Harvey Parker

There might be a lot of skepticism among the general public about this because they think, "Well, when I was a child, there were no ADHD patients in my classroom. So what has changed?"

I think there is a lot of skepticism about ADHD. It's one of the areas of psychology and psychiatry that we know a great deal about, yet it's one of the most controversial diagnoses in the area of mental health. ADHD children have been around for as long as there's been people. We've always seen people who were hyperactive, inattentive, or who had difficulty concentrating or organizing themselves.

But more so, we've paid attention to these behaviors and labeled them differently. Before we used to label them in some ways as "b-a-d" children having behavior problems. And now we see that it's really not under their control so much, and we see them more as children suffering from a neurobiological disorder of self-control and attention problems.

So there hasn't been a tremendous increase in the number of children with ADHD. It's not like it's in the water and you become infected by it. It's just that we've improved our sophistication in terms of diagnosis and recognition of this disorder, and there are more people looking out for these children now than there were in the past. . . .

In my opinion, several things caused the rise in the medication prescribing. Number one, parents understood from other parents that ADHD exists, and they had their kids evaluated. Doctors understood that medication was an appropriate treatment for ADHD, not a last-resort treatment, but in some cases, a first-resort treatment.

We realized that kids with ADHD don't have to stop taking medication when they become adolescents. We used to think that stimulant medication would stunt growth. We realize that that doesn't happen. So we continued prescribing medications to these children through adolescence.

We also realized that children could take medication more than once a day. They can take it in the morning, in the afternoon and evening, and even late in the afternoon when they come home from school to help with homework problems. And we also realized that adults could benefit if they have ADHD and they take medication. So all these factors combined to cause a rise in the prescription rates of medication today. . . .

Harold Koplewicz

. . . The reason for increased prescriptions would most probably be that we have more kids diagnosed, and therefore more children needing treatment. We have an effective treatment. In fact, we know, most times, that once we find an effective treatment and we let the public know that there's an effective treatment, patients start to appear.

I think the best example is another disorder. Look at obsessive-compulsive disorder. When I was in residency training, they told you that people who have obsessive-compulsive disorder . . . were only 1 percent of the psychiatric population. This meant that, from the people who came to a clinic, one out of a hundred had OCD. Today, since we started doing some epidemiological work on this, we find that it's three out of a hundred of the general population.

What happened in 20 years? Was our water supply different? How did we all of a sudden find ourselves with lots of patients and lots of people in the population who have obsessive-compulsive disorder, when 20 years before, we didn't have it?

The big change was that we found a treatment that really worked--two major treatments. . . . Then we had a whole new generation of medicines, like Prozac and Luvox and Zoloft, and they worked. And then we had a whole group of psychologists who came up with talk therapies that were very effective in treating these disorders. So patients who thought they were going crazy and didn't want to share it with anyone because there wasn't an effective treatment, have now come out of the woodwork and say, "I have OCD and I need to be treated for it. And I'm not even embarrassed about it, because I want to get rid of it."

Is there under-medication or over-medication of ADHD kids?

I don't know if there's under-medication or over-medication. I'm not sure if the right kids are getting medicated. That's part of the problem. To do a proper diagnosis of a child who has a psychiatric illness or a child who has ADHD really requires time. It takes time to interview the mother and father. It takes time to get ahold of a questionnaire, for observation from the teacher. It takes time to examine the child and talk to the child. And all this then requires some thinking and putting together and synthesizing this information, to decide what is the possible diagnosis, and what else could be causing these symptoms.

. . . There are regional differences in the United States. For some reason, we find now that the southeast part of the United States seems to have higher prescription rates of Ritalin and Ritalin-like medications versus the rest of the country. I'm not sure we know enough as to what is happening in those parts of the country, versus other geographical parts of the country, that is affecting the prescription policies and the prescription practices.

Russell Barkley

The question that keeps being raised in the media now is whether there's over- or under-medication. We don't know for sure, because we don't have any national databases where we keep track of all prescriptions in the United States, like some other countries do. So we can't turn to that database to answer the question.

