More and More, Families Seem Eager to Take the Ritalin Step

Pippi Longstocking just left my office on Ritalin. Of course, that’s not her real name. Her name could be Kayley, Anna, Natalie or that of a half-dozen other girls I see in a week at my behavioral pediatrics practice in an affluent suburb east of San Francisco.

Eleven-year-old Pippi was not performing “up to her potential” at her private school, according to her teacher. She daydreamed and, when called upon, was often not prepared to answer. She could be silly in the classroom. This girl in my office demonstrated academic skills two grade levels above average. She spoke to me cogently and thoughtfully about her life. She dreamed about living on a ranch with many animals. She did act a bit nervous and giggly with her parents and more serious younger brother. But she did not seem to me like a serious case of attention deficit hyperactivity disorder, or ADHD, and I told her parents so.

I didn’t think she needed medication at this time. I suggested that we work on making consequences more immediate for Pippi at home and at school, and if she still was struggling a few months from now, perhaps Ritalin could be tried then.

Pippi’s mom asked me if there was really anything bad about taking Ritalin and if not, why not do it now so that Pippi could do better in school immediately. I said that most children and adults have little problem taking Ritalin and that it was probably pretty safe. It works, ADHD or not, to improve focus and attention on tasks found boring or difficult. Pippi’s dad, uneasy about using a drug that also had abuse potential, thought they should wait.

The family came back to see me a week later. Dad had changed his mind. Another doctor felt Pippi had mild ADHD and gave them a prescription. Pippi apparently felt OK about taking it. The prescribing doctor had only left the instructions on the bottle, “1 to 3 tablets per day.” They asked me to tell them more about using the medication. I internally shrugged and started to tell them how to determine the optimal dose and frequency using a teacher-feedback sheet. They left happy. I felt strange.

I find myself evaluating and prescribing medication for more and more Pippis and Tom Sawyers. These seemingly normal children are inattentive or disinterested in school and a bit slow to finish their chores at home. Concerned and loving parents bring them in because the children aren’t performing “up to their potential” or are disruptive in their classrooms.

Ritalin production is up 700% this decade. Production of Dexedrine and Adderall, the other two stimulants used for ADHD, has tripled in the past three years. America uses 85% of the world’s Ritalin. While school-age boys remain the largest users of Ritalin, girls and adults are the most rapidly increasing groups taking the drug. The Colorado State Board of Education, concerned about too many Pippis on medication, recently passed a resolution that made national headlines, discouraging teachers from referring children to doctors for evaluations and prescriptions.

Russell Barkley, arguably the leading theorist and researcher on ADHD, has said that the use of stimulants for ADHD will be seen as one of the great discoveries of the late 20th century. I’m not so sure. Even as I prescribe more and more Ritalin to help round- and octagonal-peg children fit into square educational holes, I know that Barkley himself is worried about the trivialization of the disorder.

While several surveys say we are still undertreating ADHD, there are wide regional variations in treatment. In some rural areas, virtually no children get Ritalin. Yet in Virginia Beach, one in five white fifth-grade boys receives Ritalin at school.

Ritalin fits our current biological model of ADHD. Training parents and modifying classrooms also help, but some say these interventions are too costly and less effective than medication. That may be so, in which case I wish to offer a Swiftian “Modest Proposal” of my own. With classroom sizes now averaging 30 kids per class and about 4 million children taking Ritalin, I propose that we increase the number of children taking Ritalin to 7 million. We then could probably increase class size to 45 children and save a lot of money.

Ritalin “works,” but I don’t see it as the moral equivalent or substitute for better parenting and schools for our children. Currently, our country has an intolerance for temperamental diversity in our children. I worry about an America where there’s no place for an unmedicated Pippi Longstocking.