MR. A. MARTINEZThanks for joining us. I'm A. Martinez of Take Two on KPCC, Southern California Public Radio, sitting for Diane Rehm. Way back in 1970, Congress held a hearing about the possible overuse of a drug that treated minimal brain dysfunction, later called ADHD. Since then, rates of diagnosis have continued to tick up as have the number of prescriptions written for drugs such as Adderall and Concerta. Today, 15 percent of American children receive the diagnosis, a number significantly higher than most experts think it should be.

MR. A. MARTINEZNow, joining me to trace the rise of ADHD in America, from New York, Alan Schwartz, author of the new book "ADHD Nation." Also from New York, psychiatrist Ned Hallowell and from Berkeley, California, pediatrician, Larry Diller. Welcome to all three of you.

MR. ALAN SCHWARZThank you. Nice to be here.

MARTINEZAlan, good to cross paths with you again. It seems like we're running into each other a lot lately. But good to talk to you again. Now, you've just written this book, "ADHD Nation." It lays out the history of the disorder and its treatment. And you start with some stats about just how many kids are getting diagnosed today. So can you give us the big picture of what's happening around the country right now?

SCHWARZSure. The CDC has spent a lot of time and energy over the past 12 years trying to get a sense of how many kids have actually been diagnosed with ADHD, not how many kids have it necessarily, but how many kids have been diagnosed. And it's now 11 percent of kids aged 11 -- excuse me, 4 to 17 who have already been diagnosed. But by the time they turn 18, 15 percent of American children get diagnosed. 20 percent of all boys in the United States get diagnosed with ADHD and 30 percent of boys in some southern states.

SCHWARZThis, obviously, is vastly higher than what most all experts suggest. The official definition of ADHD in the American Psychiatric Associations manual says that it affects about 5 percent of children. Well, we're obviously diagnosing more than twice that number and that's millions of children being told that they have a serious psychiatric condition when they probably don't.

MARTINEZThe stat from Louisiana, that one really jumped out at me. Half of boys between 3rd and 5th grades are taking ADHD medications. Half.

SCHWARZWell, that's in some parishes, which is counties, essentially. So we, you know, we don't want to paint Louisiana with too broad a brush, however, they are one of those states where the number of boys overall is about 30 percent.

MARTINEZDr. Hallowell, you wrote one of the most popular books on ADHD, also, in the 1990s. And your concern then was under-diagnosis. So how much consensus is there now that maybe the pendulum has swung the other way when we talk about diagnosing.

DR. NED HALLOWELLOh, it certainly has swung the other way and I, you know, as I've often said to Alan when I was writing "Drive To Distraction," came out in 1994, nobody had really heard of ADD and my goal was to bring it to the public's attention. Well, now they've heard of it, still most people don't know what it really is, including many doctors. So now, the big issue is educating the general public as to the finer points and particularly doctors so we don't diagnose it where it isn't.

DR. NED HALLOWELLWhat I -- my career has been built on, helping people who do have it and Alan's excellent book is calling attention to the number of people who don't have it who are getting help they don't need.

MARTINEZDr. Diller, you're a behavioral developmental pediatrician and you warned against over-diagnosis over 20 years ago in a book called "Running On Ritalin." How have times changed since you wrote that book?

DR. LAWRENCE H. DILLERWell, I think everything I was talking about pretty much has come to pass and I think one line I had in the first chapter, "we may see a time when we find America running on Ritalin." We should change that to Adderall right now. And many, many social and economic and even political trends are involved in what I felt was an ominous possibility, most because while amphetamine works in everybody, it isn't the moral equivalent to addressing children's needs with nondrug strategies that engage the child, the family and the school.

MARTINEZLet's take a step back for a second, Alan. Take us back to the early days of ADHD, how it all evolved, how we kind of got to where we're at now.

SCHWARZWell, I think there has been concern for a very, very long time, more than two centuries and probably back into, you know, cavemen days that some children simply won't pay attention and won't sit still and have a hard time functioning. Now, it began being explored as a medical condition in the late 1700s.

MARTINEZ1700s, wow.

SCHWARZAnd -- yeah, yeah. And but it was really in the early 19th century that people started, you know, as medicine evolved, they started thinking, look, is this -- is there something wrong inside these children's brains? Was it caused by encephalitis? Was it caused by other brain damage? And so it came to be known as minimal brain damage. And that was in the '50s and it's been trying to find a better name ever since.

HALLOWELLYeah, the term attention deficit hyperactivity is a terrible -- if I could just interrupt for one quick second, it's not kids who won't pay attention or sit still. It's kids who can't pay attention or can't sit still.

SCHWARZYes, that's a very, very, very fair point.

