1980s. Between 1991 and 2000, the production of methylphenidate rose 740%. Amphetamine production has risen 25-fold during the same period, largely as a result of the introduction of Adderall and its heavy promotion by its maker Shire-Richwood. 1 The United States in 1999 used 80% of the world’s stimulants, down slightly from its peak of 90% in 1996. 2 Estimates on the actual number of children taking stimulants are much more difficult to determine and have varied considerably. 3 However, there is little disagreement that many more children are being treated with Ritalin now than a decade ago.

Many in the academic and popular press have hailed this increase in diagnosis and drug treatment as a public health triumph—fewer undiagnosed and untreated children with ADHD. Others, like myself, became alarmed by a seeming epidemic of children brought in by anxious parents or referred by concerned teachers for one particular and recurring diagnosis. An attempt to address my own professional ethical dilemmas over the growing amount of Ritalin I prescribed led me to write an article for peer review 4 and a book intended for both the popular and professional audience. 5

My close colleagues warned me that many would object to and protest the questions I raised. Psychiatric academia almost universally promotes a biological viewpoint on children’s behavior. 6 The pharmaceutical industry’s economic clout strongly supports this viewpoint and directs funds to research geared toward medications, 7 with the accompanying advertisements to physicians and consumers of medications for ADHD. 8 The major ADHD self-help groups were firmly aligned in the biological camp dependent on the current expert opinion and committed to develop ADHD as a legitimate “disorder” to qualify it for disability status. 9 To question the diagnosis of ADHD and our use of Ritalin was to “unnecessarily raise the anxieties of already worried parents”10 or, worse, to be potentially accused of secretly practicing Scientology.

Yet over the last 5 years I met others who were also concerned and appreciated my public questioning. Then in late February 2000, the situation changed overnight when the Journal of the American Medical Association (JAMA) published an article on the use of Ritalin in toddlers 11 along with a critical editorial questioning the trend. 12 Suddenly Ritalin was on every evening and morning talk show, the subject of political cartoons showing mothers’ holding nursery bottles and Ritalin pills for their infants. Hillary Clinton raised her own voice of concern about using these medications in such young children without clear evidence of the benefits or safety. The response from the general public ranged from questions to condemnation of the use of these medications in children so young.

Public outcry led to two separate government conferences in the ensuing 6 months. The Surgeon General’s Conference on Children’s Mental Health was followed 2 weeks later by a conference, Psychopharmacology for Young Children: Clinical Needs and Research Opportunities, sponsored by the National Institute of Mental Health (NIMH) and the Food and Drug Administration (FDA). The details of a new multi-site study on the use of Ritalin in toddlers were unveiled (Lawrence Greenhill, 2000 personal communication). Perhaps reflecting public opinion, this study, unlike the much-vaunted multimodal treatment assessment (MTA) study 13 on school-aged children that preceded it, will insist that all the families first agree to participate in a parent-training intervention before drugs will be considered for their children.

The toddlers-on-Ritalin controversy was a wake-up call for the American public. I believe the questions raised about the ADHD diagnosis and Ritalin use in 3 year olds also apply to older children and adults. These include questions of what behavior in children constitutes ADHD versus an extreme variation of normal temperament. Who should or shouldn’t receive medication? How effective in the long term is medication alone compared with psychosocial treatments or a combined approach? It appears, however, in the nation’s response to the JAMA article, that the country is still unwilling to accept a drug-only approach to the behavior and performance problems of children despite scientific studies such as the MTA that may suggest otherwise.

The controversy over ADHD and Ritalin is further clouded by a substantial gap between recommended guidelines for diagnosis and treatment 14 and actual community practice. Research published since 1998 by Rappley, 15 LeFever, 16 and Angold 17 extend Wolraich’s work of 10 years ago. 18 All demonstrate that in the real world of primary care and community medicine the use of Ritalin is inconsistently linked to the ADHD diagnosis.

