. . . Why are we seeing a rise in the use of these drugs?
. . . It starts from the fact that we, as a culture--more than any other
culture--seem to have accepted biology and the brain as the reason for
maladaptive or poor behavior. . . . American psychiatry had already begun to
focus on the brain in the 1960s and 1970s. But it really wasn't until Prozac
that the American public became interested in the brain for behavioral and
emotional problems. Prozac will allow people, with far less side effects than
earlier antidepressants, to improve their mood and become more resilient. So
it became more acceptable and easier to take a psychiatric drug. Prozac was
introduced in 1988. The explosion in Ritalin occurred in 1991. And I believe
that Prozac paved the way, in terms of acceptability, for the use of Ritalin in
children, though there are many other factors as to why Ritalin took off.
Besides the change in American psychiatry, and the public's view of behavior
being brain-related, we had other things going on in the 1960s, 1970s, and
1980s. To begin with, you needed two parents to work to maintain the same
standard of living than you did in the 1960s. . . . That means that now we
have institutional day care for children. . . . We have many more latchkey
kids. That's one factor, a major factor.
We have educational paranoia that began in the late 1980s with the downsizing
of the white-collar middle class. . . . With computers and stuff, if every
child doesn't get a four-year-plus college education, they're not going to
have any choices; they're not going to be successful. So what does that mean?
We have the expectations of three-year-olds learning their alphabet and their
numbers. We have five-year-olds all learning to read in kindergarten. We have
my eighth-grader learning algebra a year earlier than I learned it. This goes
on all the way through the educational system. So we have more pressures on
kids. And all through the 1970s and 1980s, we saw an expansion of classroom
size. . . . So, not only are we expecting more from the children, but we're
delivering less to them by their parents being at work, and by the teacher
having more students per kid.
We have other factors going on. We have a continuing erosion of parental
discipline that probably began 150 years ago. But we had the self-esteem
movement in the 1980s that basically said that conflict is not good for
children, that it further erodes their self-image. There was a misreading of
Freud in the 1950s that said to reduce stress and your child will be
neurosis-free. . . . All these things were going on through the 1970s and
1980s. And yet, Ritalin production remained stable all through the 1980s. And
in 1991, it takes off.
The question is, what was the spark? If we look at the history, and we look at
the data, the only thing that changed was the administrative change in the
educational laws guiding our country's accommodations to children. In 1991, it
began to include children with the diagnosis ADD or ADHD. And I think parents
were genuinely trying to get help for their children. But when they found out
that they could get special services and accommodations by getting the
diagnosis, they flocked to their doctors. Word spread, and along the way, you
also got Ritalin.
Can you put that in specifics what that meant for an individual family? What
kind of advantages did they get?
I don't want to disparage the families. If you have a child that's struggling
in school, you would like to find a way of helping him. And under the
disability laws in our country, specifically something call the [Individuals
with Disabilities Education Act (IDEA)] and section 504, a child who's been
diagnosed with ADHD is entitled to special services . . . such as
getting an aide, getting reduced amounts of work given to them, having
unlimited time to take an exam. These are all things that can happen for the
child with that diagnosis. . . .
And why has Europe had resistance to medication for treating ADHD, while its
use in the US has exploded?
Western Europe has been targeted by the pharmaceutical industry as the next
big market for stimulants, so we're seeing changes in using patterns.
Traditionally, England, France, and Australia used one-tenth the rates of
Ritalin that we do. They use a lot more minor tranquilizers like Valium,
particularly in the elderly. . . . But now we're starting to see English
psychiatrists and a lot of interest in France about stimulants. They've heard
from their American research brethren, virtually all of whom receive funding
from pharmaceutical companies, that this stuff works. . . .
But in general, when you talk to English psychiatrists, they continue to feel
that, unless there's extreme hyperactivity, that there are other things that
can be done for the child in his or her environment. And the French seem to
just be much more tolerant of children's differences.
