Running on Ritalin: A Physician Reflects on Children, Society, and Performance In A Pill - Hardcover

Diller, Lawrence H.

Hardcover

ISBN 10: 0553106562 ISBN 13: 9780553106565

Publisher: Bantam, 1998

Synopsis

In a book as provocative and newsworthy as Listening to Prozac and Driven to Distraction, a physician speaks out on America's epidemic level of diagnoses for attention deficit disorder, and on the drug that has become almost a symbol of our times: Ritalin.  

In 1997 alone, nearly five million people in the United States were prescribed Ritalin--most of them young children diagnosed with attention deficit disorder.  Use of this drug, which is a stimulant related to amphetamine, has increased by 700 percent since 1990.  And this phenomenon appears to be uniquely American: 90 percent of the world's Ritalin is used here.  Is this a cause for alarm--or simply the case of an effective treatment meeting a newly discovered need? Important medical advance--or drug of abuse, as some critics claim?

Lawrence Diller has written the definitive book about this crucial debate--evenhanded, wide-ranging, and intimate in its knowledge of families, schools, and the pressures of our speeded-up society.  As a pediatrician and family therapist, he has evaluated hundreds of children, adolescents, and adults for ADD, and he offers crucial information and treatment options for anyone struggling with this problem.  

Running on Ritalin also throws a spotlight on some of our most fundamental values and goals.  What does Ritalin say about the old conundrums of nature vs.  nurture, free will vs.  responsibility? Is ADD a disability that entitles us to special treatment? If our best is not good enough, can we find motivation and success in a pill? Is there still a place for childhood in the performance-driven America of the late nineties?

About this title

About the Author

Lawrence H. Diller, M.D., attended the College of Physicians and Surgeons, Columbia University, and trained at the renowned Child Study Unit of the University of California, San Francisco, and the Mental Research Institute of Palo Alto.  In addition to professional publications, he has written for Family Therapy Networker and for the Hastings Center Report, where his 1996 article on Ritalin became national news.  He practices in Walnut Creek, California, and lives nearby with his wife and two young sons.

From the Inside Flap

provocative and newsworthy as Listening to Prozac and Driven to Distraction, a physician speaks out on America's epidemic level of diagnoses for attention deficit disorder, and on the drug that has become almost a symbol of our times: Ritalin.

In 1997 alone, nearly five million people in the United States were prescribed Ritalin--most of them young children diagnosed with attention deficit disorder. Use of this drug, which is a stimulant related to amphetamine, has increased by 700 percent since 1990. And this phenomenon appears to be uniquely American: 90 percent of the world's Ritalin is used here. Is this a cause for alarm--or simply the case of an effective treatment meeting a newly discovered need? Important medical advance--or drug of abuse, as some critics claim?

Lawrence Diller has written the definitive book about this crucial debate--evenhanded, wide-ranging, and intimate in its knowledge of fam

Reviews

Is prescribing the stimulant Ritalin the best way to treat the growing number of American children diagnosed with attention deficit disorder (ADD)? According to Diller, a pediatrician and family practitioner who has contributed many articles on the subject, while Ritalin may treat problems of "brain chemistry" among some children, it also obscures social or environmental factors in many others. Writing for a popular audience, Diller argues that since Ritalin has been shown to enhance performance even among normal children, it is misleading to hold that its success in treating ADD children means that ADD can be reduced to a biological phenomenon, to chemical imbalance. Diller convincingly suggests that part of the reason that many wish to portray ADD as a purely "neurobiological" disorder and Ritalin as the "cure" is political. As victims of biology, children and adults diagnosed with ADD become legally entitled to rights not given to others. But so what? If Ritalin helps those diagnosed with ADD perform better, what difference does it make whether it treats the causes of ADD or just its symptoms? Diller's answer is that America should be concerned because the 700% increase in Ritalin use points to a social imbalance that prescribing the drug covers up: "The surge in ADD diagnosis and Ritalin treatment is a warning to society that we are not meeting the needs of our children." Whether or not one entirely accepts Diller's argument that American psychiatrists have ignored the evidence against Ritalin's effectiveness as a cure for ADD, this is an important book for anyone interested in the narcotizing of America's youth.
Copyright 1998 Reed Business Information, Inc.

