An Op Ed by Dr. Lawrence Diller, who specializes in behavioral-developmental
pediatrics,  addresses America’s obsession with children’s “self-image”
“self-esteem” and the epidemic number of children being “diagnosed” and
drugged. Dr. Diller has prescribed psychostimulants, such as Ritalin, but is
concerned that the drugs are being widely misused.

“I came to realize my analysis of the ADHD/Ritalin epidemic [in his first
book, Running With Ritalin] was incomplete. Nor did I sufficiently explain
why parents of less and less disabled children, parents of children as young
as 2, or the kids themselves (especially teenagers) were seeking the ADHD
diagnosis and medication. Neither was I entirely clear on why parents were
also interested in medications like Prozac, whose use in children has also grown
exponentially in the last 10 years.”

Dr. Diller’s new  book  (a compilation of essays)  The Last Normal Child,
describes the cultural changes brought about by psychiagtry’s shift  from
diagnostic dimension (which acknowledge a range of normal behavior) to
categorizing behavior as either normal, or abnormal–with no latitude for
degree or dimension. This diagnostic change took place without a shred of
scientific evidence to back it up. Howrver, its radical shift has
contributed hugely to increase profits for the pharmaceutical industry.

The shift has also impacted on our culture so that parents are misguidedly
pressuring doctors to attribute children’s normal behavioral problems and
less than stellar school performance to a biological pathology. Parents are
insisting that doctors ascribe a “diagnosis” for which the “fix” is a pill.

Dr. Diller states his case in the gentle tone of a pediatrician. He notes
that there is no scientific evidence to show that  a child’s self-concept
has any long-term influence.

“Still, we want our children to feel good, right? But what if that means
taking them to the doctor, getting a diagnosis that may have lifelong
implications and taking a medication potentially for years? Does that make
sense? Is it the best thing for our children?”

He points out that doctors’ prescribing pattern and parents’ perceptions
have been shaped by deceptive marketing and undue influence of the
pharmaceutical industry on psychiatry’s diagnostic criteria and insurance
reimbursement policies:

” Money also plays an important role. Insurance companies reward doctors
more for brief “med checks” than longer talking sessions. The doctors make
more money by prescribing and the drug companies make money, too.    Indeed,
the single biggest influence on the way we think about our kids’ problems
may be the power the drug companies have on the doctors’ behavior, medical
research and teaching (mostly funded these days by drug companies), and
advertising directed to the consumer (parents and teachers).”

