(Photo: Christopher Leaman)

There’s this frustration, this anxiousness, not knowing who I actually am without the medication. When I go off it now, I can’t get through simple chores, errands, tasks, anything.

The biggest thing I hate about it is that I’m a drug addict. If I’m being completely honest, I’m dependent on it. There’s a lot of anger and self-loathing that comes with that.

Trying to go off it is so hard. I’m afraid of being fired from my job, not being able to support myself. It’s truly terrifying.

It’s not like I was ever an all-star in everything. I felt like just to be average I had to take these stimulants. Who would I have been if I could have just been left to my own devices and figured it out? I don’t know.

These are the thoughts that plague the medicated, the adults in their twenties who take prescription stimulants for attention deficit/hyperactivity disorder (ADHD) and have done so since childhood. By some accounts, the number of 26- to 34-year-olds taking ADHD medication rose roughly 84 percent between 2008 and 2012 alone. “Basically we have millions of people in a society-wide experiment,” says Lawrence Diller, a behavioral and developmental pediatrician and family therapist based in Walnut Creek, California.

The CDC estimates that as many as 10,000 toddlers may be taking ADHD medication, despite a lack of research into the risks of prescribing the drugs to children that young.

Diller wrote Running on Ritalin, his first book, during a frenzied boom in stimulant prescriptions in the mid-’90s. From 1990 to 1998 — the year in which the book was published — the number of children and adults diagnosed with ADHD rose from about 900,000 to nearly five million nationwide, he wrote. By the time his fourth book, Remembering Ritalin, was published in 2011, at least 6 percent of children in the United States between the ages of four and 17 were being medicated for ADHD. The phenomenon concerned him deeply. Diller felt the medical and mental-health communities were understating or outright ignoring the addictive nature of prescription stimulants and their high potential for abuse among those aged 14 and older. Just as alarming was what seemed like a steep rise in ADHD diagnoses and stimulant prescriptions nationwide — particularly given how little was known about the long-term effects of the drugs. “It was appalling, just appalling, what was going on with the medical industry and the drug companies,” he says.

Prescription stimulants like Ritalin were considered a godsend when they first started being used to help hyperactive, unfocused kids succeed in school. So many children were on ADHD drugs in the ’90s that lines would form outside the school nurse’s office, where students went to take their midday doses. But almost 20 years have passed since Diller predicted that the tidal wave of prescriptions written in the ’90s would come to shape an entire generation. Now, those children are all grown up and living on their own. As adults, many find themselves unable to get off the drugs. Some fear losing their jobs, while others fear losing the only self they have come to know — a self with a prescription drug dependency that’s difficult to kick.

“Small things like driving are a big deal when I’m not on my medicine,” says Brittany, 22, a 2015 college graduate and marketing intern. “Grocery shopping, that’s extremely hard for me. I just wander and wander and wander, because I have no direction.”

Setting a correct alarm and waking up on time can seem like huge accomplishments for an adult with ADHD. Even answering a single email can be a maddening affair, derailed entirely by an interruption as simple as a text message. Whereas most working adults are already feeling productive and on track within the first hour or two of a typical 9-to-5, someone with ADHD may still be trying to figure out where to begin.

(Photo: Christopher Leaman)

Carly Thompson, a career counselor at a community college in Maryland, helps her clients with ADHD re-learn the most basic daily coping skills, like breaking large tasks into more manageable pieces. Over the last few years, Thompson has noticed an uptick in the number of adults with ADHD who lack the confidence to hone in on a fulfilling career path. They have come to rely on a tiny pill in order to meet the demands of life, school, and work. Some have developed an innate mistrust of their own instincts, due in part to persistent struggles with ADHD-fueled impulsiveness. Others fear that years of stimulant use have left them emotionally or physically dependent, and that they simply cannot function at all without the drugs.

Before becoming a career counselor, Thompson worked with a licensed professional counselor at a community mental-health agency, where she spent three years diagnosing issues like bipolar disorder, schizophrenia, and anxiety. Over time, diagnosing young children with ADHD became the job’s biggest drawback. “I was almost more reluctant to give that diagnosis than any other one,” she says, “because I knew the medication. I myself was on Adderall for about 10 years on and off. It got to a point when I was like, ‘I don’t know if I’m capable of doing things without this medicine.’ I started seeing these little kids and I started thinking: ‘There’s got to be a different way. I don’t want to give this experience to them.’”

