Taming Tom Sawyer with a Spoonful of Ritalin

“Would Tom Sawyer and Huck Finn be on Ritalin today?” asked child psychiatrist Dr. Lawrence H. Diller in a 2004 meeting with the President’s Council on Bioethics. “No doubt in my mind that they would be if they lived in my community. I see Tom Sawyers weekly.”

Anne Applebaum also makes that connection in her recent column :

. . . try, if you can, to strip away the haze of nostalgia and sentiment through which we generally perceive Mark Twain’s world, and imagine how a boy like Tom Sawyer would be regarded today. As far as I can tell, that fight is not just “inappropriate behavior,” to use current playground terminology, but is also one of the many symptoms of “oppositional defiant disorder” (ODD), a condition that Tom manifests throughout the book.

And Tom is not merely ODD: He clearly has attention deficit hyperactivity disorder (ADHD) as well, judging by his inability to concentrate in school. “The harder Tom tried to fasten his mind on his book, the more his mind wandered,” Twain writes at one point.

[ . . . ]

I am not being entirely sarcastic here: I have reread both “Tom Sawyer” and “The Adventures of Huckleberry Finn” several times in recent years, precisely because Twain draws such fascinating portraits of children whose behavior is familiar, even if we now describe it differently.

There is not doubt that if Tom and Huck were around today, Aunt Polly would be giving them daily spoonfuls of Ritalin. During the 1990’s the use and production of Ritalin increased 700 percent. Today, it is one of the most prescribed drugs in the country.

Ritalin is the brand name for methylphenidate, a central nervous system stimulant that is often prescribed for ADHD. ADHD is often considered a neurobiological disorder, similar to brain damage or mental retardation, despite the fact that no biological origin for the disorder has ever been discovered. The point, however, would be moot since ADHD is not diagnosed using neurological testing but by using the the criteria listed in the DSM-IV, a reference manual used by mental health professionals .

The criteria used to make the diagnosis of ADHD is established by determining if “six or more symptoms of inattention have persisted for at least six months to a degree that is maladaptive and inconsistent with developmental level.” Since the symptoms include such items as, “often fails to give close attention to details or makes careless mistakes in schoolwork” it’s surprising that every child in the country isn’t diagnosed as having the disorder.

Statistics show that we are well on the way to achieving that state. While it’s estimated that between 3 to 7 percent of school age children would meet the DSM criteria, in some areas as much as 20 percent of the schools population takes Ritalin. Not surprisingly, the boys are subject to this “neurological disorder” at the ratio of 8 or 9 to 1 higher than girls. The disorder also seems to afflict white middle and upper-middle class boys more than other ethnic groups, such as Asian-Americans. Dr. Diller once noted that the proximity to Boston is a prime indicator of an ADHD diagnosis.

But couldn’t the disparity between socioeconomic and racial backgrounds be attributed to the disparity in access to healthcare? Couldn’t it be that wealthy white parents simply have better medical insurance? Perhaps. But when the studies were done in Canada, where all people have equal access to medical coverage, the results were the same.

Ritalin, in my opinion, is a drug that is over prescribed for a very specious disorder. (Clinical, pediatric psychologists are qualified to diagnose ADD. Pediatricians are not. Nurses are not. Internists are not. General practitioners are not. Family physicians are not. They do not receive the necessary training in the course of their education. ADD is almost always “diagnosed” by a pediatrician or family physician. Draw your own conclusions as to how accurate they are.) But why is this the case? As Dr. Diller says in this book Running on Ritalin :

The ADD-Ritalin issue reveals something about the kind of society we are at the turn of the millennium—for no country besides America is experiencing such a rise in Ritalin use. It throws a spotlight on some of our most sensitive issues: what kind of parents we are, what kind of schools we have, what kind of health care is available to us. It brings into question our cultural standards for behavior, performance and punishment; it reaches into the workplace, the courts and the halls of Congress. It highlights the most basic psychological aspects of nature versus nurture, and it raises fundamental philosophical questions about the nature of free will and responsibility.

I believe that ADHD is a legitimate neurobiological condition. But I also I believe that very few children actually have a neurological disorder that affects their behavior. Legitimate treatment for ADHD involves, among other things, cognitive therapy and behavioral modification therapy. If a child truly has ADHD then they will likely be prescribed a course of behavior management. Children who exhibit behavioral characteristics of ADD but do not have a neurological disorder can be harmed if they are simply dosed with Ritalin to keep them from misbehaving.

Many children that exhibits maladaptive and antisocial behavior simply suffer from the neurological condition called “Being a Boy.” By misdiagnosing this condition and assuming it is ADHD we are impeding the moral and behavioral development of thousands of children. Taming our Tom Sawyers is a laborious, exhausting, and necessary process—it’s not a task that can be outsourced to a spoonful of methylphenidate.