It is another medication morning at Winnebago Elementary School in the middle-class Chicago suburb of Bloomingdale. Three pings sound precisely over the intercom at 11:45 a.m. Principal Mark Wagener opens a locked file cabinet and withdraws a giant Tupperware container filled with plastic prescription vials. Nearly a dozen students scramble to the office for their Ritalin, a drug that calms the agitated by stimulating the brain. These children– all ages, mostly boys–have been diagnosed with Attention-Deficit/Hyperactivity Disorder, a complex neurological impairment that takes the brakes off brains and derails concentration. The school nurse places the pills, one by one, in the children’s mouths, a rite of safe passage before lunch. “Let me see…,” says nurse Pat Nazos, as she checks under each child’s tongue for a stray, unswallowed capsule.
A decade ago, Wagener remembers, only two Winnebago students lined up for Ritalin. He is uncertain how many more “take their meds,” as some students say. Some take time-released pills before school. Others take their doses at off-hours. One boy’s jogging watch is timed to beep for Ritalin at 10 a.m. and 2 p.m. Like many administrators, Wagener is not sure what to make of it. Are doctors just catching this disabling affliction more often? Or has our culture gone so high-baud haywire that we have lost patience with the demanding quirks of our children? For some students, Wagener observes, Ritalin can make the crucial difference between failing a test or sitting still long enough to pass it. But for others, he laments, “they’ve just got an excuse to be bad.”
The Ritalin riddle, a brain teaser for the ’90s, confounds doctors, parents and, sometimes, children. The stimulant can be a godsend for those who truly need it. Pharmaceutically speaking, “Ritalin is one of the raving successes in psychiatry,” says Dr. Laurence Greenhill of Columbia university medical school. Now it’s a routinely prescribed drug at distinguished institutions from Johns Hopkins to the Mayo Clinic, a pill that allows children and a growing number of adults to focus their minds and rein in their rampaging attention spans.
But for those who don’t need it, Ritalin and its generic twins can be useless, or can even backfire. There is no X-ray, no blood test, no CT scan to determine who needs it; diagnosing attention deficit remains as much art as science. There are no definitive long-term studies to reassure parents that this stimulant isn’t causing some hidden havoc to their child. Critics dismiss the drug as just a behavioral “quick fix” for children forced to live in an impatient culture that feeds on deadlines, due dates, sound bites and megabytes. “It takes time for parents and teachers to sit down and talk to kids,” says Dr. Sharon Collins, a pediatrician in Cedar Rapids, Iowa, where reportedly 8 percent of the children are on Ritalin. “It takes a lot less time to get a child a pill.”
WHAT’S CLEAR AMID the debate is that a remarkable revolution has taken place in the care and treatment of America’s children. ADHD has become America’s No. 1 childhood psychiatric disorder. Experts believe that more than 2 million children (or 3 to 5 percent) have the disorder. According to an estimate by the National Institute of Mental Health, about one student in every classroom is believed to experience it. Since 1990, Dr. Daniel Safer of Johns Hopkins University School of Medicine calculates, the number of kids taking Ritalin has grown 21/2 times. Among today’s 38 million children at the ages of 5 to 14, he reports, 1.3 million take it regu-larly. Sales of the drug last year alone topped $350 million.
This is, beyond question, an American phenomenon. The rate of Ritalin use in the United States is at least five times higher than in the rest of the world, according to federal studies. It’s so common in some upscale precincts that a mini black market has emerged in a handful of playgrounds and campuses. “Vitamin R” – one of its recreational names – sells for $3 to $15 per pill, to be crushed and snorted for a cheap and relatively modest buzz.
Ritalin is the brand name of the drug known as methylphenidate. Doctors have discovered that this and other stimulants work like an antenna adjuster for children whose brains crackle with static interference, as if a dozen stations are coming in on one channel. Technically, the stimulant appears to increase the level of dopamine in the frontal lobe of the brain, where it regulates attention and impulsivity. It is a powerful drug, and one that the U.S. Drug Enforcement Administration has classified as a Schedule II controlled substance, in the same category as cocaine, methadone and methamphetamine. Parent groups are now lobbying to ease the restrictions on Ritalin to avoid monthly doctor’s visits. The DEA is opposing them, going so far last month as to enlist the help of the International Narcotics Control Board.