DILLERI would change that. I would change that to children who don't pay attention. The issue is whether it's won't or can't and I'd say mostly...

HALLOWELLBut Larry, the ones who have ADD can't pay attention in the...

DILLERI would say it's harder for them to pay attention and saying can't...

HALLOWELLAll right, all right.

MARTINEZWe're getting -- yeah, now we're...

DILLER...already gets to a medical disease modality.

HALLOWELLIn any case, the important point is to get rid of the -- Larry, if I can just say it's important to get rid of the moral diagnosis. And that's what's plagued these children for centuries. You don't pay attention, therefore you're bad, lazy, willful and to help you, we will beat you with a stick and that's what's happened for thousands of years and that's what I'm in business to try to free children from, the moral diagnosis and the really getting broken in school because they can't pay attention and they're punished for what is really a neurological issue, not a moral infirmity.

MARTINEZAnd Alan, I...

DILLERIt's not an either/or. It's not an either/or.

MARTINEZOkay, we've established that. But -- and Alan, I want to get you into this, too, because that's -- I guess that's part of it, too. Aside from the science and the medicine and the prescription and all that, it's how we interpret this, right, and how different doctors and different parents and different groups kind of see this through their own lens.

SCHWARZWell, I think that, you know, this diagnosis, first of all, used to be called minimal brain dysfunction, throughout the late '60s and '70s and it was only in 1980 that it was renamed attention deficit disorder and it's sort of been fumbling around for a name ever since. But as it was originally conceived, it was supposed to be for severe hyperactivity, for severe impulsivity and severe inattention. And also, those symptoms, when they couldn't be explained by anything else, whether it be anxiety, trauma in the home, bad diet, bad exercise.

SCHWARZI'm not suggesting that any of those things can explain all ADHD, but they're supposed to be ruled out first. And so what we are left with is a mere measure of whether kids, and in this case, I think I'm using the right word, whether they do pay attention, whether they do what we frankly want them to do in this very structured educational system with no gym and no recess and no way for kids to blow off steam. And so what we've evolved into is -- I think what we're doing is we're not assessing and measuring children's symptoms.

SCHWARZWe are measuring and assessing adult's tolerance for those symptoms and some kids, God bless them, fit the construct and when they take medication, things work out wonderfully. It's a great thing when it works properly. But an awful lot of dolphins are getting caught in our tuna nets and they shouldn't be labeled.

MARTINEZNow, you mentioned, Alan, you mentioned the word medication there. That's one thing that the pharmaceutical companies have. They have medication. They have it to sell. But to get that medication sold, they also have to kind of sell the reason why you should buy that medication. So how did they start to do that?

SCHWARZWell, the pharmaceutical companies, for a long time, have realized that you can't make money off of their product -- and by the way, there is no reason why big pharma shouldn't be successful in selling products. I mean, we've all bought big pharma stuff. The question is, is how do you do it? And unfortunately, in this case, as with some others, their main tactic is to scare parents with messaging, hey, if your child can't do this and can't do that, he probably has ADHD and you must give him this drug which will spare him from things like friendless school, school failure, dying in a car crash, venereal disease.

SCHWARZAnd these are risk factors for ADHD. I mean, these are things that you need to look at, but you're not going to spare that many kids those outcomes by using Adderall. It's a far more complicated situation or the kids who really do have it. And so my point, though, with big pharma is that they have really exploited the definition of what this thing really is and they have exploited parents' fears, what if I don't give my kid Concerta and it really leaves us in a bit of a mess.

MARTINEZNow, Doctors Diller and Hallowell, I want to get your thoughts on this coming up in just a second and your experience with parents on this as well. We'll also be taking your thoughts out there, 800-433-8850. That's 800-433-8850. And also, we'll take emails as well. We've got a lot already, ready to go, drshow@wamu.org. Coming up, more of our conversation. This is "The Diane Rehm Show," A. Martinez filling in.

MR. A. MARTINEZWelcome back. I'm A Martinez of Take Two, on KPCC, Southern California Public Radio, sitting in for Diane Rehm. Our guests today, Alan Schwarz, former New York Times investigative reporter and author of a new book, "A.D.H.D. Nation: Children, Doctors, Big Pharma, and the Making of an American Epidemic." Also Dr. Ned Hallowell, psychiatrist and author. His books include "Driven to Distraction." And also Dr. Larry Diller, behavioral developmental pediatrician and author of several books, including 1998's "Running on Ritalin." And we'll also take your thoughts too. 800-433-8850, that's 800-433-8850. And you can email drshow@wamu.org.

