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Time to calm down about Ritalin
Today, almost one in 20 children is diagnosed with attention deficit/hyperactivity disorder, or ADHD.
It isn't a condition like strep throat or pneumonia, which a doctor can confirm or refute using a blood test, stethoscope, or brain scan. Like many other psychological problems, ADHD appears to some critics to be a made-up problem that ''medicalizes" normal behavior. But, in fact, the increased diagnosis and treatment of ADHD may be a major public health success story.
Just as an air-traffic controller supervises the taking off and landing of flights from the runway, the brain's ''executive center" coordinates the entry and exit of thoughts from consciousness. To prevent chaos, a controller must decide which flights are urgent, and which may wait.
In ADHD, the air-traffic controller of the mind fails. Thoughts arrive and take off with no regulation. A child may steal something from a classmate without asking. He or she may repeatedly lack impulse control. The condition has serious consequences. Compared with normal children, those with ADHD later get arrested four times more frequently, develop alcoholism and drug problems more often, and end up with lower-paying jobs.
Understanding how doctors think about ADHD explains why so many children have been treated with Ritalin or Adderall and why that may not be so bad despite media attention to ''overtreatment."
The story begins with Charles Bradley, a Rhode Island psychiatrist who in 1937 gave amphetamines to 30 children who were having various problems in school. According to Bradley, 14 children had a "great increase of interest in school material." However, he lacked a reliable system to classify patients. It was like having chemotherapy but no way to tell which children had cancer.
It was not until 1979 that a psychologist named Robert Spitzer essentially made up a disorder he called ''attention-deficit disorder," (previously called, among other names, ''minimal brain dysfunction" and ''hyperkinesis"). He created a list of specific symptoms to make the diagnosis in children.
These weren't just rambunctious kids. Diagnosed children must have at least six hyperactive behaviors -- such as the inability to sit still, excessive talking, and acting ''as if driven by a motor" -- the onset of symptoms before 7 years of age, impairment of normal school function, and problems at both home and school. Once the diagnosis was more consistent, treatment could be tested scientifically. By 1997, it became clear that affected children responded spectacularly to drug treatment. Researchers at McMaster University in Canada systematically compiled 92 studies and showed that more than 70 percent of patients taking methylphenidate (Ritalin) and dextroamphetamine (Adderall) responded to the drugs.
According to an article in the New England Journal of Medicine in 1999, the drugs cause ''immediate and often dramatic improvement in behavior. Attentiveness improves, and interpersonal interactions [are] less confrontational."
Of course, there are many limitations. Studies suggest the drugs slow a child's growth, in part because some children lose their appetite.
Though Canada recently pulled the extended release form of Adderall from shelves for possibly causing a rare cardiac side effect, US regulators found the connection unlikely and didn't follow suit.
And good, controlled trials of the drugs have only followed children for a few years. No one knows for sure if the drugs will really result in long-term academic improvement and reduce high-risk behaviors as children enter adulthood. And taking the drugs for many years may cause unforeseen side effects.
Furthermore, less than two-thirds of doctors use the right questionnaires to diagnose ADHD, perhaps causing misdiagnosis. Some don't check for other problems like depression, which may be an additional or alternative explanation for school problems.
But for many children who have ADHD and need help desperately, the drugs are a breakthrough. Studies estimate that 6 to 11 percent of all children may have ADHD, and thus may benefit from treatment.
Due to increased awareness and diagnosis, drug treatment for ADHD has been skyrocketing. Maryland, which tracks ADHD cases, saw a sixfold increase in diagnoses since the 1970s.
Despite the popular impression that these drugs are overprescribed, no studies in respected medical journals confirm that fear.
Still, some critics think increased diagnosis of ADHD is society's fault. In his book ''Ritalin Nation," Richard DeGrandpre blames the uptick in diagnoses on our ''rapid-fire culture." Blaming the ''authority of American psychiatry," DeGrandpre assails modern culture for allowing kids to become ''addicted" to sensory stimulation and encourages parents to slow their own lives and spend time with their kids.
This is a noble idea, but has a curious blame-the-parents subtext that doesn't jive with the data.
While behavioral therapy and greater adult involvement have great appeal for treating ADHD, they're less effective than drugs. In a major 1999 National Institute of Mental Health-sponsored project, children getting 35 behavioral therapy sessions, an in-class teaching aide, a summer treatment program, and specialized teacher and parent counseling didn't do much better than another group of children who didn't get such intensive therapy. But a third group on medication did much better, and adding behavioral interventions for children taking the drugs provided some modest benefit.
In the end, we should stop blaming parents, teachers, and pediatricians for diagnosing ADHD. As Malcolm Gladwell write in The New Yorker, the world mourned by critics like DeGrandpre was ''a ruthlessly Darwinian place" where kids with ''neurological quirks" were simply allowed to fail.
Today, many people are no longer content to see these children left behind and they shouldn't feel guilty for using medicine to help them.
Dr. Darshak Sanghavi, a
clinical fellow at Children's Hospital and Harvard Medical School, can be
reached at www.darshaksanghavi.com.