Wide variation in Ritalin use exists in this country. Hawaii typically uses one fifth per capita of Ritalin compared with that of the highest-using states, which tend to be among the mid-Atlantic or Midwest states. 19 When controlled for socioeconomic status, black families have rates of Ritalin use one-half that of their white counterparts. 20 “Hot spots” of Ritalin use, where up to one in five boys are taking Ritalin in school, have been documented. 16 Prescriptions for Ritalin are underrepresented in rural communities. 21 Overall, statistics suggest a trend of ADHD concentrated in the white middle- and upper middle-class suburbs.

This breadth of community-based epidemiological data strongly implicates important “extraneurological” factors, primarily economic, involved in the diagnosis and treatment of ADHD. These factors have influenced decision-making in older children and cannot be ignored when addressing the much more controversial issue of ADHD in toddlers.

Demands on children have increased, whereas supports for children, families, and schools have decreased. For the middle class, children as young as 3 years of age are now expected to know their letters and numbers. Increased educational pressures begin in kindergarten and continue through to graduate school. Demands on students and their teachers increased as funding for the general classroom stagnated and student-teacher ratios increased over the past 20 years. New drives for student and teacher accountability in the form of nationwide standards testing have only increased performance pressures.

Meanwhile, parents are less available to their children because economic pressures have more mothers working and both parents working longer hours 22 Greater demands are placed on children as toddlers are placed in full-time daycare and school-aged children become latchkey kids in the afternoons. Economics also plays a role in health care in a variety of ways that increase the number of children on medication. Managed care only exacerbates the tendency toward using medication quickly. 23 Pediatricians interested in performing adequate evaluations and treatment for ADHD describe themselves as the “loss leaders” of their group practice. The cost and unavailability of effective nonmedication treatments, such as behavioral management training, also contribute to a medication-only approach. 24

Finally, the pharmaceutical industry’s influence has been profound, both in determining the kinds of ADHD studies funded and published 7 and in their drug promotions, advertising first to doctors and most recently directly to consumers on television. Although ostensibly promoting awareness of ADHD as a public health benefit, a drug company’s advertisement in a woman’s magazine displays a beaming child holding a pencil surrounded by his happy family. This image directs parents to think of their child’s homework problems only as ADHD—a neurobiological disorder—as opposed to a more complex developmental/social undertaking.

Noneconomic societal factors also likely play a role in who does and does not receive medication. A change in 1991 to include ADHD as a covered diagnosis for educational disability services under the Individuals with Disabilities Education Act (IDEA) appears to have triggered the wave of newly diagnosed and treated children with ADHD. 25 Trends in childhood discipline that promote more cognitive approaches seem ill-suited to the impulsive temperament of the potential ADHD child. American acceptance of a brain-based theory of children’s maladaptive behavior seems greater than in other countries. American culture also delivers a mixed message to children, parents, and teachers. We prize independence, spontaneity, and freedom of expression in our children while demanding their conformity at school. This would appear particularly difficult to children with the potential for ADHD who especially need consistency to perform better.

Diagnosis and treatment of ADHD in toddlers do not occur in a social vacuum, even in the rarefied atmosphere of the university centers that have been enlisted to establish criteria of diagnosis and treatment. Often overlooked in the controversy over Ritalin use in children is that Ritalin improves the behavior and performance of everyone, child or adult, ADHD or not. However, that Ritalin “works” does not make it the moral equivalent to or substitute for helping parents parent or teachers teach. The toddlers-on-Ritalin issue has thrust to the national forefront questions of how we intend to address the behavior and performance problems of American children of all ages. As physicians who prescribe Ritalin, it behooves us to examine and address this larger picture of economic and societal influences on the diagnosis and treatment of ADHD to avoid complicity with factors and values that are harmful to children and families.