MR. A. MARTINEZNow, let's start with you, Dr. Hallowell. I've got a friend and we sit around watching TV a lot. And he does this all the time, especially when an ad for a pill comes on, he starts to say, yeah, yeah. I've got all that stuff. Maybe that pill will work for me. Instead of going to the doctor to realize maybe what he has and what can be done about it, he goes immediately to the pill. So I'm wondering, when it comes to be pharmaceutical companies -- if parents see an ad for something they think is affecting their kid, is it that much of a stretch to think that this kind of can get out of control sometimes?

HALLOWELLSure. And as Alan has pointed out in his book, in some places it has gotten out of control. But, please, let's not throw out the baby with the bath water. There are many, many children and adults, I might add, whose lives are changed dramatically for the better by proper diagnosis and treatment. And proper treatment is never just medication. It is always a comprehensive treatment plan that includes education, lifestyle modification, coaching. It's an ongoing process. You really -- you're managing this condition for the rest of your life.

HALLOWELLYou know, I tell kids and adults, it's like you've got a Ferrari engine for a brain but you have bicycle brakes. But, don't worry, I'm a brake specialist. And if we work together over the years, we will help you control the power of your brain, which is really what it's all about. These kids and adults are overflowing with energy, with ideas, with all sorts of mental activity and they can't channel it. And so in school, they're scattered, they're impulsive, they're disruptive, they're inattentive. And it's not a disciplinary moral problem whatsoever. It's a brain management problem.

HALLOWELLAnd another analogy I use, it's like Niagara Falls, until you build a hydroelectric plant, you've just got a lot of noise and mist. But you build a hydroelectric plant and you light up the state of New York. Well, I'm in the hydroelectric plant business. So the success stories, the positives are tremendous. It just -- it's just, I wouldn't want listeners to think this is all a drug company conspiracy...

MARTINEZMm-hmm.

HALLOWELL...to medicate the nation. Has that happened? As Alan has pointed out, yes. There are people who overdo medication. You know, the fact of the matter is, most of the people who come to see me don't want to use medication. They say, I want a non-medication regimen. And I say, I'm happy to provide you with that. I think, however, you ought to consider, if used properly, the merits of medication, which are considerable.

MARTINEZDr. Diller, you've argued that none of the ad campaigns would have mattered if there wasn't a receptive audience. What do you mean?

DILLERWell, I've got to say, first of all, participating in this just makes me feel frustrated and sad.

MARTINEZOh, no.

DILLERI've been talking about things for...

MARTINEZWe were hoping it would be a good experience for you, Dr. Diller.

DILLERWell, you know, Ned is so articulate. Ned just says this so well. I'm not sure it's even worth reporting this because Ned's point of view is the point of view that is just culture media and gristen mill for the answer to your question. But I'm going to tell you again, I participate, but I wonder why. The -- when you consider an epidemic, you can't just consider the aspects of the virus. You have to consider aspects of the host, okay? So the virus might be, you know, doctors, drug companies, educational systems, insurance systems. But you've got to consider the families.

DILLERAnd here, ironically, over a 50- or 60-year period, as feeling have become more important, we worry about children's self image and self esteem so much. And Ned's very articulate there. We're not trying to blame anybody here. But the reality winds up that parents are so worried about their children that there's an ironic increasing intolerance for minor differences in children's performance and behavior. No one is questioning, at this stage in the 21st century, that ADHD exists. The question is, are we talking about the ADHD of the 20th century or are we talking about Tom Sawyer, Pippi Longstocking ADHD of the 21st century?

MARTINEZBut when it comes to parents -- parents that you've dealt with -- when it comes to what issues they bring up to you, I mean, are -- do they seem like they kind of are pushing toward that direction? That way it'll explain a lot of things, maybe take a lot of pressure off of them?

DILLERI think the educational/indoctrination propaganda campaign of the academics, supported by big pharma, has been entirely successful. Parents are thinking in terms of neurotransmitters and brain disease. And I like to tell them, experience also affects neurotransmitters. And if the doctor, in pressed for time and money, only offers the parents medication or no treatment, the parents will opt for medication. "Better diagnosis," quote, unquote, often means going to a child psychiatrist. And in that case, 95 percent of the children will wind up on medicine. I'm sorry, Ned. That's what happens with better diagnosis these days, because of the structural aspects...

HALLOWELLWell, Larry, I'm sorry, Larry, but my experience is...

DILLERYeah, okay.

HALLOWELL...absolutely the opposite of yours.

DILLERI know. This is hopeless.

HALLOWELLMost of the people...

