Ritalin: miracle drug of cop-out?

Public Interest, Spring, 1997 by Ken Livingstone

Imagine yourself sitting in a classroom - say, a fourth-grade social-studies class. There is a teacher at the front of the room, but a groundskeeper mowing grass outside captures your attention instead. When the mower moves away, however, you feel bored and restless. Pretty soon your swinging feet slam into the seat in front of you. The attentive student sitting there yelps and the teacher interrupts the class to ask what the problem is. This sudden activity jolts you back into focus; at least something interesting is happening. You're beyond feeling embarrassed about being the center of this kind of attention. It happens all the time, and you have quite a reputation for this sort of thing. And besides, it isn't really your fault. They all say you probably have ADD or ADHD or something like that and can't help but act this way. It's just the way life is for some kids.

Scenes like this one, with endless variations, are played out across the United States every day in classrooms, on playgrounds, and in homes. The American Psychiatric Association's (APA's) Diagnostic and Statistical Manual, Version IV (DSM-IV), says that when a pattern of such behavior persists for six months or longer, and occurs in at least two different settings (e.g., in the classroom and at home), it may meet the criteria for a diagnosis of Attention-Deficit/Hyperactivity Disorder (ADHD). The combination of attention deficit and hyperactivity is common, but either can, and often does, occur without the other. Boys are between five and nine times as likely to be diagnosed with ADHD as girls, although many researchers are now suggesting that there may be many more girls who have an attention deficit but aren't diagnosed because they aren't hyperactive or impulsive and so don't cause the kinds of problems that lead to parental or teacher intervention. And ADHD is no longer associated with just middle childhood; it is being diagnosed with increasing frequency in teenagers, adults, and even preschoolers.

Ritalin's supporters and critics

What, exactly, is ADHD? The APA considers it a mental disorder, which it defines as a pattern of thought and behavior associated with distress and impairment of functioning resulting from some dysfunction within the individual. In the case of ADHD, the most quickly noticed behavioral and psychological patterns are the hyperactivity and inattentiveness described above. Such children typically don't finish their homework, can't complete class assignments or exams in the time allowed, and are generally disorganized and forgetful. About one in five, most often those with a diagnosis of impulsivity or hyperactivity, tends to be socially inept and isolated due to an inability to understand or follow the rules that govern civil human interaction. The adult version of the disorder shows the same patterns, rescaled to the tasks and settings of the grown-up world.

At first glance, these behavioral patterns seem to count as impairments of functioning. If that is so, then it isn't a big step to conclude that some intervention is warranted. But the ADHD diagnosis has become highly controversial in recent years, with much of the controversy focused around the increasing use of the drug methylphenidate hydrochloride, an amphetamine, more popularly known by its trade name "Ritalin," as the treatment of choice.

Although Ritalin is sometimes used for the treatment of other conditions, ADHD accounts for the overwhelming majority of prescriptions for it, and these have proliferated since 1990. Figures published in the August 12, 1996 issue of Forbes magazine show a fourfold increase in the rate of methylphenidate consumption between 1989 and 1994, a rise so dramatic that the U.S. Drug Enforcement Agency asked the United Nations' International Narcotics Control Board to look into the situation. The United Nations released a report in February of 1996 expressing concern over the discovery that 10 percent to 12 percent of all male school children in the United States currently take the drug, a rate far surpassing that in any other country in the world. Indeed, citizens of the United States, most of them well below the legal drinking or smoking age, now consume over 90 percent of the 8.5 tons of methylphenidate produced worldwide each year.

There is something odd, if not downright ironic, about the picture of millions of American school children filing out of "drug-awareness" classes to line up in the school nurse's office for their midday dose of amphetamine. It is this sort of image that fires the imaginations of Ritalin's critics - critics like child psychiatrist Carl L. Kline of the University of British Columbia who was reported in the August 4, 1991 New York Times Education Supplement as saying that Ritalin is nothing more than a street drug being administered to cover the fact that we don't know what's going on with these children.

Proponents, on the other hand, include many parents like Jane Leavy, who wrote an impassioned defense of the drug's use for the March 18, 1996 issue of Newsweek. She documents dramatic improvements in her son's academic and social performance thanks to Ritalin. Similar testimonials can be found in the growing number of ADHD discussions on the internet. These parents are staunch defenders of Ritalin - this miraculous drug has relieved their children of debilitating stress and unhappiness, they say. Indeed, a temporary shortage of Ritalin, in 1993, following the government's failure to give timely approval to Ciba Pharmaceuticals (Ritalin's manufacturer) to increase production, led to a widely reported public outcry and weeks of high anxiety among parents who feared being without the little yellow pill. For these people, the child's trip to the nurse's office is far from ironic; it is a pilgrimage in honor of one of the great successes of modern psychopharmacology.