80% United States WHY NOT JUST GIVE HIM RITALIN? THE MEDICAL AND MORAL CASE FOR NON-DRUG INTERVENTIONS FOR ADHD LAWRENCE DILLER, M.D.

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1 WHY NOT JUST GIVE HIM RITALIN? THE MEDICAL AND MORAL CASE FOR NON-DRUG INTERVENTIONS FOR ADHD LAWRENCE DILLER, M.D Annual Production Quota Methylphenidate and Amphetamine (K g) MPH AMP INCREASE IN STIMULANTS/ Annual Aggregate Production (kg) Amphetamine Methylphenidate % INCREASE 3000% 1700% Estimated Number Taking Ritalin 2.5 million children in 1995 (D.Safer et al, Pediatrics 1996) 4.8 million persons in 1997 (Diller, Pediatrics 1997) 3.75 million children in 1997 (IMS America, personal com.) 2.5 million children in 2003 (CDC, MMWR, Sept. 2005) United States USES 80% OF THE WORLD S RITALIN Methylphenidate Consumption Per 10,000 Population in CY 1997 WA ME MT ND V N OR MN T H ID SD WI NY WY MI N RI NE IA PA J NV UT IL IN DE OH MD CO V W VA DC CA KS MO KY NC TN AZ NM OK AR SC MS AL GA TX LA AK FL U.S. Average: 311 grams HI Above Average = 390 grams or more Average = grams MA CT Below Average = 232 grams or less

2 ADHD and Ritalin Primarily White Middle and Upper-Middle Class ETHNIC GROUP USE AFRICAN-AMERICAN ASIAN-AMERICAN HISPANIC-AMERICANS GREAT SMOKY MT. STUDY ANGOLD et al., JAACAP kids (age 9-13) 4 years ( ) About 5% with ADHD 7% get Ritalin BUT only 3/4 s with ADHD get Ritalin > half with Ritalin had no ADHD more $ meant more Ritalin The symptoms of ADHD are dimensional/not categorical The line between extreme variations of normal temperament and disorder is blurry and shifts depending upon child, family, neighborhood and culture The majority of diagnosed ADHD by virtue of the bell shaped curve must be MILD or borderline ADHD

3 ADHD is a genetic disorder (80% of variance is heritable) Most ADHD will be mild PKU deficiency is also a genetic disorder BUT MTA study: psychosocial interventions added nothing to medication only rx BUT WHY NOT JUST GIVE HIM A PILL AND SEE IF IT WORKS? THE MYTH OF STIMULANTS PARADOXICAL EFFECT Bradley s report: appears to calm hyperactive children (1937) Military studies of stimulants (1950s) Rapoport s (NIMH) studies of normal boys and men ( ) Continued inappropriate use of stimulants as a diagnostic tool for ADHD Medication works and is safe but is not the MORAL EQUIVALENT to non-drug interventions Adverse effects: eating, sleeping, growth Pills do not teach skills: learning to deal with variations in talent and personality Developing strengths to compensate for weaknesses The struggle is it worth it? MEDICATION IS NOT THE MORAL EQUIVALENT A MODEST PROPOSAL Tilting at Windmills Diller s Wish List Parents, teachers and doctors should all take a collective sigh about children s feelings/future Involve fathers in evaluations and treatment plans All at-risk children should have a minimum education/development screening DB pediatricians and child psychiatrists more involved in coordinating educational/behavioral interventions between school and family (attending SSTs and IEPs) Insurance reimbursement reform

4 If I were King Emphasize more immediate, less talk, more action discipline Counseling/Psychotherapy directed to the parents for behavioral management End or severely limit DTC advertising Dire need for systematic post-marketing surveillance of pharmaceuticals RESOURCES FOR THE PEDIATRICIAN < age 11: 1,2,3 Magic - Thomas Phelan > age 11: Parenting Your Out of Control Teen - Scott Sells Managing/Coordinating Behavioral Interventions: Ed Psychologists/Special Education Tutors/Family Therapists (Assn. of Family Therapists of N. CA - CURRENT STIMULANTS RITALIN/ SR/ LA METHYLPHENIDATE (GENERIC) DEXEDRINE (AND SPANSULE) ADDERALL, XR, DEXTROSTAT METADATE ER/CD (Sprinkles) METHYLLIN (SOLUTION AND ER) CONCERTA FOCALIN DAYTRANA SKIN PATCH VYVANSE (LISDEXAMFETAMINE) OTHER MEDICATIONS Strattera (atomoxetine) Cylert (pemoline) - discontinued Tricyclics(Imipramine/Desipramine) Clonidine(Catapres)/Tenex (Guanfacine) Wellbutrin (Buproprion) Lithium,Depakote,Neurontin,Risperdal, Zyprexia, Lamictal, Topomax, Geodon, Abilify, etc. Methylin(methylphenidate) now in grape flavored solution! Focalin(d-methylphenidate) In theory requires 1/2 dose of Ritalin but? practical advantage. Much more $$ Daytrana Skin Patch Once a day application. Purported 12 hr duration. Takes 1-2 hr for full effect. Skin irritation common. Possibly less abusable, e.g. for use in young adults

5 LISDEXAMFETAMINE Promolecule of lysine & amphetamine which is inert unless cleaved by GI enzymes Inert if crushed, snorted, liquefied, injected - It s less abusable, stupid! Approved February 23, 2007/Sch. II Likely Shire will apply for Schedule III Abuse and addiction still possible simply with overuse Strattera(atomoxetine) Highly promoted by Lilly Not the holy grail of ADHD Rx Not abusable Less anorexia but more GI, sexual complaints Loses in head to head with Concerta Should not be used as a first line drug in children. Perhaps in adults. Still captures 15% of ADHD drug rx market Suicide warning on label Alternative rx s for ADHD After 29 years experience different fads come and go (remember the Feingold diet?) Refined sugar theory (never dies) Artificial color (red dye-maybe?) Biofeedback (still waiting for proof) Health food preparations: herbs, freeradicals, anti-oxidants, gingko biloba, omega 3 fish oil, etc. THE RISE OF ADHD/RITALIN acceptance of biological dx better diagnosis and recognition of ADHD acceptance of medication demands on academic performance 2 parent working families ( preschool) Cognitive style of discipline Changes in medical insurance Medical-Pharmaceutical influence on teaching, research and promotion (direct to consumer advertising) Toxins??? THE LAST NORMAL CHILD Our concern about our children s feelings, especially their self-image and self-esteem, has ironically led to a growing intolerance of minor differences and variations in children s behavior and performance. Lawrence Diller The Problem with I can t focus The loss of agency In my daily Sisyphian effort of pushing up the boulder of self-competency, I find the slope of that hill is getting steeper and steeper.

6 LAWRENCE DILLER, M.D. Running on Ritalin (1998) Should I Medicate My Child (2002) The Last Normal Child (2006)