MARTINEZNo, I know, I know. We've got a half an hour to go, so before we kind of go off the hills a little bit, let's kind of just stay on track here. Alan, let's go back to you for a second. Voice of reason, Alan Schwarz here. Now, when I, you know, I have a little three-year-old granddaughter. And she can get very hyper sometimes. She can kind of run around the house and kind of talk to herself and maybe, you know? And so I look at her and I wonder, like, sometimes, okay, when I'm describing her, I guess I could be describing any kid in America. And so I always worry about where my brain goes in terms of what I'm seeing in front of me.

MARTINEZSo when it comes to definition, how much of the problem lies in definitions and how we define our terms, when it comes to ADHD?

SCHWARZWell, I think you've brought up, excuse me, a serious problem with how we have allowed this diagnosis to get so loose and diagnosing so many kids, that every kid at times can look like a kid who has been diagnosed. And so the parent or grandparent will think, gee, maybe, you know, this kid is ADHD as well, when it was supposed to be severe behaviors that impaired one's ability, at least in the case of children, to perform at school and to have anything reasonably approaching a healthy home life. That's the way it was supposed to be.

SCHWARZBut unfortunately, the American Psychiatric Association and lots of other folks -- but they're the ones who write the definition of the disorder -- has spent 30 years loosening the definition and making it where it's no longer impairment, it's interfere -- these symptoms interfere with quality of life and abilities in school. And then you're talking about, you know, one whole standard deviation -- I mean, a one standard deviation instead of two.

MARTINEZHmm.

SCHWARZAnd you have this diagnosis creep, where any kid who will display these behaviors will be a candidate for diagnosis. And it's our responsibility to have the parents slow down, more -- most importantly, the doctors to slow down and assess, is this normal variant of behavior or does it qualify for what is a serious psychiatric diagnosis?

MARTINEZDr. Diller, how do you...

SCHWARZThese things are -- these things are not irreconcilable. It's very easy to slow down.

MARTINEZTake us through the process, Dr. Diller, how you diagnose ADHD. Take -- walk us through that for a second.

DILLERI was asked that earlier. So it turns out to take about three and a half to four hours. I'll meet with the parents by themselves.

MARTINEZMm-hmm.

DILLERI try to have the -- even the non-custodian fathers there. And generally they will show up for this, because they want -- or want to be involved in the decision of whether to medicate the child or not. Spend an hour with the parents. I do a conjoined family interview that's not done by most people, where I have the whole family in. Because I learn a great deal about family dynamics and parenting strategies. That's a 45 minute visit. I meet with the kid, depending on the age. At -- below age six, I used to not meet the child by themselves. But because of the increased academic demands on children, I will now do a developmental academic assessment of someone as young as four, in consideration of the demands on the child's development.

DILLERSix and older, I meet with the child and talk to the child, play with the child a little bit. The older children will just spend time, the 45 minutes, talking.

MARTINEZHmm.

DILLERI talk to the teachers on the telephone, generally a 10- to 15-minute interview. If the pediatrician is involved, I'll talk to the pediatrician. And then I sit down with the parents for an hour, going over what's going on and what are the options here, both drug and non-drug. And importantly here, the recommendations say that drug and non-drug interventions are equal, first-line interventions. That's my beef. It's not that I'm against the medicine. I prescribed Ritalin in 1978. I prescribe it every day, all right? But I make a conscious effort first, for two or three months at least, in the mild to moderate ADHD cases, to work with family and school to see what we can do over a three-month period.

MARTINEZDr. Hallowell, when it comes to medication for you, when you're doing this, is medication a last resort?

HALLOWELLNo. It's one tool in the toolbox. And I think the either/or mentality is a big mistake. Medication is one tool in the toolbox. We have many tools. And as I said earlier, medication should never be the only intervention. Education is always the starting point. It's really important that these kids -- and by the way adults have this too -- that they understand what it is and what it isn't. The racecar brain with bicycle brakes is the best analogy I have. And it stresses there are positives. But there is a big negative. You have no brakes. A Ferrari with no brakes is a dangerous machine. So how do we strengthen the brakes? And never, never, never do I just say, take this pill. Not at all.

HALLOWELLLet's learn about it. And then in that context of education, what can we do to strengthen your brakes? Physical exercise is a tremendously powerful tool. Coaching, environmental modification. The fact that kids are held in for recess, it's not good for any kid, but it's terrible for kids with ADD. The last thing they need to do is be held in for recess. So we need to get them running around. We need to get them exercise. We need to pay attention to sleep. A lot of kids are staying up too late on their laptops. I often say the most difficult differential diagnosis is, how do you tell ADD from a severe case of modern life? People are over-stimulated electronically and under-stimulated in terms of family and human connections.

