In twenty-seven years as a behavioral pediatrician, I've asked more than 2,500 children, "Why are you here?" when evaluating them for learning or behavior problems. A majority of kids over six years old (I don't usually ask children younger) answered, "I don't know" most of the time.
So I was struck when, in May 2005, I asked a nine-year-old boy named Joey this question and he told me, "Because I can't concentrate or focus. I get distracted." His answer was specific and directed, and I was intrigued.
It was fifteen years ago that a parent first asked me, "Do you test for ADD?", and I remember that I had the same reaction. "How odd," I thought. A parent had never been so direct in asking about a diagnosis. I wondered, where had she gotten the idea to inquire about a test for a specific condition?
Now, looking back, I know. In 1991 the Individuals with Disabilities Education Act (IDEA) was amended to include ADHD as one of the diagnoses that makes a child eligible for special services and accommodations in public school. Once word spread among parents that an ADHD diagnosis opened the door to special help for their children, an "epidemic" of newly diagnosed ADHD spread throughout our country. Now parents "knew" what was ailing their child—or at least they knew the magic words that could make a public school system change the way it dealt with their child.
Doctors, especially psychiatrists, have been changing their view of children's problems since the 1970s. Before then, based on the Freudian model, Johnny's problems were considered the result of inner conflicts generated primarily by his relationship with his mother. But in 1980, with the publication of DSM-III, a new concept—for most psychiatric conditions, including ADHD—was announced. These "disorders" were ostensibly based on collection of symptom behaviors that were assumed to have a biological basis in brain chemistry and heredity. But it really wasn't until 1991 and the change in the IDEA laws that the label took on pragmatic significance.
The diagnosis of ADHD and the use of drugs like Ritalin rose at rates never before seen in this country—or anywhere else, for that matter. The year 1991 marked a veritable sea change—a social movement began that changed the way our society views children's misbehavior and underperformance. Doctors started a public-education campaign directed at parents and teachers, and the latter group began to have an even greater impact on who was seen for an ADHD evaluation. Teachers were instructed to view any underperformance or unruly behavior as a possible symptom of ADHD. In parent-teacher conferences, in notes home, and in school-based evaluations, the message to parents across the country was clear: your child may have a biologically based brain disorder and should be checked by his physician for ADHD (and considered as a candidate for medication too).
The school-led drumbeat for ADHD became so strong that parents began to rebel against the pressure. Several celebrated court cases that related to child protective services' involvement in parents' refusal to medicate their children for school highlighted and anti-ADHD medication backlash. Many states passed laws prohibiting teachers or school psychologists from mentioning ADHD or medication to parents. Finally, in 2004, an amendment to the IDEA reauthorization plainly stated that school districts could not prevent a child from attending school based upon parents' refusal to give psychiatric medication to their child.
However, by then, the pharmaceutical industry had picked up the ADHD diagnosis/medication football and begun running with it. Sometime during the early 1990s, the drug industry hijacked U.S. psychiatry and its new neurobiological identity. Dominating both academic research funding and physician education, the drug companies marketed their products ever more aggressively, at first to doctors and then, in 1997, directly to consumers.
In the late 1990s, in print ads and television commercials, the drug companies began relentlessly promoting the concept of underperformance and certain forms of childhood misbehavior as symptomatic of ADHD. Ads showed pictures of perfect-looking children behaving perfectly. Slogans such as "Reach for the stars" or "Make your child's hidden potential known" were regular components of these slick and not-so-subtle campaigns.
Drug-industry advertising had its effects. First, it propelled Adderall, a not particularly unique amphetamine combination, ahead of Ritalin as the most commonly prescribed trade stimulant drug. Second, it made the acronyms ADD and ADHD common everyday phrases in every U.S. household with children. It was not so surprising then that about four years ago, the first teenagers began asking me directly for a drug to "help them concentrate."
The effects of stimulant medication on children's behavior in the classroom can be dramatic. I've never been against Ritalin. I've prescribed stimulants to children (and some adults) for a quarter-century. But this new group of teens requesting medication troubled me. I had little doubt that the medication could improve their performance. A few even met my criteria for ADHD. But many seemed very unhappy, alienated from their parents and other adults, and quite unmotivated to do much schoolwork. The request for medication seemed like a further extension of their decision to opt out—to take the easy route—which was, in part, the source of their problems.
Now the idea of "can't" has reached down to the level of fourth-graders like Joey. No doubt many children with moderate or severe ADHD have been helped by the label and by the understanding that it is hard for them to control their behavior; that, given their personalities/disorder, special ways of handling them—specifically, more immediate rewards and punishments—should be instituted; and that medication can be quite helpful to them and in their management at home and in classrooms.