“Knowing how hard it is to get off of it, I wish that I had been able to do something about it when I was 15. I feel like I still would have had it in me at that point to re-learn things.”

When Thompson was diagnosed with ADHD in college, her psychiatrist presented stimulants as the only course of treatment available to her. She started taking Adderall when she was 18 years old. Seven years later, when she had just finished graduate school, she tried weaning herself off stimulants for the first time. She was exhausted by their physical and emotional side effects, namely the cravings for isolation, erratic sleep patterns, and extreme appetite swings that had come to pervade her life. “I was willing to trade off all the benefits of the medicine for just feeling free from it,” Thompson says. She lasted a full year without stimulants before the workplace environment of her first job became too overwhelming, and she started taking them again. Now 29, Thompson says she has been medication-free for the last six months or so.

“I really don’t think I would have been able to make it through college without it,” she says. “But now, picking up on the skills I know now, it’s a really different story. I didn’t have anybody teaching those skills back then. I learned them by becoming a counselor. I learned how to help myself.”

Methylphenidate, more commonly known as Ritalin, was the first widely used medication to treat ADHD, and remains among the most popular. The drug was developed in 1944 by the Swiss pharmaceutical company Chemische Industrie Basel. After a series of experiments, chemist Leandro Panizzon eventually synthesized the stimulant from a family of medicines called piperazines, known for their stimulating abilities. Ritalin, named after Panizzon’s wife, Marguerite, was patented stateside in 1954 to treat psychological disorders and a variety of other ailments, including narcolepsy, depression, chronic fatigue, and barbiturate overdoses. The drug was licensed by the Food and Drug Administration the following year, about the same time that psychiatrists began diagnosing children with hyperactivity.

No one anticipated a prescription epidemic at the time. In 1970, it was estimated that 150,000 kids were taking stimulant medication in the U.S. By 2012, 4.8 million privately insured people nationwide had taken ADHD medication. “It appears that America suffered an increase in this psychiatric disorder of 100,000 percent in just one generation,” writes Nicolas Rasmussen, author of On Speed: The Many Lives of Amphetamine, “from tens of thousands in the 1960s to tens of millions today.”

(Photo: Christopher Leaman)

The psychostimulants used to treat ADHD today include methylphenidate (commonly known as Ritalin or Concerta), amphetamine-dextroamphetamine (Adderall), dextroamphetamine (Dexedrine, Dextrostat), lisdexamfetamine (Vyvanse), and dexmethylphenidate (Focalin). Ritalin and Focalin are not amphetamine based, but Adderall, Dexedrine, and Vyvanse are. When Adderall was approved by the FDA to treat ADHD in 1996, it exploded in popularity, and now rivals Ritalin in terms of overall usage. Some non-stimulant medications, such as Strattera, are available now as well, though they are generally considered less effective than the psychostimulants.

An ADHD diagnosis is based on a set of subjective criteria developed by the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM). The DSM lists 18 symptoms total, nine each for “inattention” and “hyperactivity-impulsivity.” They include being easily distracted, forgetful, fidgety, or restless. Children up to age 16 have to meet six or more symptoms from each of the two categories, while adolescents 17 and older have to meet five or more. Symptoms also have to be present for at least six months, affect two or more settings like home, school, and work, and must be present before a child turns 12. The average age at which an American child is diagnosed with ADHD is around seven, according to the Centers for Disease Control and Prevention (CDC), but more severe cases are often flagged earlier. Primary-care providers like pediatricians make about half of all first diagnoses, though psychologists and psychiatrists diagnose ADHD as well. Boys are diagnosed more than twice as often as girls.

The CDC provides a checklist of symptoms on its website for parents, teachers, coaches, or daycare providers — anyone who interacts with the child — to fill out and bring to a diagnosing clinician as part of the process. The checklist includes attributes such as, “Often has trouble keeping attention on tasks or play activities,” and “Often has trouble waiting one’s turn.” Yet how does one truly quantify “a lot of fidgeting” or “high distractibility,” particularly in a naturally energetic kid? And how much of that fidgeting and distractibility is just a normal part of growing up?