HALLOWELLWe're replacing the human moment with the electronic moment. So the treatment should always be an integrated, comprehensive treatment that may or may not include medication. Unfortunately, medication has become such a hot-button issue, people ask me, do you believe in Ritalin? And my answer is, it's not a religious principle. It's a medication. And if it's used properly, it can be very helpful. If it's used improperly, it can be very dangerous.

MARTINEZAlan, so...

HALLOWELLNow that's true of most medications.

MARTINEZSo both doctors go through a process, Alan. In the book, have you found that most children go through this kind of process to get a diagnosis, or any kind of process?

SCHWARZWell, there are of course no studies that will indicate, hey, how long did the doctor spend?

MARTINEZOkay.

SCHWARZYou know, there are some Medicaid, frankly, data. But I think it's fair to say that, no. In a majority of cases, these things are handled rather haphazardly. We see more diagnoses made by pediatricians rather than child psychiatrists and psychiatrists, who in general will have some training in this area, although not much. And pediatricians are visited by the parents who are struggling. And they just -- they want to help. Most doctors are really very well meaning. Unfortunately -- and this is inexcusable -- some doctors, pediatrician or not, will say, well, we only have 30 minutes. Okay? So let's figure something out within these 30 minute. And you cannot make a responsible, let alone accurate ADHD diagnosis in 30 minute. Period.

SCHWARZAnd unfortunately, what you see at the end of those 30 minutes a lot of the time is the doctor or nurse practitioner or whoever it may be says, well, Johnny's having a tough time in school paying attention. Let's try this Concerta and see if it helps. Well, guess what? Concerta works in just about everybody. You might as well say, you know, give Johnny these platform shoes. See if he gets taller. Okay?

MARTINEZHmm.

SCHWARZAnd so when the child improves on the medication, which in general they will, everybody takes that as confirmation that they have ADHD. And improvement on the medication is not a diagnostic tool. You're just sort of confirmed as human. Humans do better, in terms of attention, in terms of motivation, stick-to-itiveness. They typically are higher in those areas if they take an amphetamine, which is Adderall and Vyvanse, or methylphenidate, virtually the same thing, which is Concerta or Ritalin. And no one seems to be committed -- well, not enough people, excuse me...

MARTINEZMm-hmm.

SCHWARZ...are committed to slowing down and making sure that we diagnose correctly and not diagnose in the kids who don't, you know, shouldn't be diagnosed. It doesn't mean they're -- they don't have problems.

MARTINEZMm-hmm.

SCHWARZThese kids need to be helped. But giving them what is often described as a very serious, lifelong diagnosis, it changes their personal narrative. It changes their self image forever. Not always negatively, but I think that if we're going to tell a kid...

MARTINEZIt certain -- yeah, it's certainly changes it a little bit, yeah.

SCHWARZ...you have a serious psychiatric disorder, you'd better darn well be right.

MARTINEZI'm A Martinez. You're listening to "The Diane Rehm Show." If you'd like to join us, give us a call, 800-433-8850. That's 1-800-433-8850. Send an email to drshow@wamu.org. Or find us on Facebook or send us a tweet. You can tweet me @amartinezla. Let's go out to Lisa, Pittsburg, Pa. Lisa, you're on "The Diane Rehm Show."

LISAHi, thank you. I just really want to make a comment on one of the comments that someone on your panel said, where he felt that we were diagnosing a parent's tolerance for children like this. And I just wanted to share my experience. My son is now in his mid-thirties. But when he was born, back in the early '80s, he -- for many years, he was just uncontrollable. He could not sit still in school. He would talk out, just randomly, like the Tourette's, except it wasn't vulgar. He just would run around constantly. I -- he was -- I couldn't control him. He was really difficult, you know, get through those years. You know, the pediatrician was, well, maybe he has ADD. That's what it was called at that time. And I just didn't want to put him on meds.

LISAWe ended up doing an IQ test and found out that he's just really, really, really smart and the school he was in wasn't challenging enough. And so this is why he was running around and just whatever he was doing. Once we moved him into a more rigorous program -- they had some gifted programs here in Pittsburg -- once we moved him into that, most of those symptoms went away. And now he's a successful adult. So I just think that, had he born 10 years earlier, he might have been diagnosed and given medication. I'm not sure it would have done him much good. I mean it would have helped him, as you say, because any amphetamine would have.

LISABut I think overall in the long run, it was difficult for me as a parent. I was a single parent. It was difficult as a parent to deal with him. But I think, in the long run, by not giving him medication, he's fine now. He's just really smart.

MARTINEZComing up, more of your calls and questions. 1-800-433-8850. That's 1-800-433-8850. And as always, email us, drshow@wamu.org. A Martinez filling in on "The Diane Rehm Show."