However, given the bell-shaped distribution of children's ability to concentrate (at either end, a few children focus extremely well or extremely poorly), based on statistics alone, most children labeled ADHD have borderline or mild ADHD symptoms. As for this large group, I'm nowhere as certain that the "can't" concept is helpful or that medication is necessary. As a solution-oriented doctor searching to promote the strengths within those like Joey and his family, I find that each year, as I push my Sisyphean boulder of competence up the hill of our problem-saturated society, the slope of the incline grows increasingly steep.
I used to believe that our infatuation with ADHD and stimulant and performance-enhancing drugs was a product of corporate consumer fundamentalism, a religion of sorts for our culture. Our society's credo, announced every eight minutes in a sermon otherwise known as a television commercial, is "You will be happy if you buy this." No matter the allure of material goods offering spiritual and emotional contentment, however, the pursuit of performance at all costs doesn't explain the growth in the popularity of other psychiatric drugs, such as Prozac, for both children and adults.
To fully understand our heavy use of psychiatric medication, we have to go beyond capitalism and our own shores and understand a cultural phenomenon that has taken hold in most of the Western world. It has been dubbed the "therapy culture" by a British sociologist, Frank Furedi, who posits that as belief in traditional values (exemplified by organized religion and a politics of meaning) has declined, a new, higher valuation on feelings has risen. How we feel, how we feel about ourselves, whether we feel good, and the level of our self-image and self-esteem have become much more important over the last fifty years.
We dwell on our feelings. We believe them to be very important and think we should feel good, at least most of the time. An industry has developed around professionally assessing our feelings and keeping us feeling good. This is the therapy industry, which is part of the therapy culture. The therapy culture has designated "feeling bad"—which heretofore would have been considered a normal variant of human coping—as deviant, pathological, and "disordered," to be treated or cured. The therapy industry and the pharmaceutical companies that have come to dominate it are sincere in their efforts to promote good feelings and mental health. Their track record is another story. Indeed, most measures of mental health and satisfaction seem much more related to achieving a certain standard of living and resolving major economic inequities among the social strata.
So as the gap between rich and poor in this country grows, more people say they feel worse. The therapy industry, meanwhile, continues to broaden the parameters of what constitutes mental illness or disease. Whether it's ADHD, social anxiety disorder, or depression, the television ads tell us we should check with our doctors and seek treatment. The industry (doctors and drug companies) claim they are simply providing a public health education service as they succeed in having more and more unrecognized disease recognized and treated.
Although this may be true to a degree, when I hear nine-year-olds telling me they can't concentrate (and may have ADHD), I worry about the therapy culture that has so completely swept the nations of the West. It is true that, for various reasons, in the United States we medicate our children with psychiatric drugs ten or twenty times more than do the countries of Western Europe. Still, this loss of self-agency and competency, this belief that a doctor or medication is required to solve these allegedly brain-based problems, increases the difficulty of my work with the children and families I treat.
The threat to our country's health goes beyond the challenges I face with Joey in my office. Ironically, as more and more "diseases" are recognized, the boundaries of illness move further and further into the realm of basic human coping. We see it in the broadening of the definition of ADHD, and we see it in the treatment of depression. The relentless increase in health care costs (estimated to be 20 percent of the overall GNP by 2015) is making all our manufactured products, such as cars, more costly and less competitive in world markets. But apart from the drain on our economy, as a nation we will feel sicker and sicker until we move away from the medical model and therapy culture and begin to view most of our major health issues (mental and otherwise) as manifestations of inequitable economic and social factors.
Still, regarding little Joey in my office, I'll keep working with him, his family, and his school. I will appreciate his weaknesses, but concentrate on his strengths, his family's strengths, and the positive power of his community in order to improve his life. Outside the office, I'll continue to alert parents, teachers, doctors, and the public at large to the insidious effects of promoting the disease model of behavior and its consequent disempowerment of the Joeys in our community and across our nation.
The Last Normal Child: Essays on the Intersection of Kids, Culture, and Psychiatric Drugs.Copyright © 2006 Lawrence H. Diller, M.D. Reproduced with permission of Greenwood Publishing Group, Inc., Westport, CT.
The following Networker U Courses on this subject are available on this site:
Audio Home Study
A-109 Getting Through to Difficult Kids and Parents
CE Hours: 4
Instructor: Ron Taffel
OL-128 Psychopharmacology and Therapeutic Practice
CE Hours: 5
Authors: Lawrence Diller, Margaret Wehrenberg, Barry Duncan, Jay Lebow, Mary Wylie