contd. from

Where were these kids when you were in elementary school? Suddenly this illness is everywhere.

Many people in the public ask, "Where were these kids when I was growing up? I've never heard of this before." Well, these kids were there. They were the class clowns. They were the juvenile delinquents. They were the school dropouts. They were the kids who quit school at 14 or 15 because they weren't doing well. But they were able to go to work on their parents' farm, or they were able to go out and get in a trade or get into the military early. So they were out there.

. . . Back then, we didn't have a professional label for them. We preferred to think of them more in moral terms. They were the lazy kids, the no-good kids, the dropouts, the delinquents, the lay-about ne'er-do-wells who were doing nothing with their life. Now we know better. Now we know that it is a real disability, that it is a valid condition, and that we shouldn't be judging them so critically from a moral stance. . . .

But there are people who ask, "Why medicate the class clown?"

Well, there are people who ask, "Why should we medicate these individuals? Why shouldn't we just allow them to go ahead and do what they're doing?" Well, it's because what they're doing is getting them into a great deal of difficulty. What they're doing is leading them into major impairments in serious life activities, so that they're not going to be doing very well in life.

For instance, we know that between 25 percent and 50 percent of ADHD children will be retained in a grade at least once. We know that 37 percent of them will never finish high school, despite special educational services and all the assistance we have available. We know that only 5 percent of these people will ever complete a college program, versus 35 percent of the normal population. We know that these individuals are more likely to have teenage pregnancies, to drift into delinquency, to experience drug abuse, to be under-employed, and to change their jobs more often.

My own research has demonstrated unequivocally that ADHD creates tremendous problems for operation of motor vehicles, for managing money, for handling day-to-day responsibilities. ADHD individuals, for instance, are four times more likely to be in a serious car accident because of their disorder than are other people. . . .

So, no, we're not going to go on letting them be the class clowns who wind up getting no high school education, who are under-employed in life, who drift into substance abuse, and who therefore are prone to more criminal activity. If that's what you're asking us to do, my profession's not going to stand by and let children suffer like that--not when we have treatments that are known to be effective, and that are some of the most well-studied treatments in psychiatry. It would be criminal for us to stand by and let that happen. . . .

Do you think there's consensus among psychiatrists and among their peers about how to treat and diagnose?

Yes, unquestionably. I would have to say that there is certainly a consensus about how ADHD ought to be managed. Most people in the scientific community and in the clinical practice community understand that ADHD has to be managed through the use of a combination of interventions, and we can reduce those to four things.

First, a proper evaluation that provides for a thorough diagnosis, so that we know that you have this disorder, and what other disorders you may have as well. Second, taking time to educate families about the disorder--what it is, what causes it--so that they can be better informed in raising these children, and not fall prey to some of these media stories that tend to scandalize the subject and misrepresent it so poorly. Third, the use of medication. What are the medications that are out there? What are the side effects, what are the real effects? So families can be educated about that, as well.

And then, combining that with behavior modification techniques, child management strategies, special educational services--what I call the accommodations--can be useful. And if you use those for intervention, as many professionals do, then you're doing the best we can for dealing with this disorder.

So diagnosis, education, medication, and accommodations are the standard, most useful, treatment package for this disorder. And most people try to do that within the limits of managed care and the other constraints that we see on medical and professional practice these days.

But those limitations have a big impact on people. Most people can't go to the best psychologist and go to a pediatrician for 15 minutes.

That's true. Many people say that professionals who diagnose ADHD may not be taking enough time to do a thorough evaluation of the disorder. And although that's true, we shouldn't use that to lampoon pediatrics or psychiatry as if it's their fault. What you have at play in the United States right now is a tremendous influence of managed care trying to keep the cost of medical services down, and in doing so, dictating to physicians what they can and cannot do in the course of their practice.

So before we use this as a criticism of the professions, let's not forget that we're all struggling right now with these constraints that managed care is placing on access to services. And it's causing these very same kinds of problems that you raised. Children may not be getting as thorough an evaluation as they ought to; they may not be allowed to see experts in mental disorders as readily as they should; and therefore, they may not be given the most effective treatment package that we have available in this country. A serious problem in its own right is access to service, and that's a big problem right now for families with ADHD children. . . .

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Written 2000. Updated 2001. Reviewed: 02/2006