MARTINEZWelcome back. I'm A. Martinez of Take Two on KPCC, Southern California Public Radio, sitting in for Diane Rehm. Our guest, Alan Schwarz, former New York Times investigative reporter and author of the new book "A.D.H.D. Nation: Children, Doctors, Big Pharma, and the Making of an American Epidemic." And Dr. Ned Hallowell, a psychiatrist and author. His books include "Driven to Distraction," and also Dr. Larry Diller, behavioral developmental pediatrician and also author of several books, including 1998's "Running on Ritalin."

MARTINEZBefore we get back to you three, let me read this email from Ann. My son is a senior in high school. He believes he has ADD and wishes to be on medication. We do not believe he has ADD. I feel for my son because he is in a higher level of classes with many other students on drugs for ADD, and he wants the medication to help him focus. It's as if he's competing with students on steroids, and he isn't using. The competition is good grades and getting into college.

MARTINEZNow from that, let's go to Jameson in New York. Jameson, you're on the Diane Rehm Show.

JAMESONHey, thank you so much for having me on. I'm really enjoying the conversation. I'm -- Alan tells my story in the book "A.D.H.D. Nation," so I just wanted to call in and give some color to my personal story. And, you know, I'm one that believes that the medication does work and believes that ADHD does exist, but in my own story, I think I was a victim of the wide spectrum of attention issues that kids have and that in my personal experience and now in my professional experience, I'm seeing that a lot of times the first line of treatment is medication.

JAMESONYou know, and my own story as a 14-year-old, you know, I was very stressed, I had a lot on my plate, I had an extraordinary amount of pressure to perform. I had a poor diet, I had a poor sleeping schedule, you know, poor mental -- attention to my mental health. My parents were stressed out, putting pressure on me. I mean, this is kind of the American family these days. And I believe as a 14-year-old I wasn't designed to sit in a desk all day. I wasn't afforded any artistic or creative outlets through school, and, you know, I was definitely never given any mindfulness techniques to cope.

JAMESONAnd so when I tried Ritalin for the first time at 14, as the doctors have said, it worked for me, and then I went and told my parents that I had ADHD, and being very concerned for me, of course they took me to the doctor, and I literally acted like I had attention problems, and sure enough at the end of the test I was prescribed Adderall at 14 and would go on to really just...

SCHWARZSo Jameson, is it fair to say you faked your way to getting the medication?

JAMESONAbsolutely, yeah, totally. Now did I have attention problems? Absolutely. Was I given any other alternatives to try and combat these attention problems? No, definitely not, it was, you know, here's -- you have attention problems, here's the Adderall. And then what I've -- this is in the '90s, and then what I went on to do is I went on to try other drugs, other pharmaceutical drugs, whether they were uppers and downers, and then eventually my friends and I and even strangers would begin, you know, selling our Adderall or trading our Adderall, and I see that problem of the past 20 years just continuing to increase.

JAMESONAnd so what I see as a huge problem is that with the over diagnosis or the overmedication of these issues that they -- the market, if you will, is flooded with an excess of prescription amphetamines, methamphetamine in a pill form, and I see teenagers widely abusing them and then trading them or selling them to their friends in high school, college and even in middle school sometimes, and that only contributes to, you know, what I believe is, you know, a huge national issue of a substance abuse problem that we have in this country, which I don't think anyone could deny.

MARTINEZJameson, thank you very much for your phone call.

HALLOWELLCould I just...

MARTINEZGo ahead.

HALLOWELLCould I just interject real quick. You know, this show has talked a lot about over diagnosis, overmedication, which Alan has documented beautifully. I don't want listeners to leave the show without also realizing there's a wonderful positive story in here. People who receive proper diagnosis, proper treatment, which is never just medication, see their lives change dramatically for the better, and I could fill many ballrooms many times over with patients I've seen personally whose lives, be it age six or age 60, have done an absolute U-turn from failure to success, and it just would be a shame for listeners to think we're living in a sea of, you know, drug abuse and wrong prescribing and which it does occur, but there is a tremendously positive side to this story, which I know Alan acknowledges, as well, because we've talked.

HALLOWELLAnd Alan's done a great job in calling attention to a problem of over diagnosis, misdiagnosis, overprescribing, but I think to balance it out we also need to acknowledge that proper diagnosis and treatment is -- can be a godsend to a person of any age. The biggest undiagnosed group are adults.

MARTINEZDr. Diller, one thing that we haven't talked about yet is the safety of these drugs. What do we know about the safety of these drugs?

