Medicating Kids: Pediatric Mental Health Policy and the Tipping Point for ADHD and Stimulants

Attention Deficit Hyperactivity Disorder (adhd) holds the distinction of being both the most extensively studied pediatric mental disorder and one of the most controversial.¹ This is partly due to the fact that it is also the most commonly diagnosed mental disorder among minors.² Currently, almost 8 percent of youth from the ages of four to seventen have a diagnosis of adhd, and slightly more than 4 percent both have the diagnosis and are taking medication for the disorder.³ In other words, on average one in every ten to fifteen children in the United States has been diagnosed with the disorder and one in every twenty to twenty-five uses a stimulant medication—often Ritalin, Adderall, or Concerta—as treatment.⁴ The biggest increase in youth diagnosed with adhd and prescribed a stimulant drug occurred during the early 1990s, when the prevalence of physician visits for stimulant pharmacotherapy increased fivefold.⁵ This unprecedented increase in U.S. children using psychotropic medication triggered an intense public debate.⁶

Ironically, neither the debate nor adhd and stimulants were new. Methylphenidate, more commonly known by the trade name Ritalin, was first introduced in the United States in 1955, and approved by the Food and Drug Administration in 1961.⁷ Prior to Ritalin, another stimulant (Benzedrine) had been tested and used by small numbers of children as early as 1937.⁸ As for adhd, the basic symptoms of the disorder have gone by several different diagnostic labels since the early 1930s: “organic drivenness,” “minimal brain damage,” “hyperkinetic impulse disorder,” “minimal brain dysfunction,” “hyperkinesis,” “hyperactive child syndrome,” and “attention deficit disorder.”⁹ Even the core of the controversy, children using physician-prescribed psychoactive drugs, dates back almost four decades.¹⁰ Nevertheless, negative publicity over the “drugging of problematic children” in the early 1970s—together with a negative media blitz and a wave of lawsuits against physicians, school personnel, and the American Psychiatric Association in the late 1980s—greatly reduced the prevalence of adhd diagnoses and pharmacotherapy compared with current levels. When the 1990s began, there were around nine hundred thousand youth in the United States diagnosed with adhd, and most schools across the country had only a handful of (if any) children diagnosed with adhd and using stimulants.¹¹ By the mid-to late 1990s, there were between 3 and 4 million children diagnosed with the disorder, the majority of whom were using stimulants as treatment.¹²

This massive and rapid increase (or “tipping point”) in the number of U.S. children diagnosed with adhd and using stimulants stemmed primarily from a confluence of trends (clinical, economic, educational, political), an alignment of incentives (among clinicians, educators, policymakers, health insurers, the pharmaceutical industry), and the sizable growth in scientific knowledge about adhd and stimulants that converged in the first half of the 1990s. Growing political movements advocating for children’s welfare and mental health consumers, ¹³ along with the decreasing stigma associated with mental disorders, led to three seemingly minor policy changes—to a federal income support program (Supplemental Security Income, ssi), a federal special-education program (the Individuals with Disabilities Education Act, idea), and a joint federal-state public health insurance program (Medicaid)—in the early 1990s that helped trigger the surge in adhd diagnoses and related stimulant use.¹⁴

This article examines how and why the field of mental health underwent significant change over the course of the 1980s and early 1990s, with adhd and stimulants as a case study. It endeavors to explain the pressures and incentives that led to this change and its consequences for clinical diagnosis and treatment of mental disorders in the United States, particularly for children and adolescents.¹⁵ And, finally, the article focuses on the major political and policy changes related to adhd and stimulants that led to a significant increase in adhd diagnoses and stimulant use in the early to mid-1990s.

The DSM-III and Mental Disorders in Children and Adolescents

A paradigm shift occurred within psychiatry and the larger field of mental health in the 1980s, which resulted in...