What we have to do is to go out and find large regional databases that are being kept. For instance, each state is required to keep records on all of the Schedule II drugs, like stimulants, that are being prescribed within their state. So we may be able to go to a state, as was done in the state of Maryland just recently, and look at the number of prescriptions being used for ADHD. We might get some indication there. We can also go to school districts and survey them and see what percentage of children is on medication. When we do this, we find a rather dramatic difference in figures that's difficult to reconcile.

If we go out to Utah where a survey was recently done, it's about 1.4 percent of children in the Salt Lake City public schools. If we go to five different metropolitan areas, as Peter Jensen did in one of his studies, we might find that the figure is around 1.8 percent to about 2.4 percent of ADHD children who are taking medication. In their own survey, the state of Maryland recently found that about 2.6 percent of children within the state were taking medication during school hours for management of ADHD. So it just depends on where you look.

If you were to average across all of these figures, it appears to be that somewhere between about 1.5 percent and about 2.5 percent of school-age children are taking medication right now for ADHD. Now, you have to look at that figure in the context of how much ADHD is there. It's the only way you can answer the question of over-medication, and that is, what's the reference point? We know that approximately 5 percent to 7 percent of school-age children have this disorder. If we use the conservative figure of 5 percent, and we know that about 2.5 percent of individuals may be taking medication, there's your answer. We don't have over-medication. Only about half of all ADHD children are ever taking medication for their disorder.

Lawrence Diller

. . . Why are we seeing a rise in the use of these drugs?

. . . It starts from the fact that we, as a culture--more than any other culture--seem to have accepted biology and the brain as the reason for maladaptive or poor behavior. . . . American psychiatry had already begun to focus on the brain in the 1960s and 1970s. But it really wasn't until Prozac that the American public became interested in the brain for behavioral and emotional problems. Prozac will allow people, with far less side effects than earlier antidepressants, to improve their mood and become more resilient. So it became more acceptable and easier to take a psychiatric drug. Prozac was introduced in 1988. The explosion in Ritalin occurred in 1991. And I believe that Prozac paved the way, in terms of acceptability, for the use of Ritalin in children, though there are many other factors as to why Ritalin took off.

Besides the change in American psychiatry and the public's view of behavior being brain-related, we had other things going on in the 1960s, 1970s, and 1980s. To begin with, you needed two parents to work to maintain the same standard of living than you did in the 1960s. . . . That means that now we have institutional day care for children. . . . We have many more latchkey kids. That's one factor, a major factor.

We have educational paranoia that began in the late 1980s with the downsizing of the white-collar middle class. . . . With computers and stuff, if every child doesn't get a four-year-plus college education, they're not going to have any choices; they're not going to be successful. So what does that mean? We have the expectations of three-year-olds learning their alphabet and their numbers. We have five-year-olds all learning to read in kindergarten. We have my eighth-grader learning algebra a year earlier than I learned it. This goes on all the way through the educational system. So we have more pressures on kids. And all through the 1970s and 1980s, we saw an expansion of classroom size. . . . So, not only are we expecting more from the children, but we're delivering less to them by their parents being at work, and by the teacher having more students per kid.

We have other factors going on. We have a continuing erosion of parental discipline that probably began 150 years ago. But we had the self-esteem movement in the 1980s that basically said that conflict is not good for children, that it further erodes their self-image. There was a misreading of Freud in the 1950s that said to reduce stress and your child will be neurosis-free. . . . All these things were going on through the 1970s and 1980s. And yet, Ritalin production remained stable all through the 1980s. And in 1991, it takes off.

The question is, what was the spark? If we look at the history, and we look at the data, the only thing that changed was the administrative change in the educational laws guiding our country's accommodations to children. In 1991, it began to include children with the diagnosis ADD or ADHD. And I think parents were genuinely trying to get help for their children. But when they found out that they could get special services and accommodations by getting the diagnosis, they flocked to their doctors. Word spread, and along the way, you also got Ritalin.

