Camp fixtures: bugs, s'mores — and pills
By Jane Gross
The New York Times
July 16, 2006
BURLINGHAM, N.Y. — The breakfast buffet at Camp Echo starts at a picnic table where children jostle for their morning medications: Zoloft for depression, Abilify for bipolar disorder, guanfacine for twitchy eyes and a host of medications for attention-deficit disorder.
A quick gulp of water, a greeting from the nurse, and the youngsters move on to the next table for orange juice, Special K and chocolate-chip pancakes. The dispensing of pills and pancakes is over in minutes.
The medication lines like the one at Camp Echo were unheard of a generation ago but have become fixtures at residential camps across the country. Between one-quarter and one-half of the youngsters at any given summer camp take daily prescription medications, experts say. Allergy and asthma drugs top the list, but behavior-management and psychiatric medications are now so common that nurses who dispense them no longer try to avoid stigma by pretending they are vitamins.
"All my best friends take something," said David Ehrenreich, 12, who has Tourette's syndrome yet feels at home here because boys with hyperactivity, mood disorders, learning disabilities and facial tics line up just as he does for their daily meds.
With campers far from home, family and pediatricians, the job of safely and efficiently dispensing medications falls to infirmaries and nurses whose stock in trade used to be calamine lotion and cough syrup. Three times a day, at mealtimes, is the norm, with some campers also requiring a sleep aid at bedtime to counteract the effect of their daytime medications.
"This is the American standard now," said Rodger Popkin, an owner of Blue Stars Camps in Hendersonville, N.C. "It's not limited by education level, race, socioeconomics, geography, gender or any of those filters."
Peg Smith, the chief executive officer of the American Camp Association, a trade group with 2,600 member camps and 3 million campers, says about a quarter of the children at its camps are medicated for attention-deficit disorder, psychiatric problems or mood disorders.
Many parents welcome the anonymity that comes when a lot of children take this, that or the other drug, so none stands out from the crowd.
"It's nobody's business who's taking what," said one parent of an Echo camper who is medicated for attention-deficit disorder. The parent asked not to be named for privacy reasons. "It could be an allergy pill. The way they do it now, he feels comfortable. He just goes up with everybody else, gets it and then carries on with his day."
Increasingly popular is a service offered by a private company called CampMeds, which provides a summer's worth of prepackaged pills to 6,000 children at 100 camps. The company's founder, Dana Godel, said 40 percent of the children regularly took one or more prescription medications, compared with 30 percent four years ago. Eight percent used attention-deficit medications last year; 5 percent took psychiatric drugs.
Borrowing technology developed for nursing homes, CampMeds distributes pills in shrink-wrapped packets marked with a name, date and time. Camp nurses tear each packet and dispense, sparing them the labor-intensive task of counting pills and reducing the risk of error, and thus, liability.
The proliferation of children on stimulants for attention-deficit disorder, antidepressants or antipsychotic drugs — or on cocktails of all three — is not peculiar to the camp setting. Rather, it is the extension of an increasingly common year-round regimen that has also had an impact on schools, although a lesser one, since most medications are taken at home.
Exacting diagnoses and proper treatments enable some children to go to camp who otherwise could not function in that environment, said Dr. David Fassler, a child-and-adolescent psychiatrist and a professor at the University of Vermont College of Medicine.
Fassler said that children with one behavioral or mood disorder often "have a second or even a third diagnosis." A child with attention-deficit disorder may also be depressed and anxious, he said, a combination of symptoms that can make such children pariahs in the close quarters of a summer-camp cabin without the proper combination of remedies.
Too many meds?
Some camp owners question the trend, however. Popkin, the camp owner in North Carolina, is among them. "It's universal, and nobody really knows if it's appropriate or safe," he said.
And many experts say family doctors who do not have expertise in psychopharmacology sometimes prescribe drugs for anxiety disorders and depression to children without rigorous evaluation, just as they do for adults.
"There is no doubt that kids are more medicated than they used to be," said Dr. Edward Walton, an assistant professor of pediatrics at the University of Michigan and an expert on camp medicine for the American Academy of Pediatrics. "And we know that the people prescribing these drugs are not that precise about diagnosis. So the percentage of kids on these meds is probably higher than it needs to be."
A few medicines growing in popularity, like Abilify and Risperdal, are used for a grab bag of mood disorders. But according to the Physicians' Desk Reference, the encyclopedia of prescription medications, they can have troublesome side effects in children and teenagers, including elevated blood sugar or a tendency toward heat exhaustion, which requires vigilance by counselors during long, hot days.
Some doctors, nurses and camp directors are uneasy about giving children so-called off-label drugs like Lexapro and Luvox. Such medications are used for depression and anxiety, and have been tested only on adults but can legally be prescribed to children. Clonidine is approved as a medication for high blood pressure but is routinely used for behavioral and emotional problems in children.
"That doesn't mean they are inappropriate or unsafe," Fassler said, adding that camp nurses should be able to call the physician when they have questions, but that not all parents welcome that.
Few camp directors risk discussions with parents about behavioral or psychiatric drugs. "We don't make these judgments for families," said Marla Coleman, an owner of Camp Echo and a past president of the American Camp Association.
Trial, error, fears
Figuring out how to distribute all this medicine has taken some trial and error, beginning with supervision by the nurses, who watch the children take their pills.
Some camps do it in the mess hall, citing informality to put campers at ease and the convenience of having everyone assembled in one place.
Other camps prefer the infirmary, to provide more privacy. Camp Pontiac in Copake, N.Y., built a special medication wing with its own entrance and a porch where campers wait their turn.
In Fishkill, N.Y., at a Fresh Air Fund camp for underprivileged children, one nurse in the infirmary deals with bug bites and skinned knees and the other dispenses Strattera and Zoloft, the first for attention-deficit disorder and the second for depression, social anxiety or obsessive-compulsive disorder.
The potential for harmful drug interactions is compounded by the widespread use of allergy and asthma medications. Tofranil, an antidepressant for adults that is used for bed-wetting in children, is not recommended in combination with Allegra, for seasonal allergies; Advair, an asthma drug; or epinephrine, the injectable antidote to deadly allergic reactions to bee stings, insect bites and certain foods.
Despite a tenfold increase in childhood allergies over the past decade, some camp doctors think daily medication is overused. The owners of Camp Pontiac, Ken and Rick Etra, brothers who are ear, nose and throat doctors, urge parents to forgo prescription remedies for seasonal allergies when occasional over-the-counter antihistamines are sufficient. Their summer camp does not overlap with the height of the pollen and grass season, the Etras say.
They also discourage bed-wetting medications, which can leave a youngster groggy.
"They don't pee, but they're zombies," said Mimi Burcham, Pontiac's head nurse. Instead, camp directors train counselors to wake certain children at midnight for a trip to the bathroom and replace soiled linens with identical sheets to avoid embarrassment.
CampMeds charges $40 per child for any length of stay or for any regimen, a cost that most camps pass along to families. The Fresh Air Fund camps do not use CampMeds, but not because of cost, said Jenny Morgenthau, the fund's executive director. Rather, Morgenthau said, many of the families are too disorganized — some in shelters or in prison — to do the preparatory paperwork.
So Fresh Air's campers arrive with an array of unmarked bags and bottles that cannot be used under state regulations, and without some of their essential medications. Susan Powers and Leticia Diaz, who run the infirmary at the girls' camp, are accustomed to children bringing their brother's expired asthma inhaler or their grandmother's sleeping pills in a perfume bottle. Sometimes the medications are missing because they have been sold on the street or used by adults, Powers and Diaz said. It takes a few days to unscramble.
The nurses at high-end camps have the opposite problem, with parents who try to involve themselves in all aspects of their children's lives with ceaseless efforts to help. That mind-set has the potential to lead to overmedication, many camp owners and doctors say.
Burcham, a special-education nurse during the school year, said she often worries about her unfamiliarity with some of the drugs. She often turns to the Physicians' Desk Reference for guidance, or sometimes calls her father, a psychiatrist.
Unpacking the shipment of medicine at Pontiac in mid-June, she tried to make sense of a packet from CampMeds for an 11-year-old who, for the first time, would be taking Concerta, for attention-deficit disorder, along with clonidine and Wellbutrin, both mood-disorder drugs.
"I'm not a specialist, and that's very disturbing sometimes," Burcham said. "How do I know if we're really getting it right?"
Then she carefully placed the medications in a plastic bin marked with the camper's name.
Teen Advocates USA Archives
April & May 1999, No. 94
Published by the Heritage Foundation
Why Ritalin Rules
By MARY EBERSTADT
There are stories that are mere signs of the times, and then there are stories so emblematic of a particular time and place that they demand to be designated cultural landmarks. Such a story was the New York Times’ front-page report on January 18 appearing under the tame, even soporific headline, "For School Nurses, More Than Tending the Sick."