A concerned physician examines the skyrocketing use of Ritalin to treat attention deficit disorder (ADD) and finds its causes in a mix of disturbing social, cultural, and economic factors as well as in the psychopharmacological model of mental illness. The explosion in ADD diagnosis and Ritalin treatment in the US is a ``white, middle-to-upper-middle-class, suburban phenomenon. Diller, a California pediatrician specializing in child development and behavior, as well as a family therapist, sees ADD not as a manifestation of a chemical imbalance in a child's brain but of a living imbalance in many stressed-out American families. Among the causative factors that Diller identifies are the changing structure of family life, parents equipped with poor parenting techniques but anxious to give their child every advantage, rising academic competitiveness and pressure to succeed, and an overtaxed educational system where large classes provide many distractions and little individual attention. Also contributing are a managed-care health system that looks for low-cost solutionsRitalin works fast and is a relatively cheap pilland a school of thought that views ADD as being primarily a neurological disorder. When a behavior problem is classified as a medical disorder, Diller notes, insurance coverage is available and parental guilt is eased. He is not opposed to trying Ritalin but asks that other efforts be made to address a child's behavior and performance problems first, such as parenting/family therapy and monitoring the school situation. Diller draws on numerous cases from his two decades of practice to illustrate both the problem and his own multimodal approach. In his conclusion he proposes steps that parents and professionals can take to halt the surge in ADD diagnosis and Ritalin treatment. Balanced and thoughtful, yet sounds a powerful alarm. -- Copyright ©1998, Kirkus Associates, LP. All rights reserved.

As a pediatrician, Diller has seen an increase in the number of parents looking to attention deficit disorder (ADD) as an explanation for their children's academic and behavioral difficulties. There has been a corresponding rise in demand for Ritalin, an amphetamine-like drug that can allay ADD symptoms in some patients. Diller's book is a thoughtful examination of the science and pseudoscience surrounding ADD, the effects of Ritalin and behavior therapy, societal and parental expectations, ADD in adults, and treatment options. As the ADD debate is heavily divided between nature (biochemical origin) and nurture (parenting skills, home/school environment), the argument is unlikely to be settled any time soon. Ritalin can help some children in the short term, but reliable studies on its effectiveness have yet to be completed. Neither a jeremiad against drugging our children nor an unqualified panegyric in praise of Ritalin, this title brings balance to the discussion. Recommended for all health collections.
-?Anne C. Tomlin, Auburn Memorial Hosp. Lib., NY
Copyright 1998 Reed Business Information, Inc.

Parents of children who have or may have attention deficit disorder (ADD) might find it difficult to slog through this lengthy book. They should stick with it, though, for otherwise they will lose an excellent opportunity to learn about methods of diagnosing ADD, various treatments of it, and related problems. Behavioral pediatrician Diller explains how he interviews patients and parents, what he looks for, and how he sets up a treatment program. Often citing sympathetic case histories, he carefully spells out his reasoning and tells how he decides whether to incorporate Ritalin or some other drug. He doesn't believe that all ADD-like conditions are caused by brain malfunctions and, therefore, also examines nurture and relationship problems as etiological factors. Support groups and Ritalin enthusiasts get thorough goings-over, and--unusually for a medical author--he not only poses questions but also provides possible answers. This thought-provoking book should help anyone genuinely concerned with ADD and ADD-like problems. William Beatty

Excerpt. © Reprinted by permission. All rights reserved.

Ritalin Ascendant: A Doctor's Dilemma

Something is awry, all right, but something not entirely medical in nature.
--Robert Coles, M.D., The Mind's Fate

It's midday at an elementary school in a comfortable American suburb. The lunch bell has just rung, and kids are noisily pouring out of classrooms to enjoy a brief recess in the schoolyard before mealtime.

