Running on Ritalin
Is It the Drug of Choice or the Drug of Convenience?
It's midday at an elementary school in a comfortable American suburb. The lunch bell has just rung, and the kids are noisily pouring out of classrooms to enjoy a brief recess in the schoolyard before mealtime. Inside, next door to the principal's office, the school secretary is arranging bottles of medication on a tray. Scotch taped to the tray are little photos of 14 children, labeled with their names and keyed to the bottles. Though by now she pretty much knows who gets what, at the beginning of the school year, this system helped make sure she didn't make mistakes--that each of the children taking Ritalin at school received the right pill and dose.
At least a dozen more youngsters among the 350 attending this school took the same medication at home before school, but aren't required to take a midday dose.
At a nearby school of similar size, the kids getting Ritalin are organized in 10-minute shifts because their number exceeds 30. And this weekday ritual is carried out--with variations in the number of kids and the personnel responsible for handing out the pills--at schools across the United States.
The children are being medicated because they are underperforming at school and, often, at home. They appear inattentive, distractible and impulsive; some fidget or move about more than their classmates. However, many of these youngsters do not look much different from their peers. The uninitiated observer might wonder why these children are in line waiting for their noontime Ritalin pill.
Attention deficit disorder, or ADD--the condition for which the medication Ritalin is most commonly prescribed--was formerly called hyperactivity, as reflected in its alternative acronym: AD/HD (attention deficit/ hyperactivity disorder). Since 1990, the number of children and adults diagnosed with ADD, presumably indicating problems with attention, focus, impulsivity or overactivity at school or at home, has risen from about 900,000 to almost 5 million as we near the end of the decade. This figure--derived from the amount of medication prescribed for ADD--suggests a problem of epidemic proportions.
This sharp rise in ADD diagnosis is directly tied to another startling statistic--a 700-percent increase in the amount of Ritalin produced in the United States during the same time period. An increase of this magnitude in the use of a single medication is unprecedented for a drug that is treated as a controlled substance. Ritalin belongs to the class of drugs known as stimulants, and it is closely related to amphetamine. Although it has been around for a long time, some people are still surprised to learn that Ritalin is essentially a form of speed. Others do know this, but believe that the drug has a paradoxical "calming" effect on children, an effect different from the one it produces in adults.
In fact, Ritalin affects children and adults in much the same way. It increases the amount of the neurotransmitter dopamine in the brain, although no one knows exactly why this "works" with ADD. Ritalin and the other stimulant commonly used in ADD, amphetamine (Dexedrine and Adderal), are nearly identical in chemical structure and action. Stimulants increase both blood pressure and alertness. They also help children and adults, with or without ADD, stick with tasks they find boring or difficult.
I've become intimately acquainted with these statistics about ADD and Ritalin through real families and their children in my practice of behavioral pediatrics. At my office in a suburb 25 miles east of San Francisco, I evaluate and treat a wide variety of developmental, learning and behavior problems of children and adolescents. I see children, teenagers and their families, some of whom bring children as young as 2 years old for treatment of suspected ADD. Increasingly, adults are among my patients--most of them parents of children diagnosed with ADD who believe they, themselves, share its symptoms, or people who have heard that I do assessments for ADD. These days, I also prescribe a lot of Ritalin.
The families are mostly white, middle- and upper-class. In nearly all cases, at least one parent has a job; in most families, both parents are working outside the home. The children are experiencing problems at home, at school or in multiple settings. Some don't respond to requests; some have unusual or exaggerated fears; some lag behind in school. Some young patients display frequent temper tantrums, language delay or autism. But more and more often these days, the reasons kids are in my office is that their parents, teachers or primary-care doctors think that they might "have" ADD. More and more, those parents and caretakers are expecting me to supply Ritalin. And in a variety of circumstances--for instance, when the degree and pervasiveness of the symptoms include out-of-control behavior in my office or when there is immense, immediate pressure to keep the child in his current environment (usually a school)--I do.
Michael, age 5, had been taking Ritalin for a year when I first met him. He was about to get kicked out of his private, full-day, hi-tech kindergarten (with TV cameras in each classroom that provided electronic monitoring to the principal in her office), for hitting other children and running off school grounds when disciplined. Michael lived with his father, Steve, and his paternal grandparents. Michael's mother saw him every other weekend.
