Chapter One

Who’s Doing the Labeling?

From the analysis of triplicate prescriptions, where publication of such doctor prescribing data is permitted, the finding is that most prescriptions for Ritalin are being written by pediatricians and family physicians. However, in many cases, the diagnosis has already been made by some teacher who has simply checked items on the Attention Deficit Hyperactivity Disorder check list.

The teacher often tells the parents something like this: “Your child has ADHD. You should go to your doctor and get him on Ritalin right away. I have three boys in my class on the drug, and they don't give me trouble anymore. Ritalin does wonders.”

Sometimes the urgency of this teacher referral is reinforced with hints of special class placement or even suspension if the parents do not cooperate. This kind of pressure is illegal in the United States. A federal judge has ruled that pressuring parents to put their child on drugs is not a reasonable thing for schools to be doing. That educators would attempt to do this suggests to me that they have grown hazy about their professional competence, the limits of their mandate, and the ethics of their profession. (See “Judge Says New Hampshire Can’t Order Ritalin Use,” Boston Globe, 8 August 1991.)

Many doctors, however, simply go along with these teacher diagnoses and recommendations. “If I don't give them the drug some other doctor will,” is the common excuse. This argument is not, by any standards, a reasonable rationale for prescribing a powerful drug. I think most doctors know that.

In some communities a few doctors have become known as the local ADHD gurus. These do the bulk of the medicating. A recent study out of Michigan investigated their triplicate prescription program and established that half the Ritalin prescriptions written by pediatricians were written by 5 percent of registered doctors. Here in British Columbia, at the direction of the Health Minister, the College of Pharmacists has decreed that doctor prescribing habits will remain secret. (See Vancouver Province, 2 June 1996.) If that were not so I think we would soon learn that here in Canada too, only a few doctors are responsible for our epidemic of ADHD. (See Rapley, MD, Gardiner, JC, Jetton, JR, Houang, RT, “The Use of Methylphenidate in Michigan,” Arch Pediatr Adolesc Med June 1995 (149/6): 675-79.)

That a few doctors are doing most of the prescribing is more important than a lay person might realize. Doctors who prescribe much Ritalin maintain that they are midstream practitioners. If legally challenged for giving a child Ritalin without proper indication, as is happening more frequently now, such a doctor may feel he or she can defend this action by calling it standard practice in the community. However, if it could be shown that only a few doctors are doing most of the prescribing, this defense would no longer hold water.

What is a Parent To Do?

Since these kinds of diagnostic and prescriptive abuses are now widespread, what is a parent with a child with behavior problems to do? Here is my advice.

If you as a parent, need to take your child to a physician for diagnosis and treatment of behavior difficulties, know that you have the right to expect a proper assessment from your doctor. If you don't receive an assessment that includes the following four things, my advice is to seek another opinion.

• You have a right to expect your physician will do a full evaluation of the child. This includes taking a complete history of his or her birth, development, physical health and behavioral difficulties. Secondly the doctor should interview the child to assess his or her behavioral style. Both of these are essential to make a proper diagnosis. This is not a twenty minute procedure. In my child psychiatry practice it took two hours to do such an evaluation, along with a follow up interview to explain my findings and recommendations to the parents.

• Your doctor should inform the parents that ADHD is a controversial diagnosis, and, in the minds of many experienced clinicians, not a proper diagnosis at all. One way might be to provide “pro” literature such as supplied by organizations like “Children and Adults with Attention-Deficit/Hyperactivity Disorder” (CHADD) supply, and “con” literature such as this book, and allow you to come to your own conclusion.

·          Your doctor should inform you that Ritalin is a powerful drug with side effects, that has no understood mode of therapeutic action, has a considerable street presence, and, like other Schedule II stimulants, can lead to dependency and abuse.

·          Finally the doctor should include in his or her management of your child's behavioral problems a program of guidance to promote any delayed psychological growth in the child through effective parenting.

With respect to guidance to parents , even the ADHD enthusiasts agree that such steps should form part of any treatment program for children diagnosed with ADHD. However, nine times out of ten, no effective help is offered.

There are two reasons for this. Once Ritalin has been prescribed and the child’s behavior settles down, the motivation for the parents to seek, and the doctor to provide, such parenting guidance tends to disappear. Secondly, most family doctors and pediatricians have neither the competence nor the time to conduct such guidance. The serious fact is that, once Ritalin has been described, the likelihood of the child receiving the retraining that is his or her greatest need is sharply reduced.

Do most children diagnosed ADHD today go through the careful assessment I have described? The evidence is that they do not. Many, many children are being dropped into the ADHD bin after a cursory study and then given Ritalin by a physician largely unfamiliar with the drug's side effects and habit forming potential. Indeed, one of our local ADHD gurus has said that taking Ritalin is no worse than taking aspirin. Which should make one wonder why aspirin isn't also a street drug – Ritalin is.

Why do parents go along with shoddy diagnoses, careless labeling, and off the cuff prescribing? Some, knowing that the ADHD category appears in the vaunted Diagnostic and Statistical Manual of the American Psychiatric Association, assume that, emanating from such an august body, ADHD cannot be anything but a proper diagnosis.

Such persons may be surprised to hear that many experienced clinicians hold a very different view. I am going to devote a short chapter to presenting some of these dissenting views. The doctors involved are experienced clinicians, not just ivory tower professors. I urge the lay reader, and any doctor braving these pages, to give their views due consideration.