Stimulants: The Case for Caution

September 1, 2006

Lawrence H. Diller, MD Private Practice, Behavioral Pediatrics, Walnut Creek, California Clinical Faculty, UCSF School of Medicine Author, The Last Normal Child, Running on Ritalin and Should I Medicate My Child? Dr. Diller has disclosed that he has no significant relationships with or financial interests in any commercial companies pertaining to this educational activity.

TCPR: Dr. Diller, as a behavioral pediatrician you certainly prescribe stimulants and other psychiatric medications to children, but at the same time you have spent much of your career speaking and writing about some the potential negative consequences of the excessive use of stimulants. You’ve also studied the history of stimulant use, and have thought about how this can inform our decisions now.

Dr. Diller: To quote Santayana, those who do not follow history are likely to repeat it. There are some interesting ironies in the history of stimulants in the United States. In 1937, Charles Bradley serendipitously discovered that Benzedrine, a racemic amphetamine very similar to current-day Adderall, could be a “brain medicine” for kids.

TCPR: How did he make that discovery?

Dr. Diller: Bradley was the pediatrician at a children’s home for behaviorally disturbed and neurologically compromised children. A standard part of the diagnostic workup for these kids was a spinal tap. Many of them would complain about headache after the procedure, and Bradley suspected that amphetamine might improve the flow of spinal fluid and therefore replace the “missing” fluid that was thought to cause the headaches. Very quickly, he started getting reports from the teachers that these hyperactive kids were suddenly able to sit and do much better in the classroom. And Bradley also had a very modern insight into the action of stimulants, reflected in his initial article, in which he uses the phrase “appears to calm.” While others felt that there was something “paradoxical” about a stimulant helping hyperactivity, Bradley was clear that it is not paradoxical; it really makes anyone who takes the medicine more deliberate and more methodical in what they do. The decrease in hyperactivity that you see is really the result of the kid sticking with something rather than quickly becoming bored and being attracted to nearly anything else but the math problem that he was supposed to be doing.

TCPR: So Benzedrine became a popular drug for treating these types of children?

Dr. Diller: Actually, Benzedrine remained a relatively a minor treatment used by a couple of Northeastern pediatricians and child psychiatrists, and the main treatment continued to be play therapy for children up to the 1960s. In 1955, Ciba-Geigy introduced Ritalin. It was initially indicated for narcolepsy and poor energy; but by 1961, it had received an FDA indication for ADHD, or what was then called “MBD,”for minimal brain dysfunction or minimal brain damage. The new indica- tion allowed Ciba to advertise Ritalin to doctors for the treatment of ADHD, and one of the major selling points of Ritalin, interestingly, was they could talk to doctors and doctors could talk to parents and say, “This ain’t amphetamine.”

TCPR: Why was that a selling point?

Dr. Diller: Because by the 1960s, there was a well-publicized epidemic of amphetamine abuse in the United States, Japan, and some European countries. Ritalin, being a synthetic analogue of amphetamine, did not have the same reputation. As it turns out, however, methylphenidate and amphetamine are very similar in terms of structure and abuse potential. In fact, one of the reasons why the DEA in 1972 made both methylphenidate and amphetamine Schedule II substances was the Swedish experience in the ’60s, where the government banned amphetamine and then watched in horror as all the addicts switched quite happily to methylphenidate.

TCPR: So Ritalin became the major stimulant prescribed in the ’70s and ’80s. How did Adderall muscle into the scene?

Dr. Diller: Shire, based in the United Kingdom, had bought a U.S. company that had made a product called Obetral, a racemic amphetamine that had been FDA approved for weight loss. Eventually, the FDA withdrew the weight loss indication from amphetamines, because it was leading to so much drug abuse. So when Shire bought the company, the Obetral production facility in New Jersey had been going unused for years. Shire reopened the factory, gave Obetral a new name – Adderall – and began marketing it as a product for ADHD. Ironically, the way they marketed it was by saying “this ain’t Ritalin,” which had a lot of appeal to doctors and parents because by that time, in the mid ’90s, Ritalin had become the well-recognized boogeyman drug for ADHD. So that is the story of how Ritalin replaced the dangerous amphetamine, and then amphetamine replaced “dangerous” Ritalin.