For all the success they’ve had in treating ADHD, many doctors are convinced that Ritalin is overprescribed. “I fear that ADHD is suffering from the “disease of the month’ syndrome,” says Dr. Peter S. Jensen, chief of the Child and Adolescent Disorders Research Branch of NIMH. Teachers – even in preschool – are known to pull parents of active kids aside and suggest Ritalin. Overwhelmed with referrals, school psychologists (averaging one for every 2,100 students) say they feel pressed to recommend pills first before they have time to begin an evaluation. Psychiatrists nationwide say that about half the children who show up in their offices as ADHD referrals are actually suffering from a variety of other ailments, such as learning disabilities, depression or anxiety – disorders that look like ADHD, but do not need Ritalin. Some seem to be just regular kids. A St. Petersburg, Fla., pediatrician says parents of normal children have actually asked him for Ritalin just to improve their grades. “When I won’t give it to them, they switch doctors,” says Dr. Bruce Epstein. “They can find someone who will.”
Finding someone who will is distressingly easy. Doctors themselves admit their methods are too often hasty. Almost half the pediatricians surveyed for a recent report in the Archives of Pediatric and Adolescent Medicine said they send ADHD children home in an hour. With such a rapid turnaround, many doctors never talk to teachers, review the child’s educational levels, nor do any kind of psychological work-up – all essential diagnostic elements (chart, page 54). Most children only get a prescription.
Making matters worse is that, ADHD experts now say, most children need behavior-modification therapy and special help in school. But most of the surveyed pediatricians said they rarely recommend anything more than pills. “A lot of doctors,” says Dr. F. Xavier Castellanos, an ADHD researcher at NIMH, “are lulled into complacency. They think that by giving a child Ritalin, the likelihood of helping him is high and the downside is low.”
What is ADHD? The dis-order is almost as elusive as its name. More than a cen-tury ago, these children were known as “fidgety Phils.” In the ’50s, they were “hyper-kinetic.” The term Attention Deficit Disorder was coined in 1980. “Hyperactivity” was added in 1987 to describe the vast majority. (Roughly 20 percent suffer ADD without the hyperactivity.) But the label still isn’t quite right. “It’s not that they are not paying attention,” says Sally L. Smith, founder of The Lab School of Washington, a private K-12 institution for children with learning disabilities. “They are paying too much attention, to too many things.”
CHILDREN WITH ATTENTION problems are “lost in space and time,” says Smith. Boys are afflicted up to three times as often as girls. They tend to be bright, but are poor students. These are the children who can’t wait their turn. They blurt out answers before questions are asked. They can’t stop wiggling their legs, tapping their pencils. They lose their bookbags, their homework, their tempers . . . not sometimes, but constantly. Decades ago “these children were the outcasts, the losers, the zoned-out kids,” says Castellanos. Many just left school. “I had an uncle who dropped out in the fourth grade,” says Dr. Martha Denckla, director of cognitive neurology at Johns Hopkins. “The explanation was, “Milton was not a student’.” She is convinced he was ADHD. The difference is, today’s schools can’t afford to give up on them.
It’s not that these kids are purposely defiant. They simply can’t control themselves. Debbie Mans realized that her twin boys were more than just rambunctious when they reached preschool. Alex, the wilder of the two, couldn’t handle being with 18 children in his nursery-school class. He would hit the kids, the teacher, and then hurl himself around the room. “The teachers told me he was everything from colorblind to dumb to just plain bad,” says Mans.
She knew intelligence wasn’t the issue: this was a boy who at the age of 3 could put a broken telephone back together. After taking a host of tests, Alex and his twin, Sam, were diagnosed with learning disabilities and ADHD. They had trouble following directions because they could neither perceive them properly nor pay attention long enough to try. The twins, now 7, were given Ritalin to help untangle the gibberish. It has, but no single pill will fix everything. Attention deficit is often only a fraction of a child’s problems. Like the Mans twins, many have additional learning disabilities.
If doctors believe they have found a treatment, they do not pretend to fully comprehend the disorder. For now, scientists know ADHD is not the result of brain damage, wrong diet or bad parenting, as previously surmised. Instead, they have a new set of suspects. Dr. James Swanson, a psychologist at the University of California, Irvine, believes it may be the result of something gone awry in pregnancy, anything from fetal distress to alcohol or exposure to lead in utero. Dr. Lawrence Greenberg, a Minnesota ADHD specialist, estimates that as many as a quarter of surviving premature infants may have ADHD. Other researchers blame heredity. ADHD researcher Dr. Russell Barkley, of the University of Massachusetts, reports that nearly half the ADHD children have a parent, and more than one third have a sibling, with the disorder.