You've stated that there's over-medication.

There's over-medication and there's under-medication, depending on the community you assess, and your values for it. I generally feel that in the community I work in, which is a white middle- to upper-middle class community, there is over-medication.

Peter Jensen

You've been a psychiatrist for many years now and I'm sure that in your lifetime you've seen ADHD evolve ... How has it changed?

Just over the last 20 years, our understanding and appreciation of ADHD has changed a whole lot. Twenty years ago it was a little bit of an off-the-beaten-path kind of disorder, in the sense that people worried about a whole host of things, and ADHD was one of them. Nowadays, when we think about treating children and the most common problems they present with, ADHD is probably the major one. It comprises the lion's share of why children are often seen and why they're often treated. ...

There are reports that the use of psychotropic medications has increased 700 percent in ten years. And there are other reports that say there's a three-fold increase. What's the truth to that, and what's behind this trend?

Whether it's increased three-fold or five-fold or seven-fold is really not the big point. . . . The story is that it's increased enormously, and that's the question. And the answer to that is, I think, two or three major factors.

The first is that, in the early 1990s, the Department of Education mandated the states, and said, "Many of you have thought that ADHD was a thing you didn't have to worry about. But we've reviewed the evidence and the literature, we've listened to parents, we've listened to the scientists, we've held congressional hearings on this, and we're convinced that this disorder fits under special education law. And you can't say to a parent, 'It's not our problem.' It is your problem. And so, be on notice that that's our position." . . .

At the same time we had, I think, increasing power and passion on the part of parents, who felt like their children had fallen between the cracks, just like with learning disabilities. And those parents were organizing, becoming more eloquent and more effective, and understanding that they really had to kind of get their oar in the water, to speak up, because their children's lives and health was at stake. . . . So schools began to realize they had to do something about it, and it put them on line to use their resources for these children. . . . And so while we don't know this for certain, a lot of the big rise happened right around those years, 1990, 1991, 1992 and 1993.

Now, the other big rise, and the other big factor, I think, that took place during that time, was health care reform. And health care reform hit mental health with a vengeance in many ways. Because what it said to mental health was, "We're cutting way back on the kind of therapies that we're going to offer, and we're going to set a total number of sessions. And we're going to say when you can get sessions and why you can get, say, therapy sessions."

So what we hear from many parents was that they could not longer go see a therapist for 50 or 60 sessions a year, every week or twice a week, or something. For ADHD they would be asked, "Is your child getting medicine?" . . . More and more, doctors were being asked to say, "We can only approve therapy sessions if you've also given a trial of medicine." Or parents were being told, "We can only give therapy if the child is also getting medicine."

How does one explain that the US consumes five times more methylphenidate than any other place in the world?

It's a not a very hard explanation, actually. I and other colleagues were at a meeting set up by the Council of Economic Ministers in the European Union. Their drug enforcement czar and their health czar, or their representatives, came from each country to this meeting. And the reason they came to a meeting was because there were concerns that they were hearing more and more from parents around Europe that their children had ADHD.

We know from international studies that ADHD is pretty much the same across all of the Western world. We're not sure about non-civilized areas, or less-civilized Third World areas. But across Europe, it's pretty much always the same, and parents were feeling that their children were being denied treatments. . . . You go to some countries and they'll say, "Well, you can prescribe Ritalin, but only a child psychiatrist can do it." In the former Eastern bloc, there may be five child psychiatrists in the entire country, and three million children. I tell you, that's going to really cut the prescriptions way down.

In another place, they'll say, "You can only prescribe this medicine if it's been approved by three independent professionals." In other places, you can't prescribe it at all. . . . What this Council of Ministers concluded is that ADHD in Europe is probably under-diagnosed and under-treated by 20 to 1. ... In some countries, they're using anti-psychotic medicines at terrible rates to treat ADHD children. So, yes, they're not using Ritalin. They're using things that are much less safe, that we know cause tics or permanent kinds of motor problems if used for a long period of time. . .

