July/August 1999 - Volume 2 - Issue 6
Use of Ritalin (methylphenidate), the drug of choice for treating attention deficit disorder (ADHD) has risen nearly six fold since 1990. Up to six percent of all school-age American boys are now believed to take Ritalin for the symptoms ADHD, which include a short attention span, hyperactivity and impulsive behavior. The dramatic increase in Ritalin's use has prompted accusations that the drug is being wildly over prescribed and that the condition it treats doesn't even exist. Ritalin's defenders say the upsurge in the drug's use merely means that a safe and effective treatment is finally reaching more of the people who need it. Two experts on childhood behavior offer differing opinions on Ritalin. Arguing that Ritalin is over prescribed is Richard Bromfield, Ph.D., a psychologist on the faculty of Harvard Medical School. Defending the use of Ritalin is Jerry Wiener, M.D., a psychiatrist on the faculty of the George Washington University Medical Center.
Ritalin is being dispensed with a speed and nonchalance compatible with our drive-through culture, yet entirely at odds with good medicine and common sense. The drug does help some people pay attention and function better; some of my own patience have benefitted from it. But too many children, and more and more adults, are being given Ritalin inappropriately.
Psychiatry has devised careful guidelines for prescribing and monitoring this sometimes-useful drug. But the five-fold jump in Ritalin production in the past five years clearly suggests that these guidelines are being ignored and that Ritalin is being vastly over prescribed. The problem has finally been recognized by medical groups such as the American Academy of Child and Adolescent Psychiatry, the American Psychiatric Association and the American Academy of Pediatrics, which have written or are developing guidelines for diagnosing ADHD, and even by Ciba, the primary manufacturer of Ritalin, which issued similar guidelines to doctors last summer.
as short as 15 minutes. And given Ritalin's quick action (it can "calm" children within days after treatment starts), some doctors even rely on the drug as a diagnostic tool, interpreting improvements in behavior or attention as proof of an underlying ADHD - and justification for continued drug use.
Studies show that Ritalin prescribing fluctuates dramatically depending on how parents and teachers perceive "misbehavior" and how tolerant they are of it. I know of children who have been given Ritalin more to subdue them than to meet their needs -- a practice that recalls the opium syrups used to soothe noisy infants in London a century ago. When a drug can be prescribed because one person is bothering another -- a disruptive child upsetting a teacher, for example -- there is clearly a danger that the drug will be abused. That danger only increases when the problem being treated is so vaguely defined.
No one knows how Ritalin works. Some miracle drugs, of course, have helped people for decades or even centuries before their mechanisms of action were understood. But we need to know more about the possible effects of a drug used mainly on children.
We are willing to overlook side effects when it comes to treating a life-threatening disease. But with a less-weighty disorder like ADHD, therapeutic rewards must be weighed against possible adverse reactions. In a drug targeted at children, there is concern that harmful effects may crop up decades after treatment stops. Since Ritalin is a relatively new drug, in use for about 30 years, we still don't know whether long-term side effects await its young users. But we do know that more immediate problems can occur.
While Ritalin's mode of action isn't clear, the drug is known to affect the brain's most ancient and basic structures, which control arousal and attention. I question the wisdom of tampering with such a crucially important part of the brain, particularly with a drug whose possible long-term side effects remain to be discovered.
The surge in both ADHD diagnoses and Ritalin prescriptions is yet another sign of a society suffering from a colossal lack of personal responsibility. By telling patients that their failures, misbehavior and unhappiness are caused by a disorder, we risk colluding with their all-too-human belief that their actions are beyond their control and weaken their motivation to change on their own. And in the many cases where ADHD is misdiagnosed in children, we give parents the illusion that their child's problems have nothing to do with the home environment or with their performance as parents.
It must be true that bad biology accounts for some people's distracted and impulsive lifestyles. But random violence, drugs, alcohol, domestic trauma and (less horrifically) indulgent and chaotic homes are more obvious reasons for the ADHD-like restlessness that plagues America. We urgently need to address these problems. To do that, we need legislators who will provide support for good parenting, especially in the early years of childhood when the foundations for handling feelings, self control and concentration are biologically and psychologically laid down.
