I will be giving a very popular talk, The Sensible and Ethical Prescription of Psychiatric Drugs to Children, at Grand Rounds at Children's Hospital Oakland on Tuesday August 13th from 8 to 9 am. There will be a question and answer period at the end of the presentation. The talk is open to the public. Please join me at the Auditorium in the Outpatient Center at Children's Hospital, 744 52nd St., Oakland. Parking is available across the street from the Outpatient Center.
(first appeared on June 6th, 2013 on Huffington Post website)
Having prescribed drugs like Ritalin and Adderall to children for 35 years, I've participated with concerned fascination in the ADHD/ADD epidemic that has swept our country. Still, I was surprised that I felt so troubled when 16-year-old Joe's* mother, Susan*, called me the other day and asked if I'd be willing to prescribe him Adderall just for his finals coming up in two weeks.
I had evaluated Joe the year before for attention deficit disorder because he had complained that he couldn't concentrate. His grades had been inconsistent but included a couple of Ds. In my evaluation, I found Joe's abilities and academic performance to be at grade level. He could have been an A/B student with consistent effort. But Joe had major problems making himself do things he knew he needed to do and neither had his parents found a formula to help him get his homework done on a regular basis.
Psychiatric criteria require six of nine symptoms of inattention or distractibility to meet official standards for ADD (or technically ADHD-inattentive type). But Joe's disconnect between what he wanted and what he was doing has become the de facto clinical front-line rationale for both ADD and the use of prescription performance-enhancing stimulant drugs. Indeed, anyone whose temperament or talents fail to meet their goals or aspirations could present to a doctor for an ADD evaluation and medication and likely get both the diagnosis and drug.
Last year, I worked primarily with Joe's parents to help them organize a week-to-week academic contract for Joe. When I checked in with Susan this fall, she reported he had started his sophomore year positively. Thus, Susan request that I prescribe Joe Adderall for finals week surprised me some. Joe didn't want to take the medication on a regular basis because he was concerned about side effects but was willing to try it to help with his exams. A friend of his had a doctor who had prescribed the drug for this limited indication and use. Would I do the same for Joe?
I told her it was unlikely that I would give Joe medication just for test taking. I said I would reconsider starting Joe on a long-acting stimulant medication like Concerta or Adderall XR but that he would have to take it on a regular basis (e.g., five school days a week). I suggested that the parents and Joe come in to talk to me about Joe using Adderall. Susan said she would consult with her husband and son and get back to me. I didn't hear back from her and wonder if she called the other doctor.
I won't give Joe a prescription because I believe this type of "event-driven" dosing actually could facilitate an ADD lifestyle. High school and college students can act notoriously irresponsibly during the year and then want legally- or illegally-obtained Adderall to study and take exams at the end of the semester for finals. I'm prepared to help Joe if he wants to use the drug to improve his studying and homework completion on a weekly basis. I've stopped trying to decide who really does or doesn't have ADD. I just want the person to use the drug effectively and responsibly.
Then there are the societal concerns. Many students have raised fairness issues -- for the same reasons that athletes have complained when their colleagues/competitors are using performance-enhancing drugs. We ban these substances in sports for two reasons. We value achievement based upon effort and these drugs cheapen the achievement. But more critically allowing the use of these substances puts pressure on all competitors (athletes/students) to use them just to keep up. It's called "free will under pressure."
But there's a more Joe-specific reason for questioning using Adderall to try to improve his final exam scores. When Joe and his parents choose to use Adderall they prioritize simple achievement over other human qualities and values (like love or connections to others). They also permit Joe to skip, at least temporarily, a universal experience/maturation process that gets us to accept our own strengths and weaknesses. As we get older we get to "focus" on things we like and are good at.
We Americans live in a complete corporate meritocracy -- achievement at all costs. A college education guarantees a good job, earning power and happiness. Or does it anymore? The U.S. is 4 percent of the world's population but in 2010 produced two-thirds of the world's Adderall. In 2013 the Drug Enforcement Administration approved the production of 189 tons of legal speed (Ritalin, Adderall, Concerta, etc.) or 544 milligrams for every man, woman and child living in the U.S.
So I don't blame Joe's family at all if they wind up using Adderall for finals. I just know my limits as to how far I can ethically participate in this epidemic. But I suspect the other doctor will have no problem filling the prescription.
