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Kathleen/Moderator - Teachers.Net is pleased to welcome Larry Diller, M.D., pediatrician and family therapist. His book, Running On Ritalin, and a recent article, Would Tom Sawyer Have Been Prescribed Ritalin? (San Francisco Chronicle, March 18, 1999, p. A25) have caught the attention of national media such as PBS and CNN TalkBack Live. Doctor Diller, ADD/ADHD has been described as a syndrome, a condition, a disease, an excuse ( for lack of discipline), etc. What term do you prefer?
docdiller - ADD is "a problem"
Kathleen/Moderator - Doctor Diller, you state in your book: "Since 1990, the number of children and adults diagnosed with ADD has risen from about 900,000 to almost 5 million .... These figures—derived from the amount of medication prescribed for ADD—suggest a problem of epidemic proportions." Is this an epidemic of ADD/ADHD or an epidemic of misdiagnosis?
docdiller - It tells us the we have a serious problem of perceived underperformance and misbehavior in our children that we are choosing to address by diagnosing ADD which implies that the problem resides in the children's brain and requires medication
Kathleen/Moderator - Doctor Diller, in your opinion is ADD?ADHD "real"?
docdiller - Oh you are trying to trap me and get everyone ticked off if I say ADD is not "real." The problems the children, parents and teachers are having are quite real and some of that is due to the children's brains and personalities. The key word though here is some because some of the problem's contributions come from environmental expectations and responses to the children's abilities
Kathleen/Moderator - Doctor Diller, would you attribute the cause to nature or nurture or both?
docdiller - Clearly both and that's was gets me is this continuing "debate" if you want to call it that between the proponents of either extreme. On one hand we have the research/academic/CHADD perspective which says it is all nature and then we have the "alternative", anti-Ritalin, Breggin types that say it is all nuture. Since I believe both are major contributors I enviably get attacked by both groups. It's tough when one is common sensible.
james/ca - it seems to me that most diagnoses of ADD are because the child is having some type of conflict within the structure of the classroom......
james/ca - wouldn't it be best to deal with the situation by first looking was what is causing the conflict within the child?
docdiller - Well, it can get pretty complicated and that's not meant to duck your question. But current classroom structure with pod seating and approaches that are primarily cognitive and less based upon tangible reinforcers are not "friendly" to the impulsive child who may or may not also have learning problems
docdiller - Gee I don't know what you mean by conflict. But if your suggesting traditional play therapy to work out the conflicts unfortunately for impulsivity type problems and acting out problems in children it's not a particularly useful modality of treatment
ski.high - I believe in nature as the cause, but at this time i also see the nurture issue,in my class, i have two beautiful kids one with ADHD the other nothing, how would you encourage family involvement and education for the ones that needs it???
james/ca - conflicts arising from boredom for instance
docdiller - Well that's pretty hard if the parents are overhwelmed or have problems of their own. Fortunately for me I can usually get both parents in to see me because they are upset that the teacher is concerned about the kid. I think I would try hard not to sound judgmental with the parents and say that you are concerned and/or stuck in trying to help their kid at school and need their assistance. From there you may cautiously make some suggestions including getting some therapy if necessary for the family.
ski.high - doc.diller, isn't it true that you can see real impulsivity, against plain misbehavior, and that's where the conflict of opinions i feel is, don't you think???
docdiller - Well that's it. Since there are no definitive markers (biological or psychological) for ADD it comes down to the eye of the beholder. Some docs see ADD in virtually all underperformance or misbehavior. Others do not believe it "exists". There are likely a core group of children about whom virtually everyone would agree are neurologically driven to overactivity and impulsivity. However, that group is quite small compared to the number of children receving medication today in this country.
Linda - I don't believe in overmedicating children at all. However, I have seen some miraculous things academically and behaviorally with ritalin. Can you explain that, and why would you want to deprive any child of possible success?
docdiller - Linda, I agree one could say if Ritalin "works" and by the way Ritalin's effects on children are non-specific. Meaning whether or not you're a child adult ADD or not, the stimulants (Ritalin, Dexedrine, Adderal) will get you to stick with things you find boring or difficult. So Why not take Ritalin. Well, I don't believe that Ritalin is the moral replacement or equivalent to more appropriate parenting and schooling for our children.
kinderkate - I have never asked that a child be put on meds in my 9 years of teaching. Of course k/l classes are more appropriate for the active child. However, I see that these same children who go to higher grades just can't cope. And how is a teacher supposed to deal with a child/children with these needs and still teach the entire class? If it is not in the best interest to medicate, should the child be in a special, smaller class with a lower child/teacher ratio?
