Doctors, parents and teachers are drugging more kids to help them succeed.
Thursday, May 27, 2004
Ritalin always works. The “meth” in its real name—methylphenidate hydrochloride—indicates that it is a stimulant, a type of speed, so of course it provides an uplift to kids suffering from depression. But it also works to calm hyperactive kids. It cures emotional withdrawal and also narcolepsy. Ritalin is a kind of wonder drug.
The most common problem that Ritalin is called on to fix is ADHD, or Attention Deficit and Hyperactivity Disorder. ADHD kids generally can’t sit still, or they can’t shut up. They are the class clowns and the rule-breakers. Often intelligent, but usually poor students, ADHD kids’ biggest problem is with concentration. Far and away, the majority are boys.
Boys on Ritalin usually focus better, complete their homework more quickly and are more obedient. Like a steroid for success, Ritalin boosts kids to better grades, sports accolades and music awards. The positive effects of Ritalin and similar drugs have led psychiatrists, parents and society to accept and rely on them, fueling the creation of a multi-billion-dollar industry.
Until 30 years ago, there was hardly any such a thing as a “mental disorder” in children. But today, psychiatry recognizes a staggering 300 disorders. Three kids in every classroom in America are now thought to suffer from some mental illness. ADHD is the most common of these.
The disorder is not only relatively new—it doesn’t even exist in most of the world.
In 1996, the United Nations voiced concern that 10-12 percent of adolescent boys in the US take Ritalin, far more than anywhere else in the world. Britain has recently outlawed the use of anti-depressants for children. Almost 90 percent of the Ritalin produced globally is consumed in the US. American kids take an average of four times more medication than other children.
There is some debate as to whether all of this drugging of children is a good thing. The debate has reignited the age-old nature vs. nurture argument.
In the March 1996 issue of the Journal of the American Academy of Child and Adolescent Psychiatry, researchers proposed that ADHD is a “genetic neurotransmitter dysfunction,” an inherent imbalance in the chemical activity that controls firing synapses in the brain. In other words, ADHD is a physical problem—a brain problem—that needs a physical solution.
The “nurture” argument, on the other hand, says that ADHD is more likely caused by a child’s environment. Some psychiatrists believe that hyperactivity can be expected from kids who start their day with marshmallow cereal, pop tarts and a Coke, or from kids struggling with the fast pace of modern life. Or, that ADHD is caused by familial problems, academic pressure, and osmosis of adult mental disorder, which is also at an all- time high.
The reason that the US gives copious amounts of drugs to its youth may have less to do with mental health, and more to do with contemporary American culture.
Child psychologists who favor the “nurture” theory of ADHD point out that the demands on kids today are enormous. There are harder classes, harder-working parents, and fewer local relatives to provide support networks. As more and more kids fail to meet the grade, drug companies capitalize on their need to succeed.
Today, the psychiatric industry markets drug solutions to parents who, worrying about their children’s success, are eager buyers. Science has backed the switch to drug cures, saying that disorders like ADHD are caused by biology and genetics rather than external factors. Where yesterday’s child psychiatrists talked to kids (and their parents), the so-called “talking cure” is gone. Today the cure for childhood trauma is drugs.
Larry Diller, a behavioral developmental pediatrician from
Walnut Creek who recently discussed the topic on CNN, says
that of the four to five million kids he believes have been
diagnosed with the disorder, only a “small minority” have
“biological” or “hereditary” ADHD. The rest may show symptoms,
but do not really have it. “In the 21st century,” he says,
“Pippi Longstocking, Tom Sawyer and Huck Finn would certainly
be put on medication.”
A BOY’S LIFE
Sitting at one of the midget tables in the classroom where his mother teaches is a boy with dark hair. He is wearing Velcro sandals, as he just finished kayaking with his dad. He seems calm, even bored.
Max (not his real name) is 14 years old and has been on ADHD medication since he was five or six. This Tuesday afternoon he is on two forms of medication: Concerta, a more powerful and longer-lasting stimulant than Ritalin, and WellButrin, an anti-depressant.
Max speaks slowly and flatly. “I think I’m happier when I don’t take it,” he says.
“Sometimes I have no will to take it, and sometimes I don’t really care. If you take it and don’t eat till lunch, you’ll have a pretty big headache, and you get stomachaches. It can change your mood in certain times from being happy to sitting around and getting down about things. You just don’t think you need it.”
Max complains that his mom is too pushy with the medication. “I think my mom wants me on it all the time.”
If he didn’t take medication, Max says, “My grades would probably be a little lower—but I’d feel better at school.”
He says it is hard to explain what it’s like to be on ADHD meds.