Some people who can't concentrate probably do merit the diagnosis of ADHD and a prescription for Ritalin to treat it. But the brain, the neurological seat of the soul and the self, must be treated with the utmost respect. With the demand for Ritalin growing, we must be increasingly wary about doling out a drug that can be beneficial but is more often useless or even harmful
In defining the current use of Ritalin for treating ADHD, it's important first to emphasize that the disorder really exists.
Telling whether a child has ADHD is more complicated than a diagnosis of the mumps or chickenpox, but the diagnosis of ADHD can still be as valid as any in medicine. An analogy would be multiple sclerosis: As with ADHD it's a distinct disease, yet we don't know what causes the problem and have no laboratory test for diagnosing it.
Adding to the evidence that ADHD is a legitimate clinical problem are recent results of magnetic resonance imaging (MRI) studies showing that children diagnosed with ADHD have subtle but significant anatomical differences in their brains compared with other children. Furthermore, studies of families suggest there is a genetic component for many cases of ADHD. More specifically, recent research has found a possible link between ADHD and three genes that code for receptors (proteins that just form the surface of cells) that are activated by dopamine, a neurotransmitter (chemical that conveys messages from one nerve cell to another). Defects in these genes could mean a reduced response to dopamine signals, perhaps accounting for the uninhibited behavior observed in ADHD.
Are mistakes made in diagnosing ADHD? Of course. They usually occur when the clinician is rushed, inexperienced, untrained, pressured or predisposed either to "find" ADHD or to overlook it. As a result, there is both over- and underdiagnosis of ADHD. A reported six-fold increase in Ritalin prescriptions over the past five years is reason to reflect about possible overusage. However, repeated findings of a three percent prevalence rate of ADHD among school-age children gives as much cause for concern about underdiagnosis as for overusage; these prevalence rates mean that up to 30% of children with ADHD may not be receiving sufficient treatment.
While there is no cure for ADHD, there is very effective treatment to minimize its symptoms -- through the use of stimulant medications such as Ritalin. Such drugs are by far the most effective treatment for moderating and controlling the disorder's major symptoms -- hyperactivity, inattention and impulsivity - 75% to 80% of children with the disorder.
he safety and effectiveness of Ritalin and other stimulant drugs, including Dexedrine (dextroamphetamine) and Cylert (pemoline), have been established more firmly than any other treatment in the field of child and adolescent psychiatry. Literally scores of carefully conducted blind and double-blind controlled studies have repeatedly documented the improvement -- often dramatic - in symptoms of ADHD following the use of stimulant medication, with Ritalin the most common choice. By contrast, no other treatment, including behavior modification, compares with stimulant medication in efficacy; and in fact, no treatment besides these medications has had much success at all in treating ADD.
Stimulant medication is so effective that a parent with a child diagnosed with ADHD should receive an explanation if the clinician's judgement is not to prescribe medication. Appropriate considerations for not opting for Ritalin and similar drugs include a history of tic or Tourette's disorder, the presence of a thought disorder, significant resistance to such medications in the patient or family or insufficient severity of the symptoms or dysfunction Other classes of drugs, such as antidepressants, can be effective and used when there is concern about the use of a stimulant medication or when side effects occur.
The issue should not be whether stimulants are over prescribed but whether they may be misprescribed. The most common example: children who are described as overactive or impulsive but who do not met the criteria for the diagnosis of ADHD. Another example is use of stimulants as a diagnostic "test" in the hands of a rushed or inexperienced clinician who may not consider that a favorable response was due to the placebo effect and therefore mistakenly assumes that the diagnosis of ADHD has been confirmed.
Is Ritalin overprescribed? Not when it's used for children who meet the criteria for the diagnosis of ADHD, including the requirement that the child's ability to function must be "significantly impaired." All too often, the mistakes in prescribing Ritalin are errors of omission, where children who could benefit from the drug never receive it. Instead, they go through school labeled as troublemakers, or as unmotivated or hostile. They'll have missed out on the opportunity for at least a trial on a medication that could have significantly improved their symptoms and allowed for improved academic performance, self-esteem and social interaction.