docdiller - These are difficult structural problems that I think we must all work towards changing. Smaller classroom size undoubtadebly helps the borderline ADD child stay focused. But beyond that making sure any kid being considered for an ADD diagnosis also gets atleast screened for educational problems is a must. Also the teachers' comfort to moving away from verbal reminders and cognitive based approaches to being more comfortable with immediate tangible reinforcers, both positive rewards and consequences will be more productive.
kinderkate - But docmiller, have you ever taught a class of 30 where 29 are behaving and the one who is not gets a "reward" for the least bit of acceptable behavior?
docdiller - Again kinderkate raises difficult issues. I believe that after attempts have been made to address family/parenting issues as best as possible and one has worked with the school making sure that the educational and behavioral needs are at least attempted at being addressed and the child continues to struggle at that point it seems reasonable to offer medication. That's for the individual child. At the same time we should all be working for smaller classrooms and more realistic expectations for the wide variety of kids we see (not everyone will be a Stanford MBA).
docdiller - YOu are right, kindergate, I have the greatest respect for teachers who are in that situation. It is not reasonable for the teacher to devote all her efforts to that one child however some of these techniques are good for all the children. It might also be reasonable for the teacher to take 20 minutes in her day and structure a specific task for that child where the rewards and consequences are immediate and then extend from there.
docdiller - The best reinforcers are those that can be used immediately. A card systme can work for an older kid, but stickers and loss of privilege will work better with the younger child. It may be simply to have the child seated right in the front and putting you hand on the child as a signal ro refocus or having the child put their head down on the desk for 30 seconds or being held briefly (5 minutes) ffrom going out to recess if the assignment isn't done. The main thing is less talk and more immediacy of action.
Al from Canada - What is your advice for a situation where a parent has had a doctor prescribe Ritalin for an ADD child, but you would rather work with the child without "drugs" interfering? Does the medical doctor always have the greater credibility?
docdiller - Oooh, Al. That's going to be tough. I think the best you can do is communicate your opinions to the parent and let them decide or ask permission to speak with the doctor. I have situations where children are sent to me on 3 or four psychotropic medications and the teachers are quite upset but the parents (or parent) feels that they are useful and a doctor agrees (but not me)
Heidi - I teach Emotional Support grades 1-4. I mainstream my kids into gened. How do I educate teachers about what to expect with kids with ADD/ADHD and how to work towards their success?
docdiller - Let me get this across because this is important for all of you. Barkley says the problem is not with inattentnion and distractiblity. I tend to agree that the main problem is impulsivity defined here as the relative inability to utilize a time delayed consequence for self regulation. That's why so many of these kids do fine on things that they like but don't follow through on things that don't have immediate appeal and the consequence is delayed. They know what they're supposed to do, they simply do not utilize that knowledge. Implication for treatment, less talk and more immediacy of action from the environment.
Heidi - I have run into fear and resistance that is frightening! I am more than willing to help out but sometimes that stereotype takes over!
docdiller - Gee I answered Heidi's question before I read it
Heidi - THank you Doc for the great answer! :)
Jane/k - Medicine is not a cure all, but IT can help some children with proper structure. However, as the parent of an ADHD child, I know that it can make a difference
docdiller - The biggest problem is the belief that it's up to the kid. That's a mistake. Of course the kid is responsible for his actions and will have to suffer the consequences but it's just wishful thinking that the kid's going to change. It's up to the environment to make adjustments and that's a tall order to overworked parents and teachers. To wit Ritalin becomes the answer. No question Ritalin can be helpful. But I worry about a society where the answer to kids' nurturing needs is a medication. Again I prescribe a lot of Ritalin so for the individual child it may be the thing to do.
Aron~3 - Asked and answered, your honor. LOL BUT.... I have heard that caffiene can have the same effect as Ritalin on the ADD child, is this true? And if so, why isn't a glass of tea in the morning being presribed instead of the over-prevelant use of ritalin?
docdiller - Caffeine (in coffee or tea) has been looked at and is simply not as effective in keeping people to tasks as amphetamine or methylphenidate (which is Ritalin)
ski.high - I agrre with all that, but strongly disagree with your thought about moral replacement, every country in the world does absolutely that: immediacy of action, we do not, too many chances, too many choices, we have given the children the authority to rule the adults world, nowhere to be seen. IN school, we teachers are told no to insinuate ADHD(liability issues) but many times when you live with one you recognize the rest, and true is: not all the "Diagnosed ADD_ADHD children need mediacation but behavior modification, parenting and affection
docdiller - I'm not entirely following skihigh's line but I agree with the parenting authority stuff. I call it politically correct parenting trap-the idea that somehow if you know how to talk to ADD JOhnny you can avoid conflict and he'll listen. My experience is that before you've finished your first sentence he's half-way down the street.
ski.high - Coffee with milk is given as breakfat in every south american home, been there
docdiller - By the way we currently use 85% of the world's Ritalin and Ritalin rates vary 5 fold between states (Hawaii is always the lowest) and twenty fold within states. Something is going on here and it ain't just their brains.
