Lawrence Diller

The Run on Ritalin: Attention Deficit Disorder and Stimulant Treatment in the 1990s

Ritalin use has increased by 500 percent in the last five years. The reasons for this dramatic surge are rooted in changes and pressures in psychiatry and society at large.

Science, Ethics, and the Psychosocial Treatment of ADHD

Psychosocial treatments, such as behavior modification, figure prominently in the guidelines for the treatment of ADHD from both the American Academy of Pediatrics (2000, 2001) and the American Academy of Child and Adolescent Psychiatry (AACAP; Greenhill, 2002). But given the results of recent studies, are these recommendations simply political concessions to the biopsychosocial model? Are parents unfairly biased when they rate behavior therapy as more acceptable than medication for the treatment of their child’s ADHD (Krain, Kendall, & Power, 2005)? Is it finally time to concede that psychosocial interventions add “nothing” to stimulant medication treatment and need not be pursued for uncomplicated ADHD as some prominent recent reviews have suggested (Rappley, 2005)? The answers to these and related questions, although important for individual families, also have great implications for social policy (e.g., funding of schools, parenting programs, or treatment modalities). It is assumed that the answers to these questions are known and in a fair and reasoned way guiding such policy. Indeed, for the most part, they are not known nor are they guiding policy. More than 100 studies demonstrate that parent and teacher training programs improve child compliance, reduce disruptive behaviors, and improve parent/teacher– child interactions (Maughan, Christiansen, Jenson, Olympia, & Clark, 2005; Pelham et al., 2005; Pelham, Wheeler, & Chronis, 1998). Though a number of shortterm studies have scientifically demonstrated the effectiveness of psychosocial interventions for ADHD (Evans, Langberg, Raggi, Allen, & Buvinger, 2005; SemrudClikeman et al., 1999; Tutty, Gephart, & Wurzbacher, 2003), the case for medication’s exclusive status in ADHD treatment derives from two major studies. The first is the National Institute of Mental Health ADHD Treatment (MTA) ongoing study of 600 children (Special Section, Journal of the American Academy of Child & Adolescent Psychiatry, 2001). Three years after the initial MTA results were published, Klein et al. published a series of articles reviewing their study of 103 children during a 3-year period (Klein, Abikoff, Hechtman, & Weiss, 2004; Klein, Weiss et al., 2004). A multisite population of highly screened, well-diagnosed, impaired children with ADHD characterized the subjects of both studies. Most important, unlike previous long-term research on ADHD, children in both studies were randomized into medication only, combined treatment and community treatment groups. The initial headlines from the MTA study emphasized that the combined medication and psychosocial treatment group did no better than the medication only group. However, further analysis of the data indicated that this was true only for the minority of children with uncomplicated ADHD (Conners et al., 2001). The majority of participants diagnosed with ADHD also had comorbid Oppositional Defiant Disorder and/or anxiety. Adding the psychosocial component for these youth to medication treatment statistically improved outcomes compared to the medication only group (Conners et al., 2001). Data collected after 2 years tended to further diminish the superiority of the medicated groups (alone or combination) compared to the psychosocial only and communitybased service groups for all the children in the study (MTA Cooperative Group, 2004). The subsequent study completed in New York City and Montreal was firmer in its conclusions about the lack of increased benefits in adding psychosocial treatment to the effects of medication alone. Over a variety of parameters (e.g., academic achievement, socialization, emotional status, parent practices), the conclusions were the same. The authors were quite clear about the lack of benefits from psychosocial interventions for ADHD when medication was employed. These two studies appear to drive the final nail into the psychosocial treatment coffin. Despite current American Academy of Pediatrics and AACAP guidelines suggesting equality between treatment choices, these studies have been used to promote a medication first approach to ADHD. An MTA research paper was mailed to pediatricians and child psychiatrists in the United States by one of the manufacturers of a medication used to treat ADHD. But whether, on medical or moral grounds, medication

ADHD in the College Student: Is Anyone Else Worried?:

The illegal, non-prescriptive use of prescription stimulants appears to be growing among college students. Recent analyses using DSM-IV criteria suggest that this group of misusers may actually represent cases of undiagnosed ADHD. Such analyses, however, are limited by a diagnostic system that is neither contextural nor dimensional. The ADHD symptoms of the newly diagnosed college student may be highly context and time specific and represent a normal response to temporarily increased demands on intellect and motivation. Diagnosing college students who are misusing stimulants with ADHD runs the risk of further trivializing the ADHD diagnosis. Also from a historical perspective, legitimizing the use of prescription stimulants in this age group may unintentionally only further increase the likelihood of a greater prescription stimulant abuse epidemic.

Book Review: The ADHD explosion: Myths, medication, money and today’s push for performance

The ADHD Explosion by Stephen Hinshaw and Richard Scheffler is simply the best book in the last 15 years to describe the social phenomenon we call ADHD. Hinshaw and Scheffler have taken a very broad view of the problems of children we diagnose as ADHD and properly relabel the condition a biopsychosocial disorder. That they should be hailed for such insight is both justifiable and ironic. Practitioners and the public alike for nearly 30 years have been presented with a deluge of information on ADHD which emphasized its neurological, genetic, and biochemical etiologies. Much of this information was based on drug industry–supported research and promoted by their advertising. Hinshaw and Scheffler are now clearly stating that psychosocial factors play a major role in either the formation or presentation of what we are calling ADHD in America. This takes courage. The authors correctly say “Emphasizing the biological was as misleading as suggesting it (ADHD) is a social construct” (p. 11). But it is also ironic because some of us over two decades have maintained a vigil for the importance of emotions, family, neighborhood, and culture (Diller, 1998). The ADHD Explosion does not neglect the individual or the benefits of diagnosis and treatment of ADHD even as it addresses the very important broader associated societal issues. Each chapter opens with a short clinical vignette that then is connected with the larger themes the chapter addresses. They repeatedly acknowledge the pain, suffering, and real costs of an untreated or unrecognized disorder. Chapter Five (“What a Difference a State Makes”) is pivotal and provocative. In it, Hinshaw and Scheffler take on the wide variations in diagnosis and treatment that exist within the United States. North Carolina is noted to have diagnosis rate of 15.5% for children (ages 4-17) whereas California’s is only 6%. (Note that boys in North Carolina have an ADHD diagnosis rate of 30%! [Visser et al., 2014]). Clearly there is something else going on with American ADHD diagnosis and treatment besides genes and synapses. It is to authors’ credit that they finally acknowledge, in a mainstream academic book, what has been obvious for years—psychosocial factors matter in ADHD. Hinshaw and Scheffler look at four broad factors to account for this wide variation in diagnosis and treatment. The authors consider demographics, health care factors, cultural values, and teacher accountability laws. Looking at the United States, the pattern of ADHD diagnosis and treatment (except for Vermont and Massachusetts) seems to conform to a Red State/Blue State pattern (associated with political and social values) with the Red States having the highest rates of ADHD diagnosis and stimulant medication treatment. The authors contend that their analysis leads them to believe the first three factors are not as important as teacher accountability laws (e.g., schools and teachers are assessed by the performance of their students in statewide exams). They believe the earlier the state adopted such accountability laws (before the “No Child Left Behind” law made teacher accountability a federal statute) the higher the rates of ADHD diagnosis and medication treatment. It is too bad Hinshaw and Scheffler chose to present this intriguing theory in book form where there is no peer review. I, for one, was not dissuaded by their relatively brief discussion on the importance of cultural values. But I could understand their reluctance to conclude that decreased tolerance for talent and temperamental diversity (especially in minority populations) might better explain why the American South and Midwest had much higher rates of stimulant use in children compared with those growing up in the Western and most of the Atlantic coast states. Still, it is refreshing and encouraging to simply have a discussion of these questions finally raised by mainstream experts in the field. I do have some other questions or challenges. The authors suggest that the national cost of ADHD is US

Book Review: The Gift of ADHD: How to Transform Your Child’s Problems Into Strengths

100 billion a year just for the care of children with the diagnosis. This figure assumes that the diagnosis is accurate. Given that ADHD rates approach 30% in boys in some states, one might conclude that the US

Fallout from the pharma scandals: the loss of doctors' credibility?