“I think there are a lot of people out there who are convinced they have a little ADHD and now they’re being medicalized. I think this is epidemic. The locomotive has left the station.”

Because ADHD symptoms must affect a child in more than one setting, a diagnosis necessitates that parents, teachers, babysitters, and others fill out the questionnaire. Given the subjectivity of the criteria and the variability of opinion among the people involved, some critics argue that as many as half of the stimulant prescriptions written for children may be doled out to those who don’t fully meet the DSM criteria.

“There is no biological test or even marker for ADHD,” Diller says. “All those things create ambiguity. And so the range of people who have it, to who continues to have it after childhood, is very variable in all the studies.”

Adderall, Ritalin, and Dexedrine are all classified by the Drug Enforcement Administration as Schedule II drugs, given their high potential for misuse, abuse, and psychological or physical dependency. Other Schedule II drugs include Vicodin, cocaine, OxyContin, and opium. Diller believes there is reason to be cautious about long-term use of ADHD drugs. “In my experience, the kids who have been on it for years improve behaviorally, but many of them wind up still feeling psychologically dependent when, in my opinion, they no longer need it,” he says. He mentions the risks of dependence to families, but also recognizes that there’s a tradeoff. “We have to weigh the short-term benefits of getting them through the next five years of school.”

Dependency is determined by the presence of physical or mental symptoms during withdrawal from repeated substance use, like night sweats or irritability. It is possible to become dependent on a substance even when used as directed. Addiction is defined by the National Institute on Drug Abuse as compulsive drug use, despite harmful consequences to one’s life. There is a fine line between dependency and addiction, and the two are often conflated, with addiction being the more commonly used term in everyday conversation.

“I felt like I was addicted to it,” says Amy, 31, a graduate student who started taking Adderall in high school. She abused her medication in college, mostly as an appetite suppressant. She also sold extra pills during finals, and to friends in search of a poor man’s substitute for cocaine.

Cocaine and amphetamine work somewhat similarly. Both flood the brain with dopamine, a neurotransmitter, or chemical messenger. Depending on its location in the brain, dopamine can influence pleasure, motivation, attention, psychosis, or desire.

“In my practice, if I use the word ‘amphetamine,’ parents immediately are in shock,” says William Graf, a professor of pediatrics and neurology at the University of Connecticut School of Medicine and Connecticut Children’s Medical Center. “If you say ‘stimulant medication’ or ‘Adderall,’ people don’t blink.”

(Photo: Christopher Leaman)

When asked to comment on the possibility that users can become dependent on or addicted to their product, a representative from Teva Pharmaceuticals, makers of a generic form of Adderall, responded that the medication “is a Schedule II controlled substance, and the package insert clearly states the risks associated with incorrect dosage, misuse or abuse and recommends that doctors properly monitor patients.” Janssen Pharmaceuticals, makers of Concerta, an extended-release form of methylphenidate, acknowledges that the medication “should be given cautiously to patients with a history of drug dependence or alcoholism, and that chronic abusive use can lead to marked tolerance and psychological dependence.” Other manufacturers of ADHD medications have issued similar statements.

When Carly Thompson voiced her concerns about developing a stimulant dependency to her psychiatrist, she was advised to follow a basic weaning plan: three pills daily for one week, two pills daily the next, and one pill a day the week after, before stopping entirely. There was no mention, she says, of any withdrawal symptoms common among prescription stimulant users, which include exhaustion, night sweats, and feelings of severe self-doubt and worthlessness. She wishes she had known what she was getting into when she filled her first prescription.

“This is addictive, you can become dependent on this, this is very hard to get off of, we don’t know the long-term effects — that’s all written down from what you get from the pharmacist,” Thompson says. “In my experience, no one says to you or to the parent: ‘Do you really understand what this means?’” The physical addiction is one thing, but the mental aspects of withdrawal might be even worse. “Everything feels so much harder,” she says. “It’s just a mind fuck.”

