100 years ago doctors had little credibility. A education reformer's report remarkably reformed medical education and physicians' professionalism. In the last thirty years this credibility has been eroded by financial ties between doctors and the drug companies. Is it time for another Flexner Report.
The decision by the Massachusett's Board of Registration in Medicine to allow the psychiatrist in the Rebecca Riley murder case to practice again without any restrictions makes no sense in light of the specific facts that emerged in testimony during the trials. However, punishing the doctor would have also challenged Harvard's Pediatric Psychopharmacology Clinic which promotes the bipolar diagnosis and aggressive use of psychiatric medication in children.
Apparently, the closer you are to Harvard the more legitimate Pediatric Bipolar Disorder becomes. Carolyn Riley, the mother of Rebecca Riley who was killed, four years ago was convicted on February 9th of second degree murder. The doctor who prescribed the girl three psychiatric drugs was granted immunity from prosecution and continues to practice.
Posted first: 12/23/2013 12:44 pm on the Huffington Post (http://www.huffingtonpost.com/larry-diller/ritalin_b_4470702.html?view=screen)
I've been uncomfortably married to Ritalin for 35 years. That's how long as a behavioral pediatrician I've been prescribing stimulant drugs like Ritalin, Adderall and Concerta to children and adults in my suburban private practice outside of San Francisco.
Prescription stimulants, which are all a version of amphetamine, have been controversial since their introduction in 1929. They are front-page news again. This Sunday's New York Times offers a detailed report on the role of drug companies' influence through advertising, medical education and research on attention deficit disorder (ADD) and its treatment. Today one in seven American children have been told they "have" ADD.
The pharmaceutical industry did not come up with the idea of using drugs to treat children's problems of behavior and performance. Doctors did. But several large drug companies in the mid-1990s grabbed this ideological football and ran with it. Five years later, these companies had become the dominant influence in the way we Americans think about children's mental health and school performance.
The "f" word in my practice is not four letters -- it's five for "focus." Parents and teachers attribute virtually every type of children's misbehavior or underperformance (especially in school) as a problem of focus or attention. Does he or she "have" ADD is the daily question. The ADD diagnosis is technically categorical -- either you have it or you don't. But in reality the qualities of distractibility and inattention fall across a spectrum of ability/disability that follows a bell-shaped curve.
There are no blood or brain scan tests for ADD. At one extreme are children whose personalities and behavior are so shaped by neurological and biochemical factors that there is little question they meet the behavioral criteria for ADD and benefit from medication. However, by virtue of the bell-shaped curve, the vast majority of children receiving the ADD diagnosis are of the mild variety. There, abnormal behavior blends into variations of normal and controversy rages on whom should be treated with drugs.
Relatively speaking, the stimulant medications when used properly are safe and improve short-term performance in behavior and grades potentially for everyone (child/adult, ADD or not) who takes them. However, for mild or moderate ADD, non-drug interventions like parenting strategies, behavior modification techniques and special education also work. The drug approaches prioritize efficiency and cost. Non-drug interventions prioritize engagement with the child. School systems and insurance companies value the former. Parents and most teachers prefer the engagement strategies. But too often when parents are offered only drugs or no other treatment for their child, they'll try the drug approach.
However, we cannot just blame the drug companies for our ADD/stimulant epidemic. We are 4 percent of the world's population but in 2011 produced 70 percent of the world's legal stimulant drugs. In any epidemic, there are host factors that make the population particularly susceptible to the infection. Ritalin and Adderall are like the jeweler's chisel that has exposed the cracks and faults in our society's view of our children. We have lost our place as the predominant manufacturing power in the world. Jobs are either technical or service oriented. The gap between the rich and the middle class has grown enormously. There is real fear in the air. We've come to expect more from our children (and teachers) educationally at an earlier and earlier age. Everyone now is expected to go to college in order to be "successful." Our ideas about discipline are very confused. Children are expected more than ever to perform and self-regulate their behavior. And when many, especially boys, don't, we medicate them because they "have" ADD.
But at the core of this epidemic, the drug companies exploited a key shift in our thinking about feelings in general and especially the importance of children's feelings of self-image and self-esteem. We are so concerned about our children's immediate and continuing happiness, that we have become paradoxically intolerant of minor differences in their behavior and performance that temporarily might have them feeling badly about themselves.
Of course, we love our children and want them to feel good. However, we worry so much about our children's feelings (and how they will do in the future) that we then take them to our doctors who diagnose them with a mental disorder and treat them with psychiatric drugs. It is a curious, unique and sad way our society is handling children's differences.
Large Fortune 500 companies now earn $9 billion a year treating and exploiting this worry. The glare of publicity on drug company influence along with the increasing reports of Adderall misuse, abuse and addiction may give pause to some. But the social and economic factors that have fed this epidemic will continue into the foreseeable future. Fifteen years ago I suggested we might become a nation "running on Ritalin." I continue to worry about our country's use of prescription stimulants because a society that copes by using drugs does so at its own peril.
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.