That’s no surprise to the Schmidt family of Rochester, Minn. Over the past three years, all five have been diagnosed with attention deficit. The first case was Stephen, 8, who appeared to be hypersensitive and hard of hearing. “You would look straight at him, and say something, and he’d always say “What?”’ says Joan, 40, his mom. The psychiatrist determined that Stephen, Dennis, 37, and Daniel, 10, all had ADHD. Joan and her daughter, Maggie, 5, were found to have ADD, without the hyperactivity. One child takes Ritalin, another the antidepressant Wellbutrin. The rest take daily combinations of Ritalin for ADHD, plus antidepressants (Prozac, Wellbutrin or Paxil) for accompanying depression.
There are three distinctive signals of ADHD: inattention, impulsivity and hyperactivity. But all can be part of an ordinary child’s modus operandi, too. Most kids get distracted during the day, do impulsive things and bounce off walls. So, how can doctors tell when the behavior means “normal kid” and when it means trouble?
Doctors should take family histories, observe behavior, give cognitive tests and a battery of behavioral exams. They rule out other diseases. And they ask questions. Dr. Edward Hallowell, a child psychiatrist and coauthor of “Driven to Distraction,” asks: “How does he get dressed in the morning? How does he behave at dinner, in restaurants, with other kids?” Eventually physicians make a judgment. “Parents need to make sure their child has a full evalua-tion before the first pill is put in their child’s mouth,” says Dr. Stanley Greenspan, psychiatrist and author of “The Challenging Child.”
Noticing ADD is even trickier. These children are the lethargic daydreamers, “little absent-minded professors,” says Barkley in his book, “Taking Charge of ADHD.” They neither finish their work nor cause a fuss. Many are girls. “People think children with ADD look like baby gorillas, ripping wallpaper off the wall,” says Dr. Betsy Busch, a pediatrician in Chestnut Hill, Mass.
This would all be a lot easier if science could isolate a flaw in the brain to aid diagnosis. Several studies indicate that ADHD brains may look and function slightly differently from “normal” brains. PET (positron emission tomograph) scans indicate that ADHD brains use less glucose – meaning less energy – in the prefrontal-lobe control center for attention and impulsivity. Other tests show less electrical activity in the same zone directly behind the forehead. In the most recent study, NIMH researchers measured the brains of ADHD boys using an MRI (magnetic resonance imaging). Preliminary findings show slightly smaller areas in the frontal lobe in boys who have attention deficit than those who don’t. These are important pieces to the puzzle, but pieces, nonetheless.
After the tests, the anxiety and the judgment comes the pill. It’s ubiquitously called Ritalin, even though the patent expired 23 years ago and generic methylphenidate is widely sold. For Ciba-Geigy, the Swiss pharmaceutical giant which last week announced a proposed merger with Sandoz, another drug goliath, Ritalin remains a glittering profit center. And for patients, a benefit if not a panacea. NIMH experts report that this stimulant is a positive treatment for nine out of 10 ADHD children who require medication. (Two other stimulants, Dexedrine and Cylert, are prescribed less often.) Older children testify to its effects. “Ritalin is like my training wheels,” says Dylan MaGowan, a junior at The Lab School of Washington. “It helps keep me on track.”
Researchers believe methylphenidate juices up the central nervous system. The drug appears to have its own attention deficit, taking effect in 30 minutes and then petering out after three or four hours. Kids usually take five to 10 mg three times a day for prime-time schoolwork. They often take “drug holidays” on the weekends and every few months.
Most experts believe that Ritalin is risk-free, having witnessed no permanent disabilities. “Stimulants have been used since the late ’30s,” says the NIMH’s Jensen, “with no evidence of long-term damage.” But studies are still inconclusive. Adding a flurry of doubts to the debate, the Food and Drug Administration last month released a study of mice that found Ritalin may have the potential to cause a rare form of liver cancer. Since there has been no comparative rise in hepatoblastoma among those on the drug over the decades, the FDA still regards Ritalin as “safe and effective.”
Another story emerges, however, when the drug is abused on the playground. High doses, snorted or injected, can become addictive. The DEA warns that the “smart drug” may become a problem “street drug” in the near future. But aside from one death due to Ritalin overdose last April, the numbers of abusers seem to be next to negligible. Scientists believe it will have a tough time making an appearance on the favorite-party-drug list. Ritalin is too complex to manufacture illegally. It doesn’t create anything near the euphoria of cocaine. Kids on prescribed doses, more often than not, want to stop when they get older. They get tired of the hassle and are often embarrassed by being different. “It’s the opposite reaction to addiction,” says Denckla.
Some side effects have been spotted, even when correct doses are followed. Children often complain of loss of sleep, stomach pains and irritability, particularly when the dose is wearing off. The most distressing, though still fairly rare, problem is facial tics.