100 billion is the cost of addressing children’s externalizing problems in general in the United States. Hinshaw and Scheffler are to be congratulated for including a good discussion of the ethics and values surrounding a correct and incorrect diagnosis of ADHD and its treatment. But the discussion left out the critical issue of 543370 JADXXX10.1177/1087054714543370Journal of Attention Disorders research-article2014

100 Years Later, the Flexner Report Is Still Relevant

Whether there are truly more hyperactive and inattentive children in America, there can be no doubt that rates of the diagnosis of ADHD have skyrocketed during the past 15 years. ADHD is the leading childhood psychiatric diagnosis and has become the way we understand and treat many acting out and underperformance problems in children. The very success of ADHD as an explanation has led some to feel that the condition is overdiagnosed, misdiagnosed, and ultimately trivialized by its association with many minimally impaired children. Still, many parents are disturbed by the lifetime implication of the ADHD diagnosis in their children and are wary of the primary recommended treatment: stimulant medication. It is those concerned parents of minimally affected children with ADHD who will find Lara Honos-Webb’s new book, The Gift of ADHD: How to Transform Your Child’s Problems Into Strengths, quite appealing. HonosWebb addresses a potentially large audience of parents who are at best ambivalent about the ADHD label and would prefer not to use drugs to manage their children’s problems. The Gift of ADHD is in the tradition of several older books that emphasized temperament variations (within a normal range) to explain the behavior of mild ADHD. The Difficult Child (Turecki, 2000), Raising Your Spirited Child (Kurcinka, 1998), and Attention Deficit Disorder: A Different Perception (Hartmann, 1997) all acknowledge, even celebrate, the difference of personality in the ADHD child. The Gift of ADHD joins this literature that abjures the medical model and its nearly automatic reliance on a drug intervention. Honos-Webb rounds up the usual suspects in her criticism of the biological explanations for ADHD—the lack of a definitive biological marker and no clear line between normal and abnormal behavior. She worries about the implications on self-image in labeling a child with a lifelong disorder. She acknowledges Ritalin’s positive effects on ADHD symptom reduction: “Research has shown it is the most effective treatment” (p. 187). But three sentences later, she smears its reputation by innuendo in comparing Ritalin to cocaine and morphine and their long-term addiction potential. This book is well written, easy to read, and well organized for parents, but it is not balanced. Honos-Webb does a marvelous job in reframing problem behavior into positives—defiance becomes self-reliance; hyperactivity is exuberance. She offers many useful exercises to remedy the emotional fallout from ADHD: low self-esteem and low morale (in both children and parents). But she spends only two pages on discipline. She spends little time with evidence-based behavior modification strategies. Rather, her emphasis on cognitive behavioral approaches belies its proven ineffectiveness for impulsive behavior. It is not for lack of knowledge about consequence that dooms the impulsive child. It is the relative inability to use that knowledge at any given moment when the impulse takes over. Honos-Webb makes good points in reminding us of the etiologic role of trauma in producing overactivity and inattention in children, which is often overlooked when one simply uses symptom checklists to make the ADHD diagnosis. But supportive talk therapy and biofeedback remain unproven as treatments for ADHD. Her antipathy for the proven effective interventions (medication and behavior modification) is problematic. Overall, there is a place for a book such as The Gift of ADHD when these days it seems this label is regularly misapplied to the most minor of variations of childhood temperament and performance. It is quite possible that the perspective and interventions offered in The Gift of ADHD will help the Tom Sawyers and Pippi Longstockings who are diagnosed with ADHD. But when it comes to the appropriately diagnosed, more highly impaired ADHD child, this book may mislead with false hopes and potentially delay the implementation of more proven effective ADHD treatments.