"Ritalin, Ritalin, seizure drugs, Ritalin," in the words of its sing-song opening. "So goes the rhythm of noontime" for a typical school nurse in East Boston "as she trots her tray of brown plastic vials and paper water cups from class to class, dispensing pills into outstretched young palms." For this nurse, as for her counterparts in middle- and upper-middle class schools across the country, the day’s routine is now driven by what the Times dubs "a ticklish question," to wit: "With the number of children across the country taking Ritalin estimated at well over three million, more than double the 1990 figure, who should be giving out the pills?"
"With nurses often serving more than one school at a time," the story goes on to explain, "the whole middle of the day can be taken up in a school-to-school scurry to dole out drugs." Massachusetts, for its part, has taken to having the nurse deputize "anyone from a principal to a secretary" to share the burden. In Florida, where the ratio of school nurses to students is particularly low, "many schools have clerical workers hand out the pills." So many pills, and so few professionals to go around. What else are the authorities to do?
Behold the uniquely American psychotropic universe, pediatrics zone — a place where "psychiatric medications in general have become more common in schools" and where, in particular, "Ritalin dominates." There are by now millions of stories in orbit here, and the particular one chosen by the Times — of how the drug has induced a professional labor shortage — is no doubt an estimable entry. But for the reader struck by some of the facts the Times mentions only in passing — for example, that Ritalin use more than doubled in the first half of the decade alone, that production has increased 700 percent since 1990, or that the number of schoolchildren taking the drug may now, by some estimates, be approaching the 4 million mark — mere anecdote will only explain so much.
Fortunately, at least for the curious reader, there is a great deal of other material now on offer, for the explosion in Ritalin consumption has been very nearly matched by a publishing boom dedicated to that same phenomenon. Its harbingers include, for example, Barbara Ingersoll’s now-classic 1988 Your Hyperactive Child, among the first works to popularize a drug regimen for what we now call Attention Deficit Disorder (ADD, called ADHD when it includes hyperactivity). Five years later, with add diagnoses and Ritalin prescriptions already rising steeply in the better-off neighborhoods and schools, Peter D. Kramer helped fuel the boom with his bestselling Listening to Prozac — a book that put the phrase "cosmetic pharmacology" into the vernacular and thereby inadvertently broke new conceptual ground for the advocates of Ritalin. In 1994, most important, psychiatrists Edward M. Hallowell and John J. Ratey published their own bestselling Driven to Distraction: Recognizing and Coping with Attention Deficit Disorder from Childhood to Adulthood, a book that was perhaps the single most powerful force in the subsequent proliferation of add diagnoses; as its opening sentence accurately prophesied, "Once you catch on to what this syndrome is all about, you’ll see it everywhere."
Not everyone received these soundings from the psychotropic beyond with the same enthusiasm. One noteworthy dissent came in 1995 with Thomas Armstrong’s The Myth of the add Child, which attacked both the scientific claims made on behalf of ADD and what Armstrong decried as the "pathologizing" of normal children. Dissent also took the form of wary public pronouncements by the National Education Association (NEA), one of several groups to harbor the fear that add would be used to stigmatize minority children. Meanwhile, scare stories on the abuse and side effects of Ritalin popped out here and there in the mass media, and a national controversy was born. From the middle to the late 1990s, other interested parties from all over — the Drug Enforcement Administration (DEA), the Food and Drug Administration (FDA), the medical journals, the National Institutes of Health (NIH), and especially the extremely active advocacy group chadd (Children and Adults with Attention Deficit Disorder) — further stoked the debate through countless reports, conferences, pamphlets, and exchanges on the Internet.
To this outpouring of information and opinion two new books, both on the critical side of the ledger, have just been added: Richard DeGrandpre’s iconoclastic Ritalin Nation: Rapid-Fire Culture and the Transformation of Human Consciousness (Simon and Schuster, 1999), and physician Lawrence H. Diller’s superbly analytical Running on Ritalin: A Physician Reflects on Children, Society and Performance in a Pill (Bantam Books, 1998). Their appearance marks an unusually opportune moment in which to sift through some ten years’ worth of information on Ritalin and add and to ask what, if anything, we have learned from the national experiment that has made both terms into household words.
Let’s put the question bluntly: How has it come to pass that in fin-de-siècle America, where every child from preschool onward can recite the "anti-drug" catechism by heart, millions of middle- and upper-middle class children are being legally drugged with a substance so similar to cocaine that, as one journalist accurately summarized the science, "it takes a chemist to tell the difference"?
What is methylphenidate?
The first thing that has made the Ritalin explosion possible is that methylphenidate, to use the generic term, is perhaps the most widely misunderstood drug in America today. Despite the fact that it is, as Lawrence Diller observes in Running on Ritalin, "the most intensively studied drug in pediatrics," most laymen remain under a misimpression both about the nature of the drug itself and about its pharmacological effects on children.
What most people believe about this drug is the same erroneous characterization that appeared elsewhere in the Times piece quoted earlier — that it is "a mild stimulant of the central nervous system that, for reasons not fully understood, often helps children who are chronically distractible, impulsive and hyperactive settle down and concentrate." The word "stimulant" here is at least medically accurate. "Mild," a more ambiguous judgment, depends partly on the dosage, and partly on whether the reader can imagine describing as "mild" any dosage of the drugs to which methylphenidate is closely related. These include dextroamphetamine (street name: "dexies"), methamphetamine (street name: "crystal meth"), and, of course, cocaine. But the chief substance of the Times’ formulation here — that the reasons why Ritalin does what it does to children remain a medical mystery — is, as informed writers from all over the debate have long acknowledged, an enduring public myth.
"Methylphenidate," in the words of a 1995 dea background paper on the drug, "is a central nervous system (CNS) stimulant and shares many of the pharmacological effects of amphetamine, methamphetamine, and cocaine." Further, it "produces behavioral, psychological, subjective, and reinforcing effects similar to those of d-amphetamine including increases in rating of euphoria, drug liking and activity, and decreases in sedation." For comparative purposes, that same dea report includes a table listing the potential adverse physiological effects of both methylphenidate and dextroamphetamine; they are, as the table shows, nearly identical (see below). To put the point conversely, as Richard DeGrandpre does in Ritalin Nation by quoting a 1995 report in the Archives of General Psychiatry, "Cocaine, which is one of the most reinforcing and addicting of the abused drugs, has pharmacological actions that are very similar to those of methylphenidate, which is now the most commonly prescribed psychotropic medicine for children in the U.S."
Such pharmacological similarities have been explored over the years in numerous studies. DeGrandpre reports that "lab animals given the choice to self-administer comparative doses of cocaine and Ritalin do not favor one over another" and that "a similar study showed monkeys would work in the same fashion for Ritalin as they would for cocaine." The dea reports another finding — that methylphenidate is actually "chosen over cocaine in preference studies" of non-human primates (emphasis added). In Driven to Distraction, pro-Ritalin psychiatrists Hallowell and Ratey underline the interchangeable nature of methylphenidate and cocaine when they observe that "people with add feel focused when they take cocaine, just as they do when they take Ritalin [emphasis added]." Moreover, methylphenidate (like other stimulants) appears to increase tolerance for related drugs. Recent evidence indicates, for example, that when people accustomed to prescribed Ritalin turn to cocaine, they seek higher doses of it than do others. To summarize, again from the dea report, "it is clear that methylphenidate substitutes for cocaine and d-amphetamine in a number of behavioral paradigms."
All of which is to say that Ritalin "works" on children in the same way that related stimulants work on adults — sharpening the short-term attention span when the drug kicks in and producing equally predictable valleys ("coming down," in the old street parlance; "rebounding," in Ritalinese) when the effect wears off. Just as predictably, children are subject to the same adverse effects as adults imbibing such drugs, with the two most common — appetite suppression and insomnia — being of particular concern. That is why, for example, handbooks on add will counsel parents to see their doctor if they feel their child is losing too much weight, and why some children who take methylphenidate are also prescribed sedatives to help them sleep. It is also why one of the more Orwellian phrases in the psychotropic universe, "drug holidays" — meaning scheduled times, typically on weekends or school vacations, when the dosage of methylphenidate is lowered or the drug temporarily withdrawn in order to keep its adverse effects in check — is now so common in the literature that it no longer even appears in quotations.
Just as, contrary to folklore, the adult and child physiologies respond in the same way to such drugs, so too do the physiologies of all people, regardless of whether they are diagnosed with add or hyperactivity. As Diller puts it, in a point echoed by many other sources, methylphenidate "potentially improves the performance of anyone — child or not, add-diagnosed or not." Writing in the Public Interest last year, psychologist Ken Livingston provided a similar summary of the research, citing "studies conducted during the mid seventies to early eighties by Judith Rapaport of the National Institute of Mental Health" which "clearly showed that stimulant drugs improve the performance of most people, regardless of whether they have a diagnosis of adhd, on tasks requiring good attention." ("Indeed," he comments further in an obvious comparison, "this probably explains the high levels of ‘self-medicating’ around the world" in the form of "stimulants like caffeine and nicotine.")
