Out of Control? Interesting article about Ritalin from Popular Science Magazine

Jun 16 09:28 UTC 2001

Out of Control? 

As prescriptions to treat Attention Deficit Hyperactivity Disorder 
continue to skyrocket, new research suggests drugs alone may not help 
kids long-term. 

June 2001 

By Gunjan Sinha 

Dr. Lawrence Diller zips through his voice mail while waiting for his 
next client. He quickly finds himself wading through unnecessary 
details. One longtime patient lists her afternoon schedule, presumably 
so Diller will know when to return her call. A new patient states her 
name, address, and occupation—she's a lawyer—then adds what seem like 
trivial details. 

But unlike many doctors prone to hit "delete" after jotting down the 
phone number, Diller is all ears: In his practice, listening is the key 
to exorcising patients' demons. It's this notion that has flagged 
Diller as something of a renegade. 

A pediatrician and family therapist, Diller's practice is tucked 
between rolling hills in Walnut Creek—a wealthy San Francisco suburb—
where he evaluates and treats children and adults for psychological 
disorders. Most people knocking on his door these days want to know if 
they or their children have Attention Deficit Hyperactivity Disorder, 
or ADHD—a behavioral malady that predominantly affects young boys. 

Production of one of the main drugs to treat ADHD —Ritalin—has rocketed 
700 percent since 1990. And with a longer-acting version called 
Concerta, which eliminates some of the stigma associated with kids 
popping pills at school, hitting the market, experts are predicting 
that those numbers will soar even higher. In fact, last year 
prescriptions for a long-lasting formulation of a related drug called 
Adderall surpassed Ritalin and have increased almost fivefold since 
1996. 

The rise, while huge, hasn't set off alarm bells among most scientists. 
Experts estimate the disorder afflicts 3 to 7 percent of Americans and 
believe that the increase has been a simple case of treatment catching 
up to a prevalent problem. 

But Diller became convinced in the early 1990s that too many people 
were using the medication as a quick fix for larger social and cultural 
problems. With dwindling school resources, bloated classrooms, and time-
strapped parents, medication is becoming an easy out, Diller says—which 
is a dangerous situation with a drug primarily prescribed for children 
and whose long-term effects haven't yet been studied. 

Today, an estimated 3 million to 5 million American children have been 
diagnosed with ADHD—including as many as 200,000 ages two to four. 
Diller was the first to publicly raise the red flag on the growing 
problem of overdiagnosis in his book, Running on Ritalin, published in 
1998. Yet scarcely anyone paid attention. Since then, he has continued 
to voice his opinions in editorials and also won a Society of 
Professional Journalists award for a series he wrote on Salon.com last 
fall. But recent negative publicity and preliminary research suggesting 
that medication alone doesn't help ADHD children perform better over 
the long term is only now dredging up more widespread concern over the 
soaring numbers of children on medication. 

Doctors diagnose ADHD based on guidelines listed in the American 
Psychiatric Association's "bible"—the Diagnostic and Statistical Manual 
of Mental Disorders (DSM). The guide divides the disorder into three 
types: inattentive, hyperactive/impulsive, or combined. 

If a child exhibits at least six symptoms from a list that includes 
fidgeting and excessive climbing and running about, he can be 
considered hyperactive. "Inattentive" children include those who fail 
to listen or to follow through, and have a tendency to lose things. 

But how impulsive, overactive, and inattentive must a child be to 
warrant an ADHD diagnosis? All children behave badly at times. Because 
the disorder has no testable biological hallmarks, such as a hormone 
imbalance, the diagnosis is somewhat subjective. 

"You get the sense that almost everyone who sees a doctor about ADHD 
walks out with a prescription if they want it," says Diller, who stands 
just under 6 feet tall, has a slender build, and wears his mottled gray 
hair neatly combed back, Bill Clinton-style. He speaks with so much 
animation and enthusiasm that his face often flushes as red as a 
tomato. 