NINE-YEAR-OLD JOHN White, as he asks to be called, experieced the worst aspects of Ritalin, from conflicting diagnoses to near disaster. At first, nothing but a taste for Jarlsberg and an exceptional intelligence distinguished the child from others. Then he transferred to a more structured school in the middle of first grade. Within weeks the new teacher was complaining that John was talking out of turn; he wouldn’t concentrate on his assignments. After a battery of tests, a neurologist declared him to be borderline ADHD. “I knew that if we didn’t accept some kind of diagnosis, we wouldn’t get help from the school,” says his mother, Sarah.
Soon after his first Ritalin dose, John began losing his appetite. He stopped sleeping. He would explode with laughter one minute, shed tears the next. “It was scary,” says Sarah. Then, the facial tics developed: eye tics, mouth tics, vocal tics. A hair-pulling habit – one that continued months after she pulled him off Ritalin – left a bald spot on the back of his head. Sarah enrolled him in biofeedback therapy and schooled her son at home for some months. Three years later John is thriving, Ritalin-free. “We choose to look at him as just a very bright child,” says Sarah, “with some quirks.”
When she talks about Ritalin, Sally Smith likes to hold up a ruler. “This is how much Ritalin does for you,” says Smith, pointing to the one-inch mark. “Ritalin makes you available to learn. You and your parents and teachers have to work on all the rest.” Smith’s Lab School in Washington works with the most severe cases of ADHD and learning disabilities. And her staff has developed all sorts of clever strategies to help children get through their days. Teachers put down masking tape in the hallways so the kids will be reminded of where they should stand. Others will divide desk tops into different colored segments: one side for work, the other for storage. Children earn points for self-control and can cash them in for pizza slices or free time.
But The Lab School, and others like it, are extraordinary – and expensive. Most families can’t afford $15,000-a-year tuitions. Experts believe that many kids are languishing in classes that are way too big, on medication that is not quite right. Peter Briger, 7, has spun through several different drugs and as many different classroom settings in the past six months. Ritalin didn’t work. Cylert was no better. Now imipramine, an antidepressant, may be causing breathing problems. It does seem to calm him. Without special attention from teachers, he has yet to demonstrate much focus. Peter spends half his day in Manhattan’s PS 191 in a class of more than 20 second graders. On a typical day recently, he sat on top of his desk, headed for the drinking fountain and banged his head with a three-ring binder. His notebooks were filled with scribbles, decorated intermittently with half-written assignments. “He’s lost so much time,” says Millie Morales, the aunt who has cared for Peter since his mom died and his dad went to prison.
To researchers, it’s a classic “pay now or pay more later” situation. “Studies indicate that those with untreated ADHD are more likely to become alcoholics, smokers or drug abusers than the general population,” says Castellanos of NIMH. More than one third drop out of school, says Barkley of the University of Massachusetts. And, he says, about one tenth of ADHD adults attempt suicide.
In the end, what makes all this debate so urgent is its subject: the nation’s children. The fear, simply put, is that too many who need help may be going unnoticed, untreated, while too many who don’t are getting pills instead of proper care. But there is glory here, too. Children who otherwise would be cast aside are receiving world-class treatment. Obviously, we need more of the latter, less of the former. And to do that, parents, doctors, therapists and teachers need to exercise care. It may be a truism, but one that can too easily be forgotten in a rush to diagnosis.
In a recent survey, almost half of the pediatricians said they spent less than an hour evaluating children before prescribing Ritalin. ..MR.-
Consumption of Ritalin, 1994, in grams per 100 population
Under 1 gram: Hawaii .25 Washington D.C. .36 California .58 New York .78 Maryland .83 New Jersey .85 Oklahoma .87 Wyoming .88 Oregon .90 Utah .98 1 to 1.5 grams: Mississippi 1.01 Connecticut 1.05 New Mexico 1.05 Florida 1.09 Colorado 1.11 South Dakota 1.11 Washington 1.12 West Virginia 1.13 Maine 1.20 Nebraska 1.32 Nevada 1.32 Arkansas 1.33 Rhode Island 1.34 Louisiana 1.36 Kansas 1.37 Illinois 1.41 North Dakota 1.44 Kentucky 1.49 Texas 1.49 1.5 to 2 grams: Pennsylvania 1.51 Massachussets 1.54 Arizona 1.55 Montana 1.56 Missouri 1.62 Virginia 1.74 Idaho 1.81 Vermont 1.81 Alaska 1.82 North Carolina 1.83 Iowa 1.84 Minnesota 1.91 Wisconsin 1.91 Tennessee 1.95 Over 2 grams: Alabama 2.00 New Hampshire 2.02 Indiana 2.15 Ohio 2.17 South Carolina 2.19 Michigan 2.32 Georgia 2.36 Source: Drug Enforcement Administration ..MR0-