A third myth about methylphenidate is that it, alone among drugs of its kind, is immune to being abused. To the contrary: Abuse statistics have flourished alongside the boom in Ritalin prescription-writing. Though it is quite true that elementary schoolchildren are unlikely to ingest extra doses of the drug, which is presumably kept away from little hands, a very different pattern has emerged among teenagers and adults who have the manual dexterity to open prescription bottles and the wherewithal to chop up and snort their contents (a method that puts the drug into the bloodstream far faster than oral ingestion). For this group, statistics on the proliferating abuse of methylphenidate in schoolyards and on the street are dramatic.
According to the dea, for example, as early as 1994 Ritalin was the fastest-growing amphetamine being used "non-medically" by high school seniors in Texas. In 1991, reports DeGrandpre in Ritalin Nation, "children between the ages of 10 and 14 years old were involved in only about 25 emergency room visits connected with Ritalin abuse. In 1995, just four years later, that number had climbed to more than 400 visits, which for this group was about the same number of visits as for cocaine." Not surprisingly, given these and other measures of methylphenidate’s recreational appeal, criminal entrepreneurs have responded with interest to the drug’s increased circulation. From 1990 to 1995, the dea reports, there were about 2,000 thefts of methylphenidate, most of them night break-ins at pharmacies — meaning that the drug "ranks in the top 10 most frequently reported pharmaceutical drugs diverted from licensed handlers."
Because so many teenagers and college students have access to it, methylphenidate is particularly likely to be abused on school grounds. "The prescription drug Ritalin," reported Newsweek in 1995, "is now a popular high on campus — with some serious side effects." DeGrandpre notes that at his own college in Vermont, Ritalin was cited as the third-favorite drug to snort in a campus survey. He also runs, without comment, scores of individual abuse stories from newspapers across the country over several pages of his book. In Running on Ritalin, Diller cites several undercover narcotics agents who confirm that "Ritalin is cheaper and easier to purchase at playgrounds than on the street." He further reports one particularly hazardous fact about Ritalin abuse, namely that teenagers, especially, do not consider the drug to be anywhere near as dangerous as heroin or cocaine. To the contrary: "they think that since their younger brother takes it under a doctor’s prescription, it must be safe."
In short, methylphenidate looks like an amphetamine, acts like an amphetamine, and is abused like an amphetamine. Perhaps not surprisingly, those who value its medicinal effects tend to explain the drug differently. To some, Ritalin is to children what Prozac and other psychotropic "mood brightening" drugs are to adults — a short-term fix for enhancing personality and performance. But the analogy is misleading. Prozac and its sisters are not stimulants with stimulant side effects; there is, ipso facto, no black market for drugs like these. Even more peculiar is the analogy favored by the advocates in chadd: that "Just as a pair of glasses help the nearsighted person focus," as Hallowell and Ratey explain, "so can medication help the person with add see the world more clearly." But there is no black market for eyeglasses, either — nor loss of appetite, insomnia, "dysphoria" (an unexplained feeling of sadness that sometimes accompanies pediatric Ritalin-taking), nor even the faintest risk of toxic psychosis, to cite one of Ritalin’s rare but dramatically chilling possible effects.
What is methylphenidate "really" like? Thomas Armstrong, writing in The Myth of the ADD Child four years ago, probably summarized the drug’s appeal best. "Many middle and upper-middle class parents," he observed then, "see Ritalin and related drugs almost as ‘cognitive steroids’ that can be used to help their kids focus on their schoolwork better than the next kid." Put this way, the attraction to Ritalin makes considerable sense. In some ways, one can argue, that after-lunch hit of low-dose methylphenidate is much like the big cup from Starbucks that millions of adults swig to get them through the day — but only in some ways. There is no dramatic upswing in hospital emergency room visits and pharmacy break-ins due to caffeine abuse; the brain being jolted awake in one case is that of an adult, and in the other that of a developing child; and, of course, the substance doing the jolting on all those children is not legally available and ubiquitous caffeine, but a substance that the dea insists on calling a Schedule II drug, meaning that it is subject to the same controls, and for the same reasons of abuse potential, as related stimulants and other powerful drugs like morphine.
What is CHADD?
This mention of Schedule II drugs brings us to a second reason for the Ritalin explosion in this decade. That is the extraordinary political and medical clout of CHADD, by far the largest of the add support groups and a lobbying organization of demonstrated prowess. Founded in 1987, chadd had, according to Diller, grown by 1993 to include 35,000 families and 600 chapters nationally. Its professional advisory board, he notes, "includes most of the most prominent academicians in the add world, a veritable who’s who in research."
Like most support groups in self-help America, CHADD functions partly as clearing-house and information center for its burgeoning membership — organizing speaking events, issuing a monthly newsletter (Chadderbox), putting out a glossy magazine (named, naturally enough, Attention!), and operating an exceedingly active website stocked with on-line fact sheets and items for sale. Particular scrutiny is given to every legal and political development offering new benefits for those diagnosed with add. On these and other fronts of interest, CHADD leads the add world. "No matter how many sources of information are out there," as a slogan on its website promises, "chadd is the one you can trust."
One of CHADD’s particular strengths is that it is exquisitely media-sensitive, and has a track record of delivering speedy responses to any reports on Ritalin or add that the group deems inaccurate. Diller quotes as representative one fundraising letter from 1997, where the organization listed its chief goals and objectives as "conduct[ing] a proactive media campaign" and "challeng[ing] negative, inaccurate reports that demean or undermine people with add." Citing "savage attacks" in the Wall Street Journal and Forbes, the letter also went on to exhort readers into "fighting these battles of misinformation, innuendo, ignorance and outright hostility toward CHADD and adults who have a neurobiological disorder." The circle-the-wagons rhetoric here appears to be typical of the group, as is the zeal.
Certainly it was with missionary fervor that chadd, in 1995, mounted an extraordinary campaign to make Ritalin easier to obtain. Methylphenidate, as mentioned, is a Schedule II drug. That means, among other things, that the dea must approve an annual production quota for the substance — a fact that irritates those who rely on it, since it raises the specter, if only in theory, of a Ritalin "shortage." It also means that some states require that prescriptions for Ritalin be written in triplicate for the purpose of monitoring its use, and that refills cannot simply be called into the pharmacy as they can for Schedule III drugs (for example, low-dosage opiates like Tylenol with codeine, and various compounds used to treat migraine). Doctors, particularly those who prescribe Ritalin in quantity, are inconvenienced by this requirement. So too are many parents, who dislike having to stop by the doctor’s office every time the Ritalin runs out. Moreover, many parents and doctors alike object to methylphenidate’s Schedule II classification in principle, on the grounds that it makes children feel stigmatized; the authors of Driven to Distraction, for example, claim that one of the most common problems in treating add is that "some pharmacists, in their attempt to comply with federal regulations, make consumers [of Ritalin] feel as though they are obtaining illicit drugs."
For all of these reasons, CHADD petitioned the dea to reclassify Ritalin as a Schedule III drug. This petition was co-signed by the American Academy of Neurology, and it was also supported by other distinguished medical bodies, including the American Academy of Pediatrics, the American Psychological Association, and the American Academy of Child and Adolescent Psychiatry. Diller’s account of this episode in Running on Ritalin is particularly credible, for he is a doctor who has himself written many prescriptions for Ritalin in cases where he has judged it to be indicated. Nevertheless, he found himself dissenting strongly from the effort to decontrol it — an effort that, as he writes, was "unprecedented in the history of Schedule II substances" and "could have had a profound impact on the availability of the drug."
What happened next, while CHADD awaited the dea’s verdict, was in Diller’s words "a bombshell." For before the DEA had officially responded, a television documentary revealed that Ciba-Geigy (now called Novartis), the pharmaceuticals giant that manufactures Ritalin, had contributed nearly $900,000 to CHADD over five years, and that chadd had failed to disclose the contributions to all but a few selected members.
The response from the dea, which appeared in the background report cited earlier, was harsh and uncompromising. Backed by scores of footnotes and well over a 100 sources in the medical literature, this report amounted to a public excoriation of CHADD’s efforts and a meticulous description, alarming for those who have read it, of the realities of Ritalin use and abuse. "Most of the adhd literature prepared for public consumption and available to parents," the DEA charged, "does not address the abuse liability or actual abuse of methylphenidate. Instead, methylphenidate is routinely portrayed as a benign, mild stimulant that is not associated with abuse or serious effects. In reality, however, there is an abundance of scientific literature which indicates that methylphenidate shares the same abuse potential as other Schedule II stimulants."