Medication may be the easiest way to treat ADHD, but it is not the only way, nor is it necessarily the most effective way, at least not when it is the sole form of treatment. The fact is, even after more than half a century of prescribing stimulants for hyperactivity, the national medical communities still don’t agree on the best approach to treating ADHD.

Organizations like the American Academy of Child & Adolescent Psychiatry recommend medication, therapy, or both, depending on the individual needs of the child. The American Psychological Association also endorses both treatments, but notes that little is known regarding which order is most effective — medication, or therapy, first. In 2006, a report from its Working Group on Psychotropic Medications for Children and Adolescents raised the question of whether a behavioral treatment-first approach could lower societal use of stimulants overall. “Given that ADHD is recognized as a chronic disorder and treatment needs to be implemented over long periods of time, a relevant question is when, if ever, can treatment be stopped?” the report asks. “These are questions practitioners and parents face on a daily basis that beg answers.”

(Photo: Christopher Leaman)

Behavioral therapy aims to re-shape negative thought patterns and problematic behaviors through a consistent re-structuring of one’s daily environment. Strict rules and routines and reward systems for jobs well done are common tactics, as are honing in on specific challenges, like arriving to work on time, and developing step-by-step approaches to staying on track. Keeping meticulous checklists, planners, and schedules is encouraged. Other goals include strengthening critical reasoning, controlling impulsive behavior, and navigating feelings of self-deprecation and insecurity that inhibit proactive decision-making.

Therapy may provide lasting benefits throughout one’s life, but stimulants are only effective for the four to 12 hours that they remain in the body’s system, says William Pelham, director of the Center for Children and Families at Florida International University. “The guidelines recommend behavioral treatments and pharmacological treatments, but, in practice, typically medication is the first and only intervention,” he says. “And that’s what pediatricians are taught to do.”

“You’re giving amphetamines to little children. It should be evident why one would be concerned. I was taught as an intern that we never give Ritalin below the age of six, ever.”

Pelham was the lead researcher of a study published earlier this year that suggests that beginning with behavioral therapy instead of stimulants could prove far more beneficial for children overall. He and his research team randomly assigned 152 children diagnosed with ADHD, ages five to 12, to either a low-dose stimulant or low-intensity behavioral therapy at the beginning of the school year from 2006 to 2008. Therapy included working with teachers to improve specific school goals (like listening to directions) and setting up ways to measure and impact progress (like a daily report card). Additional tutoring, time-outs, and homework-skills training were used at school as well, if needed. Parents were tasked with attending weekly parenting-skills training programs and setting up a daily report card for jobs well done at home. Children in the therapy group took social-skills training classes as well.

After eight weeks, any child in Pelham’s study who didn’t improve was assigned a second treatment at random. A child initially prescribed low-dose medication, for example, either started taking a higher dose or began therapy but remained on a low-dose medication regimen.

By the end of the year, ADHD symptoms improved across the board, regardless of which treatment came first. Children who went to therapy first and took medication later — the most successful pairing, Pelham’s team found — performed best on classroom observations and parent/teacher ratings, however. Therapy-first children also required less disciplining throughout the school year. Medicating first, followed by therapy, was the least effective option; it was much harder to change a child’s behavior if they had already been medicated for some time. Parents were also substantially less likely to show up to behavioral training if their child had been previously medicated. Why bother if a pill seemed to be doing the trick?

“If pediatricians start with their first treatment as medication for ADHD, and they start with a low dose of treatment, it will be very helpful for about half the kids,” Pelham says. “However, for the other half of the kids, if they started with a low dose of medication, they’ve essentially ruined the opportunity to add psychosocial treatments, meaning they unwittingly undermined the parents’ motivation to learn new parenting skills, and the teachers’ motivation to implement programs in the classroom. Doctors don’t realize that they’re doing that, but that’s what this study shows.”

In her work as a career counselor, Carly Thompson has seen firsthand what can happen when young people aren’t given the chance to learn how to cope with life’s challenges on their own. “We just take pills because the doctor says it’s going to help us,” she says. “I think the bigger issue is, people are struggling in some way with how to focus in their lives.”