TCPR: Aside from the abuse dangers of stimulants, you’ve written about some of the more subtle ways in which the American “love affair” with stimulants may cause danger to our society. Can you give us a summary of these ideas?

Dr. Diller: First, I want to impress upon your readers that I am not against prescribing stimulants per se, and that as a behavioral pediatrician, I write stimulant prescriptions every day. But over the last 10-15 years, I have become concerned because I get referred children who are far less impaired than I would have seen 15 years ago. Parents bring their children in with the question, “Does my child have ADHD?” And as I prescribed all these stimulants, I began to wonder if I could be doing something which, while in the short-term might be good for the child, in the long-term may be bad for society. Initially, in Running on Ritalin, I focused on the inappropriate use of stimulants as performance-enhancement agents – these children become better performers in school so they can become good corporate consumer citizens.

TCPR: That’s when you introduced the idea of “Tom Sawyer ADHD?”

Dr. Diller: Right. Tom Sawyer ADHD refers to the child who is definitely struggling in school and has some problems with impulse control. His interests and talents are not necessarily what the adults want, but when he is interested in something he focuses fine. That kind of behavior has been redefined as pathology, and there is no question in my mind that Tom Sawyer and Huck Finn would be taking medication today.

TCPR: With your new book, The Last Normal Child, you take a slightly different approach.

Dr. Diller: One of my observations is that children with relatively minor misbehaviors are brought to an expert for a diagnosis and then are often treated with psychiatric drugs for years and years. What we fail to appreciate when we are worried about our children is that most of them are going to turn out like us, because that is what the genetic evidence suggests.

TCPR: Are you saying that when we jump to medications for children, we may be depriving them of the normal difficult experiences of growing up that help them to develop character and resilience?

Dr. Diller: I think the struggle of growing up, in and of itself, is not necessarily bad. One of the common arguments for jumping to meds in kids who are having relatively minor symptoms is that their self-image will be crushed if you don’t target their symptoms right away. But in many cases, there are very simple things that one can do before turning to meds. One of the simplest is to make sure that fathers are involved in evaluation and treatment as much as possible right from the beginning. In addition, every kid who is being considered for medication should have at least a cursory educational evaluation and have those learning issues addressed in the classroom before medicine is tried. And finally, child psychiatrists should become more involved in coordinating plans between school and home instead of just remaining at the office and diagnosing and medicating.

TCPR: I hear your point, but certainly in my practice many parents have already been through the educational evaluations and the therapy and come into my office at their wit’s end, saying that they want their child medicated.

Dr. Diller: I certainly get that kind of patient, and if the parents are very eager to use medicine, that will be one of the factors involved in my decision. But in doing my evaluations, I’m often frustrated by how inadequate and patchwork the previous interventions have been. In particular, virtually nobody is counseling the parents. Yes, they may get a brief parenting educational class in a group, but no one is really taking a look at how the parents can coordinate their parenting efforts with a good
school plan.

TCPR: Most frequently, what are the interventions that you find yourself offering to these parents that have been missing in this kind of patchwork approach?

Dr. Diller: In terms of parenting approaches, I try to teach parents to move away from an overly cognitive style of parenting to the immediate-consequences approach embodied in books like 1-2-3 Magic by Thomas Phelan. One of the basic deficits in ADHD as defined by Barkley is the relative inability to utilize knowledge of delayed consequence, and so the consequence must be brought to the act as quickly as possible.

TCPR: And what interventions have you found most helpful in the classroom?

Dr. Diller: A very simple but lovely intervention is the “on-task card.” It’s a card with 16 empty squares that the teacher puts on the kid’s desk everyday. Every time the child completes a task, he can get a check or a smiley face in one of the squares. Let’s say Johnny is 8 or 9 years old and each smiley face represents a nickel when he brings it home – that is 80 cents a day, and 4 dollars a week. That is starting to add up to a little bit of change for Johnny. Again, this is not revolutionary, but it can be a very effective alternative (or addition) to medications.

General Psychiatry