The dea went on to note its "concerns" over "the depth of the financial relationship between CHADD and Ciba-Geigy." Ciba-Geigy, the dea observed, "stands to benefit from a change in scheduling of methylphenidate." It further observed that the United Nations International Narcotics Control Board (INCB) had "expressed concern about non-governmental organizations and parental associations in the United States that are actively lobbying for the medical use of methylphenidate for children with add." (The rest of the world, it should be noted, has yet to acquire the American taste for Ritalin. Sweden, for example, had methylphenidate withdrawn from the market in 1968 following a spate of abuse cases. Today, 90 percent of Ritalin production is consumed in the United States.) The report concluded with the documented observations that "abuse data indicate a growing problem among school-age children," that "adhd adults have a high incidence of substance disorders," and that "with three to five percent of today’s youth being administered methylphenidate on a chronic basis, these issues are of great concern."
Yet whatever public embarrassment chadd and its supporters may have suffered on account of this setback turned out to be short-lived. Though it failed in the attempt to decontrol Ritalin (in the end, the group withdrew its petition), on other legislative fronts CHADD was garnering one victory after another. By the end of the 1990s, thanks largely to chadd and its allies, an add diagnosis could lead to an impressive array of educational, financial, and social service benefits.
In elementary and high school classrooms, a turning point came in 1991 with a letter from the U.S. Department of Education to state school superintendents outlining "three ways in which children labeled add could qualify for special education services in public school under existing laws," as Diller puts it. This directive was based on the landmark 1990 Individuals with Disabilities Education Act (idea), which "mandates that eligible children receive access to special education and/or related services, and that this education be designed to meet each child’s unique educational needs" through an individualized program. As a result, add-diagnosed children are now entitled by law to a long list of services, including separate special-education classrooms, learning specialists, special equipment, tailored homework assignments, and more. The idea also means that public school districts unable to accommodate such children may be forced to pick up the tab for private education.
In the field of higher education, where the first wave of Ritalin-taking students has recently landed, an add diagnosis can be parlayed into other sorts of special treatment. Diller reports that add-based requests for extra time on sats, lsats, and mcats have risen sharply in the course of the 1990s. Yet the example of such high-profile tests is only one particularly measurable way of assessing add’s impact on education; in many classrooms, including college classrooms, similar "accommodations" are made informally at a student’s demand. A professor in the Ivy League tells me that students with an add diagnosis now come to him "waving doctor’s letters and pills" and requesting extra time for routine assignments. To refuse "accommodation" is to risk a hornet’s nest of liabilities, as a growing caseload shows. A 1996 article in Forbes cites the example of Whittier Law School, which was sued by an add-diagnosed student for giving only 20 extra minutes per hourlong exam instead of a full hour. The school, fearing an expensive legal battle, settled the suit. It further undertook a preventive measure: banning pop quizzes "because add students need separate rooms and extra time."
Concessions have also been won by advocates in the area of college athletics. The National College Athletic Association (NCAA) once prohibited Ritalin usage (as do the U.S. and International Olympic Committees today) because of what Diller calls its "possible acute performance-enhancing benefits." In 1993, citing legal jeopardy as a reason for changing course, the ncaa capitulated. Today a letter from the team physician will suffice to allow an athlete to ingest Ritalin, even though that same athlete would be disqualified from participating in the Olympics if he were to test positive for stimulants.
Nor are children and college students the only ones to claim benefits in the name of add. With adults now accounting for the fastest-growing subset of add diagnoses, services and accommodations are also proliferating in the workplace. The enabling regulations here are 1997 guidelines from the Equal Employment Opportunity Commission (EEOC) which linked traits like chronic lateness, poor judgment, and hostility to coworkers — in other words, the sorts of traits people get fired for — to "psychiatric impairments," meaning traits that are protected under the law. As one management analyst for the Wall Street Journal recently observed (and as CHADD regularly reminds its readers), these eeoc guidelines have already generated a list of accommodations for add-diagnosed employees, including special office furniture, special equipment such as tape recorders and laptops, and byzantine organizational schemes (color coding, buddy systems, alarm clocks, and other "reminders") designed to keep such employees on track. "Employers," this writer warned, "could find themselves facing civil suits and forced to restore the discharged people to their old positions, or even give them promotions as well as back pay or reasonable accommodation."
An add diagnosis can also be helpful in acquiring Supplemental Security Income (SSI) benefits. ssi takes income into account in providing benefits to the add diagnosed; in that, it is an exception to the trend. Most of the benefits now available, as even this brief review indicates, have come to be provided in principle, on account of the diagnosis per se. Seen this way, and taking the class composition of the add-diagnosed into account, it is no wonder that more and more people, as Diller and many other doctors report, are now marching into medical offices demanding a letter, a diagnosis, and a prescription. The pharmacological charms of Ritalin quite apart, add can operate, in effect, as affirmative action for affluent white people.
What is Attention Deficit Disorder?
Another factor that has put Ritalin into millions of medicine cabinets has to do with the protean nature of the disorder for which it is prescribed — a disorder that was officially so designated by the American Psychiatric Association in 1980, and one that, to cite Thomas Armstrong, "has gone through at least 25 different name changes in the past century."
Despite the successful efforts to have add construed as a disability like blindness, the question of what add is remains passionately disputed. To CHADD, of course, it is a "neurobiological disorder," and not only to CHADD; "the belief that add is a neurological disease," as Diller writes, also "prevails today among medical researchers and university teaching faculty" and "is reflected in the leading journals of psychiatry." What the critics observe is something else — that "despite highly successful efforts to define add as a well-established disorder of the brain," as DeGrandpre puts it in a formulation echoed by many, "three decades of medical science have yet to produce any substantive evidence to support such a claim."
Nonetheless, the effort to produce such evidence has been prodigious. Research on the neurological side of add has come to resemble a Holy Grail-like quest for something, anything, that can be said to set the add brain apart — genes, imbalances of brain chemicals like dopamine and serotonin, neurological damage, lead poisoning, thyroid problems, and more. The most famous of these studies, and the chief grounds on which add has come to be categorized as a neurobiological disability, was reported in The New England Journal of Medicine in 1990 by Alan Zametkin and colleagues at the National Institute of Mental Health (NIMH). These researchers used then-new positron emission tomography (PET) scanning to measure differences in glucose metabolizing between hyperactive adults and a control group. According to the study’s results, what emerged was a statistically significant difference in the rates of glucose metabolism — a difference hailed by many observers as the first medical "proof" of a biological basis for add.
Diller and DeGrandpre are only the latest to argue, at length, that the Zametkin study established no such thing. For starters — and from the scientific point of view, most important — a series of follow-up studies, as Diller documents, "failed to confirm" the original result. DeGrandpre, for his part, details the methodological problems with the study itself — that the participants were adults rather than children, meaning that the implications for the majority of the Ritalin-taking population were unclear at best; that there was "no evidence" that the reported difference in metabolism bore any relationship to behavioral activity; that the study was further plagued by "a confounding variable that had nothing to do with ADD," namely that the control group included far fewer male subjects than the add group; and that, even if there had been a valid difference in metabolism between the two groups, "this study tells us nothing about the cause of these differences."
Numerous other attempts to locate the missing link between add and brain activity are likewise dissected by Diller and DeGrandpre in their books. So too is the causal fallacy prevalent in add literature — that if a child responds positively to Ritalin, that response "proves" that he has an underlying biological disorder. This piece of illogic is easily dismissed. As these and other authors emphasize, drugs like Ritalin have the same effect on just about everybody. Give it to almost any child, and the child will become more focused and less aggressive — one might say, easier to manage — whether or not there were "symptoms" of ADD in the first place.
In sum, and as Thomas Armstrong noted four years ago in The Myth of the ADD Child, ADD remains an elusive disorder that "cannot be authoritatively identified in the same way as polio, heart disease, or other legitimate illnesses." Instead, doctors depend on a series of tests designed to measure the panoply of add symptoms. To cite Armstrong again: "there is no prime mover in this chain of tests; no First Test for add that has been declared self-referential and infallible." Some researchers, for example, use "continuous performance tasks" (cpts) that require the person being tested to pay attention throughout a series of repetitive actions. A popular CPT is the Gordon Diagnostic System, a box that flashes numbers, whose lever is supposed to be pressed every time a particular combination appears. Yet as numerous critics have suggested, although the score that results is supposed to tell us about a given child’s ability to attend, its actual significance is rather ambiguous; perhaps, as Armstrong analyzes, "it only tells how a child will perform when attending to a repetitive series of meaningless numbers on a soulless task."
In the absence of any positive medical or scientific test, the diagnosis of add in both children and adults depends, today as a decade ago, almost exclusively on behavioral criteria. The diagnostic criteria for children, according to the latest Diagnostic and Statistics Manual (DSM-IV), include six or more months’ worth of some 14 activities such as fidgeting, squirming, distraction by extraneous stimuli, difficulty waiting turns, blurting out answers, losing things, interrupting, ignoring adults, and so on. (To read the list is to understand why boys are diagnosed with add three to five times as often as girls.) The diagnostic latitude offered by this list is obvious; as Diller understates the point, "what often strikes those encountering dsm criteria for the first time is how common these symptoms are among children" generally.
