No Quick Fix
Most kids on Ritalin get it from doctors who truly don't know what they are treating, but there is a better way.
Illustration by Chris Buzelli
A handsome Latino boy of 10 answers the door, his hand outstretched. “I’m Nick,” he says confidently.
Nick has agreed to talk about problems with his behavior at school, yet he comes off as remarkably mature. As we chat across a granite kitchen counter, he sits upright, hands crossed in front of him, ironed white shirt tucked neatly into his pants, brown hair combed smoothly to the side. He refers to his peers not as kids but as “classmates.”
Could this be the same boy who wouldn’t stop making pig noises in the second grade?
That behavior, as well as Nick’s difficulty sitting still for long periods and his occasional flashes of temper, led to regular visits to the principal’s office. School authorities at Walnut Creek’s Parkmead Elementary suggested Nick seek a medical evaluation for attention-
deficit/hyperactivity disorder (ADHD), a condition whose principal symptoms are inattention, hyperactivity, and impulsivity.
Nick’s teacher, a young substitute for the regular instructor who had gone on maternity leave, filled out a questionnaire about Nick’s behavior. Nick’s mother, Michelle Kaufman, filled out one as well. Both were submitted to a pediatrician at a local hospital who, after a 10-minute consultation, Kaufman says, wrote Nick a prescription for Concerta, a variation on the stimulant Ritalin.
Medication could quite possibly have been the solution to Nick’s problems. The media has often vilified drugs like Ritalin and raised the specter of doctors turning kids into zombies, but the true state of affairs is far more complicated. In most cases, a comprehensive evaluation can determine quite conclusively if a child has ADHD or ADD (attention deficit disorder, which does not include hyperactivity as a main symptom). Furthermore, Ritalin, Concerta, and Adderall, all considered relatively safe drugs after years of use, can work wonders at improving the ability of a child with ADD/ADHD to focus.
Yet, the evaluation that Nick experienced—questionnaires filled out by parent and teacher followed by a visit to a doctor with just minutes to spend with a patient—was frighteningly crude. More disturbingly, it is the norm. Studies show that family doctors lacking expertise in psychology and relying on the questionnaire approach are the ones prescribing to at least 80 percent of kids who take Ritalin and other stimulants.
For as much as anyone knew, Nick might have been suffering from a learning disorder, a hearing impairment, or dyslexia, from which he would continue to suffer for as long as these conditions went undiagnosed. He might have needed eyeglasses or had a problem with his thyroid. Scarier still, he might have suffered from bipolar disorder—which can look every bit like ADD/ADHD but can lead to violent reactions when a patient is given stimulants like Ritalin. As it turned out, Nick apparently doesn’t have ADHD, or any other serious condition, and, after changing schools, is doing quite well.
But what are parents to do with a so-called difficult child, the ones like Nick who are obviously intelligent but aren’t making it in the classroom? Often, these parents are taxed by wild behavior at home and worried about what they hear from their kids’ teachers. They want the best for their children, yet the determination of whether to use medication is not easy, and the typical tools of evaluation are flawed.
Here in the affluent communities of the suburban East Bay, kids are more likely to be prescribed such drugs than are kids in less wealthy areas. Yet, experts who work in the schools talk not only about overprescription and conditions other than ADD/ADHD being overlooked, but also about kids who could benefit from the medication and don’t get it. In either case, the kids are suffering, and for the parents, the gnawing question of doing right by a child can become an ailment of its own.
Luckily, there appears to be a way for parents to go—slowly and deliberately—over emotionally rocky terrain toward steadier ground. The stories of parents who take a more thorough approach to determining if their kids need medication aren’t necessarily black and white with fairy-tale endings, but they represent a much better route to an accurate diagnosis and proper treatment than the usual quick fix.
Carol Agrees to an interview at her house in Walnut Creek, a towering wooden structure with plenty of open land for kids to play. She makes it clear from the outset that she doesn’t want her family’s real name used for the article. Although she’s comfortable with the decision she made to have her 10-year-old son take Concerta and is pleased with how it has affected his behavior, she has been as private about it as she has been cautious. Unlike many couples, Carol and her husband went out of their way to find the right help, which many experts say involves at least four to eight hours of evaluation with a mental health professional.