*Names have been changed.
Shock and incredulity greeted a front-page New York Times article last week that nearly 1 in 5 American high school boys had attention deficit/hyperactivity disorder (ADHD). The Times analysis of the most recent Center for Disease Control (CDC) survey of 76,000 households had the overall rate of ADHD for children ages 5 to 17 at 11 percent. Approximately 6.4 million children have received the diagnosis. Two-thirds of those with a current diagnosis were receiving prescription stimulant drugs like Adderall, Ritalin or Concerta. Annual sales last year of these drugs reached $9 billion.
In 2010, the Drug Enforcement Administration's (DEA) total annual quota for legal stimulant drugs (controlled substances because of abuse and addiction potential) was 84 tons. The U.N.'s International Narcotics Control Board (INCB) monitors legal stimulant production worldwide. According to an analysis of 2009 data, the U.S., which accounts for 4 percent of the world's population, produced 88 percent of the legal speed on this planet.
Some doctors have viewed last week's Times report (along with nearly a dozen articles or op-eds in the past 18 months) as some sort of anti-ADHD/medication crusade. It's hard to say whether the Times is leading or reflecting growing unease with our country's reliance on psychiatric drugs, especially for children (see the editorial in this week's Times). But as a doctor who's been prescribing Ritalin drugs to children for 35 years and wrote 15 years ago we could become a country "running on Ritalin," I can assure you these disturbing numbers and trends are only going to become more extreme in the next several years.
Our use of psychiatric drugs with children is tied to deep social, cultural and economic prerogatives. We fear our children's relative failure and differences that might temporarily lead to a diminished self-image or esteem. We've come to believe that behavior is brain-based and genetically determined. There is less stigmatization in use of psychiatric drugs to address children's behavior or learning problems. Older teens and college students are attracted to the "quick fix" nature of the prescription amphetamine drugs for cramming (and getting high). Finally, the medical/pharmaceutical industrial complex has had the largest impact on our view of children's health and behavior by co-opting medical education and research, and advertising to doctors and directly to parents (and their kids).
There are children with serious problems associated with hyperactivity and impulsivity. A recent Kaiser analysis of 850,000 children ages 5-12 in 2010 had only 3.1 percent meeting ADHD criteria when a medical specialist made the diagnosis. However, the discrepancy between what parents have been told (in the CDC study) versus a specialist's diagnosis becomes meaningless when these drugs work as performance enhancers for everyone.
Yet what rankles more is the moral problem of using drugs for behavior problems and school performance. Drugs are cost-efficient and fast when compared to non-drug interventions like parenting strategies, behavior mod and special education. Parents prefer the non-drug strategies be tried first. Schools, insurance and drug companies prioritize efficiency. Reports from colleges and high schools raise the specter as well of a growing doctor-prescribed Adderall misuse and abuse epidemic.
These ADHD numbers are disturbing, but my 20 years' experience in what's been called "the Ritalin Wars" tells me that nothing leads to substantive change except the deaths of children. My cynical prediction is based on participating in the FDA Prozac and children's suicide hearings of 2004-5. When people learned that the FDA knew of seven negative Prozac studies that hadn't been shared with the public, a woman at the hearings, whose son committed suicide on the drug, pointed to an FDA official and alleged, "You killed my son!"
The hearings, with the additional political support of Senator Charles Grassley, led to tectonic type shifts in the relationship between the drug companies and doctors, new "sunshine" laws on the publication of medical studies and a decline in the use of Prozac in children.
Changes in the prescription of the stimulants for ADHD will come only with very high negative publicity, and the threat of malpractice suits and loss of licensure to doctors. I've been proposing a major "summit meeting" on ADHD and Adderall much like a DEA-sponsored meeting held 17 years ago. The DEA this time seems preoccupied with opiates like Vicodin and Oxycontin. Perhaps they haven't checked -- amphetamine just passed the opiates in the most recent survey of high school students' use of illegal drugs.
Meanwhile, the highly-awaited, highly-controversial, next edition of the Diagnostic and Statistical Manual of Psychiatry (DSM 5) comes out next month. I suspect the disorder most ailing our country will not be included -- SSD -- or Sick Society Disorder. We even have the drugs to treat it. Your children are already taking them.