Inside, next door to the principal's office, the school secretary is arranging bottles of medication on a tray. Scotch-taped to the tray are little photos of fourteen children, labeled with their names and keyed to the bottles. Though by now she pretty much knows who gets what, at the beginning of the school year this system helped make sure she didn't make mistakes--that each of the children taking Ritalin at school received the right pill and dose.

At least a dozen more youngsters among the 350 attending this school took the same medication at home before school but aren't required to take a midday dose. At a nearby school of similar size, the kids getting Ritalin are organized in ten-minute shifts because their number exceeds thirty. And this weekday ritual is carried out--with variations in the number of kids and the personnel responsible for handing out the pills--at schools across the United States.

Attention deficit disorder, or ADD--the condition for which the medication Ritalin is most commonly prescribed--was formerly called hyperactivity, as reflected in its alternative acronym: ADHD (attention deficit/hyperactivity disorder). Its diagnosis is based on problems with attention, focus, impulsivity, or overactivity at school or at home. Since 1990 the number of children and adults diagnosed with ADD has risen from about 900,000 to almost 5 million as we near the end of the decade. This figure--derived from the amount of medication prescribed for ADD--suggests a problem of epidemic proportions.

The sharp rise in ADD diagnosis is directly tied to another startling statistic--a 700 percent increase in the amount of Ritalin produced in the United States during the same time period. An increase of this magnitude in the use of a single medication is unprecedented for a drug that is treated as a controlled substance. Ritalin belongs to the class of drugs known as stimulants, and it is closely related to amphetamine. Although Ritalin has been around for a long time, some people are still surprised to learn that it is essentially a form of speed. Others do know this but believe that the drug has a paradoxical "calming" effect on children, an effect different from the one it produces in adults.


I vividly recall the first time I witnessed the change that some children exhibit when they start taking Ritalin. One of our patients at the Child Study Unit was a little boy who had never been able to play with a toy for more than a minute without throwing it aside and racing off. After Ritalin, he sat and played quietly for twenty minutes, while his parents and I marveled at the transformation.

Since then I have evaluated hundreds of children and adolescents for the diagnosis of ADD and treatment with Ritalin. Each individual and family has had a unique background, circumstances, and problems--but patterns have emerged. The most obvious pattern has been a distinct shift in the number and kinds of patients referred for an ADD evaluation. Over the first fifteen years of my practice, perhaps two dozen kids each year emerged from my office with an ADD diagnosis. Most of them fit the typical profile long associated with the condition: boys from six to twelve years old, extremely hyperactive and impulsive, functioning poorly (if at all) in a normal school situation. Many of these kids were quite out of control, and intervention with medication (usually Ritalin) was often needed to give other treatments a chance to work.


As of the early 1990s, however, my experience with families and ADD was clearly changing. The sheer volume of my cases went up dramatically, from two dozen a year to more than a hundred at present. I was evaluating more and more children under the age of five for the condition, as well as more children, teenagers, and adults with no signs of hyperactivity--people whose main problem was an inability to pay attention and get their work done. Many of this newer group of patients I judged to be less severely affected by ADD symptoms, and some I thought were doing fairly well.

Let me introduce some people from this later generation of patients whose situations raise questions for me about ADD and Ritalin:

Johnny Hester had just turned four when his parents brought him in. His headstrong behavior at home and in preschool had been driving his parents crazy and stressing his teacher, who suggested he might have ADD. Certainly the boy I saw in my office was very intense and determined, but he didn't race around constantly, and he played with toys almost normally. (He did raise a fuss when his parents asked him to put the toys away.) What I saw made me consider him only mildly impulsive and slightly distractible. And even without exploring his situation at school, I felt that family problems were contributing to his behavior. His parents, who had just reconciled after a separation, disciplined him inconsistently. They too were intense, both with full-time, high-pressure jobs. Having read about ADD, they insisted that I prescribe Ritalin on a trial basis.

