PERSPECTIVES ON ATTENTION DEFICIT DISORDER

Would Tom Sawyer Have Been Prescribed Ritalin?

IN 20 YEARS of practice as a behavioral pediatrician, I have seen some
2,000 children for their behavior and school problems. I've written
many prescriptions for Ritalin, the stimulant used to treat Attention
Deficit/Hyperactivity Disorder. ADHD is a condition of excessive
inattention, distractibility, impulsivity and sometimes hyperactivity,
primarily affecting children.

In the early 1990s, I began to see a new kind of ADHD candidate:
younger than 6 years old, teenagers and adults. Many of the children
seemed far less impaired by their personalities compared with the
previous generation of patients. Nevertheless, their parents and
teachers were concerned.

I wondered if Tom Sawyer or Huck Finn were brought to my office, would
I, after reviewing their home and school environments, prescribe Ritalin.

I am not the only doctor writing more Ritalin prescriptions these
days. The production and use of the drug has increased by 700 percent
since 1990. In 1998, the United States used 84 percent of the world's
Ritalin. What's behind this increase and why us?

Demands on children have grown while the strength of their social
supports -- school and family -- has decreased. Today, there is a
rampant educational paranoia that declares everyone must have a
college degree to succeed. Children are expected to learn earlier and
learn more, yet we have higher student-teacher ratios in the
classroom. Parents are working harder and longer. That means less time
for their children and more structured day-care and latchkey kids.

Parents are additionally handicapped by a ``politically correct''
parenting philosophy which appeals to conscience and conflict
avoidance when disciplining Johnny. ``If you know how to talk to
Johnny he'll listen to you.'' Unfortunately, from my experience, if
you try talking to attention-deficit Johnny he's halfway down the
street before you've finished your first sentence.

More managed health care means more ``quick-fix'' medication. Being
``labeled'' attention deficit gets you special services at school.

Children in England and Japan use one-tenth the Ritalin we do so it
couldn't just be today's fast-paced life that makes us Ritalin-unique
among nations. Unlike those countries, we prize individuality and
self-expression yet demand conformity at school. Limitations of class
and intelligence are more accepted in London and Tokyo.

Here we have the American Dream where anyone can be the next Bill
Gates. We also believe in a ``medical utopia,'' where all the problems
of life can be solved by visiting the doctor and taking a pill.
Performance enhancers like Ritalin, Prozac and Viagra are ``in.''

The cause of ADHD is increasingly viewed by experts as biological and
genetic. ADHD is a heritable as height, studies conclude. Brain scans
detect differences in the ADHD brain, headlines proclaim. Sure,
personality is heritable, but these same studies indicated that a
spectrum of personality is passed from one generation to the next.
Each culture decides at what point an impulsive personality becomes a
disorder.

Some experts compare impulsivity to having lower intelligence. I don't
know how they can be so sure. That comparison depend on how one
defines intelligence and makes a judgment on what kind of intelligence
is more valued or ``higher.'' Traditional IQ scores predict life

contentment less well than ``emotional intelligence.'' Unlike
traditional definitions, theories of multiple intelligences include
qualities like creativity, musical and artistic abilities in assessing
intelligence. Many of our most ``successful'' people played off their
temperament or learning weaknesses in school and developed valuable
skills that served them and others well -- once they left high school.
Benjamin Franklin, Thomas Edison and Bill Clinton have all been
described as ``being ADHD.'' No doubt a core group of ADHD children
will struggle in any environment. But there is an intolerance of
temperamental diversity in our country that views present-day Tom
Sawyers as nothing but genetic detritus. Human diversity in the past
has contributed to the richness of our culture and civilization. I
worry about a society where there's no place for an unmedicated Tom.
He is so many of our sons and daughters.

Lawrence Diller, M.D., practices in Walnut Creek and is the author of
"Running on Ritalin: A Physician Reflects on Children, Society and
Performance in a Pill," (Bantam Books, 1998).