The first signs of her son’s condition started when he was about four years old and she observed his apparent lack of physical awareness. His sister, two years younger, might notice a rock in the path, while he would trip over it. In the first grade, he had a tendency to lean on his neighbors in circle time, and like so many, he had trouble sitting still. Although the boy scored high on aptitude tests and was clearly intelligent, his problems continued in the second grade. He made grunting noises in class and couldn’t stay focused, to the point that the teacher was disarmingly direct with Carol: “It was like, ‘Your son has problems. You need to fix them.’ ”
A behavioral psychiatrist in Walnut Creek wanted to try to improve the boy’s focus before prescribing medication. His hesitation frustrated Carol, who craved a definitive answer. “I wanted him to tell me one way or the other,” she says. The couple then hired an occupational therapist to meet weekly with their son at $90 an hour. When his troubling behaviors persisted, they paid another $3,000 for a psychological assessment, which concluded that their son was slightly depressed and clearly had ADHD.
Carol says she was relieved to move forward with a plan and noticed an improvement as soon as her son began medication. He could focus in class, and he would no longer collapse in a meltdown when he didn’t get his way at home. He grew more interested in organized sports—basketball and football—which he could play with his dad, and was less prone to isolating himself.
The drug had physical effects: The boy lost 16 pounds and had insomnia at first. And even some of the benefits had unexpected downsides: Over time, Carol’s son grew more socially aware—and insecure. As Carol speaks of this, her face flushes. “He has confidence in every realm except his own peer group,” she says. Medication, while improving his focus, has led to the inevitable shedding of some innocence.
Asked how she’s feeling at that moment, she bursts into tears. “Sad,” she says, then nods. “Just sad.”
Yet, she says she feels comforted having explored all the options, particularly the professional evaluation, which banished most of her doubts. If she had simply stopped with the first advice she received, she might still be tormented by strong uncertainty. But, she pressed forward for something more conclusive, and despite the emotional stress of seeing her son struggle, she has the peace of feeling she is doing the right thing.
If anyone knows how we got into so much confusion over when it is appropriate to prescribe amphetamines to children, Lawrence Diller, is the one to ask. As a behavioral-developmental pediatrician and family therapist in Walnut Creek, he has been prescribing drugs for kids for 30 years and has written three books on the subject. The most recent, The Last Normal Child, questions the morality of what he sees as a rush to give medication to kids who might not need it.
Not that he’s against drugs. If anything, he says he is prescribing more than ever, yet in many cases, he prefers to try behavior modifications first, such as discipline and reward plans at home and at school. To give a sense of his approach, he estimates that while his colleagues may prescribe medication for 90 percent of their clients, based on a general study of such rates, he prescribes for about 60 percent.
Diller is a bit of a character, a made-for-TV kind of guy who favors tailored suits—cream today with a gold embroidered tie—and spendy haircuts, yet he clearly has an exceptional perspective on the topic of kids and medication. In his many years of practice, he has watched the popularity of Ritalin rise and fall, only to skyrocket in 1991 when federal officials agreed to include a diagnosis of ADD/ADHD in its list of official disabilities.
This allowed for special privileges, such as longer time given for taking the SAT, and suddenly, many more parents wanted to find out if their kids might have the condition. In the years since, especially after drug companies won the right to advertise directly to the public, the quantity of Ritalin consumed in our country has risen more than 700 percent, predominantly in white middle-class communities.
Diller says he has watched with concern as what’s considered normal has gotten narrower and more rigid. He describes a bell-shaped curve with one low part of the curve representing a narrow segment of the population that clearly fits the definition of ADD/ADHD and the low part on the other side of the bell representing the population that clearly does not fit. The majority is somewhere in the swelled middle of the curve, the Pippi Longstockings and Tom Sawyers, he calls them, who all too often get misdiagnosed under the current paint-by-numbers approach to evaluating kids.
The problem, he says, falls largely on the nature of our culture and health-care system, which rewards short consultations and straightforward, definitive diagnoses. This, in turn, plays well for parents, he says, who are desperate to solve the problem. “They want an answer,” he says.
Certainty, however, is an illusion, as ADD/ADHD can’t be verified with the stock list of questions filled out by parent and teacher. He considers the questionnaire “a valiant effort at standardization, but it has become the very fallible sine qua non of diagnosis,” he says and slaps his knee, pleased with himself for the turn of phrase.