shel - When the children become high school age and are trying to come off meds, the slightest phone call to the parent regarding any problem and the parent's first response is to put the child back on medication. How can we as teachers approach the parent without causing the child to be put back on ritalin so quickly? Often I do not even know they have a history until I make that first call whether for behavior or academics. I hate seeing this be used as a "quick fix."
docdiller - Parents are so concerned and paranoid these days and given the media who can blame them. I try talking to parents and teenagers about the meaning of "success" and the idea that there are square and octagonal peg children that don't easily fit into round educaitonal holes.
docdiller - I ask teens, three questions, "What are you good at? What do you want to do? What do you think you should do?" In this society if the answer to those three questions aren't similar the kid becomes a candidate for medication
carrottop/GA - Are there any food supplements, vitamins, or diets that you might recommend? Have you ever taught in a regular public school classroom? Possible follow-up question
docdiller - No I've been sheltered as a doctor for twenty two years. But I go to more IEP meetings now than I did ten years ago because I think it is so importat for the doctor and teacher and resource people to interface over the kid. The NIH consensus conference felt there was a structural problem of communication between the doctors and teachers and I agree. I call the teacher on the telephone rather than simply getting her to fill out another questionnaire. YOu know some schools actually have voice mail at this point. I'll get to nutrition in a moment.
Carol/tx - I am a teacher and a parent of ADD and ADHD children. My ADD child is in college and has refused her medications and is struggling with retention but, gradewise is doing very well. My 15 yr old ADHD son was diagnosed as a "true" ADHD child (whatever that means) and put on Ritalin at age 9. He has grown up having to take responsiblility for his own behavior and understands and accepts the fact the Ritalin is just a "tool" to help him focus during school. He is an A/B student. I have tried taking him off of the Ritalin, but his grades suffer. Can you recommend a substitute? I am concerned about the potential for liver damage. He contends that caffeine tends to make him jittery and nervous.
docdiller - I think that Ritalin is relatively safe when taken properly even or years. The bigger concern in the teen and adult population is abuse and addiction. I think in my patients that is rare but as more and more doctors prescribe stimulants to adults I think we will have another doctor prescribed stimulant abuse epidemic as we had with diet pill in the 70's Aand feel good doctors in the'60's.
ski.high - what about food? colorants?presrvatives?
docdiller - Okay, the diet alternative stuff...It's very attractive because we are dealing with chronic complex problems that don't go away easily and many people are frightened about Ritalin. Unfortunately, when these alternative (diet, allergy, biofeedback, etc.) are studied systematically they fail to come through. That said there hasn't been a great deal of research relatively compared to the medications in part because the pharmaceutical industry is what is driving research today. there is a bit of evidence that food coloring in children under five in hugh amounts made the children more irritable. That should be enough evidence that if your child is struggle to try and avoid the stuff if possible but sugar haS BEEN LOOKED at quite closely and found not to have an effect on behavior (oh I see a hundred teachers shaking their head at this moment) but really if you're going to battle a kid battle him over putting away his toys and not over a cupcake.
james/ca - I know for certain, that those student types who are now diagnosed with ADD, in decades past were prescribed with physical punishment, in this light, is there any chance that ciba-geigy may in the future expand into the paddle manufacturing businesss if c
james/ca - corporal punishment makes a comeback?
docdiller - I have said James we're a society that is more comfortable in giving a kid a pill rather than a swat. But the idea here is not the physical punishment is more effective, but rather that the immediacy of tangible consequences be delivered and that a short immediate PUNISHMENT is not necessarily damaging to a child's self image if it leads to more long lasting change. We are just so uncomfortable these days with doing that (including a spank every now and then-not at school!) that we wind up calling these kids abnormal with disroders and giving them medication.
Linda - I totally agree that not every child will be a Stanford MBA. However, teachers are being pressured to get kids ready to take local or national tests. The scores of these tests seem to be the MOST important. To have a separate program for each of these children is a luxury from the past. Improving test score is what is "IN." I have tried to fight this for years, but instead of getting any better the demands on these children are getting more and more ridiculous.
docdiller - Hey Linda, I think you're doing the right thing. It may be time for the parents to get their act organized or the kid will need medication.
kinderkate - Docmiller, did you just say that the child won't change, that the environment will have to? Please elaborate - we don't live in a vacuum. Children have to fit in. The saddest thing I have seen with these children is not the problems the teacher and parent have. Rather the other children often don't want to be around them.
docdiller - Kindergate is right the peer relation stuff is quite important. YOu know, I'm starting to feel overwhelmed with the problems of the world here. Listen there are kids when many things are tried and it then is reasonable to use medication. I just am concerned when the first and only thing tried is medicatioin for a variety of performance and behavioral problems.
dustbath - Doc, I would like to know what the social effects of taking meds and do children actually start getting invited to parties etc...
docdiller - The medication may improve social relationships in that they make the children less impulsive. A socially awkward kid will likely remain socially awkward but the impulsive kid will improve. That again suggests that these problems are complex and one diagnosis hardly describes a kid adequately yet Ritalin is the most common answer.