“Knowing how hard it is to get off of it, I wish that I had been able to do something about it when I was 15,” Brittany says. “I feel like I still would have had it in me at that point to re-learn things. And because I would have still been at home, I would not have been in charge of my own care so much.” As an adult with rent and bills to pay, she feels she has a lot more at stake now.

A version of this story first appeared in the July/August 2016 issue of Pacific Standard.

For his part, Diller remains skeptical about how many children need to stay on medication into adulthood. Of the nearly 3,700 children he has treated for ADHD, he has prescribed stimulants to fewer than half of them. Of those, only a small minority still required medication into their twenties and thirties, he says. Most of his patients matured enough neurologically to get by without them. Or they found other niches outside of the standardized school or work environments in which to flourish.

“You get no lasting benefit from taking stimulant drugs,” Pelham says. “You have to take them every day for your whole life. Who cares whether you still have eight of the required DSM symptoms of ADHD? It’s how are you functioning in life,” he says. “Medication during childhood has zero impact on how people turn out as adults in terms of their functioning in daily life.”

Meanwhile, in an already fast-paced culture, a society that is hyper-aware of hyperactivity, in which focus and output are highly valued, the number of adults seeking diagnoses later in life is also on the rise. In 2013, the DSM criteria were updated to include specific guidelines for diagnosing adult ADHD. Over the four years prior, between 2008 and 2012, the number of adults taking ADHD medication had already increased by roughly 53 percent.

And not only is the number of adults taking stimulants for ADHD rising, the age group to which stimulants are first being prescribed is getting lower. Data from the CDC — presented at the Georgia Mental Health Forum at the Carter Center in 2014 — indicates that nearly one in 225 toddlers between the ages of two and three were being medicated for ADHD, based on Georgia Medicaid claims. The CDC estimates that as many as 10,000 toddlers nationwide may be taking ADHD medication, despite a lack of research into the risks of prescribing the drugs to children that young.

“We just take pills because the doctor says it’s going to help us. I think the bigger issue is, people are struggling in some way with how to focus in their lives.”

One risk concerns appetite suppression, a common side effect of stimulant medication, which can cause nutritional deficits in young children. Melissa, a 28-year-old assistant to a financial advisor who took Ritalin in grade school, recalls coming home with her lunchbox full, day after day. “There were a few months when I actually stopped growing,” she says. Sleep problems, not surprisingly, are also associated with stimulant use. “I had horrible insomnia,” Brittany says. “When I was about 10 years old, they put me on Ambien to counteract the Adderall. I would take a little quarter of one to go to bed a couple times a week.”

The American Academy of Pediatrics doesn’t even address children under the age of four in its practice guidelines to treat ADHD. And while the package insert for methylphenidate explicitly cautions against its use by those under the age of six, prescriptions for the drug tripled among preschoolers nationwide between 1991 and 1995 alone. Two other popular stimulants, dextroamphetamine and Adderall, are being administered at even younger ages. According to a paper from the American Academy of Child and Adolescent Psychiatry, these drugs have been approved by the FDA for use in children as young as three, “even though there are no published controlled data showing safety and efficacy.”

This trend is “totally mind-blowing,” Graf says. “You’re giving amphetamines to little children. It should be evident why one would be concerned. I was taught as an intern that we never give Ritalin below the age of six, ever,” he adds. “There is a place, rarely, for medication for out-of-control behavior in a four-year-old, but not with any of the stimulants.”

Has ADHD become so deeply ingrained within our society that widespread stimulant use is simply accepted? Has it become so normalized that anyone who occasionally gets distracted can go running to the doctor’s office for a prescription? Have we become, as Diller predicted, a culture running on Ritalin?

Graf recalls an afternoon driving in the car with his daughter, as she flipped the radio from song to song. “I think I have a little bit of ADHD,” she said. “She was joking, of course,” Graf says, “but the fact is that it trickles down to kids’ day-to-day vocabulary. I think there are a lot of people out there who are convinced they have a little ADHD and now they’re being medicalized. I think this is epidemic. The locomotive has left the station and it’s moving forward. This is the way we’re raising kids these days.”

The names of those featured in this story and its sidebars have been changed.