The Ritalin Generation
Are We Doping the Kids?
HighGrader Magazine September/October 1998
by Brit Griffin
Kid climbing the walls? Acts as if school is the most boring place on the planet? Are you getting a few too many calls from the teacher? If any of this sounds familiar, your boisterous boy is probably a shoe-in for an ADHD diagnosis. ADHD - Attention deficit-hyperactivity disorder - is all the rage these days, with everyone from the doctor, parent and next door neighbour willing to point out the `hyperactive' kid.
Close on the heels of a diagnoses of ADHD comes ritalin, the trade name for methylphenidate (MPH), the most commonly prescribed medication for ADHD children. Parents praise it, teachers appreciate it and doctors prescribe it. So if ritalin is so good for your kid, how come its being peddled inside prison for a dollar a pop?
The answer is simple: ritalin is a psycho-stimulant, a speed-like narcotic. Individuals using it for non-medical purposes can either pop the pill or crush it up and snort it for a bit of a buzz. But it isn't illicit use that is pumping up drug sales.
Health Canada estimates an increase in ritalin use of 547% since 1990. According to IMS Canada, a Vancouver-based health information company, the number of MPH prescriptions in Ontario has almost quadrupled in the same time period. IMS findings also indicate a whopping 9-fold increase in the Prairie provinces. Are we looking at an epidemic or is something seriously wrong in how we understand and treat children?
Who's On it?
"If Prime Minister Jean Chretian called today and asked how many kids were taking stimulants on a daily basis in Canada, no one could really tell him," says David Cohen, a teacher of social work at the University of Montreal," This is a significant public health issue and it is almost a scandal that we don't know."
After an exhaustive search of ritalin use in the Province of Quebec, Cohen was only able to find out information on those receiving social assistance 12% of all kids receiving welfare were also receiving stimulants. The provinces do not keep track of drugs prescriptions except for those on social assistance. But by all estimates, the use of the drug is sky-rocketing across North America.
Cohen recently conducted in-depth interviews to determine how ritalin comes to be prescribed. After talking with parents, teachers and doctors, Cohen found that teachers, not doctors, were often the "engine" driving medicalization. "According to parents and physicians, teachers identify and diagnose children, propose the use of medication to parents and, in some cases, the schools require the doctors write a prescription." Although describing the findings as limited due to the small scale of the study, Cohen concludes that when it comes to ritalin use, the system is functioning "irrationally".
But for parents who may be at their wit's end with an unruly child, ritalin often seems more like a godsend. After all, they are reassured by the experts that it is safe, parent support groups advocate its use and the drug gets results. Working almost immediately, ritalin renders the child compliant, focused and calm. A child who has been hopping up and down in his seat can pay attention to school work. For both parents and teachers it is probably a welcomed relief.
But it's relief with a price. Despite claims by many experts and parents groups that the drug is safe, Cohen says there is definitely reason to be concerned. "Ritalin is a stimulant. These are drugs with a long history of abuse. They are also extremely addictive drugs. These are illicit drugs (when used by adults), but when they are given to children suddenly they become very useful. We tell ourselves `oh, no, it can't hurt them, the doses are too small, there are no documented cases of addiction.' It's just dismissed. But these have powerful abuse potential."
Advocates of ritalin argue that the drug is not addictive. The American Drug Enforcement Administration (DEA) disagrees. In 1995 the DEA issued a Statement that described ritalin as a potentially dangerous narcotic: "Every indicator available, including scientific abuse liability studies, actual abuse, paucity of scientific studies on possible adverse effects associated with long-term use of stimulants, divergent prescribing practices of U.S. physicians and lack of concurrent medical treatment and follow-up, urge greater caution and more restrictive use of MPH."
Greater caution in the use of ritalin is important in the face of mounting evidence of ritalin abuse. Although advocates of the drug dismiss fears as exaggerated, a recent Wisconsin study (Journal of Development and Behavioral Pediatrics, 1998) found 16% of ADHD children had been approached by classmates wanting to score some ritalin. The DEA also found that "...a significant number of children and adolescents are diverting or abusing MPH medication." In 1995, a group of teens were drinking and experimenting with crushed ritalin when one teen went into cardiac arrest and died.
Even where the drug is properly administered there is evidence that ritalin may affect the heart and in extreme cases be toxic to heart muscle. It can also cause brain shrinkage and stunt growth. Commonly it produces a `zombie' like or `flattening' behavior in kids. It can cause stomach aches, hair loss, skin rashes and, in rare cases, facial tics that persist even when the medication is discontinued.
Kids on ritalin suffer from insomnia and loss of appetite. One of the riddles of ritalin is how a tired and hungry child can pay attention in school. But taking a child off ritalin can result in a re-bound effect, where the child becomes even more agitated. Usually enough to convince the parent that their child really does need the drug.
Children as young as four may now be starting on the medication. Some ADHD advocates also suggest that this childhood disorder may continue into adulthood, hence the continued use of ritalin. Yet no long-term studies seem to have been done. One expert maintains that the only `long-term' study he was aware of was conducted only over a period of 14 months. Even the makers of ritalin admit that the long-term effects are not known.
