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| DR. LAWRENCE DILLER | |
 
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Dr. Lawrence Diller practices behavioral pediatrics in California and is an assistant clinical professor at the University of California, San Francisco. Susan Dentzer talks with Diller about his response to a recent study. |
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Q. What do you make of the fact that one clear sign that comes out of this study is that higher levels of medication were used, and appeared to be more beneficial than the prevailing dosages used in community type treatment. A. What I say is that Ritalin works. We've known that Ritalin works for 100 years - not Ritalin, but amphetamine, and Ritalin and amphetamine are very similar, and in lower doses these stimulants allow adults, children, ADD or not, to stick with materials they find boring or difficult. So the fact that if you give Ritalin three times a day, it's more effective than only giving it one time a day shouldn't be a big surprise. I think what's important here is the level of care and management these children got in the study is so far above what happens on the community level, where typically the doctor might spend only 20 minutes to 30 minutes with the child and the mother only, and maybe if the doctor is good, does get a feedback form from the teacher, and then sends the kid out on a standard dose of medication, usually only once a day. |
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| Community care | ||||||||||||||||||||
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Q. So in effect this study is in essence an indictment of most community level care. A. Right. And my fear, though, is the message that is taken from the study via the media to the community also will only further, further deteriorate community care. You don't see the message saying, you know, three times a day dosing, monthly visits with the doctor, you know, close connections with the teacher in terms of feedback between doctor and feedback - you don't see that in the headlines, of course. What you see is Ritalin works best. Other treatments aren't as effective, and that's where I have grave concern about the impact of this study. Q. I don't want to put words in your mouth, but could we go back to that question I asked about whether this is an indictment of community level. I asked you that question, you said right. Do you feel comfortable in effect making that as a statement? A. Well, community care varies so widely, you know. But I would say in general there are forces that conspire against the child receiving good care with regards to behavioral or school based problems. And ultimately, it comes down to more than anything money. It takes time and money to do a decent ADD evaluation. It takes some time and money to follow up a child who goes out on medication. Both the National Institutes of Health and the CDC in their conferences pointed out that there's a structural communication problem between teachers and doctors. So the kind of treatment these children got in this study versus the average kind of treatment in the community is a criticism implicit of what goes on in the community when it comes down to dollars and cents. Q. As you noted, this study did not at all completely dismiss the value of psycho-social and behavior modification type approaches. In fact, it did demonstrate that these were of particular value for certain groups of individuals. Let's talk a bit about that. What do you think the key findings were? A. Well, again, Ritalin very specifically addressed problems of impulsivity. I already mentioned are not specific to children with or without ADD, or even children, because adults respond the same way, so Ritalin works on that level. This study represented children with ADD, and 70 percent of them had other problems. It's in that 70 percent of this total group where the psycho-social treatments begin to have significant benefits. I also again worry about this very more severe group of children put together in this study versus the kind of child we see in general pediatrics, or in family medicine. And in those situations, on the borderline of ADD or not, behavioral management techniques can be very, very useful helping the parents learn how to manage their children more specifically and more directly, or giving the teacher specific techniques for classroom management. I think that in this . . . group of kids it makes a big difference, but I realize, Susan, I'm not answering your question. I think the study so we can cut into any point in terms of I'm going to start again, the study did show and I don't think the headlines will capture this, that in that very large subgroup, the psycho-social treatments did have benefits, and they were additive to the effects of the medication. Q. Specifically, those included kids with various . . . . A. Right. But 70 percent of the children had comobidities, so it's a large group. And the other area that I think is important here is that the parents themselves reported higher levels of satisfaction in the multi-modal or combined treatment groups, rather than the groups that just received either the medication or the psycho-social interventions. I think a problem, again, with these kinds of studies is it's trying to make some generalizations, and again, I give credit to the authors like Peter Jensen who repeat that treatment has to be tailored to the individual child and family. So where it may seem that for a particular group of kids that psycho-social interventions may not be as useful, that for a particular child and family who are very eager to approach this problem in a behavioral management or family therapy kind of way, that that family may be much, much more affected in a positive way by these kind of interventions. One could say, as a rule, that medication will be helpful. I mean, this study establishes that quite clearly. Saying that, again, I worry about the impact this study's message will have on the general society, because I do make a distinction of what is good for the individual child, and you know I prescribed 700 prescriptions of Ritalin or Dexodrin this year, so it's not like I don't prescribe medication. But we use 85 percent of the world's Ritalin. Our Ritalin use rates have skyrocketed in the last nine or ten years. The question we have to ask ourselves as a society, is this a good thing. And I do have my concerns. Q. Let's go back - you made a couple of great points and I want to take them one by one. As we well know, it is very common for kids with ADHD to have these other comobidities, and the study samples bore that out. So if we now know on the basis of this study that the combined approaches can be very effective in what is, in fact, a large number of kids, isn't that good news? A. Isn't that good news. Well, for some people it's news. I mean, again, that medication is effective, and a combination of the two can be more effective for those kids with the comorbidities. I suppose it's good news. I don't think we're out of the woods yet. I think this is a "long term study" being 14 months long. These children started at seven or nine. That means they're now maybe eight to eleven. I think the long-term picture really has to look at these kids at sixteen, seventeen, and eighteen. And so I suppose it's - well, Susan, what do you mean by good news? Q. Well, I meant in the sense that we have established something important here which is that for the very large number of kids with severe ADHD, we do tend to have comorbidity. The combined therapies work very well. That seems to me to be an extremely important finding because it speaks to the issue you raised that in effect Ritalin isn't everything. A. But I don't think that's - I think if you read the body of the report, the researchers, and I give Peter Jensen credit again for going out of his way to frame the data within this notion of multi-modal still may make the most sense for many of the children coming in for this problem. But I fear very much that the media, the general public, and managed care companies will see this as a major green light for a medication only strategy for children. So I cannot be sanguine about the way the study is going to be played out in terms of the spins that it's going to offer various people. Q. Let's turn to another point that you were making which is, in effect, that there are a lot of kids who are not in the severe ADHD category who are in fact more borderline, and the point I understood you to be making is that what this study doesn't tell us is that behavior modifications..... alone can be very effective with those borderline kids, and in fact, these study results don't appear to address that. A. Well, that's not what they were after, and again, my concern is that this data get interpreted again - let's start again. The question was what about these borderline kids. My concern, again, is not an issue of whether Ritalin works or not. Ritalin works. But I don't believe that Ritalin is a moral substitute or equivalent for better parenting and better schools for kids. So for the very severely compromised child, absolutely. After you've explored the other possibilities, give them medication because it will allow other things to work better. But there's a whole group of children out there, particularly boys - I call them the Tom Sawyers and the Huck Finns - but there is an increasingly large group of girls and other Pippi Longstockings who fit into a culture maybe 100 years ago quite nicely, and now they are the round pegs trying to fit into the square educational holes. Ritalin will allow them to fit in better. However, again, I am uneasy with the society that sees the answer to this kind of social problem as a medication. I don't think it's a moral substitute for a better approach to schools, and more direct parenting on these children.
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