. . . Meanwhile, the French, as a people, use more pharmaceuticals than other
country per capita in the world. And yet they haven't been using Ritalin.
In your view, what is ADHD?
First of all, it's basically a subjective experience of a child who has extra
trouble with inattention, impulsivity, and hyperactivity.
"A subjective experience of a child." What do you mean by that?
Well, it depends on who's doing the deciding, and in what environment and
culture these people are living in.
Why don't we just test them? You just test them. That's what parents are
told--you test them. What's subjective about it?
There is no test, unlike a blood test or brain scan that defines a gold
standard for ADHD. That said . . . we see a very hyperactive kid running
around the room, and usually they have other problems. They might have
learning disorders, or might be mildly mentally retarded, or whatever. And you
and I would have no problem agreeing there's something wrong with that kid.
It's probably partly his brain.
But I tell you, the kids who I see who sit there like this, and they answer my
questions beautifully, and they do really quite decently outside of school, or
non-academic endeavors at home. And yet they're still struggling in school.
Depending on the family, depending on the community, I might wind up giving
that kid Ritalin. Does he have ADHD? Well, it's an eye-of-the-beholder
decision. . . . There is no brain scan. There is no blood test that
definitively says who has ADD and who doesn't. . . . The decision where to
draw the line between abnormal and normal variance of behavior is an arbitrary
What does Ritalin do in the brain?
. . . If you're just curious what Ritalin does to the brain, we can tell you
what we know. How it works, for sure, in ADHD, nobody knows. There isn't a
single unifying concept for ADHD, probably because ADHD and ADD represent just
a whole group of different problems that are put under one label. Ritalin, and
stimulants in general . . . cause dopamine to be released in excess amounts.
Dopamine is a neurotransmitter. It tells one nerve cell to tell the next nerve cell
what to do. That's one way of putting it. And what you get is this rush of
dopamine between the nerve cells. And I use the word "rush" intentionally,
because if you use this drug improperly, it will cause a euphoria similar to
cocaine and methamphetamine.
So it is similar to cocaine and methamphetamine?
Well, again, I want to put in perspective. Used properly, these drugs seem
very, very safe, at least in children. But no, they are very, very similar to
cocaine and methamphetamine. And I heard some friends who used cocaine in the
1980s say that they would take a little and they'd be able to do their work. I
think cocaine is different enough that it creates more euphoria.
Methamphetamine--and people don't know this--is in the Physician's Desk
Reference for the treatment of ADHD. The trouble is, it's real expensive,
probably because people want to get it illegally. And Ritalin and Dexedrine,
and all these drugs, circulate illegally in the high schools and the
colleges these days. Ritalin is . . . a nitrogen different from Dexedrine and
Adderall, which is amphetamine. But again, used properly, used in the proper
way in low doses, these drugs appear pretty safe.
You've stated that there's over-medication.
There's over-medication, and there's under-medication, depending on the
community you assess, and your values for it. I generally feel that in the
community I work in, which is a white middle- to upper-middle class community,
there is over-medication.
And how dangerous is it? Is it a problem?
. . . I think 60 years of experience with stimulants suggests it's pretty safe
stuff. If we're choosing to medicate children who, if they had a smaller
classroom size, or one parent could be home, or issues like that, that becomes
a moral ethical decision, rather than one of physical safety. I think we have
a pretty good track record. Three to five years' worth of Ritalin use is
probably pretty safe. . . . We have no data on adolescents taking this drug
for any length of time. And we have anecdotal data that if you don't abuse
amphetamines too much, as an adult, it's probably safe. But it's not any kind
of systematic data.
And what about the risks of under-medicating?
That's a good question. And the decision is to try to address other issues
along the line of parenting, and the schools, and learning of the child, and
the struggling. What if parents decide they still don't want to medicate? Or
there's less access to these medications and systems? And there are data that
show children with impulsivity do have more problems, both in terms of getting
along with other kids, and in terms of finishing high school and avoiding
substance abuse. The question is, does giving them medication make a
difference? Nobody knows.