Mary K&1 - I was surprised when you said that you go to IEP meetings! Is it normal procedure for a Dr. to ask for a teacher's input when he/she is trying to diagnose a child? Some do and some don't - what's the norm?
docdiller - Mary K/1 It's unconscionable for a doctor to "make a diagnosis" of ADD without teacher feedback yet many prescribe Ritalin after just meeting with the mother and child for 15 minutes
docdiller - Kathleen, I said that Suzanne's techniques are good. Time to move to the parents
mariel - What about children that have a genetic predisposition to substance abuse with parents, grandparents with history of alcoholism/drug dependance. Since that child is already at "risk" would you consider prescribing an amphetamine appropriate?
docdiller - Oooh..Mariel's been reading. There is great controversy whether prescribing stimulants to children leads them to use drugs more or are protective in some way in keeping them from using drugs as teenagers. I would say there is little evidence either way. Long term suggest that psychosocial treatments (special ed where necessary and family counseling, especially parental behavioral management techniques) along with medication are in the long term the best treatments.
Dee/mb - Dr. what would you say to teachers who adamantly insist AD/HD does not exist...? As a parent of a son (now 16) with ADHD, and a teacher (still am)for many years, I believe it does.. but as a DR... what would you suggest saying to them?
ski.high - what other tests should be requiered to diagnose ADD-ADHD??
docdiller - At the minimum the child should be screened for learning problems (or genius), a history should be take from both parents (especially the father who often doesn't have as many problems with the kid because he isn't there or is tougher), a brief child interview to se how the kid feels about things (is he sad, anxious or very angry). I meet the entire family one time for 45 minutes and find it the most valuable time I spend with the kid but very few docs do this. Then direct feedback from the teacher (I prefer the phone but many docs use the questionnaires).
james/ca - What are your feelings on Ritalin becoming a gateway drug? Children intuitively know that it's not good to be taking drugs. And the idea that it's a drug that works in school but not at home, it works during school days but don't have to give it on vacations, it's so obvious that we're just drugging children to push them into situations that they can't stand.
docdiller - If a kid has been doing reasonably well on medication I think it is sensible every six months or so to have him go to school ro three days without medication and tell the teacher "you're making a medicatioin adjustment". Then you get feedback from the kid and teacher. Many adolescents take themselves off medication when they are about 13 or 14. Some return when they are older
kinderkate - Did we address the "drug baby" the child who was exposed to drugs in the womb? Are those behaviors considered add/adhd?
docdiller - Too much has been made of the "drug exposed" babies. Turns out their poor performance is mostly environmental. Alcohol is another issue. No question that drug affects both intelligence and focusing. But what's done is done. One moves on to deal with the child's damaged brain.
Shelly - What is the most common true disorder/problem when a child is misdiagnosed with ADD?( I hope I said that right) Is Ritalin used to treat other disorders?
docdiller - Shelly-I find that auditory processing problems are frequently missed and sent up as possible ADD. Now again Ritalin will help that problem but not as specifically as shorter oral commands, written supplementation and permission to ask to repeat. Also basic limit setting issues are recast as ADD over and over
docdiller - Listen everybody, I just want to say one or two more things before I sign off. I think ADD is better viewed as a "living imbalance" rather than a "chemical one." By the former I mean the demands on children and their brains have increased while the social supports to them , their families and schools have decreased. Ritalin will address that imbalance but is not the moral replacement. We have a performance driven/fear driven society where material acquisitioin is felt to be the source of emotioinal satifaction and contentment. I think the price for many of our children to achieve that goal will be Ritalin. I question that goal as valid and suggest that the 700% increase in the use of the drug in this decade is telling us about all our children and not just the ADD kids. It's time we begin paying attention. Thank you all for joining tonight and check out my book Running on Ritalin or my website at www.docdiller.com
Kathleen/Moderator - Doctor Larry Diller, thank you for your insight into what is often a hot topic among educators and parents. I hope you will consider returning to chat about this topic and/or others within your considerable expertise. We deeply appreciate your willingness to be with us this evening.
docdiller - Thank you all, I found it interesting and demanding to try to respond to all of you. However, after I've given my fingers a rest and more exercise I would be happy to return another time. And also check out the NASPCommunique, they really like my book and have a lot of thoughtful things to say about the questions you raise.
Al from Canada - NASP is on the net at www.naspweb.org
Kathleen/Moderator - goodnight all :-) and thank you!
