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Lawrence Diller, M.D.

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The United States of Adderall

Posted: 09/09/11 09:26 AM ET

Last week, the Centers for Disease Control (CDC) released analysis of data revealing a major increase in the incidence of attention deficit hyperactivity disorder (ADHD) among children in the United States. The number of children between the ages of five and 17 reported by their parents to "have" ADHD or the non-hyperactive form of the disorder (ADD) had risen from 7 to 9 percent over a decade ending in 2009. Nine percent translates to 4,858,210 children according to 2010 U.S. Census data.

In actuality, the researchers do not know for certain whether these children actually meet criteria for ADHD/ADD. The data is culled from a national telephone survey which asks parents the question, "whether or not a doctor or other health-care provider had ever told them that their child had attention deficit disorder or attention deficit hyperactive disorder, that is, ADD or ADHD.'"

Since there is no biological or psychometric test for ADHD/ADD no one can be certain these children have a definitive neurological condition. In its extreme form the hyperactivity and impulsivity of ADHD are easy to recognize. But most children are commonly diagnosed with the mild variety which blends seamlessly into the behavior of normal but active or lively children. It is with this mild form where opinions vary widely between professionals. This survey then only measured what parents had been told.

Still the continued rise in the diagnosis and treatment of ADHD/ADD in children is unmistakable. As a long time observer and participant (I prescribe drugs like Ritalin, Adderall and Concerta every day) of this trend, I have watched the 20-year growth of this condition with curiosity and some consternation. I have also been involved in what has been colloquially called "The Ritalin Wars" -- an often polemical debate conducted in the media as to whether the widespread use of prescription stimulant drugs (essentially amphetamine) is good or bad for the children of this country.

The upward trend continues. Given the current CDC data, one can safely estimate (based on previously detailed distribution curves) that one of six 11-year-old white boys with medical insurance currently take a stimulant drug at least during the school week. Is this over medication or simply good medical care for children with a previously undiagnosed and untreated condition? What I do know is that we are the only society currently managing our under performing/misbehaving children with drugs to this degree.

While the diagnosis of ADHD/ADD can seem ephemeral, the production of prescription stimulants, whose use is closely tied to the diagnosis, is monitored by the Drug Enforcement Administration (DEA). Since 1966 the annual amount of Ritalin-type drugs approved for production by the DEA quadrupled to 50,000 kilograms, and for Adderall increased ten-fold to 26,000 kilograms. In more common terms nearly 84 tons of legal speed were approved for production in 2010.

The U.S. is a signatory to a 1972 United Nations treaty monitoring the production and sale of potentially addicting substances. The U.N.'s International Narcotics Control Board (INCB) based in Vienna, monitors the production of legal stimulants worldwide. INCB data shows that in 2009 the U.S., representing 4 percent of the world's population, produced 88 percent of the world's legal Ritalin type drugs. Canada uses a third per capita of prescription stimulants compared to the U.S. -- Germany, one eighth, the U.K. one twelfth, Japan, one fiftieth.

These drug production amounts do not separate child from adult use and clearly there has been a surge in adult ADHD/ADD and their use of stimulants in America in the last decade as well. Still the CDC study marks a continued increase in the diagnosis and use of these drugs in children. Is this a good thing or a bad thing?

I suppose it comes down to values. Amphetamine when used (in low doses) immediately improves focus and attention in anyone (including ADHD/ADD children) who takes them. Specific behavioral interventions (especially by parents) and educational interventions (by schools and teachers) also improve the performance and behavior of ADHD/ADD children.

Pills, however, place value on efficiency -- they work quickly and are relatively less costly. The non-drug interventions value engagement with the child; they require more time, more involvement by adults and initially cost more money. Medical and educational systems value efficiency. Parents generally value engagement but if the treating systems only offer pills, parents will surely take them over no treatment.

Ritalin type drugs have been around for 80 years, used in children for 70. They are reasonably safe and effective in children -- not so for older teens and adults, where the specter of over-use, tolerance and addiction has a long historical precedent. The trends that have fostered the United States of Adderall continue.

I see no countervailing influences in the immediate future that may slow the use of prescription stimulants in children (and adults) in our country. As with most things in America, money factors rule. But a society that chooses to cope by using drugs, in the long term, does so at its own peril.

CORRECTION: An earlier version of this post stated that since 1996 the annual amount of Ritalin type drugs approved for production by the DEA multiplied 4,000 times to 50 million kilograms, for Adderall 10,000 times to 26 million kilograms, and that 83,776 tons of legal speed [Adderall] were approved for production in 2010.

This has been changed to reflect corrected information: Since 1966, the annual amount of Ritalin type drugs approved for production by the DEA quadrupled to 50,000 kilograms, and for Adderall increased ten-fold to 26,000 kilograms. Nearly 84 tons of legal speed [Adderall] were approved for production in 2010.