. . . It's enormously frustrating for a parent to face these kinds of
answers, because there's no clarity. I don't know what to do. I'm a parent; I
have children. I wouldn't know what to do after listening to what you said.
People want clarity. And that's the seduction of the biological model. And I
can think that's one of the reasons why in our particular technological
society, this has great attraction. But parents also worry. I think there are
a couple of things that parents can do to try to stay sensible about this. I
think if they're getting a prescription after 15 or 20 minutes of talking to
the doctor, then they know that is going to be a very, very limited evaluation.
And all the interventions that follow are going to be very, very, limited. A
good, decent ADHD evaluation takes a couple of hours. And almost everyone
agrees with that. Now, can the parent get that without paying for it out of
their own pocket? That's another question. . . .
I think another thing that evaluators and families are often overlooking is the
absence of participation of fathers--if they're associated with the children in
the family, or still have a connection with the child. . . . And I think too
many evaluations go on with only the mothers involved. . . . The likelihood of
that medication being used properly goes way up when we have both parents
involved in the process.
The other major problem in terms of an evaluation is what's been termed a
structural divide--between schools and teachers, who make the complaints about
the child--the doctors who prescribe the medications--and the parents, who
are the couriers in between. Unfortunately, a lot is lost in both directions.
Concerns that the teacher has, or views that the teacher has, get mediated
through the parent's worries, or lack of worries. Ideas that the doctor has,
both on medication and other interventions, don't get translated either. So
there's this structural divide. . . .
What role do the insurance companies and pharmaceutical companies play in
the world of ADHD?
. . . There's a suit going on right now in three states. It alleges that the
major pharmaceutical company that makes Ritalin, the Novartis Company, along
with the American Psychiatric Association, the main representatives of
organized medicine in the ADHD movement, and the self-help group CHADD have
conspired to dupe the American public into believing that there's such a thing
as ADHD, and then thrust upon innocent children a potentially dangerous drug.
The suit alleges that there's a conspiracy. Now, there may be some legal
definition that meets the conspiracy angle. But I don't believe that there's
any conspiracy at all. We have what I call the "invisible hand" of Adam Smith
at work. Adam Smith, as you know, wrote the fundamental textbook on
capitalism. And we have market forces at major play here, getting people to
think a certain way about medications, and then operating on the doctors and
the patients to get them to take them first--often at the expense of other
interventions that work.
As a doctor, how do you experience those forces?
. . . I experience them, first of all, by this unbelievable advertising barrage
that has hit me first, and now is hitting the consumer directly . . . I think Novartis has acted
quite responsibly, relatively speaking, because I think Ritalin represents a
drop in the bucket to them in terms of the kind of money they make. They're
much more worried about their bio-engineered foods these days than they are
On the other hand, the makers of Adderall have presented what I consider
to be . . . the most disingenuous, elaborate campaign I've ever experienced.
. . . Adderall has passed Ritalin in terms of trade medication written for
ADHD. I've been offered $100 if I will sit and listen to someone talk about
ADHD, funded by Adderall, for 15 minutes on the telephone, and then fill out a
five-minute questionnaire. . . .
And now, with the loosening of controls on the pharmaceutical industry by the
FDA, there is this direct marketing to families. You see this picture. . . .
Well, it doesn't say that it's for Concerta. It says, "Learn more about ADHD."
And it's this picture of this smiling boy who has a pencil in his hand, and on
either side of him, his parents are beaming. . . . And underneath, it says
something like, "They're happy, because now they know his ADHD is being
treated." What's the problem with that? The problem is it pushes people to
only one way of thinking about the problem--that this is a biological problem,
and that it needs a drug. . . .