“I feel nothing at the moment,” he says, “but when you look back at it, it changes decisions. Like if you have to decide one thing more common sense versus what you want to do, like if you want to go somewhere when you should do your homework, on meds you’ll make the right decision.”
Max thinks he could be better at “anything” without the medication.
“I’m more relaxed when I don’t take it, but I don’t pay attention as much. Social stuff could be better, because you’re probably more happy.”
He seems to have mixed feelings about the drugs.
“There are kids you can tell should be taking it. If you put anyone on it, it would help to some extent.
“If you’re on it you’ll just be staring at the book. When I’m not on it I can read better. It’s ‘cause I can get into it more. I can actually think about the book. On it, you can read something and it will have no meaning to you.”
During our first meeting, Max seemed shy, humorous, smart and mature for his age.
In our second interview, Max was not on any drugs.
“It’s like night and day,” his mother forewarned me. “When he’s not on his meds he swings from the trees.”
He was eating fajitas in the kitchen of his mom’s house in Pebble Beach. It was Sunday and he had slept in and seemed in a good mood. He looked like he might go on eating for a while, until his mom told him he had eaten enough and that we should do the interview. He took me downstairs and showed me his room. It was immaculately clean. He said his mother insisted it be that way. We sat down in the workout room by a treadmill.
Max reiterated his hope that he would not take medication forever.
“It depends on what kind of job I get,” he said. “I’d like something where I don’t have to concentrate all day or sit in an office.” He said he thought about being “a small business owner, like a restaurant or a tourist shop.
“Mom is being all weird about it,” he said about his daily use of medications. “She makes herself crazy. I’m taking three different things—extended release Concerta, and a fast one, and stuff that has to stay in me. I dunno, I don’t pay attention to that stuff.”
We joked around and Max showed me how fast the treadmill could go. We took turns sprinting on the thing.
By and large, there seemed to be very little difference in
the unmedicated Max. Perhaps he was slightly more energetic,
and in a better mood, but then, kids love the weekend.
For Larry Diller, who has written two books on ADHD (Should I Medicate My Child and Running On Ritalin), Max’s ADHD most likely falls on the “nurture” side of the disorder spectrum.
“This kid is not seriously disabled,” he says, “but probably has some biological factors that make him more susceptible to the disorder. In a better environment he might do fine.
“This is not to say the parents aren’t doing a good job. Whether this kid has a disease is another question.”
Diller believes parents ought to try alternative solutions so as to rule out biological causes.
“The single most underused methods,” he says, “are involving the fathers, and organizing the parents and the school.”
He says many non-drug treatments are too focused on the kid.
“In many cases you can talk to the kid till the cows come home but it’s not going to change anything—you have to work with parents and teachers to accommodate the child.”
If Diller is right, then Max may not need to alter his brain chemistry as much as his environment. The tendency to define this and other mental disorders as physical, Diller calls the “medical model.”
He says psychiatry has had to fight to maintain a place in the mainstream medical community, which, increasingly, only acknowledges physical problems and physical solutions. Diller believes the medical model now “reigns supreme” due to historical and economic pressures on psychiatry.
Richard Morriss, a school psychologist who worked with the Monterey Peninsula Unified School District for 35 years specializing in ADHD, agrees with Diller. Morriss says that in his experience in the area, ADHD has increased in levels on par with national figures.
“You will have trouble finding any local statistics about this,” he says, “but over 35 years I saw an increase from maybe a few kids a year coming into my office in the ‘60s and ‘70s, to a few students every week in the ‘90s.
“ADHD is misdiagnosed in well over fifty percent of the cases. Kids who just can’t sit still in school are being medicated.”
While Morriss, like Diller, has prescribed Ritalin for years, he described it as an extremely difficult decision. Around here, he says, most clinicians are not so careful. Morriss believes that the central cause for the eruption of so many new ADHD cases is that “diagnosis methodology is poorly enforced.”
The American Psychiatric Association (APA) has an 18-symptom diagnostic criteria, which it lays out in the Diagnostic and Statistical Manual, or DSM. According to the DSM, patients should be observed in their natural environment over many months before a clinician can diagnose them with ADHD.
“Most pediatricians haven’t heard of the manual,” Morriss says, “and even if they have, they don’t have the time to follow the requirements.”
It wouldn’t be surprising if doctors didn’t bother carrying out the lengthy checkups for each of the 18 symptoms listed in the APA Manual. In a recent survey of pediatricians, published in the Archives of Pediatric and Adolescent Medicine, nearly 50 percent of doctors admit to spending an hour or less with a child before making a diagnosis and prescribing medication.
