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Lawrence Diller, M.D.

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A Prescription for America's ADHD Epidemic

Posted: 10/13/11 09:20 AM ET

In a previous HuffPost blog I detailed America's use of prescription stimulant drugs like Adderall, Concerta and Ritalin as the highest in the world. We are 4 percent of the world's population but produce and use 88 percent of these amphetamine-like drugs primarily for the treatment of children's attention deficit/hyperactivity disorder (ADHD) or attention deficit without hyperactivity (ADD).

In my last HuffPost blog I offered my best guesses as to why we occupy this top spot. They included psychiatry's ideological shift from environmental causes to those of biology and the brain, drug companies' promotion of psychiatric drugs and industry's influence on medical and other professional education, increased educational demands on children with larger class sizes, more two-parent working families leading to more preschool time and latch-key kids, insurance companies that reimburse doctors more for "med checks" than for psychotherapy visits, too much play therapy and not enough counseling for parents, mixed up ideas about discipline and finally, parents' worries about their children feeling different and concerns over their self-esteem.

I should have clarified that none of these social or environmental influences alone, without some genetic/biological/temperament susceptibility in a child, could lead to ADHD/ADD or the use of medicines to treat it. In some children the inherent neurological contribution to the problem behavior is minor. The family, school and social factors create the tipping point. In other children, their neurological problems are so great that it wouldn't matter what kind of family, school or culture they lived in -- they would still need medication. However, I strongly believe the latter situation is actually only a small minority in our country compared to the number of children taking prescription stimulants today.

Some experts feel our use of stimulant drugs simply reflect better awareness of the diagnosis and an effective treatment. I worry more about a living rather than chemical imbalance affecting our children. I'm concerned about the overuse of an efficient, cheaper treatment rather than making changes that require more time, money and especially engagement with children.

Here are some suggestions for treating our children and society that may decrease the rates of diagnosed ADHD/ADD and the use of Adderall-type drugs in our country.

  • Involve fathers in all evaluations and treatment plans for ADHD/ADD. The father often has a different perspective (rightly or wrongly) from the mother with regard to the child's problem behaviors and their causes. Fathers' input and buy-in to any treatment plan make non-drug interventions, like behavior modification, and even taking the medications themselves, more likely to succeed.
  • All children being considered for an ADHD/ADD diagnosis should have a minimum screening by the school for learning or processing problems. So many children are inattentive and distractible only at school or when doing homework. Addressing learning problems with small group instruction or tutoring could eliminate the need for a medication.
  • Discipline should emphasize more immediacy, less talk and taking action sooner. Impulsive children "know" the consequences of their behavior. But if consequences are delayed, these children are less able to utilize that knowledge to make the proper decision in the present. Parenting manuals, like 1,2,3...Magic for children up to age 12 and Parenting Your Out-of-Control Teen for families with older kids, emphasize this less talk/more immediate form of discipline (and rewards).
  • Counseling should be directed primarily to parents for support, education and behavioral management strategies (see above). Play therapy and individual counseling for ADHD/ADD children, while more available, have not been shown to be effective for this type of problem.
  • Mental health professionals (especially child psychiatrists and behavioral-developmental pediatricians) should be more involved in coordinating approaches between family, school and doctor. There's no legitimate reason why doctors can't participate more often in IEP (Individualized Educational Plan) meetings at the school. The only real reason is that it cost someone money.
  • End or severely limit direct-to-consumer advertising for drugs by pharmaceutical companies. The practice is based upon corporate "free speech" rights and the hypocritical notion that these advertisements "educate" the consumer. They might, but they are also biased toward making parents believe there's something wrong with their children's brains that require a doctor's diagnosis and medication. Unfortunately there are no corporate equity companies promoting family counseling or special education.
  • Parents and teachers can take a collective societal "sigh" about our children's feelings. Our worries about our children's self-esteem and self-image turn out to be not as important long term as we believed. Of course we want our children to feel good about themselves. But our concerns have ironically led to an intolerance of minor differences in children. Children still need our support and intervention until they get to their late teenage years -- when opportunities to do more of what they want or what they are good at become available to them. But until then, we don't have to operate as parents with our hearts in our throats.

I have no illusions that any of these suggestions will be implemented on a large scale at any time soon. Most take a bit more time and cost more money than giving children pills. I'm not against the pills -- I've said that many times. I am against pills as a first or only choice for children with ADHD/ADD.

Pills work and are efficient but are not the moral equivalent to non-drug interventions that also work. To make my point very clear I offer my own Swiftian "Modest Proposal." With about 3 million children taking Adderall-type drugs today, classroom size averages about 29 kids per class. I propose we increase the number of children taking Adderall to 4 million and then can increase class size to 40 per class, in the process saving a lot of money directed to paying teachers and building classrooms.

No responsible, sensible politician would ever support such a proposal. But in fact, this trade-off in pills for dollars happens every day in our country. I see no discernible short-term influences to disturb this trend. The United States of Adderall will continue at least into the near future until our values change substantially or, more ominously, we experience some social catastrophe from the adult use of these drugs. Stay tuned for my last U.S. of Adderall HuffPost installment on the next doctor-prescribed stimulant abuse epidemic in America (psst... it's taking place now).