Jenny Carter was a ten-year-old who worked too slowly and had trouble completing her assignments at school. Her parents complained that she didn't finish her chores at home, either. Sent to her room to clean up her toys, she'd be found dawdling or playing one of the games she was supposed to be putting away. Both parents worked and wanted her to help take responsibility for her two younger sisters. Jenny would stoically accept her punishments for incomplete work and missed chores, but she sounded sad about her situation when we met.

Jenny struck me as a bright, lovely child who was kind and thoughtful, had many friends, and wanted to please her parents and teacher. It just seemed as if her internal clock was set too slow for the rapid pace and the demands made on young people in late-twentieth-century America. She might have thrived, I imagined, had she been born earlier this century or before compulsory education was adopted. Now she was being evaluated as a candidate for Ritalin.

Gavin Donaldson was fifteen when I met him. Both his parents were Ph.D.'s, and they were concerned about Gavin; he wasn't getting the top grades they felt he could achieve if he overcame his "concentration problem." They worried about his college options, given his current grade-point average, which hovered just below B plus. Some of his teachers thought he was distractible, others that he was insufficiently motivated.
Gavin himself felt he was doing okay. He didn't mind getting a few B's and C's. He acknowledged that he was easily distracted from schoolwork; he could get A's if he cared more and tried harder, he told me, but he had other interests, such as music and his friends. He was sensitive to his parents' expectations and wanted to please them, but he wasn't enthusiastic about the idea of taking a medication that would affect his brain and personality. I suspected he felt that taking Ritalin would signal that he was inadequate as a person.

I thought the drug could probably improve his performance, focus him more on his schoolwork, perhaps even raise his motivation. His pleasure in doing better and winning his parents' approval might outweigh any loss of self-image caused by taking medication. On the other hand, his performance wasn't bad without it, and I believed his grades would improve once he found something that genuinely engaged him academically.

Karen McCormack, age thirty-three, single, and a highly talented architect, found me through some friends whose child I had treated. She was happy to learn that I evaluated patients for ADD, for she'd read a book on adult ADD and was convinced that she had it. Karen's sense of design was brilliant, but she struggled to read through reports and felt frustrated by her lack of advancement in the engineering firm where she worked. I thought she might also be depressed--she seemed very hard on herself. Karen was surprised when I didn't offer her medication right away, and resisted my idea that she go for psychological testing for her reading problem and career issues. In her view, I was simply being a roadblock to her getting Ritalin, which, she had learned via the media and the Internet, was the definitive treatment for her problem. She soon went in search of a more cooperative doctor.


In many cases, medication is surely called for. In many others, I have doubts. Offering Ritalin can help people who don't fit well into the here and now, I've assured myself. Inarguably, it can help certain kids adapt to an ever more challenging school environment. But I've wondered: Is there still a place for childhood in the anxious, downsizing America of the late 1990s? What if Tom Sawyer or Huckleberry Finn were to walk into my office tomorrow? Tom's indifference to schooling and Huck's "oppositional" behavior would surely have been cause for concern. Would I prescribe Ritalin for them, too?

The surge in Ritalin use tells us volumes about how we explain--and deal with--the problems many children and adults are having in coping with their world today. And the controversy over its use reflects the divide between two competing theories about behavior and performance problems. In one camp are those who believe such problems are chiefly attributable to a child's inherent brain chemistry. According to this view, medication is the best (sometimes the only) treatment. The other side posits that problem behaviors are the result of how children have been and are being treated. According to this view, children develop problems because they are subject to inappropriate or misguided expectations and responses. In other words, there is nothing inher...

Edition details

• Publisher: Bantam
• Publication date: 1998
• Language: English
• ISBN 10: 0553106562
• ISBN 13: 9780553106565
• Binding: Hardcover
• Number of pages: 400