In my office, Michael moved from one toy to the next, while his grandmother hovered ineffectually about him and Steve seemed uncertain what to do. My screening for learning problems indicated Michael's development was normal.
In meeting with Steve and school personnel, I went over the need for immediate rewards and consequences for Michael's behavior, but it was clear that the teacher had already given up on him. Trying to keep him at the school, I suggested a higher dose of Ritalin, but doubted whether that alone would work. A week later, the school expelled Michael.
I talked with Steve about the need for immediate reinforcement with Michael ("less talk, more action") and addressed some of Steve's guilt feelings over the divorce and living with his parents. Seven weeks later, I saw Michael with his father. The change in the boy was remarkable. He sat next to his father and conversed for about 10 minutes, then sat on the floor and played quietly with some toys while his dad and I talked.
"How much medication is he taking?" I asked. "None," Steve said. I asked him what accounted for Michael's dramatic change in behavior. Steve explained that Michael now went to a public-school kindergarten for only three hours a day. Steve's girlfriend picked up Michael and her daughter, who was in the same class, each day and took them to her house for the afternoon. Steve had taken over the parenting from his mother with a firmness and immediacy that I saw demonstrated the one time it was necessary that day in my office. He had stopped giving Michael the medication three weeks earlier without any deterioration in Michael's behavior at school or at home. Michael's changes made sense to me. I was surprised only with the speed and degree of the progress.
Sorting out myth from fact about Ritalin isn't easy, but the remarkable rise in its use makes it imperative that we try. Perhaps it's even more important to explain why the demand for it--and the pressure on parents and physicians to provide it--has become so intense. I believe that certain factors in American society are contributing to the rising rates of ADD diagnosis, among them the changing structure and function of the family, an overtaxed educational system, an emerging culture of disability and the exigencies of managed care. But beyond the social forces that determine whether or not a child will be diagnosed with ADD, certain other trends in health care and pharmacology help explain how Ritalin has become the answer for so many families coping with behavioral disorders.
Ritalin became the primary drug used for the treatment of behavior and performance problems in children by the mid-1960s. Why Ritalin? Given the close similarity in clinical responses to Ritalin and amphetamine, the chief reason for Ritalin's much greater acceptance early on among doctors and government regulators for use with children was simply that it was not amphetamine. By this time, amphetamine already had a bad reputation as a dangerous drug with the potential of abuse. But other factors may have influenced Ritalin's growing popularity. Its quick action and lack of major side effects made it an ideal drug to study in children. Therefore, it was studied often--and the more studies there are, the more legitimacy accrues to a drug.
Who is taking all this Ritalin? Research supports the general observation that males are much more likely to be diagnosed with ADD and to take Ritalin and related medications than females, in all age groups. In addition, the ADD-Ritalin boom appears to be a primarily white, middle- to upper-class, suburban phenomenon. Minorities are underrepresented, in proportion to their numbers, in their use of the drug. Several surveys have confirmed that African American children receive the ADD diagnosis and Ritalin less frequently than Caucasian children. Cultural and economic factors most likely are responsible for this. Many black families lack the financial wherewithal to take their children to medical specialists for behavior and performance problems, and others may not wish to. Crack cocaine has been so injurious to the black community that some parents are apprehensive about using any kind of stimulant for their children. And in general, blacks are less comfortable than whites with the use of drugs to treat behavior problems, and are skeptical of an educational system they perceive as too ready to fault black children for behavior that is judged and determined by a white-dominated society.
It's no accident that the Ritalin boom that began in 1991 followed the Prozac explosion by just a few years. Prozac and its sister drugs (primarily Zoloft and Paxil) have revolutionized medically prescribed drug taking for emotional problems in this country and much of the world. In just a few years since its introduction in 1987, a popular mythology has developed around Prozac that strongly reinforces the belief in the genetic and biological causes for behavioral problems and that the most appropriate and effective way to address these problems is through a chemical agent. And more than any other single factor, the Prozac phenomenon has made Americans familiar with the metaphor and the model of biological psychiatry, and comfortable with the idea of using medication to improve personality and enhance performance.