DILLERAmphetamine was synthesized in the late 1920s. By the mid-'30s, it was clear that it was an addictive substance. That said, the experience in children suggests that it's pretty safe, meaning if someone's not dying or developing a severe allergy, doctors say the side effects are minor. So -- and the threat of future drug abuse, which is really frightening to parents to consider, just hasn't played out as a factor in the under-13 use of the medicine.

DILLERThe risk in terms of future drug abuse has to do with the misuse and abuse of prescription stimulants by people I'd say older than 14 or 15, and there Jameson is talking about an absolutely below-the-radar moment but just about to hit the media, serious crisis in prescription amphetamine abuse and addiction.

MARTINEZDr. Hallowell, I guess any pill that's abused can be dangerous, but standing alone, the medications for ADHD, for the most part, are they safe? Can you say, can you make a sweeping, blanket statement like that, or do we have to kind of nuance it a little bit?

HALLOWELLWe have to nuance it. When used properly, they're safe. When used improperly, they're dangerous. The same could be said of penicillin or aspirin, by the way. If you use them improperly, they're dangerous. If you use them properly, they're safe. Now don't get me wrong, I'm not saying in any way that stimulants are analogous to aspirin. I'm just saying that all medications carry with them potential dangers and side effects, and the absolute clarion call that Alan has sounded is let us be careful in how we describe particularly controlled substance because they do carry with them a significant danger when used improperly.

HALLOWELLI'm here to say used properly, they can be a godsend. I think we all agree that the need now is for education not only of the general public but of doctors so they won't hastily write a prescription, so they won't be conned, if you will, into giving a medication that a person does not need so that they won't be handed out as performance-enhancing drugs at, you know, high-pressure high schools and colleges where people are angling to get a better grade and that this condition, which is such a fascinating condition because it's such an admixture of positive and negative qualities, that the people who truly have it can get the help they actually need, as opposed to our being left with the people who are angling to get a prescription that they don't need. I just -- I just want to advocate for -- the positive story is a real story because I see it in my office every day of people who are struggling, and once they get the right help, which is never just medication, they go from struggling to soaring.

HALLOWELLIt's as if they go from driving on square wheels to driving on round wheels.

MARTINEZAlan, as you were putting this book together, talking to doctors and parents, in your experience doing that, how many times would you say that you maybe you ran into lazy doctors or undereducated doctors when it comes to dealing with this?

SCHWARZWell of course it's all anecdotal, okay? I mean, I can't take a survey of the United States to see how many bad doctors there are.

MARTINEZRight.

SCHWARZIn the same way we can't find out how many bad journalists there are. But there are way too many stories of doctors just making the diagnosis in 10 minutes, particularly in adults. I mean, the joke in and around New York and Houston is that if you wear a suit, you'll walk out of there in 10 minutes because you couldn't be somebody angling for drugs. And, I mean, I've seen journalists go under cover, now I never did that at the New York Times, it was against New York Times guidelines to do anything remotely approaching that, but, I mean, I've listened to the actual meetings with the doctors, and they -- and too many of them, it's not a majority by any means, but way too many of them are not trained, they have chosen not to train themselves, which is terrible.

SCHWARZDr. Hallowell actually, with Dr. Peter Jensen, has started an education program that isn't going to change everything, but at least it's trying to help, but yeah, way too many doctors, or medical providers, it's not all doctors, are just not performing the role -- you know, these doctors, these folks have signed a covenant with the people of their state to, in exchange for the monopoly on the controlled substances distribution business, okay, you need a controlled substance, you've got to go to the doctor.

SCHWARZIn exchange for that monopoly, which is a very large financial benefit, they have promised the people of their state to behave responsibly, and too many of them are breaking that covenant.

MARTINEZDr. Diller, how much is under-education an issue from your experience?

DILLERI'm afraid, looking at history, that education of doctors rarely have changed their behavior. Given the standard of care is so broad at this point, to include, you know, eight psychiatric drugs being prescribed to a single child, the past has shown that only the threat of suit, loss of license and high negative publicity -- doctors are human beings, okay, they're affected by economic factors just as much as anybody else, and when the doctor makes twice as much money doing four med checks in an hour versus doing one 45- to 50-minute consultation with the family, that's a tremendous influence on the doctor's behavior.

DILLERSo I wish I could support Ned's belief that education of the doctors -- and even Alan's notion that education of the doctors will make a difference, but the historical record shows until things get really, really bad, and the doctors' licenses and malpractice suits are going, that doctors' behaviors doesn't change.

MARTINEZI'm A. Martinez. You're listening to the Diane Rehm Show. And as always, you can call us, 1-800-433-8850. That's 1-800-433-8850. Or email us, drshow@wamu.org. Let's go out to Edie in Fort Wayne, Indiana. Edie, you're on the Diane Rehm Show.