He suggests parents go to a pediatrician for advice, and then consult with an educational psychologist, who can observe and make something of a child’s behavior. “Because if you go to a doctor whose only tool is a hammer,” he says, “all solutions involve nails.”
Another expert in the area of children’s behavioral and learning problems asks, “Why is it we expect proper diagnosis in every aspect of medicine except psychiatry?” Ali Hashemian, Ph.D., is the director of the Attention and Achievement Centers in Walnut Creek, Pleasanton, and Fremont, clinics that emphasize giving kids a thorough evaluation and using alternatives to medication when possible.
Diagnosis and treatment are complicated by the fact that Ritalin and its variations are simply amphetamines, Hashemian says, and will improve some cognitive functions in almost anyone who takes them. With a learning disorder, for instance, intelligence combined with the brute acceleration of the drugs may be enough for a child to get along until about the fourth, fifth, or sixth grade, when the work becomes unmanageable.
With dyslexia, the problems often remain hidden until about the third grade, when a child moves from memorization of words to actually reading to learn. A bright child on Ritalin might make it further, but as the tasks advance in sophistication, the dyslexia eventually reveals itself. Meanwhile, years have been wasted treating the wrong condition.
Raymond and Erik, twin seven-year-old brothers, are already in their pajamas on a late afternoon after school. “After a hard day, I like to relax,” Erik says, reclining onto a coffee table behind him and almost toppling a vase. He’s big boned and roundheaded, a good 90 pounds lumped pell-mell around his four-foot-tall body.
The boys wriggle themselves into an array of acrobatic positions as we talk, one draping himself over the couch, the other hanging from his mother’s neck before moving on to another contortion. At one point, Raymond accidentally kicks Erik in the eye. Apologies are quickly exchanged, and Erik continues the interview while cupping his eye with one hand.
When asked about rules at school, Raymond explains a few of the no-no’s on the play yard, obviously well versed. “No climbing up the slide the wrong way. No jumping off the play structure. No going headfirst down the slide.”
Erik, who may have ADHD, recently changed schools and describes how things are different at his new playground. “You can go down the slide headfirst,” he says thoughtfully. “But, not upside down headfirst.”
“’Cause it’ll pull all your hair off,” his brother explains.
Clearly, the boys are a handful.
Their mother, Margaret Scheving, the director of a Montessori school in Moraga, says she reacted in anger when she first heard suggestions that her boys had behavior problems. Having given advice to parents for 20 years, she found it surprisingly hard to accept any negative feedback, especially from her own staff, who had the boys in their classrooms. “I wanted to crawl under a table,” she says.
She was especially upset, she says, when she transferred the boys to a different preschool and the teacher informed her that Raymond had somehow managed to climb onto a neighbor’s roof and had spent the day up there, refusing to come down. “When you get calls from the principal’s office more than once,” she says, “you know it’s not just perception.”
After giving the boys a battery of tests, a developmental pediatrician suggested Erik might have ADHD. Raymond’s case was less clear, and he seems to have responded well to changing schools.
For Erik, the developmental pediatrician prescribed Ritalin. But more than a year passed with the bottle sitting unopened on a shelf in the kitchen, and Sheving has since thrown it out. She wants to explore every possible alternative before giving her son medication. For the moment, she is trying to coordinate with his teachers a structured behavior plan to apply in the classroom and at home. This is undoubtedly difficult, as Scheving must continually respond to her sons’, and particularly Erik’s, diffuse energy. But this slower, more cautious approach works for her. Results so far have been mixed.
“The questionnaire approach was too simple for me,” she says. “I don’t want to put medicine in my child if I don’t know for sure.”
She and I retreat to the living room to talk in a more peaceful setting. “You want your kid playing baseball, riding around on his bike, invited to all the birthday parties—and to know he’s going to behave well.”
It’s growing dark outside, almost dinnertime, and a glance into the kitchen reveals Erik raiding the refrigerator, his arms loaded down with more than enough provisions to spoil his appetite. Scheving shrugs. “He walks to the beat of his own drum. He’s indifferent to authority,” she says. “I’m thinking, someday: CEO.”
Meanwhile, the option for Ritalin, she says, still plays in the back of her mind.
Matt Isaacs is a freelance writer based in the East Bay.