The belief that ADD is a neurological disease--the nature stance--prevails today among medical researchers and university teaching faculties. Its dominance is reflected in leading journals of psychiatry, such as theAmerican Journal of Psychiatry and the Journal of the American Academy of Child and Adolescent Psychiatry . Its eloquent proponents include Joseph Biederman, chief of the Joint Program in Pediatric Psychopharmacology at Massachusetts General and McLean hospitals. Two other advocates are Edward Hallowell and John Ratey, authors of the bestselling Driven to Distraction and its sequel, Answers to Distraction . They are joined by Russell Barkley of the University of Massachusetts Medical School, who describes Ritalin as the definitive treatment for ADD and suggests that it may need to be taken throughout the patient's lifetime. Overwhelmingly--save for a small community of doubters and dissenters--specialists, general physicians, the media and patients have increasingly heeded the researchers' clarion call: ADD is a neurological disease.
The explanation of ADD is also widely accepted within the leading self-help group for ADD: Children and Adults with Attention Deficit Disorder, or CHADD. In fewer than 10 years, this influential organization has grown to encompass 35,000 families and several hundred chapters around the country. The group's interests in promoting a neurological cause for ADD are understandable--with the new emphasis on biological causation, no one is to blame . Biology now offers CHADD a welcome relief from guilt, as well as the possibility of classifying ADD as a medical disorder to win insurance coverage and disability rights.
The broad acceptance of ADD as a biological brain disorder leads to a natural but illogical conclusion that the treatment must also be biological, i.e., a medication like Ritalin. Yet for many biological conditions in medicine--for example, essential hypertension or adult-onset diabetes--the initial treatments are life-style changes: losing weight, getting exercise, reducing stress. Patients psychiatrically diagnosed with Obsessive-Compulsive Disorder find their symptoms and PET scans equally improved with medication or behavioral desensitization treatment.
Is America ready to have 10 percent of its children taking Ritalin? Because boys are disproportionately represented in the total population of kids diagnosed with ADD, this would mean giving the drug to one in six boys between the ages of 5 and 12 . Some researchers seem not to be fazed by this prospect. In their view, if a medication "works," then we ought to use it.
The evidence that parenting trends may be contributing to the ADD-Ritalin boom is mostly anecdotal and suggestive. Does inappropriate parenting lead to ADD-type behavior in a child, or does the child's inherent personality wear down the parents and lead to their acting inconsistently and ineffectively? The answer is probably a little of both--or, as a clinician would say, the effects are "bidirectional and circularly" reinforcing. In fact, where the cycle begins is arbitrary. Say a child with a "difficult" temperament elicits inconsistent parenting, which leads to more behavior problems, and so on. In another version, wrongheaded if well-meaning leniency forces a parent to try the same unsuccessful approaches over and over, inevitably culminating in "the blowup"--that dreaded loss of control that is the ultimate sin of "politically correct" parenting. Having lost control, the parent feels guilty and vows never to do that again, resulting in even more leeway for the child. And so the cycle continues. Ritalin for your child becomes attractive when you've "tried everything" for several years and nothing has worked. The idea that the problem must be biochemical then takes on great appeal.
Over the last three decades, many cultural changes have affected the ways in which parents raise their children. Nothing has had a greater impact on recent parenting trends than the growing public awareness of an old social ill--child abuse. The furor over child abuse, which has resulted in protecting many children truly at risk, has also had some unfortunate side effects: first and foremost, a confusion and uncertainty among parents over how to discipline their children. Some parents worry that children may be psychologically damaged by almost any kind of discipline--a wrongheaded worry, indeed.
Of course, my criticisms of inappropriate parenting are focused chiefly on its inefficiency with a child of difficult temperament, and are in no way meant to blame parents. Such children are very tough to raise. Their personalities can wear down the best parent's resolve and elicit inconsistent responses. And the economic stresses that create two-parent working families do not help matters. One of the last things a parent wants to do, when he or she has only two hours at the end of the day with his or her kid, is to spend that time disciplining the child. Most of the parents I see with their incipient-ADD children love them very much, but sometimes ineffective parenting can render their interactions much more stressful than necessary (their child is constantly challenging them), and ultimately makes the expression of their love more difficult.
