The past few decades have seen both skyrocketing rates of children diagnosed with psychological disorders and a related rise in prescriptions for psychiatric drugs. In The Last Normal Child, Lawrence Diller offers a balanced perspective on these trends, focusing mostly on ADHD and its treatment by stimulant medications. Diller's previous books (Running on Ritalin and Should I Medicate My Child?) have explored the same topic, and this latest book is actually a collection of similar essays, including many first published elsewhere.

Diller is one of the few writers who is openly ambivalent about providing medication for children with ADHD symptoms. He points out the ways in which family and school contexts define psychiatric disorders, the worrisome influence of pharmaceutical companies on medication efficacy studies, and the cultural changes that have led to an ADHD epidemic. However, he also deftly deflates some of the unfair criticism of medications for ADHD, noting that the stimulant drugs are among the most researched and safest drugs available, that their abuse potential is low, and that for many families, medication is a more viable option than major lifestyle changes.

This combination of skepticism toward increasing rates of medication and a defense of medications against erroneous accusations leads to a sense of discomfort throughout the book. This discomfort is certainly refreshing when compared with the overconfidence and self-assuredness found in most books about ADHD and its treatment (on both sides of the debate), but it can also lead to awkward case studies from Diller's files, in which he enumerates cogent arguments against prescribing medication for various children, only to prescribe in the end. He seems vaguely aware of this awkwardness, at one point offering the following analogy and defense of his apparent hypocrisy (p. 15):

If as a pediatrician I were presented with an epidemic of serious diarrhea occurring in my community, of course I would treat these children with hydration, oral or intravenous fluids if necessary, and add other medications to help them get through the course of their illness. But if I suspected that the epidemic were caused by drinking water that had been polluted by the effluent of an upstream factory, it would be unconscionable for me to remain silent.

It is an interesting analogy; Diller views his writings as analogous to blowing the whistle on the factory, by exposing the real (e.g., societal) roots of the ADHD epidemic, and sees his continued prescribing of medication to borderline cases of ADHD as an unfortunate but necessary practice to be continued only until the source of the problem is neutralized. In each essay, then, Diller reiterates the difficulties inherent in determining the course of treatment for controversial childhood psychiatric conditions, and meditates on his own regret and eventual resignation as he prescribes medication for yet another child.

Since almost all of the essays are variations on a single theme, it is worth asking why the book is worth reading in its entirety. First, the details of the individual case studies are invariably interesting and, for those without professional experience in the field of child mental health, some of the situations Diller is faced with must seem outrageous. Readers may laugh, cry, or become angry as they encounter adolescents who unabashedly request medication to improve their SAT scores, parents who are more eager to accept medication than to make any changes in their parenting practices, and physicians who consider a parent's failure to give children ADHD medication a kind of child abuse. Additionally, the book is full of canny clinical observations that are not to be found in child psychiatry textbooks but that derive from Diller's decades in the trenches with families struggling to help children reach their potential. His thoughts on distinguishing motivation/effort problems from ADHD and choosing one medication over another can be read with profit by laypersons and professionals alike.

These strengths, however, should be judged against the book's weaknesses. First, although many of the essays have been revised since they were initially published, no attempt has been made to avoid frequent repetition of information about ADHD and its diagnosis. Some analogies are used more than once in the book, each time presented as though they were novel. Second, although Diller often cites sources for his information and presents full citation information in a "Notes" section at the end of the book, some of his more contentious claims are stated without adequate references, and many of Diller's claims about what certain high-profile ADHD researchers think about medication are based on unpublished interviews and informal, private conversations, making certain passages sound more like gossip columns than scholarly writing. Finally, Diller's interest in the cultural influences on the expression of ADHD symptoms leads him to romanticize certain behaviors associated with ADHD. For instance, in the first chapter, he pronounces an inattentive and distractible 8-year-old boy to be a new incarnation of Disney's Absent Minded Professor, whereas actual individuals with clinically significant inattention would be unlikely candidates for meticulous scientific work.

The bioethicist Carl Elliott, in his Better than Well: American Medicine Meets the American Dream, noted that in the United States, there are constant concerns over "lifestyle drugs"–medications used to enhance desired traits rather than to merely treat illnesses–but that these concerns do not seem to keep people from using the drugs. As Elliott puts it, "We take the tablets, but we brood about it." Diller seems to be caught up in a similar phenomenon: physicians who have doubts and misgivings about prescribing lifestyle drugs (of which ADHD medications are one variety) but do so anyway. They prescribe, but like Diller, they brood about it. The Last Normal Child is certainly full of brooding, to the exclusion of any bottom lines or final answers about medications. It may, then, be a frustrating book for readers looking for confident solutions. However, the humility found in the book's uncertainty is ultimately comforting in its own way, and is clearly the main reason that so many families continue coming to Diller for help.

© 2007 Ben Lovett

Ben Lovett is currently a doctoral candidate in the psychology department at Syracuse University, where his research interests include learning disabilities and ADHD.

Categories: ChildhoodDisorders, Ethics