Contact: Vera Hassner Sharav
veracare@ahrp.org

~~~~~~~~~~~~~~
http://www.sfgate.com/cgi-bin/article.cgi?file=/c/a/2006/11/19/INGT9MCJHF1.DTL
San Francisco Chronicle
Sunday, November 19, 2006
DON’T DRUG THEM /
Parents’ obsession with their children’s self-esteem plus profit-driven
diagnoses create a dangerous prescription
Lawrence Diller

In our zeal to help our children feel better about themselves, are we
really doing them any favors, or could we actually be hurting them? It’s
counterintuitive, but our worries over our children’s self-image and
self-esteem may be unwarranted and unintentionally lead to unnecessary
medical intervention and possible harm.

I’ve come to this opinion after evaluating and treating over 2,500
children for attention deficit/hyperactivity disorder, the condition that
has become the explanation for virtually all children’s underperformance
and misbehavior at school.

November is a busy month for me because it’s time for the first
parent-teacher conferences prior to the year’s first report card for most
schools. And this time of year parents are all asking the same question,
“Does my kid have ADHD?”
As someone who has prescribed drugs like Ritalin, Adderall and Concerta
to children for more than a quarter century, I’ve become very uneasy about
how much medication we use in this country. In 1998, I wrote a book called
“Running on Ritalin,” which examined the factors that might explain the
phenomenal growth and use of this drug in the United States.
However, I came to realize my analysis of the ADHD/Ritalin epidemic was
incomplete. Nor did I sufficiently explain why parents of less and less
disabled children, parents of children as young as 2, or the kids
themselves (especially teenagers) were seeking the ADHD diagnosis and
medication. Neither was I entirely clear on why parents were also
interested in medications like Prozac, whose use in children has also
grown exponentially in the last 10 years.

These parents weren’t after perfect “trophy” children. They loved their
kids but were worried about them. It occurred to me that it was their
worry over their children’s feelings, especially their self-image and
self-esteem, that was driving this epidemic of psychiatric drug use.
In our concern about our children’s feelings, we’ve ironically become
less and less tolerant of minor differences or variations in their behavior and
school performance. Several years ago, I treated an 8-year-old patient who
had an IQ of 130 but was getting only B’s and C’s at his private school
because he wouldn’t turn in his homework despite his teachers’ and
parents’ best efforts. He was more focused on reading adult level texts
about the Sahara desert, his current interest. But he was feeling worse
and worse about his less-than-stellar grades, so I ultimately prescribed
Ritalin for him. After that experience and many similar ones, I began to
wonder if someday I’d be seeing “the last normal child” in my office.

This concern about our children’s feelings reflects a profound change in
our society’s values over the past four decades. Our beliefs have shifted
away from religion and meaningful politics to an obsession about caring
and believing in ourselves.    In the process, how we feel has become much
more important to us, and we expect (and possibly demand) that we feel good. And that’s especially true
for our children.     Yet despite much popular belief, there is little evidence that in the long
run children’s views of themselves make any difference.

Most of the original work on self-esteem was based on retrospective
interviews (notorious for creating distortions). It didn’t matter whether
the subjects were now CEOs, artists or criminals. All of them seem to have
had lousy childhoods. Both the successes and the failures in life told
researchers that as kids they suffered low levels of self-esteem. And more
reliable types of studies have failed to prove that high or low
self-esteem in childhood is predictive of good or bad outcomes later in life.

Whatever its influence right now, a child’s self-concept appears to have
little long-term influence.    Still, we want our children to feel good,
right? But what if that means taking them to the doctor, getting a diagnosis that may have lifelong
implications and taking a medication potentially for years? Does that make
sense? Is it the best thing for our children?

ADHD has become the ubiquitous way we view problems of children’s
behavior and performance. While the Centers for Disease Control report 2.5 million
children take a medication for ADHD, most research epidemiologists say the
number is closer to 4 million. A more precise gauge comes from a
medication insurance clearinghouse report that shows nearly 1 in 10
11-year-old white boys is currently treated with a stimulant such as Ritalin.
The amount of legal stimulants used as medication and produced in our
country has grown 2,000 percent in the last 15 years. Data from the U.N.
Narcotics Control Commission has been consistent over the years: The
United States consumes 80 percent of the world’s legal stimulant drugs
(this does not include our use of illegal stimulants like cocaine or
methamphetamine).

More parents, teachers and doctors are ready to accept a biological
explanation (an ADHD diagnosis) and a medical treatment for children’s
underperformance at school, where children are being asked to learn more
at an earlier age. With more two-parent working families, parents have
less time to spend with their kids, either for monitoring homework or having
fun.
Our discipline practices have changed. We put forth much more effort in
talking to our kids about bad behavior before we take action (a style
poorly suited for the hyperactive mind).
Money also plays an important role. Insurance companies reward doctors
more for brief “med checks” than longer talking sessions. The doctors make
more money by prescribing and the drug companies make money, too.
Indeed, the single biggest influence on the way we think about our kids’
problems may be the power the drug companies have on the doctors’
behavior, medical research and teaching (mostly funded these days by drug
companies), and advertising directed to the consumer (parents and
teachers).
Yet the bedrock supporting this epidemic is our love, fear and worry over
our children’s present and future feelings. Must we make a pathology of
our children’s struggles and treat them with psychiatric drugs for “their
own good?”
I suggest there is another way. Perhaps, the primary reform we should
undertake as a society is to breathe a “collective sigh” about our kids.
Things will likely turn out well for most of the offspring of the
middle-class families who bring their kids to the doctor’s office for
evaluation.
Don’t forget that some of our greatest strengths are the result of
compensating for our weaknesses.

Also, there are a number of simple actions we could take to help our kids
that don’t involve using a psychiatric medicine at all.
First, we should make a concerted effort to involve fathers more
immediately and directly in the evaluation of their children’s behavior or
school performance. In my years of practice, I can recall only about a
dozen fathers who lived in the area who refused to participate in an
evaluation, especially if I called the dad directly.
Father’s involvement is critical. He often has a different perspective
than the mom (he generally sees less of a problem because he’s around less
and also stereotypically is more effective with discipline). His
participation with any behavior plan (or medication treatment for that
matter) makes its success far more likely than without him.
Second, all kids should have a minimal educational evaluation at school
or
by the doctor before they are started on a medication. So many of the
children I see have learning or processing problems that have been
ignored. It’s no wonder they are looking out the window when the teacher
is talking if they have an auditory processing disorder (or another
learning problem). Yet over and over again, I get kids referred who have
not even been screened by their school.

Finally, I make a direct plea to my colleagues in child psychiatry and
behavioral-developmental pediatrics. You, who have achieved the pinnacle
of power and expertise within the community to evaluate and treat children
for these problems, are spending way too much time in your offices
“diagnosing” disorders and dispensing pills. Instead you should be going
out to the schools to attend individualized educational plan meetings to
coordinate an effective behavioral-educational plan between the school and
parents. Over and over, parents tell me the single most valuable effort I
made in helping their child was the 45 minutes I spent with them at such a
school meeting.
I know there’s a core group of kids that — no matter what you do for
them — will need these medications, but I think this group is about one-tenth
of the number we treat now.
We too often forget that medication is not a moral equivalent to helping
children cope with what has become an increasingly perilous journey
through childhood.

Lawrence Diller, M.D., practices behavioral-developmental pediatrics in
Walnut Creek and is the author of “The Last Normal Child” (Praeger, 2006).

Contact us at insight@sfchronicle.com.

Copyright 2006 SF Chronicle

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