What makes quick evaluations disastrous is that ADHD is
especially tricky to diagnose. Its three central
symptoms—impulsivity, hyperactivity, and inattention—are
common to young people, especially boys. And the synaptic
mis-firings that allegedly cause the disease are impossible to
spot, even with a CAT scan. Deciding who has ADHD is
A TRUE BELIEVER
Max’s mom, Susan (not her real name), teaches special education and works with ADHD students. She is tall and loquacious, with bright blue eyes, short hair and high energy. Abundantly enthusiastic about the success of medication, it was her decision to put Max on meds.
“In first grade he was ahead of everyone but was bugging the other students,” Susan says. “His father was in denial when it was obvious. Max had all the symptoms…but [his father] could not accept it at the beginning. I said, ‘Let’s not wait.’ I took my son and went through the checklist. It’s difficult to do that.”
Being aware of the disorder through her profession, Susan says she medicated her son because she was worried about him. Some kids with the disorder she says, can “feel like failures. They wear through friends quickly or go to kids that are like them. These kids frequently use drugs and alcohol to self-medicate.”
Not so long ago, Susan says, Max was “bombing out of school.” She started finding his medication hidden around the house and in his pockets. Now she stands by his bed each morning to watch him, lest he try to “fling it.”
“When he gets up he’s tired and makes bad choices,” she says, “when he takes it he’s fine.”
Susan says her son doesn’t have a learning disability. Without meds, she says, he succeeded in spelling bees and scored high on standardized tests, but was not doing well in school.
Since getting back on medication, “he gets A’s and B’s in school and he’s no longer at the back of the room,” she says.
His sports performance, too, has improved.
“Before he started taking meds, for baseball, he was all over the place. He would do acrobatics in the field and couldn’t concentrate. He was sitting the bench. So I called his coach. But now he pitches and has been on All Stars most years.
“When he focuses he’s great, and it means so much to him.
“Still, we have to sit with him if he has homework. My son is different than other kids on meds because of his high metabolism. It’s a constant battle. He goes up and down. It’s amazing how much we have to give him.”
Last summer, when Max didn’t take his meds at band camp, she says, it was a disaster. “He was like the class clown,” she said, “impulsive, shouting out in class.”
Max’s mom says her son “likes the feeling of being out of control and being really free.” The drug “controls him.” But, she says, “[Max] doesn’t like the side effect of nausea on the bus ride to school. By the time he arrives he is totally nauseated.”
Other kids, she says, get headaches. “It takes away his appetite, so at night [when the drugs wear off] he eats and eats and eats, even in bed. One reason he didn’t want to take medication is because he didn’t want to be the runt.”
It may be that Max’s story proves the “nature” argument, that ADHD is biological and hereditary. Susan says that her husband, Max’s dad, “just tunes out,” so that calendar deadlines for bills and work slip out from under his attention.
In fact, six years ago, a year after Max started meds, his dad, a psychologist, also began taking ADHD medication, at 40 years old. Susan and her husband are now separated.
Susan goes on to say that her husband’s brother would be more successful if he took ADHD meds. “And I’m sure his father was hyperactive.
“I probably should be on it,” she says. “I’m on the hyper
side but I am highly focused and organized. I’m more obsessive
compulsive but I put it to good use. I have compensated for
MOTHER’S LITTLE HELPER
Perhaps Susan is correct, and three generations of men in Max’s family suffered from this newly discovered malady. But both Morriss and Diller believe that of the spectrum of causes of ADHD, including genetics, most diagnosed cases are actually caused by a child’s surroundings.
The “nurture” argument, which says the disorder is sociological, precludes medication as a fix-all.
If children’s difficulties stem from social pressure to get good test scores as a prerequisite for good colleges and good jobs, and any unproductive behavior instantly qualifies them as “out of order,” pills are probably not the answer.
Parents, too, feel the pressure for success. And with their busy schedules and kids in daycare, they often have little time to deal with “glitches” in their kids.
Teachers overburdened with large class sizes may be quicker to recommend that parents put unruly children on medication, if not for the child’s success, then for the success of those around them.
Under new changes to the school system, the academic curriculum has also been squeezed into 12 fewer months than previously and teachers have been made personally responsible for the success of each student.
Subtle comments from teachers and after-school counselors can pressure parents to medicate their children.
As ADHD and Ritalin have become more widely accepted, parents have grown increasingly ready to accept, depend on and even chase after the drug to solve their children’s difficulties. Ritalin means less hassle and better grades, hitting two major parent needs with only one 25-cent pill.
Parents then pressure doctors—Morriss says that parents
would sometimes grow angry if he refused to diagnose their
kids with ADHD—and soon the whole eager coterie is staring at
the medicated child, waiting for output.