William Dodson

Twenty years ago, the only child who was going to be identified, and therefore treated, was the hyperactive child who was pinging off the wall, who was aggressive, uncontrollable, and obnoxious. And so this was the child who was referred for evaluation. This was the child that everybody could agree was hyperactive and who would benefit from medication.

It has only been in the last 10 to 12 years that we see that actually, the hyperactive aggressive child makes up only a small percent--20 percent or 25 percent--of people who have ADHD. There are far larger numbers of people who don't have any hyperactivity at all, and they are purely the inattentive subtype. . . .

The inattentive and impulsive symptoms continue unabated for a lifetime. And so it is this recognition--that there are a lot of people out there who have purely inattentive symptoms, who aren't hyperactive, who are not aggressive or obnoxious--who also have this disease. And this is where we start picking up females. When I was in medical school, I was taught that women did not get Attention Deficit Disorder. It turns out that women get it just as often as men do. The assumed prevalence is about one to one, male to female. It's that it's exceedingly rare for a woman to be hyperactive. . . . And so now what we're doing is doubling the apparent prevalence rate by recognizing that the quiet, inattentive child who daydreams in the back of the class also has Attention Deficit Hyperactivity Disorder, just without the hyperactivity. . . .

So that's why we have such a rapid increase in the prescription rates?

Dr. James Swanson in California did a study of that. And we are seeing an increase in the number of people who are being diagnosed and treated. But the biggest increase in the number of prescriptions, according to Swanson, is that people are being treated for longer periods of time. Once a person starts on the medication, we now recognize they'll benefit from the medication their entire life. They're being treated for more days--not just Monday through Friday while they're in school. They're being treated 7 days a week, 52 weeks a year.

There is more of an acceptance of the disorder. People are more willing to give their children a trial on medication. And there's more of an awareness in teachers and Girl Scout leaders and doctors, in people who work with children, to recognize the disorder, and to suggest to parents that they might want to have it looked into.

Lots of people say there's also over-diagnosis--that a certain hysteria is taking over that it has become the disorder of the decade.

It is very common for people to say very emphatically that the diagnosis is being too easily made. But there's very little evidence to support that point of view. And there's a lot of evidence to support the exact opposite point of view. In 1995, the National Institute of Mental Health did a study, not only of ADHD, but of all childhood mental disorders. They found that, in the previous year, only one in eight children who had ADHD received any services--medication or otherwise.

The diagnosis is still missed two out of three times, and even when it is made, it is under-treated. ...

How does the ADHD diagnosis differ between social classes?

The disorder is found pretty much equally through different socioeconomic groups. ADHD is found in every culture, in every socioeconomic group, in pretty much the same prevalence. . . . I'm aware of one study that showed that black inner-city males were diagnosed with ADHD more commonly than you would expect from the general population. But again, this could be clustering. It could very well be a valid diagnosis. ...

Harvey Parker

Sometimes health care providers might write a prescription for Ritalin or Adderall or another stimulant medication, just as a test to see if the behavior improves. And if it does, voila: ADHD. But we can't use those medications to confirm a diagnosis, because most kids, even if their behavior was normal, would improve in terms of attention and behavior with these medications. So the diagnosis takes some time, and in our managed care system, time is something that doctors often don't have. So in some areas of the country, there can be over-diagnosis.

On the other hand, the diagnosis of ADHD is sometimes missed, because there's either a lack of awareness about ADHD, or a lack of time taken to properly make the diagnosis. For example, one out of six children in our country comes to a doctor's office with a diagnosable behavior or mental health disorder. Parents often don't report these symptoms to their primary care doctor, their pediatrician, or the family practitioner. . . . We should really be concerned about misdiagnosis a lot more than overdiagnosis. Of course, we don't want to diagnose kids with ADHD who don't have it, but we certainly don't want to miss the diagnosis in kids who do have it.

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Written 2000. Reviewed: 02/2006