"I don't know if I medicate less than other people," he adds, "but with 
a number of the kids I see whose teachers think they have ADHD, I'm 
able to manage without medication, using behavioral approaches both at 
home and at school." 

Diller spends a minimum of 3 hours conversing with and evaluating each 
child before giving his diagnosis. He also talks to a child's teachers 
to get a sense of the child's behavior in real-world settings. But 
physicians can spend as little or as much time as they see fit 
evaluating patients—there are no formal guidelines. One survey of 
Virginia physicians found that they spend an average of 1 hour and 22 
minutes making a diagnosis. 

Manufactured by Novartis Pharmaceuticals, of Basel, Switzerland, 
Ritalin is the trade name for the generic chemical methylphenidate, a 
stimulant that's related to caffeine and cocaine. Several other 
stimulant-type drugs are now prescribed to treat ADHD, such as 
Adderall, Concerta, and Dexedrine. Side effects of these drugs include 
sleeplessness and appetite loss, but they usually wear off as the 
effects of the drug do, after a few hours. 

In the brain, methylphenidate interacts with dopamine —a biochemical 
that conveys pleasure, among other sensations. When sensory information 
stimulates a nerve cell, the cell shoots dopamine into the synapse 
between cells. Dopamine messengers the information to neighboring 
cells, and then the nerve cell sucks the extraneous chemical back into 
the cell. Ritalin slows this reuptake of dopamine (other stimulants 
also act on dopamine levels but in different ways). How this stifles 
hyperactivity and sharpens focus is still unclear. 

But stimulants don't just help people with ADHD; they boost almost 
anyone's ability to focus, which is precisely the problem. "We have a 
condition that is ill defined, and the main professed treatment 
improves everyone's ability to stick with things they find boring and 
difficult. And what we've got in our performance-obsessed culture is 
the makings of an epidemic," Diller argues. 

Take the Taylor family, for example. Kate and Mike Taylor (not their 
real names) have three kids ages 8, 11, and 13. The entire family is 
taking Ritalin in varying dosages. Doctors at UCLA had already 
diagnosed the children with ADHD; the family came to Diller 
seeking "reassurance." 

Mike is a fireman, Kate a stay-at-home mom. Seated in Diller's office, 
the blonde-haired, fair-eyed group seems the quintessential American 
family. All three kids have been homeschooled for more than a year and 
excel in their studies, with the two eldest currently taking classes at 
a community college. 

The 11-year-old takes Ritalin three times a day—the highest dose of the 
five. During the session, Diller wonders if the evening dose is 
necessary, but Kate seems reluctant to give it up. The child swims 
competitively and the drug helps her focus. Diller then explains that 
several studies in the 1950s showed that stimulants slightly increase 
endurance. Having less-than-top-level endurance, of course, is not a 
medical problem. Kate seems interested but nonplussed. 

"The middle child is the only one who has ADHD," Diller argues. "She's 
quite impulsive and near hyperactive off medicine." Otherwise, writes 
Diller in his notes, "the child scored in the superior range of 
intelligence" when she was attending school. Diller observes that Kate 
and Mike needed some help in learning how to better discipline their 
children. In fact, he sees discipline issues initially present in 90 
percent of his ADHD families. In the Taylor family's case, he coached 
the parents through behavioral therapy for more than a year. For a 
while, the therapy moved away from helping the kids and focused on Mike 
and Kate's marriage. While there were some improvements, Diller 
recounts, the parents still felt that their children needed medication. 

While Ritalin has been remedying behavioral disorders in children since 
the 1960s, most studies followed kids for only a few weeks and were 
intended to test how well treatments worked in easing ADHD symptoms. 
The largest and longest study to date, published in 1999, lasted 14 
months and found medication to be superior to behavioral therapy in 
alleviating ADHD symptoms. But several researchers are now reevaluating 
the data and are finding that medication plus behavioral therapy was 
more effective than medication alone. And no one has yet looked at the 
possibility of more subtle negative influences: Some children, for 
example, become hyperfocused on solitary activities rather than seeking 
playmates. In addition, the medication, when taken for several years, 
may have long-term effects on a child's self-esteem and other behavior. 