For the ADD-temperament child, today's typical American elementary school can be a mine field. A hundred years ago, ADD per se did not exist, though the temperament or biological predisposition for it surely did. Among the reasons why it wasn't identified as a serious problem was, no doubt, the ironic fact that children were offered more alternatives than is the case today. Then, if it was too hard for a child to sit still in school, he or she could go back to helping on the farm, for example, or work in the family store or help care for younger siblings.
But when the 20th century brought compulsory education to the industrialized world, for the first time, children en masse had to function in a school setting for about six hours a day. This was a revolutionary new challenge for all children, but especially for those with the specific temperament we today label ADD. In the bad old days, there was a ready response to children who misbehaved in school--they were likely to be beaten into submission. We're no longer willing to intimidate children into compliance, but we might just be willing to drug them into it.
More recent changes in the school setting have been a factor, too. Pupil-teacher ratios have been creeping up and, thanks to popular tax-cutting measures, many classrooms have more than 30 children per teacher. Large classes produce more distractions, permit less flexibility and make it hard for a teacher to attend to each child's individual needs. Generally, ADD-type children require close monitoring and immediate reinforcement for good or bad behavior, but the teacher in a classroom of 30-plus simply does not have the time or energy to be effective with the more demanding children.
In addition, parents generally sense that both they and their children are overloaded and there's no free time for anyone in the family. Not just nightly homework, but a huge array of extracurricular and social activities--in which parents are necessarily involved--fill up the lives of today's kids.
As usual, we come back to Ritalin. It's not hard to see why, in the present circumstances, it's so often seen as a solution, and why doctors who raise questions about Ritalin use are not always welcomed by teachers and school administrators. Ritalin can help many students (and their teachers) cope with larger class sizes. So, too, can the classroom and curriculum adjustments often recommended for learning-disabled kids--only these involve vastly more work for teachers, and more money.
Today, we expect more for our children, and we expect more of them. At the same time, the old network of social supports for children and their families has been undercut. A 10-year-old patient of mine, upon hearing about the idea of a "chemical imbalance" underlying ADD, produced this insight about his own situation: "It's not a chemical imbalance, Dr. Diller, it's a living imbalance." The phrase has stuck with me, because it seems clear that life imbalances of various kinds can cause trouble for that large group of children within the shadow of the ADD diagnosis. With their spirited temperaments, they might be able to function well enough in less stressful environments. In more demanding situations, they become problem kids. Indeed, they may show enough symptomatic behavior to meet someone's criteria for ADD and receive Ritalin.
Over the past decade, the bureaucratic nature of managed care has reinforced the dominant biological view of mental illness in ways that should concern doctors, patients and all of society. As a doctor, I'm concerned about how managed care affects the individual families I treat and the kind of care they can receive. There's no doubt that HMOs have intensified pressure on physicians to prescribe a drug rather than spend time with a patient or his family. In health coverage today, the overriding principle is value for money, and for the mental health community, this means an overwhelming emphasis on the use of medication in preference to any other treatment.
The story of one young family is fairly typical. When 7-year-old Todd Foster came to see me, his parents were arguing over how to deal with their son, who wouldn't listen to their instructions. After meeting with them twice, I found Todd a bit impulsive and quite intense and stubborn when he didn't get his way or was frustrated. Still, I thought his family might manage without Todd's taking Ritalin if they could work out their parenting differences and practice a new approach with their son. This would involve further "talk therapy," but they couldn't afford to pay for more sessions with me. Unfortunately, their HMO permitted doctor visits for mental health problems only if medication was being considered or offered to the child. Though few other providers in their health plan could offer the range of treatment and experience I had with ADD-type children and their families, the Fosters would have to turn elsewhere for help unless I prescribed medication.
Under such circumstances, the lure of a quick-fix solution becomes powerful. And there's no getting around Ritalin's dramatic effects in changing a child's short-term behavior, even though long-term studies have suggested its ultimate failure as the sole treatment for ADD. Logic suggests that the rate of medication with Ritalin is higher among families with managed-care plans, compared with those using other forms of payment. Surveys focusing on the use of psychotropic drugs in managed care certainly confirm this tendency.