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REFERENCES

1. Drug Enforcement Administration, Office of Public Affairs: Methylphenidate and Amphetamine Yearly Production Quota (1980–2000). Washington, DC, Department of Justice, 2001

2. United Nations International Narcotics Control Board: Report of the UN International Narcotics Control Board, 1999. New York, NY, UN Publications, 2000

3. Diller LH: The case of the missing methylphenidate (letter). Pediatrics 100:730, 1997

4. Diller LH: The run on Ritalin: Attention deficit disorder and stimulants in the 1990s. Hastings Center Report 25:12–18, 1996

5. Diller LH: Running on Ritalin: A Physician Reflects on Children, Society and Performance in a Pill. New York, NY, Bantam, 1998

6. Barkley RA: ADHD and the Nature of Self-Control. New York, NY, Guilford Press, 1997

7. Angell M: Is academic medicine for sale? N Engl J Med 342:1516–1518, 2000

8. Zernike K, Petersen M: Schools’ backing of behavior drugs comes under fire. New York Times, August 19, 2001, p 1

9. Children and Adults with Attention Deficit Disorders (CHADD): CHADD Fact 1: The Disability of ADD—An Overview of Attention Deficit Disorders. CHADD, Plantation, FL, 1993

10. Joseph Biederman on CBS Sunday Morning, November 15, 1998

11. Zito JM, Safer DJ, dosReis S, et al: Trends in the prescribing of psychotropic medication to preschoolers. JAMA 283:1025–1030, 2000

12. Coyle JT: Psychotropic drug use in very young children. JAMA 283:1059–1060, 2000

13. MTA Cooperative Group: A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder. Arch Gen Psychiatry 56:1073–1086, 1999

14. Assessment and treatment of children, adolescents and adults with attention-deficit/hyperactivity disorder: Practice parameters for assessment and treatment. J Am Acad Child Adolesc Psychiatry 36:S85–S121, 1997

15. Rappley MD, Mullen PB, Alvarez FJ, et al. Diagnosis of attention-deficit/hyperactivity disorder and use of psychotropic medication in very young children. Arch Pediatr Adolesc Med 153:1039–1045, 1999

16. LeFever GB, Dawson KV, Morrow AL: The extent of drug therapy for attention deficit-hyperactivity disorder among children in public school. Am J Pub Health 89:1359–1364, 1999

17. Angold A, Erkanli A, Egger HC, et al: Stimulant treatment for children: A community perspective. J Am Acad Child Adolesc Psychiatry 39:975–984, 2000

18. Wolraich ML, Lindgren S, Stromquist A, et al: Stimulant medication use by primary care physicians in the treatment of attention deficit hyperactivity disorder. Pediatrics 86:95–1010, 1990

19. Drug Enforcement Administration, Office of Public Affairs. State Per Capita Use Rates of Methylphenidate 1999. Department of Justice, Washington DC, 2000

20. Zito JM, Safer DJ, dosReis, S, et al. Racial disparity in psychotropic medications prescribed for youths with Medicaid insurance in Maryland. J Am Acad Child Adolesc Psychiatry, 37:179–184, 1998

21. Eaton S, Marchak E. Ritalin prescribed unevenly in US. Cleveland Plain Dealer. May 6, 2001, p 1

22. Employment status of women by marital status and presence and age of children: 1960 to 1995, in Statistical Abstracts of the United States, No. 626. Washington, DC, Department of Commerce, 1996

23. Schreter RK. Managed care cost-containment strategies and their impact on physician prescribing and treatment of depression. Am J Manag Care 6:S47–S52, 2000

24. US Public Health Service. Report of the Surgeon General’s Conference on Children’s Mental Health: Developing a National Action Agenda. Washington, DC, US Department of Health and Human Services, 2000

25. Swanson JM, Lerner M, Williams L. More frequent diagnosis of attention-deficit/hyperactivity disorder (letter). N Engl J Med 33:994, 1996

© 2002 Lippincott Williams & Wilkins, Inc.

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