Teacher’s Pet

Is Ritalin Overprescribed?

By Dr. Jeffrey Tipton

Ritalin is being dispensed with a speed and nonchalance compatible with our drive-through culture, yet entirely at odds with good medicine and common sense. The drug does help some people pay attention and function better; some of my own patients have benefited from it. But too many children, and more and more adults, are being given Ritalin inappropriately.

Psychiatry has devised careful guidelines for prescribing and monitoring this sometimes-useful drug. But the five-fold jump in Ritalin production in the past five years clearly suggests that these guidelines are being ignored and that Ritalin is being vastly overprescribed.

The problem has finally been recognized by medical groups such as the American Academy of Child and Adolescent Psychiatry, the American Psychiatric Association, the American Academy of Pediatrics, and even by Ciba, the primary manufacturer of Ritalin. These organizations have written or are developing guidelines for diagnosing ADHD, and Ciba issued similar guidelines to doctors last summer.

Under the pressure of managed care, physicians are diagnosing ADHD in patients and prescribing them Ritalin after interviews as short as 15 minutes. And given Ritalin’s quick action (it can “calm” children within days after treatment starts), some doctors even rely on the drug as a diagnostic tool, interpreting improvements in behavior or attention as proof of an underlying ADHD — and justification for continued drug use.

Studies show that Ritalin prescribing fluctuates dramatically depending on how parents and teachers perceive “misbehavior” and how tolerant they are of it. I know of children who have been given Ritalin more to subdue them than to meet their needs — a practice that recalls the opium syrups used to soothe noisy infants in London a century ago. When a drug is prescribed because one person is bothering another — a disruptive child upsetting a teacher, for example — there is clearly a danger that the drug will be abused. That danger only increases when the problem being treated is so vaguely defined.

ADHD exists as a disorder primarily because a committee of psychiatrists voted it so. In a valiant effort, they squeezed a laundry list of disparate symptoms into a neat package that can be handled and treated. But while attention is an essential aspect of our functioning, it’s certainly not the only one. Why not bestow the label of “disorder” on other problems common to people diagnosed with ADHD — such as Easily Frustrated Disorder (EFD) or Nothing Makes Me Happy Disorder (NMMHD)?

Once known as Minimal Brain Dysfunction and Hyperkinetic Syndrome, ADHD is considered a neurological disorder. Certainly, some people diagnosed with ADHD are neurologically impaired and need medication. But nervous system glitches account for the disruptive behavior of only a small minority of people who are vulnerable to distraction or impulsive behavior — perhaps 1 or 2 percent of the general population. Yet many more people have ADHD symptoms that have nothing to do with their nervous systems and result instead from emotional distress, depression, anxiety, obsessions, or learning disabilities.

For these people, who exhibit the symptoms of ADHD but suffer from some other problem, Ritalin will likely be useless as a treatment. Taking it may postpone more effective treatment. And it may even be harmful.

No one knows how Ritalin works. Some miracle drugs, of course, have helped people for decades or even centuries before their mechanisms of action were understood. But we need to know more about the possible effects of a drug used mainly on children.

People are willing to overlook side effects when it comes to treating a life-threatening disease. But with a less-weighty disorder like ADHD, therapeutic rewards must be weighed against possible adverse reactions. In a drug targeted for children, there is concern that harmful effects may crop up decades after treatment stops. Since Ritalin is a relatively new drug, in use for about 30 years, we still don’t know whether long-term side effects await its young users. But we do know that more immediate problems can occur.

It’s already clear that Ritalin can worsen underlying anxiety, depression, psychosis, and seizures. More common but milder side effects include nervousness and sleeplessness. Some studies suggest that the drug may interfere with bone growth. And last February, the United Nation’s International Narcotics Control Board reported an increase in teenagers who were inhaling this stimulant drug, which is chemically similar to cocaine but not nearly as potent.

While Ritalin’s mode of action isn’t clear, the drug is known to affect the brain’s most ancient and basic structures, which control arousal and attention. I question the wisdom of tampering with such a crucially important part of the brain, particularly with a drug whose possible long-term side effects remain to be discovered.

The surge in both ADHD diagnoses and Ritalin prescriptions is yet another sign of a society suffering from a colossal lack of personal responsibility. By telling patients that their failures, misbehavior, and unhappiness are caused by a disorder, we risk colluding with their all-too-human belief that their actions are beyond their control and weaken their motivation to change on their own. And in the many cases where ADHD is misdiagnosed in children, we give parents the illusion that their child’s problems have nothing to do with the home environment or with their performance as parents.

It must be true that bad biology accounts for some people’s distracted and impulsive lifestyles. But random violence, drugs, alcohol, domestic trauma, and (less horrifically) indulgent and chaotic homes are more obvious reasons for the ADHD-like restlessness that plagues America. We urgently need to address these problems. To do that, we need legislators who will provide support for good parenting, especially in the early years of childhood when the foundations for handling feelings, self-control, and concentration are biologically and psychologically laid down.

Some people who can’t concentrate probably do merit the diagnosis of ADHD and a prescription for Ritalin to treat it. But the brain, the neurological seat of the soul and the self, must be treated with the utmost respect. With the demand for Ritalin growing, we must be increasingly wary about doling out a drug that can be beneficial but is more often useless or even harmful.

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1 Comment (+add yours?)

  1. Trackback: ADHD Report» Blog Archive » Teacher’s Pet

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