To give medication for a condition whose chief trait is the failure to perform up to one's potential--or to manage one's life efficiently--crosses the line, in my view, between treating a disorder and enhancing a particular aspect of personality. In essence, it is "cosmetic psychopharmacology." Proponents say that Ritalin only serves to level the playing field for individuals with attention deficit. But since the drug exerts similar effects on everyone, why should only those operating below the norm have access to its performance-enhancing qualities?
Here is where serious questions about fairness arise. Take two students with borderline attention problems: does the child who tries hard without the aid of Ritalin simply live with the lesser grades, while his fellow student taking Ritalin gets As? As more students turn to Ritalin for help in completing assignments and for examinations, will this influence others to try it--will they, like athletes, have to exercise "free choice under pressure" to win their academic race? And should colleges, grad schools and corporations be informed that applicants use Ritalin when their scores are evaluated?
We still don't know how using Ritalin affects people's self-image in the long term. Do they feel fundamentally more in control of their lives, or do they lose confidence in their ability to cope without medication? We do know that children--especially teenagers, whose identities are notably vulnerable--are susceptible to feelings of inadequacy when taking Ritalin, even as their performance improves; and we have heard from adults who feel emotionally harmed by having taken Ritalin as children. But the rising acceptance of cosmetic drug use may eradicate such negative feelings or stigmas as time goes on. If this process eventually overwhelms our belief in the power of the unmedicated self, is this a good thing?
The widely varying rates of Ritalin use from one community to another speak volumes about the effects of sociocultural rather than neurological factors when it comes to the "prevalence" of ADD. After years of internal debate, I've come to view Ritalin as having the potential to improve performance for anyone, regardless of their condition. The questions I confront daily are those of performance and behavior: who is deciding for whom, and what standards of performance are reasonable?
A teacher reports that a child in her classroom with known learning problems doesn't complete her assignments and requires frequent reminders to stay on task. She receives some tutoring in school. Her family reports no problems at home except when they battle with her over homework. Ritalin would allow her to work longer on a task that she finds difficult or boring. Do I prescribe her Ritalin? A stockbroker whose son takes Ritalin complains that he can no longer concentrate well enough at his job. Twenty years ago he tracked 25 stocks. Now, in order to remain competitive, he must follow 100. We talk about the increased demands on him, the meaning of success and the general quality of his life. Do I prescribe him Ritalin? A college sophomore who struggled academically in high school is now barely passing his courses. He procrastinates, is easily distracted when he must study and he admits he's not especially motivated. He can't think of what else he might do instead of attending college. In the past, another doctor had prescribed Ritalin for him.The student tells me he used Ritalin primarily before exams to help him study. He feels the medication worked well for that purpose, but he doesn't want to use it on a regular basis because it decreases his sociability. He says he doesn't really "need" it, except for studying. Do I prescribe him Ritalin?
Different doctors could make different decisions for each of these patients. After some thought and a number of consultations, I ended up prescribing Ritalin for the little girl. I did the same, somewhat uneasily, for the stockbroker. But I said no to the college student because I believed his use of Ritalin would enable him to lead a disorganized and chaotic life. I felt it was better that he examine his goals and life-style rather than cope with his current situation by taking Ritalin.
I believe that none of these patients met my own "official" criteria for ADD. However, given the ambiguity of ADD diagnosis, they might easily have met someone else's. Ritalin would likely help all three patients, but that says nothing about whether they have ADD, because Ritalin can enhance performance for virtually everyone. For me, the question is no longer who should receive Ritalin. As more and more people present themselves or their children for the treatment of behavioral problems, the question has become who shouldn'treceive Ritalin. And this makes me very uncomfortable.
The surge in ADD diagnosis and Ritalin treatment is a warning to society that we are not meeting the needs of our children and that adults are struggling as well. It should serve as a flashing red light for the white middle class--analogous to the deaths of inner-city children from violence and illicit drugs--alerting us to the need to allocate greater resources to children and their families. If we do not address some of these issues soon, we could see a time in the not-too-distant future when a large part of America will be running on Ritalin.
Adapted, with permission, from Running On Ritalin (Bantam Books) . Lawrence Diller, M.D., practices behavioral pediatrics and family therapy in Walnut Creek, California, and is an assistant clinical professor in pediatrics at the University of California, San Francisco.
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