Two weeks ago in a HuffPost article, I wrote of the recent CDC report, which determined that now 9 percent of all children age 5 to 17 in America (about 5 million) have been noted by a health professional to "have" ADHD/ADD (attention deficit disorder with and without hyperactivity). I added, based upon data maintained by the U.N.'s International Narcotics Control Board, that the U.S., which constitutes 4 percent of the world's population, in 2009 produced 88 percent of the legally-prescribed amphetamines (drugs like Adderall, Concerta and Ritalin).
The article ignited another round of the "Ritalin-Adderall Wars," a public debate about ADHD/ADD and children's psychiatric drugs. The myriad comments, mostly anti-drug, were laced with hyperbole and polemic diatribes. In a second HuffPost piece, I called for restraint and reason in the discussion, if the serious questions about children's mental health and our society are to be addressed.
I tried to remain balanced in expressing my opinions in the first two articles. I said I've prescribed stimulant drugs to children for more than three decades (most often after attempting non-drug interventions like behavior modification and special education). Despite belief in the effectiveness and safety of these medicines, I remain worried about a medical system/society that is so dependent on this treatment. My belief that I maintain a sensible middle ground on ADHD and Adderall was reinforced by comments that attacked my position from both the pro and con sides of the war.
What follows are my opinions on the causes of the American ADHD/Adderall "epidemic." I believe epidemic a fair description for a drug that has multiplied in use ten-fold from 1996 to 2009, according to the Drug Enforcement Administration. I offer these ideas as opinions, not facts -- though many of the points are buttressed by academic research. A few are just common sense.
- Poverty, racism, adult violence and substance abuse are the main reasons for all children's mental health problems, including ADHD/ADD. A particularly revealing study showed that when a Native American tribe's income suddenly rose as a result of a nearby casino, all "acting out" children's problems (including ADHD) declined. However, Adderall treatment for ADHD/ADD is disproportionately directed to middle and upper middle class children.
- Since the 1980 publication of American Psychiatric Association's Diagnostic and Statistical Manual of Psychiatry, Edition III (DSM-III), more and more Americans have been willing to interpret children's under-performance and misbehavior as ADHD/ADD. As more and more people have accepted the idea of a "chemical imbalance" (never proven but only inferred by the response to drugs like Prozac and Adderall), the stigma of psychiatric diagnosis and use of psychiatric drugs in children has declined.
- While American organized psychiatry reintroduced the biology/genetics/chemical imbalance view of mental illness in 1980, the pharmaceutical industry grabbed this conceptual football and ran with it. Since the mid-1980s, the drug companies have been arguably the single biggest influence on America's thinking about children's mental health and illness -- by virtue of their financial clout to fund research and medical professional education (which in turn informs the education of other mental health and educational professionals), advertise first to physicians and then directly to parents, and offer free samples (vouchers, in this case, for amphetamine, a controlled substance).
- Larger class sizes and increased and earlier educational demands on children create stressors for the children, their teachers and parents. For example, more than 20 years ago kindergartners only had to sing the ABCs and play "ring around the rosie." Now, they are expected to read and do simple math before the start of first grade. The increased educational pressures to perform continue on toward getting into a good college and graduate school.
- The declining American standard of living for the middle class leads to both parents working, the need for preschool and more latch-key children. It's a long day for toddlers, school age children and their parents. Managing within the structured bureaucracies of preschool and after-school programs sets up behavioral demands that many children cannot meet. Parents are tired, too, when they finally get their kids at the end of the day.
- Insurance companies reimburse American psychiatrists significantly more when they see four patients in an hour for "med checks" rather than one 45-50 minute talking session with the child or his/her family.
- Therapy, when offered to ADHD/ADD children, is often individual play therapy, which is not effective for this problem. What works is family/parent oriented counseling for behavioral management strategies and support. It's harder to find a good family therapist than individual play-oriented therapists.
- Americans are mixed up about discipline and also worry more about their children than other cultures. A talking/cognitive approach to discipline is poorly suited to an impulsive or inattentive child. Worries about children's self-esteem undermine uncertain, tired parents' resolve about setting limits that may necessitate conflict or punishment.
- A 60-year cultural trend has made feelings more important in general. Pre-1970s parents simply didn't think about their kids as much. Parents worry about their children falling behind and feeling different and bad. Their concerns about their children drive them to professionals, who then offer medication. We are the only society that addresses sometimes minor differences in children's behavior or performance with drugs to such a degree.
There are items that are not on my list. I don't include sugar, processed foods, additives, TV, video games, Internet and cell phones. There is either no good research to support these factors or sometimes multiple studies that show no or very weak links at best (as with sugar). I know proponents of each factor will exaggerate its influence with at least one study that purports to "prove" a link. I anticipate many aggrieved disclaimers from readers (e.g., "My son stopped eating _______ and all his ADHD symptoms disappeared!").
I also believe there are no conspiracies to drug the children of America. Rather, a number of economic "invisible hands" work together to make children and families less able to cope and Adderall an attractive, efficient solution.
I welcome readers' comments. I am not denying the existence of ADHD/ADD or the value of Adderall for the particular child or adult using it. I am not presuming I "know" for certain why we are the "United States of Adderall." But I worry less about our children's chemical imbalances than their living imbalances, which may contribute to the ADHD/Adderall epidemic.
CORRECTION: A previous version of this post stated that Adderall use multiplied 10,000 times from 1996 to 2009. Adderall use multiplied ten-fold from 1996 to 2009, according to the Drug Enforcement Administration.