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The drug can be justified and is helpful at least in the short term for the very small number of children (1-2%) whose inattention or overactivity is severe and for whom extensive efforts at environmental changes have proven ineffective. Yet, even for this small group the drug is not without possible unfavorable consequences. And the long-term effects have scarcely been scrutinized.
The Multimodal Treatment Study (MTA), published a year ago in December of 1999, was hailed by many as the definitive proof of the superior value of medication as compared with psychological management for the treatment of children diagnosed with ADHD. However, a careful reading of the report discloses some important methodological flaws. The supposedly "medication only" group also got some behavioral counseling, and the "behavioral treatment only" group did not have the same sustained maintenance and individualization of care as did those given the medication. The results are, therefore, not so clear as proponents would have us believe.
Some have suggested that, if the child does better on Ritalin, this is reason enough to administer the drug in order to improve performance. That same line of false reasoning would claim that there is nothing wrong with giving steroids like testosterone to normal children or adults to improve their athletic achievement and self-esteem.
The crisis of legal compulsion to take the drug
The possibility that school officials or judges could order the parents of a child to administer Ritalin to him/her is alarming. In view of the vagueness of the diagnosis, the inconsistent way in which it is applied, and the non-specificity of action of Ritalin and similar drugs, it would be an abuse of authority for persons in positions of responsible leadership arbitrarily to require parents to give their children this drug or to face exclusion from school.
Some suggestions for a solution to the problem
1) Broader knowledge. Teachers, physicians, educators, and the general public must acquire a greater awareness and acceptance of the wide range of normal behavior displayed by children. In Texas and in the country at large we must return to a recognition of and respect for the broad variations in temperament and behavioral adjustment. Children are not necessarily abnormal if they are not exactly the way their caregivers want them to be. The present pressure for total conformity to some idealized norm of behavior must be restrained. In particular there must a greater awareness of the many reasons why children may be inattentive beside a deviation of brain function: normal temperament variations, fatigue, hunger, previous experiences with abuse or neglect, present experiences of family and community stressors, etc.
2) Better evaluations. When children have problems with school performance or behavior, the various possible contributing physical, psychological, social, and educational factors must be considered. All children with such problems should be adequately screened for learning problems by one of the school's educational specialists. Teachers should not diagnose ADHD, a condition of neurological malfunction, any more than physicians should instruct teachers how to conduct their classes.
3) Better management. The management of children with problems in performance and behavior in school should rely first and foremost on the established educational techniques known to be effective, including discipline. Consideration of referral to a physician for medical intervention should be reserved for only the most severe cases after they have been thoroughly evaluated and when sustained efforts with the recognized forms of treatment have failed. Even if drugs are responsibly prescribed, the schools must still assess learning problems and other contributory factors, making certain that the students are helped by individualized remedial methods. Responsible care for our children must be tailored to their specific needs. One diagnosis and one treatment do not fit all.
4) Change the diagnostic terminology In my opinion, this crisis in diagnosis and management cannot be resolved until the faulty diagnosis of ADHD is revised. Unfortunately there is little enthusiasm for change among members of the psychiatric establishment. The Diagnostic and Statistical Manual (DSM) system is unquestionably an improvement over the lack of shared diagnostic criteria that prevailed as recently as 30 years ago. However, since the American Psychiatric Association's DSM does not recognize normal variations, its diagnostic system can only describe disorders and "subthreshold disorders." Therefore, it is entirely appropriate for concerned citizens and official bodies such as the Texas State Board of Education to write to the American Psychiatric Association, the American Academy of Child and Adolescent Psychiatry, the American Academy of Pediatrics, and the Institute of Medicine of the National Academy of Sciences to tell them that the diagnosis of ADHD, as presently formulated, is too vague and cannot be applied with a sufficient rigor at the practical level.
Conclusion
Thank you for inviting me to share with you my concerns about the present crisis of overdiagnosing and misdiagnosing of ADHD and of the widespread overuse and misuse of cerebral stimulants such as Ritalin. We are witnessing a crisis of a magnitude and type never seen before. I congratulate you for having the wisdom and courage to try to find a sane solution to this situation. I hope my remarks have been helpful.