The dsm criteria for adults are if anything even more expansive, and include such ambiguous phenomena as a sense of underachievement, difficulty getting organized, chronic procrastination, a search for high stimulation, impatience, impulsivity, and mood swings. Hallowell and Ratey’s 100-question test for add in Driven to Distraction, an elaborately extrapolated version of the dsm checklist, illustrates this profound elasticity. Their questions range from the straightforward ("Are you impulsive?" "Are you easily distracted?" "Do you fidget a lot?") to more elusive ways of eliciting the disorder ("Do you change the radio station in your car frequently?" "Are you always on the go, even when you don’t really want to be?" "Do you have a hard time reading a book all the way through?"). Throughout, the distinction between what is pathological and what is not remains unclear — because, in the authors’ words, "There is no clear line of demarcation between add and normal behavior."
Thus the business of diagnosing add remains, as Diller puts it, "very much in the eye of the beholder." In 1998, partly for that reason, the National Institutes of Health convened a conference on add with hundreds of participants and a panel of 13 doctors and educators. This conference, as newspapers reported at the time, broke no new ground, and indeed could not reach agreement on several important points — for instance, how long children should take drugs for add, or whether and when drug treatment might become risky. Even more interesting, conference members could not agree on what is arguably the rather fundamental question of how to diagnose the disorder in the first place. As one panelist, a pediatrician, put it succinctly, "The diagnosis is a mess."
Who has ADD?
To test this hypothesis, I gave copies of Hallowell and Ratey’s questionnaire to 20 people (let’s call them subjects) and asked them to complete it and total up the number of times they checked "yes." The full questionnaire appears at the conclusion of this piece so that interested readers can take it themselves. "These questions," as Hallowell and Ratey note, "reflect those an experienced diagnostician would ask." Although, as they observe, "this quiz cannot confirm the diagnosis" (as we have seen already, nothing can), it does "offer a rough assessment as to whether professional help should be sought." In short, "the more questions that are answered ‘yes,’ the more likely it is that add may be present."
In a stab at methodological soundness, I had equal numbers of males and females take the test. All would be dubbed middle- or upper-middle class, all but one are or have been professionals of one sort or another, all are white, and the group was politically diverse — which is to say, the sample accurately reflects the socioeconomic pool from which most of the current Ritalin-taking population is drawn. As to the matter of observer interference, although some subjects may have guessed what the questionnaire was looking for, all of them (myself excepted, of course) took the test "blind," that is, without any accompanying material to prejudice their responses.
We begin with results at the lower end of the scale. Of the 18 subjects who completed the test, two delivered "yes" scores of 8 and 10 (a professor of English and his wife, an at-home mother active in philanthropy). These "yes" results, as it turned out, were at least threefold lower than anyone else’s. In "real" social science, according to some expert sources, we would simply call these low scores "outliers" and throw them out for the same reason. We, however, shall include them, if only on the amateur grounds of scrupulousness.
The next lowest "yes" tallies — 29 in each case — were achieved by an editorial assistant and a school nurse. That is to say, even these "low scorers" managed to answer yes almost a third of the time (remember, "the more questions that are answered ‘yes,’ the more likely it is that add may be present"). After them, we find a single "yes" score of 33 (an assistant editor). Following that, fully six subjects, or a third of the test-finishers, produced scores in the 40s. These include this magazine’s editor, two at-home mothers (one a graphic designer, the other a poet), a writer for Time and other distinguished publications, Policy Review’s business manager, and — scoring an estimable 49 — the headmaster of a private school in Washington.
Proceeding into the upper echelons, a novelist who is also an at-home mother reported her score as 55, and a renowned demographic expert with ties to Harvard and Washington think tanks scored a 57. A male British journalist and at-home father achieved a 60, and a female American journalist and at-home mother (me) got a 62. Still another at-home mother, this one with a former career in public relations, garnered a 65.
In the lead, at least of the test-finishers, was a bestselling satirist whom we shall call, for purposes of anonymity, Patrick O’Rourke; he produced an estimable score of 75. "Mr. O’Rourke" further advanced the cause of science by answering the questions on behalf of his 16-month-old daughter; according to his proud report, 65 was the result. Then there were the two subjects who, for whatever reason, were unable to complete the test in the first place. One of these subjects called to say that he’d failed to finish the test because he’d "gotten bored checking off so many yes answers." When I pressed him for some, any, final tally for me to include, he got irritated and refused, saying he was "too lazy" to count them up. Finally he said "50 would be about right," take it or leave it. He is a Wall Street investment banker specializing in the creation of derivative securities. Our last subject, perhaps the most pathological of all, failed to deliver any score despite repeated reminding phone calls from the research team. He is the professor mentioned earlier, the one who reported that ADD is now being used as a blanket for procrastination and shirking on campus.
Now on to interpreting the results. Apart from the exceedingly anomalous two scores of ten and under, all the rest of the subjects reported answering "yes" to at least a quarter of the questions — surely enough to trigger the possibility of an add diagnosis, at least in those medical offices Diller dubs "Ritalin mills." (As for the one subject who reported no result whatsoever, he is obviously entitled to untold ADD bonus points for that reason alone.) Fully 15 of the finishers, or 80-plus percent, answered yes to one-third of the questions or more. Eight of the finishers, or 40-plus percent of the sample, answered yes more than half of the time, with a number of scores in the high 40s right behind them. In other words, roughly half of the sample answered yes roughly half of the time.
My favorite comment on the exercise came from the school nurse (who scored, one recalls, a relatively low 29). She has a background in psychiatry, and therefore realized what kind of diagnosis the questionnaire was designed to elicit. When she called to report her result, she said that taking the test had made her think hard about the whole add issue. "My goodness," she concluded, "it looks like the kind of thing almost anybody could have." This brings us to the fourth reason for the explosion of add and its prescribed corollary, Ritalin: The nurse is right.
What is childhood?
The fourth and most obvious reason millions of Americans, most of them children, are now taking Ritalin can be summarized in a single word that crops up everywhere in the dry-bones literature on add and its drug of choice: compliance. One day at a time, the drug continues to make children do what their parents and teachers either will not or cannot get them to do without it: Sit down, shut up, keep still, pay attention. That some children are born with or develop behavioral problems so severe that drugs like Ritalin are a godsend is true and sad. It is also irrelevant to the explosion in psychostimulant prescriptions. For most, the drug is serving a more nuanced purpose — that of "help[ing] your child to be more agreeable and less argumentative," as Barbara Ingersoll put it over a decade ago in Your Hyperactive Child.
There are, as was mentioned, millions of stories in the Ritalin universe, and the literature of advocates and critics alike all illustrates this point. There is no denying that millions of people benefit from having children take Ritalin — the many, many parents who will attest that the drug has improved their child’s school performance, their home lives, often even their own marriages; the teachers who have been relieved by its effects in their classrooms, and have gone on to proselytize other parents of other unruly children (frequently, it is teachers who first suggest that a child be checked for the disorder); and the doctors who, when faced with all these grateful parents and teachers, find, as Diller finds, that "at times the pressure for me to medicate a child is intense."
Some other stories seep through the literature too, but only if one goes looking for them. These are the stories standing behind the clinical accounts of teenagers who lie and say they’ve taken the day’s dose when they haven’t, or of the children who cry in doctor’s offices and "cheek" the pill (hide it rather than swallow, another linguistic innovation of Ritalinese) at home. These are the stories standing behind such statements as the following, culled from case studies throughout the literature: "It takes over of me [sic]; it takes control." "It numbed me." "Taking it meant I was dumb." "I feel rotten about taking pills; why me?" "It makes me feel like a baby." And, perhaps most evocative of all, "I don’t know how to explain. I just don’t want to take it any more."
But these quotes, as any reader will recognize, appeal only to sentiment; science, for its part, has long since declared its loyalties. In the end, what has made the Ritalin outbreak not only possible but inevitable is the ongoing blessing of the American medical establishment — and not only that establishment. In a particularly enthusiastic account of the drug in a recent issue of the New Yorker, writer Malcolm Gladwell exults in the idea that "we are now extending to the young cognitive aids of a kind that used to be reserved exclusively for the old." He further suggests that, given expert estimates of the prevalence of add (up to 10 percent of the population, depending on the expert), if anything "too few" children are taking the drug. Surely all these experts have a point. Surely this country can do more, much more, to reduce fidgeting, squirming, talking excessively, interrupting, losing things, ignoring adults, and all those other pathologies of what used to be called childhood.
Do you have ADD?