The other major way economics plays a role here is in the managed care
phenomenon of the United States, which was a legitimate attempt to address
costs spiraling out of control. . . . What managed care did, pretty much, was
only make worse the pressure on doctors, particularly on pediatricians and
family doctors, to diagnose quickly and to do something quickly.
Since Ritalin works on everyone, as I said, it becomes even a higher incentive.
The doctor loses money if he spends time with the kid. The American Academy of
Pediatrics recently offered guidelines for the diagnosis of ADHD. And my
letter to the American Academy of Pediatrics in their journal said if doctors
followed this model, they'd go broke. . . .
Well, it's horrible for a parent for a parent to just think of this as a
debate. For them it's a major life issue, and it's not a debate.
. . . I wish we could have a balanced discussion on this. . . . It quickly
tends toward exaggeration and hyperbole that Ritalin is the best thing since
sliced white bread, or Ritalin is the devil's drug. And it's neither. Yet, as
a phenomenon, it got this 700 percent increase in the use of the stuff in our
country, and we use 80 percent of the world's Ritalin. Why?
. . . Is there an imbalance in how much money goes to studying the efficacy
of drugs versus the efficacy of other things?
Yes. That's the other way that the market forces are operating here, in that
virtually every ADHD researcher, now, because of previous cutbacks and because
there is money out there, takes money from the pharmaceutical industry to do
their research. And whether or not you're a doctor in the local hospital . . .
or you are one of the editors of the New England Journal of Medicine, we
all know that research gets influenced by the funding source.
And this is not impugning these men. It's just how it works. They don't
publish negative findings. The studies are tilted more toward counting
symptoms and pills, rather than looking at the bigger picture. And if you look
at a very narrow picture, if you just ask very narrow questions, you will get
answers that miss the big picture. . . .
Dr. Peter Jensen, a respected authority in this field, says that, in the
case of children's psychiatric medications, that it's not true; that the
research money . . . comes from the government, because the pharmaceutical
companies are afraid of litigation, and they don't want to go there.
That was the case. . . . It was difficult to fund pharmaceutical research in
children, particularly psychiatric pharmaceutical research in children,
because there was seen to be no market until the 1990s. . . . The government
. . . added this rider, where the pharmaceutical company will get an extra six
months of patent protection if they study the drug in children. So what we're
going to get, and what we're getting, is a flood of pharmaceutical research
money directed toward children. And one could be very glad for that in some
ways. . . . But again, if we only ask questions about how many symptoms does
the kid have, and how many pills should he take, we are going to get a very,
very narrow group of answers of what ails the kid, and what should be done
So we are entrusting the research on our children's mental health and the
solutions for their problems to pharmaceutical companies with vested
. . . You got it. . . . It's clear to all of us, even those of us who do
receive medication pharmaceutical money, which I don't. And I would like to,
because I have to pay for my own trips. But the moment I do, I'm potentially
influenced by that money. . . .
How much money are we talking about here?
. . . I think I've heard the stimulant market these days is getting close to a
billion dollars. That's the legal stimulant market, because the illegal
stimulant market, I think, is in the order of tens of billions of dollars. . . .
Why did you write the book Running on Ritalin?
I wrote the book Running on Ritalin to deal with my own
professional ethical dilemma. As a physician, my job is to heal and to ease
suffering. So after addressing the child's family life, particularly the
parenting, and if it's appropriate with the child's temperament, and looking at
the school and learning environment . . . I'll prescribe medication, because
it will allow that octagonal, or round-peg child, primarily, to fit in that
square educational hole.
But I also have a role as a citizen. And my role as a citizen demands that I
speak out about the larger social, cultural, and economic forces, that come
into play here with the diagnosis of ADHD. And if I don't speak out about those
forces, then I become complicit as a physician, because I'm making money, I'm
prescribing this medication, with factors and values that I think are bad for
children and families. That's why I wrote Running on Ritalin, so I
could go to bed at night and sleep better. . . .
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