Cohen believes that the escalating use of ritalin needs to be closely examined. "We have to ask why are the drugs given. What is going on with kids that we need to drug them? After all, we are talking about a lot of children one in ten, maybe one in twenty. What problems are children manifesting now that they didn't manifest before or that we didn't have to resort to drugs. What kind of problems do we have that we have to mass drug children?"

Attention Deficits
The reason for the rise in ritalin use is the growing diagnoses of children with ADHD. Described by rather vague and all-encompassing symptoms of inattention, hyperactivity and impulsiveness, ADHD is considered by many experts in the field to be a widespread disorder affecting principally boys.
Dr. Laurence Greenhill is an ADHD researcher at the New York State Psychiatric Institute at Columbia University. He does not seem overly alarmed by the increase. According to Greenhill, people are being kept on the drug longer and there is a growing number of girls being identified. But he still admits there has been at least an 2.5 increase in the number of people diagnosed with ADHD.
"It is controversial, this number of individuals being identified. Does this mean that the disorder is spreading like an epidemic or are the people who are diagnosing the disorder finally getting the message and accurately identifying the number of individuals in the community with ADHD?"
If more mental health professionals are getting the message about ADHD, the advocacy group CHADD (Children and Adults with Attention Deficit Disorder) would like to claim some credit for that. CHADD is a parents support group founded in Florida in 1987 in response to the "frustration and isolation experienced by parents and children with ADD". Their growth has been as meteoric as ritalin use. Within a decade the group has grown to 32,000 members in 500 chapters across the U.S. (there is a similar parents group in Canada called Attention Deficit Disorder Organization). CHADD takes the lion's share of credit for spreading the word about ADHD.
If CHADD is to be believed, more children, not less, should be on ritalin. A quick visit to the web site would leave a parent convinced that ADHD is widespread, under-diagnosed and seemingly out of control.
Greenhill says that pinning down the particularities of ADHD is a very complicated matter. He points to two recent epidemiological studies. One, done on a sample of 1200, found that only one of eight children identified with ADHD were getting treatment. Another with a sample of 3000 found most kids who had the disorder weren't getting the treatment and most kids who were getting the treatment did not have the disorder.
Why the confusion? Partly it's in the the open-ended "symptoms" of what constitutes ADHD. Cohen is quick to point out that there is no physical test to diagnose ADHD, and as his study found, `hyperactivity' is a plague almost anyone feels comfortable identifying.
"Is it a disease with a biological basis? No. Who gives the diagnosis? Well, everyone does teachers, parents. You hear ADHD being mentioned all the time but the question remains, is it just a bunch of symptoms?"
And what are these symptoms? Fidgeting. Inattention. Day-dreaming. Interrupting others and not waiting one's turn. Nothing on the list of behaviors seem surprising given that we are talking about children. But according to many experts, any child exhibiting a solid majority of the identified symptoms (see box) is suffering from ADHD.
The disorder is often described as a neurobiological disorder by `bio-psychiatrists' who attribute mental illness to biological causes and down-play social causes such as family environment or social conditions such as stress or poverty.
Cohen has difficulty understanding how ADHD can be called a "genetically transmitted neurobiological disorder". "This has simply not been established. I don't know how plain one can be but at the very least it is an error to say that. If it had been established as a genetic neurological disorder there would be a slew of Nobel Prizes and it would be called a neurological disorder in neurological textbooks."
Dr. Harold Taukulis is a psychology professor at the University of New Brunswick. He recently teamed up with a pediatric neurologist to conduct a study on the effects of ritalin on children with ADHD. As he explains it, ADHD isn't what one would think. "The children aren't bouncing off the walls because their brain is racing, but are bouncing off the wall because their brains aren't racing. They are compensating."
Taukulis describes the diagnostic techniques as still fairly `crude' and wonders if too many kids are getting the label unnecessarily. He points out that most diagnoses are based on reports by parents and teachers but that probably the symptoms haven't been observed by the doctor in his office.
"I suspect there is some inflation there," says Taukulis, "there may be some misdiagnoses. It's like depression in some ways, you know. To a certain extent it was a phenomenon created by the drug companies who wanted to sell anti-depressants. I know it sounds cynical and I'm very sympathetic with people who experience clinical depression. But what I am saying is that something similar may be happening with hyperactive kids. Any behavior that is disruptive, I mean I've seen kids who maybe just aren't very good academically, or children with interests outside the classroom. You can say this child is hyperactive, well, I'm sorry, but this child is simply not interested in what you are doing."

Growth Industry
ADHD may or may not be a neurological disorder, but it certainly is a North American one. One study found that only one in 2000 children in Great Britain were identified as ADHD while in North America it was one in twenty. Cohen says the discrepancy is due to the European tendency to give more weight to social causes and a reluctance to rely on medication.
"There is a hundred times as many (children being diagnosed in North America than in Europe).You have the same child, manifesting the same behavior, but the British mental health professional will be much more reluctant to say the child has ADHD."