POLITICS ON DRUGS
The Centers for Medicare and Medicaid Services, an agency of the federal government, estimates that overall spending on prescription drugs rose 16.4 percent last year, to $142 billion. Spending on drugs for ADHD have increased 122 percent over the past four years, and accounted for 8 percent of the total spent on prescription drugs for children, and adds up to almost $2 billion.
Such vast sales have led drug companies to go political. During the 2001-2002 election cycle, drug makers contributed $5.7 million to congressional candidates, with nearly 70 percent going to Republicans.
A more subtle force plays an even bigger role in the spread of psychiatric medication for children, according to Diller.
“In the 1970s psychiatry was in danger of being pushed out of modern medicine because it was based on a Freudian model that made research and testing almost impossible,” he says. “There was a revolution in thinking that shifted from blaming Johnny’s mom to blaming Johnny for the problems.”
By adapting the “medical model,” Diller says, “psychiatrists retained their air of scientific ‘professionalism,’ and their services remained an insurance-covered treatment.
“The biological revolution in American psychiatry was hijacked by the drug companies in the 1990s,” he says. Suddenly, “drug companies saw it to their advantage to maximize and control research and professional education in psychiatry, and modern medicine.”
Diller believes that every leading academic researcher has some tie to a drug company. Pediatricians too, have abandoned “talking” for “prescribing,” which can earn a doctor, on average, two to three times more money, he says.
Diller is now even skeptical of scientific journals. “I think they are being influenced by the drug companies,” he says. The only studies he tends to believe are governmental, but recently even these have come into question. “The NIH (National Institute for Health) now has been found to do moonlighting contracts with drug companies,” he says. Also, he explains that the government provides a five-month patent extension incentive to drug companies that conduct research on new drugs, but there is no obligation to present the results. Thus studies unfavorable to stockholder interests get withheld. If Diller is right, the government is indirectly aiding slanted research results.
Finally, Diller believes the dominance of drugs in psychiatry has been cemented by “direct propaganda in magazine ads and TV by drug companies,” after direct marketing to the public was legalized in 1997.
At that point Diller says “the invisible hand” of capitalism took over.
Meanwhile, there is very little money available to counteract the forces pushing medication for children.
Parents, teachers and psychiatrists might be less inclined to opt for the magic Band-Aid of Ritalin and other drugs if there were more funding for the expansion of alternative treatment programs and research. Education could probably also bring a significant reduction in cases, as well as special-care procedures in the YMCA and other after-school programs. Identified children could then be given the opportunity to improve without drugs.
Morriss says there are hardly any non-drug solutions offered on the Peninsula. Schools don’t have the money for separate instruction and, in line with most after-school programs, the Monterey YMCA doesn’t offer its counselors any training on how to cope with ADHD kids. Morriss did run a Monterey Children with ADD (CHADD) chapter for parents, but it closed five years ago when Morriss retired.
There is still a Salinas chapter, however, and the Family
Service Agency on Pearl Street in Monterey offers affordable
services and counseling for parents, but those may be the only
fixed resources. The first place for parents with questions to
go is probably to the school psychologist. Morriss highly
recommends two videos for parents as well, which, he believes,
can help them maximize their non-drug alternatives before
turning to medication. Both were created by a psychologist
named Tom Phalan; the first is called 123 Magic, about
parenting 2-12- year-olds, and the second is called
Surviving Your Adolescent.
There are many problems with relying on drugs to normalize a tenth of America’s children. Studies show that in the long run, kids who take Ritalin have recurring problems. Never having to develop the psychological mechanisms to deal with their high energy, ADHD people who are treated at a young age usually remain reliant on the drug.
Furthermore, the psychiatric community and society at large have yet to recognize the positive characteristics of ADHD people.
Morriss says the symptoms of ADHD can help patients succeed in everything from stand-up comedy to sales— or other fast-paced, high-energy jobs that require people who are not afraid of the lime-light.
The social proclivity of ADHD people has also been identified as crucial to forming and maintaining the community links that bond us together. The decline of community in the US through urbanization and industrialization could explain the sudden identification of such individuals as “problematic.”
Still others say ADHD people may be the “hunters” in a “gatherers” society.
The incredible upswing of ADHD diagnosis is not an isolated phenomenon. A million children are also diagnosed with bipolar disorder, and thousands of others with obsessive-compulsive disorder, social-anxiety disorder, post-traumatic stress disorder, pathological impulsiveness, and sleeplessness, to name a few. Ritalin is just one name among a growing list of medications including Zoloft and Celexa, Seroquel, Tegretol, and Depakote, with more coming along all the time.
It seems unlikely that there is something so fundamentally wrong with one in ten children as to warrant medication. The billions spent annually on prescription drugs might be spared if the government were to develop alternative programs for ADHD students. Besides, unexpected rewards might result if society were to harness rather than oppose these abnormal minds.