1. Are you left-handed or ambidextrous?
2. Do you have a family history of drug or alcohol abuse, depression, or manic-depressive illness?
3. Are you moody?
4. Were you considered an underachiever in school? Now?
5. Do you have trouble getting started on things?
6. Do you drum your fingers a lot, tap your feet, fidget, or pace?
7. When you read, do you find that you often have to reread a paragraph or an entire page because you are daydreaming?
8. Do you tune out or space out a lot?
9. Do you have a hard time relaxing?
10. Are you excessively impatient?
11. Do you find that you undertake many projects simultaneously so your life often resembles a juggler who’s got six more balls in the air than he can handle?
12. Are you impulsive?
13. Are you easily distracted?
14. Even if you are easily distracted, do you find that there are times when your power of concentration is laser-beam intense?
15. Do you procrastinate chronically?
16. Do you often get excited by projects and then not follow through?
17. More than most people, do you feel it is hard to make yourself understood?
18. Is your memory so porous that if you go from one room to the next to get something, by the time you get to the next room you’ve sometimes forgotten what you were looking for?
19. Do you smoke cigarettes?
20. Do you drink too much?
21. If you have ever tried cocaine, did you find that it helped you focus and calmed you down, rather than making you high?
22. Do you change the radio station in your car frequently?
23. Do you wear out your TV remote-control switch by changing stations frequently?
24. Do you feel driven, as if an engine inside you won’t slow down?
25. As a kid, were you called words like, " a daydreamer," "lazy," "a spaceshot," "impulsive," "disruptive," "lazy," or just plain "bad"?
26. In intimate relationships is your inability to linger over conversations an impediment?
27. Are you always on the go, even when you don’t really want to be?
28. More than most people, do you hate waiting in line?
29. Are you constitutionally incapable of reading directions first?
30. Do you have a hair-trigger temper?
31. Are you constantly having to sit on yourself to keep from blurting out the wrong thing?
32. Do you like to gamble?
33. Do you feel like exploding inside when someone has trouble getting to the point?
34. Were you hyperactive as a child?
35. Are you drawn to situations of high intensity?
36. Do you often try to do the hard things rather than what comes easily to you?
37. Are you particularly intuitive?
38. Do you often find yourself involved in a situation without having planned it at all?
39. Would you rather have your teeth drilled by a dentist than make or follow a list?
40. Do you chronically resolve to organize your life better only to find that you’re always on the brink of chaos?
41. Do you often find that you have an itch you cannot scratch, an appetite for something "more" and you’re not sure what it is?
42. Would you describe yourself as hypersexual?
43. One man who turned out to have adult ADD presented with this unusual triad of symptoms: cocaine abuse, frequent reading of pornography, and an addiction to crossword puzzles. Can you understand him , even if you do not have those symptoms?
44. Would you consider yourself an addictive personality?
45. Are you really more flirtatious than you mean to be?
46. Did you grow up in a chaotic, boundariless family?
47. Do you find it hard to be alone?
48. Do you often counter depressive moods by some sort of potentially harmful compulsive behavior such as overworking, overspending, overdrinking, or overeating?
49. Do you have dyslexia?
50. Do you have a family history of ADD or hyperactivity?
51. Do you have a really hard time tolerating frustration?
52. Are you restless without "action" in your life?
53. Do you have hard time reading a book all the way through?
54. Do you regularly break the rules or minor laws rather than put up with the frustration of obeying them?
55. Are you beset by irrational worries?
56. Do you frequently make number of letter reversals?
57. Have you been the driver and at fault in more than four car accidents?
58. Do you handle money erratically?
59. Are you a gung-ho, go-for-it sort of person?
60. Do you find structure and routine are both rare in your life and soothing when you find them?
61. Have you been divorced more than once?
62. Do you struggle to maintain self-esteem?
63. Do you have poor hand-eye coordination?
64. As a kid, were you a bit of a klutz at sports?
65. Have you changed jobs a lot?
66. Are you a maverick?
67. Are memos virtually impossible for you to read or write?
68. Do you find it almost impossible to keep an updated address book, phone book, or Rolodex?
69. Are you the life of the party one day and hang-dog the next?
70. Given an unexpected chunk of free time, do you often find that you don’t use it well, or get depressed during it?
71. Are you more creative or imaginative than most people?
72. Is paying attention or staying tuned in a chronic problem for you?
73. Do you work best in short spurts?
74. Do you let the bank balance your checkbook?
75. Are you usually eager to try something new?
76. Do you find you often get depressed after a success?
77. Do you hunger after myths and other organizing stories?
78. Do you feel you fail to live up to your potential?
79. Are you particularly restless?
80. Were you a daydreamer in class?
81. Were you ever the class clown?
82. Have you ever been described as "needy" or even "insatiable"?
83. Do you have trouble accurately assessing the impact you have on others?
84. Do you tend to approach problems intuitively?
85. When you get lost, do you tend to "feel" your way along rather than refer to a map?
86. Do you often get distracted during sex, even though you like it?
87. Were you adopted?
88. Do you have many allergies?
89. Did you have frequent ear infections as a child?
90. Are you much more effective when you are your own boss?
91. Are you smarter than you’ve been able to demonstrate?
92. Are you particularly insecure?
93. Do you have trouble keeping secrets?
94. Do you often forget what you’re going to say just as you are about to say it?
95. Do you love to travel?
96. Are you claustrophobic?
97. Have you ever wondered if you’re crazy?
98. Do you get the gist of things very quickly?
99. Do you laugh a lot?
100. Did you have trouble paying attention long enough to read this entire questionnaire?
From the book Driven to Distraction by Edward M. Hallowell, M.D., and John J. Ratey, M.D. Copyright © 1994 by Edward M. Hallowell, M.D., and John J. Ratey, M.D. Reprinted with permission of Pantheon Books, a Division of Random House, Inc.
RITALIN: MIRACLE DRUG OR COP-OUT
by Ken Livingston
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.
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.
Discovering which view represents the better understanding of Ritalin and the condition it is intended to treat is not quite as simple as talk-show discussions and magazine articles sometimes make it seem. The difficulties begin with the fact that no one really understands the etiology of ADHD. Environmental factors from lead to sugar and food additives have been blamed, but there is no clear empirical support for such claims. Nor have investigators been able to explain the disorder by appeal to parenting styles or other socialization factors. Instead, what has emerged in recent years is mounting evidence that the problem runs in families. Among monozygotic (genetically identical) twins, when one twin is diagnosed with ADHD the other also receives the diagnosis 51 percent of the time. In contrast, among dizygotic twins, no more related to each other genetically than ordinary siblings, the concordance rate is only 33 percent. Combined with the fact that adoption studies show that the relationship runs more strongly in genetic families than in the family of upbringing, these data suggest that there is a genetic contribution to whatever is going on in ADHD.
This does not mean, however, that ADHD is genetically determined. If it were, then the concordance rate for monozygotic twins would be 100 percent, as it is for eye color. Rather, it means that there may be something in the genetic blueprint for wiring up the brains of some people which disposes them to the pattern of thought and action that gets labeled ADHD. At best, however, this is but a small part of the story, for it does not tell us what kinds of experiences in the world act together with this genetic disposition to produce the ADHD pattern. Most researchers are now convinced that there is no single answer to that question; it seems increasingly likely that there are many different paths to the syndrome. That makes it difficult to offer simple prescriptions for preventing the ADHD pattern from developing. The best the psychiatric community has to offer is treatment once ADHD does develop, and, at the moment, the most popular treatments involve stimulant drugs like Ritalin.
Interestingly, the effectiveness of Ritalin and similar stimulants in changing the behavior of ADHD children has led researchers to think that they know what is different about the brains of those afflicted with ADHD. One of the most systematic attempts to piece together this puzzle has been made by James McCracken, professor of psychiatry at UCLA and his colleagues Steven Pliszka and James Maas, both professors of psychiatry at the University of Texas Health Science Center in San Antonio. Writing in the March 1996 issue of the Journal of the American Academy of Child and Adolescent Psychiatry, they proposed what is known in the community of ADHD researchers as the "catecholamine hypothesis" to explain what is wrong in the brains of people with attentional dysfunction. It's worth spending a little time trying to understand this theory because knowing just what is going on in ADHD patients helps to clarify what is really at stake in the controversy over Ritalin.
The catecholamines referred to in the phrase "catecholamine hypothesis" are among the dozens of special chemicals in the brain, known as neurotransmitters, that make it possible for the millions of nerve cells that make up that organ to communicate with each other. When a nerve cell "fires," it releases tiny amounts of these chemicals into the small gaps, called synapses, that separate it from the cells to which it sends connections. These chemicals diffuse across the gap and attach themselves to special receptors on the receiving cell. Upon attaching, they change the chemical balance inside the receiving cell, making it more or less likely to fire in its own turn. All of the activities of the mind, including those that make it possible for you to read these sentences, are the result of quadrillions of such events taking place every second in the brain.