According to the DEA, the U.S. manufactures and consumes five times more MPH than the rest of the world combined. That's good news for pharmaceutical giant, Novartis.
Prior to 1996, ritalin was produced by the Swiss corporation Ciba-Geigy. A merger with Swiss-based Sandoz created Novartis, one of the big three in the world of pharmaceuticals. Ritalin is just one of the products in its corporate stable: the company also cranks out a wide range of items from herbicides to Gerber baby food. 1996 profits were in the range of a $1.5 billion and its research and development budget is upwards of $2 billion.
Novartis has been very active in promoting awareness of ADHD. Last fall Novartis provided ADHD educational material to 11,000 U.S. school nurses in order to "ensure appropriate diagnoses and treatment of this disorder, including the appropriate use of any indicated drug therapy."
In 1995, CHADD came under fire in a PBS documentary for accepting on-going grant money to the tune of a million dollars from then Ciba-Geigy. (CHADD did not reply to HighGrader's request for information on their funding - see Breggin review on page 20 for more info).
Cohen says it is not difficult to understand why parents want to believe that it is a biological problem.
"Families historically have always been blamed for the problems of their off spring. And families were very ashamed of their contact with mental health professionals. That was the dominant way until the mid 1970s. Now families have become partners and the discourse has changed. Now we no longer blame families. So who do we blame? Well, we'll blame the genes."
Families know, says Cohen, that if biology isn't to blame, they will be. But he maintains that we have to move away from trying to blame someone or something, and instead take responsibility as parents and teachers who care about the child.
"This is not to dismiss the reality that some kids may have real pain or very low self-esteem and may cause some real problems and shame for their parents. But we need to ask some of the larger questions because they are just as important as the smaller, clinical questions."

Larger Issues
Neil Postman is a Professor of Communications at New York State University. He has written extensively on modern culture and media, notably his critiques of television (Amusing Ourselves to Death) and modern society's assault on childhood innocence (Disappearance of Childhood).
"There are some disorders that emerge at certain times, " explains Neil Postman, "that is to say the behaviors might be there but are not significantly widespread enough to give a name to it. Now this particular disorder is related, I understand, to the inability of some youngster to pay attention, to be immobile for long periods of time. Well, this was also a problem back in the time of the philosopher John Locke who wrote that in order to educate children you first must get them to be immobile for long periods of time, which is not natural to them."
What is natural to a child is germane to the discussion concerning what is ADHD. It is possible that children have not changed, but the society in which they are asked to function has. The changes in family life have been many and varied.
Twenty or thirty years ago, most families did not have the public life they do now. Going out for dinner was a rare treat and most time was centered on the home and neighbourhood. Children were less often called upon to be model citizens. Children enjoyed much more physical freedom to `run wild in the streets'. School behavior was managed by social sanction and the threat of punishment - tedium was endured.
The last decade has also been characterized by a breakdown in the family that is so commonplace as to not raise an eyebrow. Single-parent families, mostly with mothers as the primary parent, are becoming more of the norm.
This absence of real, active fathers has also been pointed to as a partial explanation for why 80% of the kids on ritalin are young boys. This lack of a stable male role model creates what one expert calls D.A.D.D, dad attention deficit disorder. Studies show that Caucasian middle-class boys are by far the most likely candidates for an ADHD diagnosis.
Cohen is concerned. "Someone asked me `Are we trying to emasculate our boys'? Is it not politically correct to be a boy anymore?" He believes that society no longer makes room for the rambunctious boy. Poor Tom Sawyer would have been on ritalin faster than he could say Huckleberry Finn.
Any discussion of attention deficit should surely lead to an examination of television. Some individuals working in the field of ADHD have described it as a symptom of a `short attention span' culture. Postman has been a vigilant critic of television for many years. "If you just measure the average length of a shot on network T.V., last I had anyone check, it was about 3.5 seconds. Commercials are about 2.5 seconds. So that means that on average every 3 seconds you would have a new image to process and a new point of view from with to see something. People, especially young people, expect change very rapidly and TV is partly responsible for that." Postman estimates that before a child is in the first grade he or she will have watched 5,000 hours of television.
Postman says he has college students who can't sit through the slow pace of movies made in the 1940s and 1950s.
Postman wonders if the ADHD phenomenon is also indicative of another element of North American life. "Part of this is the idea that through technology there is some sort of scientific product that can cure any of our maladies. This is a very strong strain in American culture. If there is some kind of behavior that is causing difficulty for the parents and children, well, there's a drug that will fix that up. This is a society that has given alot of sovereignty to technology to handle our problems."
The rampant growth in the market of ritalin should at the very least cause mental health professionals, parents and teachers to examine why so many of our children are being drugged. No doubt, some children do suffer from serious mental and emotional problems, but how many others are being caught up in the dragnet?
ADHD is changing our lexicon of childhood. Where once boys were rambunctious, now they are hyperactive. Day-dreamers now suffer from inattention. The over-eager student who blurts out answers lacks proper self control. Only time will tell if ADHD is symptomatic of an epidemic, or a very worrisome experiment in social control.

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