EDIEYes, hi there, thank you very much. Just a quick scenario here. I agree with both speakers there. My little grandson, who went into the elementary school system, he was -- he just could not sit still. He was not combative, not mean by any means. But like the speakers were saying, he was condemned. He was taken out of gym class. He would sit in front of -- outside in the hallway, or he would be taken to the principal's office.

EDIEThe teacher had 25, 26 kids. She didn't have time to control this child. So the notes went out to my daughter, do something, do something. She goes to her pediatrician, again no proper diagnosis, not that half-hour or hour or four hours were spent. Based on those standard protocols for ADHD, at the age of eight, nine, 10, he was put on one medication, and it's a trial-and-error basis on these meds.

EDIEThis little boy didn't react, you know, whatever, whatever. Again, the teacher would send notes, my daughter went to the pediatrician, and by the time he was 10 years of age, he was on three kinds of medication, and one particular to the point you'd up and down, you just didn't know what that little boy was doing.

EDIEAnd inside, as a grandmother, I saw Laura take him off of these medications, stop this, to the point that one day his eyes were dilated, his lips were swollen, he had a tremendous rash over him. We went to the ER, and he was given Narcan, prednisone and Benadryl. Now -- but I also agree when we switched pediatricians, totally different. And I went along, and I said, Laura, we need to ask this doctor to take his time, proper diagnose this little boy.

EDIEAnd after all of this and nearly his throat swelling in the ER because of the -- you know, 11 years old that he was finally give (unintelligible) and he's doing very well.

MARTINEZEdie, thank you very much for the phone call. This is for both doctors, and Edie mentioned that at the start of her call, and we haven't really brought this up yet. When it comes to the people that spend as much or sometimes even more time with our kids, it's teachers. So I'm wondering how much or how little do teachers know about this to be able to maybe be part of this solution. Dr. Hallowell or Dr. Diller on this.

HALLOWELLWell, I think teachers are the single most reliable source of information. It is certainly not up to them to make a diagnosis. But whenever I see someone, I say please bring teacher comments with you, not checklists but narrative teacher comments. What is Joey like in the classroom? What is Nancy like in the classroom? It's a wonderful source of information because teachers have a cohort of peers, whereas parents only have, you know, a few kids. Teachers can really help me separate out, you know, what is true ADHD from what is, you know, a case of modern life.

MARTINEZDr. Diller?

DILLERI sympathize with the teachers. They have an often impossible job. I sympathize with the parents who are raising often difficult children. And I sympathize with the children themselves. However, education systems, medical systems, insurance systems prioritize efficiency and cost. The pill is fast. Parents, and many teachers individually, prioritize engagement with the child. And in mild to moderate ADHD, there are non-drug interventions that work.

DILLERIf you give a kid a pill right away, it'll, quote, take care of everything, all right, and the motivation to address other issues decreases tremendously. A pill and working with the child, family and school are not the same thing.

MARTINEZAlan, what do you hope people will take away from this book?

SCHWARZWhat -- I guess what I said before, which is just to slow down, okay. We can have ADHD exist in its current construct, as defined by the American Psychiatric Association. Now we can argue whether it's real, whether the symptoms are this or the symptoms are that, but let's just take that for now because it is the only practical way of going about this and simply demand that the symptom function far closer to what it is supposed to be than the wild west we have allowed it to be.

SCHWARZRight now 11 percent of children in the United States are currently diagnosed with ADHD. Let's just say we got that down to 10, still have almost all the kids who really deserve the diagnosis get it, which they need, okay. But let's just say we get one percent down. That's 600,000 children who will either not be labeled -- will not receive this diagnosis with its treatments but may get more targeted interventions.

SCHWARZThey may do a lot better. You know, the last thing a kid with anxiety or trauma needs is amphetamine. These kids deserve -- this is the grownups' fault, it's not the kids' fault. And we need for the grownups to slow down and behave responsibly, even when it's harder and even when it costs more money. Tough.

MARTINEZAlan Schwarz, former New York Times investigative reporter and author of the new book "A.D.H.D. Nation: Children, Doctors, Big Pharma, and the Making of an American Epidemic." Dr. Ned Hallowell, psychiatrist, author. His books include "Driven to Distraction." And also Dr. Lawrence Diller, behavioral developmental pediatrician and author of several books, including 1998's "Running on Ritalin." My thanks to all three of you.

DILLERThank you.

HALLOWELLThank you.

MARTINEZI'm A. Martinez of Take Two on KPCC, Southern California Public Radio, sitting in for Diane Rehm. Thank you very much for listening.