But these electrochemical processes must occur at the right levels of intensity and in the right patterns for the mind to function effectively. Too much of a neurotransmitter, or too little, being released in various parts of the brain can lead to a variety of disorders. For example, a deficit of a neurotransmitter called dopamine, one of the main classes of catecholamines, means that it can't send the right messages to control the contractions in the body's muscles, and one sees, as a result, the tremors of Parkinson's disease.
Pliszka, McCracken, and Maas have proposed that ADHD is such a neurotransmitter dysfunction, in this case a catecholamine imbalance. The catecholamines are used by many different circuits in the brain, but these researchers suggest that when there is an imbalance in the circuits that control attention, some form of ADHD is the result. Although these are among the most complex systems in all of nature, the basic logic of their hypothesis is simple enough. Controlling attention means that one has to be able to do two things. On the one hand, one has to be able to stay focused on a task or activity in the face of unavoidable distractions from the world outside and from one's own thoughts and sensations. But there has to be a way to disengage and then shift attention to a different activity if the need arises. A person's being too focused and unable to disengage can be just as much a problem as his not being able to stay focused in the first place. A balance must be struck, and that's what the attention circuits are supposed to do.
But what is the right balance? The answer is, and this is the most important point, the right balance must be appropriate to the kinds of tasks and situations one encounters. The balance is likely to be different for someone trading commodities in the pit of the Chicago Mercantile Exchange, a surgeon performing a delicate operation in a hospital, or a parent trying to cook dinner and keep an eye on the baby at the same time. And the precise nature of that balance is related in a complex way to the balance of the catecholamines in the attention circuits.
Stimulant drugs such as Ritalin affect that balance by increasing the amount of time that catecholamine molecules remain active in certain synapses. Exactly where the balance is reset is still unclear and may vary from one person to the next. The complex neurophysiology of these circuits may also help to explain why many school-age children, and even more preschoolers and adults, don't seem to respond positively to methylphenidate but do respond to other stimulants like dextroamphetamine. These drugs are very similar in their effects, but the differences can be important in a circuit this complex. About 70 percent of the children diagnosed with ADHD will respond to one of the amphetamines, most of them to Ritalin. Of the remaining 30 percent, at least one-half will show improvement when they are given one of a class of anti-depressant drugs also known to affect the catecholamine neurotransmitters. And some children do not respond to any of these drug therapies.
So far there is no way to know before the fact which drugs, if any, will be useful for a given child. Only trial and error reveals which drug treatment will improve the troublesome pattern of behavior. And that suggests that the diagnostic criteria for establishing the presence of ADHD are incomplete.
Indeed, although many physicians use the drug as a diagnostic tool--in other words, if Ritalin seems to improve attention, the patient is assumed to have ADHD--an improvement in attentional control after taking a drug like Ritalin does not, in fact, establish the diagnosis of ADHD. Studies conducted during the mid seventies to early eighties by Judith Rapaport of the National Institutes of Mental Health clearly showed that stimulant drugs improve the performance of most people, regardless of whether they have a diagnosis of ADHD, on tasks requiring good attention. Indeed, this probably explains the high levels of "self-medication" around the world (stimulants like caffeine and nicotine, for example). Particularly interesting is the fact that cocaine, still reputed to be the illegal drug of choice in the world of the young, upwardly mobile, and highly focused crowd, has a psychopharmacology that is very similar to that of methylphenidate. In short, even if you have never been diagnosed as having a problem paying attention, many of these drugs will improve your focus and performance. The fact that a child is more attentive while taking Ritalin doesn't then mean that he has a documentable mental disorder.
So how is it decided that a child, or adult, should be considered attentionally disordered? The answer has varied over the last 40 years. In 1957, the first APA Diagnostic and Statistical Manual contained no mention of any disorder remotely like ADHD. By 1968, however, when DSM-II was published, there was a new diagnostic category known as "hyperkinetic reaction of childhood." The use of the term "reaction" here is significant, because the APA makes a distinction between a disorder and a reaction, the latter suggesting a milder, possibly less chronic condition. It wasn't until the appearance of DSM-III, in 1980, that attention deficit disorder or ADD was recognized. At that time, a distinction was made between ADD with hyperactivity (ADD/H) and without (ADD/WO). By 1987, the APA found it necessary to revise its manual again, and, in DSM-III-R (for revised), it was decided that there was a single dimension of disorder known by the now-familiar ADHD designation. However, by the time of the 1994 publication of DSM-IV, diagnosticians were convinced that the earlier DSM-III distinctions had been closer to the mark, and they proposed the current classification system with its three sub-types (with hyperactivity only, with inattention only, and the combined form).
Why has it been so difficult to stabilize the diagnostic criteria for ADHD? There are several possible answers. One of them is that the disorder itself is subtle and difficult to detect in all but extreme cases. This explanation is similar to ones that physicians offer when challenged to defend the diagnosis of chronic fatigue syndrome, a medical condition that, like ADHD, wasn't even in the diagnostician's toolbox a few decades ago. One who wanted to defend the diagnosis could argue that the disorders were known, at least in extreme cases, but that there were other, more folk-psychological explanations for these patterns which prevented people from seeing them as true disorders. People with chronic fatigue syndrome were simply thought to be "malingering." And children with ADHD were thought to be either "slow," if the problem was inattention, or "wild," if the problem was impulsivity. The shift to viewing ADHD as a mental disorder could be seen, from this vantage, as an enlightened move.
But there is another reason why the criteria for ADHD might have been so difficult to articulate, and it calls into question the very foundation of the APA's diagnostic system. The APA has made the decision to formulate its diagnoses as categories of disorder. This means that one either does or does not have ADHD, or obsessive-compulsive disorder, or conduct disorder, or what-have-you. The alternative would be to focus on dimensions of difference. Our growing understanding of how we pay attention makes it clear that attentional capacities are measurable on dimensions of persistence, distractibility, impulsivity, flexibility, and control. These different factors define a multi-dimensional space of possibilities for how we pay attention, and each of us occupies a unique region in that space.
From this perspective, diagnosing a child as having an attentional disorder seems to require drawing lines along the various continua and deciding that people on one side are normal and those on the other are not. Somewhere between the person with exquisite control over the focus of his attention and the befuddled scatterbrain, we judge the attention-control system to be broken and in need of treatment.
But how are we to decide which side of the line a given person is on? There are, as it turns out, two answers to this question. One is the official answer, and the other reflects what actually happens in the offices of school psychologists and pediatricians.
Officially, experts make very specific and stringent recommendations about how to correctly diagnose ADHD. Dennis Cantwell, in a recent review of the last decade of research on ADHD for the August 1996 issue of the Journal of the American Academy of Child and Adolescent Psychiatry, summarizes the current recommendations. The diagnosis should begin with thorough interviews of anyone who acts as parent to the child. The goal is to establish, in detail, under what circumstances the presenting symptoms occur and to take a complete developmental, medical, and family history. Following these interviews, the clinician should interview the child in order to elicit his view of the problem. This interview should include screening for other problems that might be the real source of difficulty, including other mental disorders (depression, anxiety, hallucinations, etc.). The child should also be given a thorough medical examination to rule out neurological or sensory problems (poor hearing or eyesight, for example) as the cause of symptoms. The child should then be given tests of intelligence and achievement, and the clinician should evaluate questionnaires filled out by both parents and teachers. These questionnaires ask the respondent to indicate the degree to which the child displays the patterns of behavior that are considered markers for ADHD. Further tests may be required to rule out possible problems that emerge during this lengthy examination.
In reality, few physicians report anything like this level of scrutiny before prescribing treatment. In a recent survey of pediatricians, published in the Archives of Pediatric and Adolescent Medicine, nearly 50 percent of doctors confess to spending an hour or less with a child before making a diagnosis and prescribing medication (usually Ritalin). Obviously, the thorough regimen of examinations suggested by the experts can't be performed in such a short period of time. What should make this particularly worrisome, even for those who are willing to defend the current criteria for diagnosing ADHD, are recent findings by Mark Wolraich and his colleagues at the Vanderbilt University Child Development Center that as many as two-thirds of all children who meet the DSM-IV criteria for ADHD have other problems as well. These are referred to in the psychiatric community as "comorbid conditions," and they most often include things like anxiety and so-called conduct disorders. This is particularly significant information to have when prescribing medications, because stimulant drugs actually may be counterproductive for children with certain of these problems. Combine this with the finding by Linda Copeland and her colleagues, reported in 1987 in Developmental and Behavioral Pediatrics, that most pediatricians do not adequately monitor the medications of their ADHD patients once they have prescribed them and you have a troubling situation indeed.
