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.
Lawrence Diller will appear on the nationally acclaimed news show, The Stream, on the Al Jazeera Network, viewed by nearly 32 American families. The show will air live on Thursday, November 15th, at 3:30 PM. The topic will be the reported use of stimulant drugs like Ritalin, Concerta and Adderall on non-ADHD children performing poorly in low income schools. The program can also be viewed online at http://stream.aljazeera.com/.
Lawrence Diller will be interviewed on the Daily Circuit News Program on Minnesota Public Radio on Wednesday, November 14th at 9 am local time (7 am Pacific Time). He is scheduled to be on for 45 minutes. The topic will be the emerging adult ADHD market for stimulant medication.
You can listen to the program locally on air in the St. Paul/Minneapolis area and other feeds in Minnesota. You can also listen to a live streamed version by going to http://minnesota.publicradio.org/features/ or afterwards by going to the archives of the Daily Circuit on the same MPR website.
(First appeared in the Huffington Post on October 10, 2012)
"Give me my Adderall!" Matthew, a 15-year-old patient of mine, recently demanded of his parents. When they refused, Matthew slashed his left wrist with a box cutter. His parents called the police and he was taken to the county hospital emergency room for evaluation and possible admission to the psychiatric ward. His parents had withheld the medication for Matt's purported attention deficit disorder (ADD) because they hadn't liked the side effects of irritability and anger they had associated with their son's use of the medication.
Matthew was enraged. His parents had taken away his cell phone and all access to the Internet because they felt he was making no effort at all early in his sophomore year in high school, either in class or in doing homework. Matthew felt he "couldn't" do his work without the medication and didn't think his mood on the medicine was a major problem. He and his parents had been arguing about his restrictions when, in essence, Matthew had a temper tantrum, threatening to cut himself. When his parents held firm, he injured himself with a dramatic act but fortunately made only superficial lacerations to his wrist.
I've witnessed many other dramas in my 34 years as a behavioral pediatrician and family therapist, but Matthew's recent episode epitomized for me a tectonic shift in the way adolescents view psychiatric drugs, especially the performance-enhancing stimulants (Adderall, Ritalin, Concerta, etc.). As recently as 15 years ago, I had a difficult time convincing young to mid-adolescents to try any psychiatric drug: Prozac, Adderall, whatever. I used to share my frustration with parents that their child was refusing my medications but was quite ready to self-medicate with marijuana, alcohol or other illegally-obtained substances. But with teenagers now insisting on pharmaceuticals as solutions to their problems, I wonder if that's really making progress.
While there could be multiple reasons for their problems, these days I've noticed teenagers regularly telling their parents they "can't" concentrate on school or homework and asking for medication. Ironically, it's their parents who have become more uneasy or reluctant to immediately give their children stimulants (amphetamines or some variation of them) to improve their school performance or behavior at home.
Some parents are understandably worried about side effects or the risks of addiction and abuse. Actually, most children (and people) can tolerate the side effects (if any) to the stimulants. Used properly (in my practice parents are entirely in charge of these drugs), the risk of physical addiction is close to if not zero. But many parents are also concerned about Adderall's "quick fix" nature of the teens' solution to their problems.
Adderall improves anyone's performance on boring and repetitive tasks. It will not make someone smarter. Indeed, despite decades of use, evidence that long-term learning or grades improve is absent to scant. Most consistently, it does give someone the sense that they are doing better and therefore often improves motivation. The work gets done. However, inconsistently or unmotivated naturally-distracted teenagers learn nothing about how to make themselves do the uninteresting or challenging tasks necessary to grow to be mature adults.
Undoubtedly some will say "Well that's exactly what teenage ADD is -- difficulty making yourself do something you're not interesting in!" Indeed, it's impossible to distinguish the behavioral symptoms of ADD from those of an inconsistently or unmotivated adolescent. There is no blood test or brain scan for ADD or for any psychiatric disorder for that matter. Nevertheless, doctors do seem more ready to offer these drugs to all people. What have changed are the teens' attitudes toward these meds. They want them and ask for them.
While not worrying about physical addiction, I've seen psychological addiction and dependency in teenagers for Adderall. Also, teens in high school and college students are increasingly obtaining the drug illegally (mostly from friends who've gotten prescriptions from their doctors). Some colleges report 35 percent of the students have tried Adderall-type drugs for studying or getting high (remember, it is amphetamine). For subgroups, like fraternity or sorority seniors, rates have been estimated as high as 80 percent. Used improperly or unsupervised, serious abuse and addiction can occur. Additionally, these drugs can be a pathway to the misuse and abuse of other prescription medications like Oxycontin and street drugs like methamphetamine.
There's certainly a place for these medications in the treatment of ADD. But I think we've done too good a job of "selling" ADD and Adderall as the answer to many teenagers who are in a normative struggle toward maturity. Unfortunately, there are few cultural influences strong enough to the counter the power of the medical-pharmaceutical industry that successfully brought our country's attention to the problems of attention. "Just say 'No'" didn't work with street drugs. Sadly, it's unlikely to work with ADD drugs like Adderall as well.