Fifteen years ago, Dr. Lawrence H. Diller, a pediatrician from Walnut Creek, Calif., ignited a national debate over the steep rise in children being diagnosed with attention-deficit hyperactivity disorder and treated with stimulant medication.
Diller's 1996 book, "Running on Ritalin," suggested that ADHD was being over-diagnosed, and that Ritalin, and the many formulations of amphetamine-like drugs that would follow, was being prescribed in many cases to children who would respond well to family therapy and tailored programs and routines at home and at school.
Diller warned that as harried parents, teachers and physicians attached the ADHD label to more and more children who were dreamy, unmotivated, forgetful, restless, impulsive or distractible, the nation's tolerance for children's natural temperamental variance would narrow. Instead of helping children work around weaknesses and choose strategies and paths that played to their strengths, society's growing inclination to medicate them, Diller cautioned, could turn many into lifelong patients.
Today, nearly 5 percent of American children between ages 6 and 17 - about 4.5 million children - have been diagnosed with ADHD, and two-thirds of those take medicine to control their symptoms. The drugs have helped define a generation of young adults widely known as "Generation Rx."
In a new book, "Remembering Ritalin," released this month by Perigee Books, Diller revisited 10 of his patients, now in their 20s and 30s, to ask how the ADHD diagnosis, and the medication that often came with it, had affected their lives.
Q: Those you treated as youngsters are now young adults, and studies suggest that as many as two-thirds of them will continue to have ADHD into adulthood. Is this what you saw?
A: The outcomes from the kids I've been seeing were not as bad as that suggested by the limited formal research. Of the 10 former patients who talked to me, maybe only two still seemed to be significantly bothered by problems of ADHD.
Only about 400 children (out of millions who have been diagnosed with ADHD and treated with Ritalin-type drugs) have been followed from childhood into young adulthood by formal research studies, and some of the most respected of those studies have been done by Russell Barkley of the State University of New York's Upstate Medical University. For reasons that I think have a lot to do with economics, the kids that I treated, now in their mid-20s to mid-30s, are doing much better than Barkley and other researchers would have suggested.
For instance, only 5 percent of Barkley's group graduated from college, while half of my patients did - although it took one kid until age 27 to do it. Half of Barkley's patients had been fired from jobs. My group had only two. Up to half of Barkley's patients had substance-abuse problems. Again in my group of 10, only two, perhaps three, were problem users.
Q: What did your patients remember about being on medication? How do they feel about it now?
A: Nine of the 10 kids I revisited had taken Ritalin. Of the eight who took it for years, seven said they were glad they had taken it, though there were side effects (mostly loss of appetite and trouble falling asleep). They said they would have gotten in far worse trouble or failed even more school if they hadn't taken the drug.
Some hated taking it when they were kids because they felt different. But most felt it wasn't that big a deal. This was all before the full-day formulations of ADHD drugs became available, so all these kids had to go to the office at lunchtime for their pill. That's no longer necessary.
When I do prescribe Ritalin, I've always described it as an aid to making better decisions, which these kids nevertheless have to make on their own. I can't tell you how pleased it made me to hear from those I revisited how important that was to them - that I told them they were making decisions.
Q: What do they say about the nondrug treatments you emphasize?
A: Many told me they thought the family therapy was useful in tuning down family tensions. But a few said, even though it helped, they hated hearing their parents tell me about the bad things they had done since the last visit. I've really taken their remarks to heart. I always tried to have parents talk to their kids instead of me when telling me about the good and the bad. But now, I really insist that the parents talk to their kids, not me. The alternative is to have the kids feel like pieces of furniture while the parents describe their defects to the doctor.
Q: You write about "middle-class ADHD" as a less impairing form of the disorder. Can you explain?
A: I work in a private practice in a pretty affluent community. A child who comes to see me is coming from a family where someone has a job with health insurance, or can pay out-of-pocket. The four or five big studies that have tracked those with ADHD over time drew from lower-middle class and Medicaid populations. I think that accounts for the better outcomes I see in my small sample.
Kids from middle- and upper-middle-class families have some key advantages: The parents have the means and the wherewithal to cocoon them from the worst aspects of their personality, especially in school and with peers. They do this by securing special education services, counseling and tutoring for their child.
If they can get their kid to 18 or 20 without a lot of time in the juvenile system, and managed to keep him or her from major substance abuse, the future looks much brighter. By that point, the impulsivity and the hyperactivity begin to abate, and these kids are beginning to choose, after getting through high school, what they want to pursue. The choices open up and they do better.
Q: On pressing for nondrug treatments before Ritalin, are you still swimming against the tide?
A: I've never been against medicine; have prescribed it for 32 years.
Pills represent efficiency, and effective nondrug interventions like special education or behavior-modification value engagement with the child. The medical and educational systems value efficiency. Parents, when offered a choice initially between efficiency and engagement, almost always choose engagement. However, when offered the choice of only a pill or nothing, they'll take the pill. And that's often the only choice they're given.
So I remain a relatively lonely professional voice pointing out this moral dilemma. But it is greatly edifying that when people hear the full message, they invariably say, "You know, he's right."