If diagnoses and follow-ups are not being conducted by experts' examinations, then how are they being made? The research literature suggests that it is behavioral ratings of teachers and parents which are most often used to assign the ADHD classification. The parent or teacher is presented with a number of statements such as, "Is easily distracted by extraneous stimuli," and is asked to indicate the degree to which this statement applies to the child. Responses to all of the questions are summed, and the result is compared to established norms. If the child falls outside this normative range, he receives the ADHD diagnosis. In other words, a line is drawn beyond which an individual difference is labeled a pathology.
The problem, of course, is that the decision about where to draw that line is a judgment call. Wolraich and his colleagues applied the criteria for ADHD from both DSM-III-R and DSM-IV to the same sample of 8,258 children and found that 7.3 percent of them have ADHD according to DSM-III-R, while more than half again as many, 11.4 percent, qualify using DSM-IV criteria. Even using the same rating scales yields different percentages depending on the standard one uses. If a teacher has to say that various characteristics, like distractibility or forgetfulness, very much describe a child before ADHD is diagnosed, the proportion of ADHD children may run as low as 4 percent. But if the teacher can say either that the traits are very much characteristic of the child or only pretty much so, the proportion rises to over 18 percent.
So this is the situation in which we find ourselves. The psychiatric community has decided to collapse a complex, multidimensional pattern of behavior into two categories. One it considers normal; the other it considers pathological (with three variations) and labels ADHD. Meanwhile, treating physicians have collapsed a thorough diagnosis regime into a one-hour visit. As a result, diagnosis and treatment outside the research laboratory vary widely: The number of grams of Ritalin used per 100 population ranges from a low of 0.25 grams in Hawaii to a high of 2.36 grams in Georgia, a nearly tenfold difference. Nevertheless, taking the country as a whole, we learn that the overall trend is toward increasing use of the label ADHD for school-age children and its gradual extension to cover adults and pre-schoolers as well. And this growth in the number of diagnosed cases is accompanied by a dramatic increase in the last decade in the use of certain stimulant drugs to treat the symptoms of the disorder.
What remains unclear is why there should be an increase in the use of the diagnosis. After all, the flexibility of the criteria for considering a child to have ADHD could just as well have been used to decrease the number of children so diagnosed. Why have the numbers gone up?
There is no existing research to answer this question definitively. The research suggests that changes in the DSM criteria may have had an effect on the overall numbers of children who are considered to have ADHD, but that doesn't explain why the percentages of children who are diagnosed and put on medication vary from one part of the country to another. The best we can do in response to this question is to propose hypotheses for future research. To do that, however, it helps to have a few additional facts about the typical sequence of events leading up to a diagnosis of ADHD.
The precipitating events almost always take place at school. It is no accident that the disorder was long considered to be a problem that did not arise until about the age of five. The growth in the number of children attending nursery schools, beginning at age three or four, probably then accounts for the recent rise in diagnoses of the disorder at these younger ages. What this means is that the first suggestion that a child might have ADHD is usually made by a teacher, often during a parent-teacher conference, and not by a parent. The teacher already may have asked the school psychologist to observe the child and filled out one of the teacher rating forms for assessing attention and impulsivity. The teacher may then suggest an evaluation by the family's pediatrician or some other specialist.
Once this formal evaluation begins, as we have seen, the process can move with great rapidity. A few minutes with the child, some discussion with a concerned parent, and perhaps a look at the teacher's rating forms and a report from the school psychologist, and the doctor makes a diagnosis of ADHD. Medication is prescribed, most often Ritalin initially, and the child officially joins the ranks of the attentionally impaired.
But why of late are more teachers making such referrals? The most innocent explanation is that as teachers, and to some degree parents as well, have become better educated about this problem, they have tended to seek professional help when signs of ADHD are first detected. Indeed, there is a trend underway toward making the school an extension of the therapy establishment. For example, school psychologists have been very active proponents of the need for increased mental-health services for school children. Beth Doll, of the University of Colorado at Denver, writing in the Winter 1996 issue of the School Psychology Quarterly, urges the establishment of training programs that would "create therapeutic schools in which ownership for students' mental health is fostered among every teacher and administrator in a building." This is newspeak for the idea that teachers and administrators have to be taught how to think and act as therapists as well as educators. This vision of the school as a mental-health facility may already be affecting how teachers and school psychologists view their roles in the system, with the rise in the number of children with the ADHD diagnosis as a kind of lagging indicator of these changes.
Not everyone in the school system, however, seems eager to embrace the therapeutic model of the school. Cost-conscious school administrators and school boards are leery of this new focus on mental health. And they cringe every time another student is added to the ADHD population in a school, for many parents are being informed by physicians who diagnose their children that ADHD counts legally as a disability and therefore qualifies the child for special treatment under the Americans with Disabilities Act. By this law, the school system is obligated to provide "equal access" to the curriculum for such children, which may mean paying for special remedial services or other therapies. Given a fixed school budget, the funds for such services have to come out of other programs, with net negative results for other students in the school. So from the standpoint of school administrators, there is a financial disincentive to ADHD diagnoses.
However, it may turn out that state departments of education and local school boards are finding themselves nonetheless hoist with their own petard. It may prove significant that the rise in the number of referrals for ADHD tracks the adoption throughout the country of outcome-based educational goals. Outcome-based systems are predicated on the idea that every child can and should be brought to some high minimal standard of performance in the curriculum. These systems are motivated philosophically by an egalitarian view of society; we are all entitled, on this view, to an equally effective education at the public's expense.
But once you have adopted such a system, teachers cannot respond to uncooperative and inattentive students by simply passing them on to the next grade. Outcome-based programs make the teacher directly accountable for the child's performance. Teachers now become desperate seekers after anything that will enable them to improve the child's performance to the mandated level. Hence their eagerness to suggest the quick fix of drug therapy if the child's problem seems attentional.
It would require careful and elaborate research to test this hypothesis thoroughly, but a crude check of its plausibility can be made by comparing the rate of Ritalin consumption in the 50 states and District of Columbia with data from the U.S. Census on whether or not the state has some sort of exit exam or competency requirement for graduation from high school. The latter data are crude, require some interpretation, and are not quite as contemporary as the data for Ritalin consumption; so the result must be viewed as very tentative. But it is interesting that states with competency or exit requirements have higher levels of Ritalin consumption than states that do not, on average. The difference is not large, amounting on average to only about .3 grams per 100 population, but it is statistically significant. This means that it is at least possible that the pressure to get students to perform to high levels in the public-school classroom is leading teachers to promote the ADHD diagnosis and subsequent treatment with a drug that improves the child's behavior.
Indeed, the data on how Ritalin affects performance are consistent with this view. The child for whom Ritalin (or one of the other drugs) works tends to remain "on task" longer and, therefore, tends to complete more work. This includes work on exams and homework assignments, with the result that the child's grades may actually show improvement. The child tends to become more cooperative, to follow directions better, and thus to get along better with other children and with the teacher. This has the beneficial side effect of improving the classroom environment by reducing disruptions and time away from other students, and so increases the teacher's effectiveness with the class as a whole.
What Ritalin does not do, and this is a finding about which proponents of the ADHD diagnosis tend to be defensive, is to improve long-term achievement-test scores. The drug simply makes the child more manageable and better able to work to the level of the system's expectations. It does not seem to produce long-term changes in cognitive functioning.
It is tempting to view this pattern as suggesting that the ADHD diagnosis provides teachers with a new technique for regaining control of the classroom in a world where many of the traditional methods of control have been eliminated. Drugs have replaced the reprimand.
But it seems to me that the real problem may be that the concept of compulsory, cookie-cutter education needs rethinking. In spite of the rhetoric in schools of education about the importance of taking into account the individual needs of the children in a classroom, the current system of public education is designed to make that nearly impossible. State curriculum guidelines and requirements, coupled with further requirements from the local community, prevent teachers from making any serious effort to tailor materials and assignments to the differing abilities and dispositions of individual children. Nor is there any mechanism, of the sort one would find in a school-choice-based system of education, for parents to seek out schools tailored to the temperaments and capabilities of their children. Instead, it becomes necessary to find ways of making children able to perform in the environment as they find it. And, in late twentieth-century America, when it is difficult or inconvenient to change the environment, we don't think twice about changing the brain of the person who has to live in it. The rise in consumption of Ritalin is only one manifestation of this cultural practice. Consider Prozac or, in previous decades, Valium.
None of this should be taken to suggest that there are no cases of genuine brain damage or dysfunction that require medical intervention. There have always been diseases of the brain, as of any other organ, and they should be treated as such. But difference does not automatically equal disease. Is changing the child's brain chemistry, by prescribing Ritalin-like drugs, really the most appropriate response to the child who doesn't perform well in the modern school environment? Perhaps it's time we asked ourselves whether the fact that so many children can't learn well in our schools is a reflection on the schools, not the children.
* Livingston is a professor in the Department of Psychology and Program in Cognitive Science at Vassar College. Reprinted with permission of the author from The Public Interest, No. 127 (Spring 1997), pp. 3-18 ©1997 by National Affairs Inc.