Diller's critics, such as Russell Barkley, a neuroscientist and leading 
ADHD expert at the University of Massachusetts, counter that while 
there may be anecdotal reports of overdiagnosis and adults and children 
suffering from subtle side effects, they are isolated cases. 

"ADHD is very well studied, valid, with a real biological basis," he 
asserts. "Larry's problem is that he tries to translate anecdotes into 
scientific data but that doesn't mean we have an epidemic. You can 
always find a secretary sniffing Wite-Out, but you can't pass that off 
as an epidemic of people sniffing liquid paper in their offices." 

While the debate over the disorder's epidemic status rages, some long-
term data on whether the drugs are actually helping ADHD children, 
however, have begun to trickle in. A study by William Fankenberger and 
Christine Cannon at the Human Development Center at the University of 
Wisconsin in Eau Claire published in 1999 found that 13 ADHD children 
on medication performed progressively worse over 4 years on 
standardized tests when compared with a group of 13 normal children 
with similar IQs and other characteristics. 

Gretchen LeFever, an assistant professor of pediatrics and psychiatry 
at Eastern Virginia Medical School, is also comparing the educational 
outcomes of ADHD kids to that of their peers in elementary schools in 
Virginia. In preliminary findings, she found results similar to the 
University of Wisconsin study. While both studies are small and require 
further validation, "these studies also suggest that the care kids are 
getting in routine community settings is not the same as what's 
delivered through tightly controlled clinical studies that have shown 
medication to be effective," LeFever says. "We really need to be 
looking at this closely." 

While these studies fall short of answering questions about the long-
term effects of medication on personality, they have, along with other 
recent events, stirred up a lot of controversy. Most notably, several 
lawyers led by Richard Scruggs of Pascagoula, Mississippi, have filed 
class action lawsuits in two states and Puerto Rico against the 
American Psychiatric Association and Novartis, claiming that they 
colluded to create a disease and later hyped the drug's benefits. 
Decisions were pending at press time. 

Experts like Barkley are bitterly critical of the negative publicity 
surrounding ADHD. The lawsuits are unfounded and blown out of 
proportion, he says. And as for Diller and others who argue that ADHD 
is overdiagnosed, he adds: "Larry is a medical practitioner. What we 
all say to him is 'show me the data.'" 

Diller has learned to roll with the punches. When he published his 
book, he knew he was sticking his neck out. But he felt he just 
couldn't keep silent about the "larger factors" contributing to the 
disorder—one of which is our culture, Diller argues. American and 
Canadian kids consume nearly 80 percent of all stimulants taken by 
children worldwide. Western Europe, while showing evidence of having a 
similar prevalence of ADHD, does not choose to medicate as readily, at 
least not yet. While Barkley says this is because Western Europe "is 
still locked in the stranglehold of outdated psychoanalysis that blames 
parents for misbehavior [as does much of the American public]," Diller 
finds another explanation more satisfying. 

"American culture is inconsistent," he argues. "We prize independence 
but at the same time demand conformity at school. That's a very mixed 
message for a vulnerable and temperamental group—that is, boys ages 4 
to 14. They struggle with that message." 

Even Barkley, albeit reluctantly, admits that culture plays a role in 
America's love affair with performance pills: "The more demands placed 
on your population, the more you are going to unearth disorders. Take 
dyslexia, for instance. You don't find it until you require the 
population to read. The genes for the problem have always been around, 
they just never posed a problem until the culture began to make demands 
on that trait." 

"We're a fix-it culture," Diller continues. "I play a role in this. I 
medicate because I'm not going change school systems or cultural 
attitudes. But if I don't challenge the factors and values that I think 
are dangerous and harmful to children, then I become complicitous. It 
comes down to, What kind of society do we want for our kids?"