RITALIN ABUSE: THE CHEMICAL DEPENDENCY OF INADEQUATE SCHOOLS by John R. Woodward, M.S.W. Center for Independent Living of North Florida, Inc. Case History #1: Vonelle M., a black single mother living on welfare benefits, has three children in the public schools. All have been labeled as troublemakers with inferior learning capacities. Over the years, Vonelle has developed some very personal antagonisms with the county school officials. Her youngest child, a seven-year-old boy, has just been referred for evaluation because "he has adjustment problems in the classroom." The school social worker intends to refer him to a physician for Ritalin treatment when the evaluation is complete, and Vonelle has already been told by the elementary school principal that if he doesn't take the drug, he will be taken out of his mainstream classroom and put in a "disciplinary situation." What is this magic drug that abolishes the effects of poverty, bigotry and cultural deprivation, transforming any child into an "appropriate scholar"? For fifty years now, the drug methylphenidate (casually known by the brand name "Ritalin") has been the principle agent of social control used by the medical community to fit creative or willful children into mediocre classrooms. The Cult of Ritalin and Hyperactivity is still promoted by school officials to deflect the blame for poor learners away from inept teachers, meaningless curricula and overcrowded classrooms, and onto the victims of these phenomenon. As a "Ritalin Survivor," I want to examine with you why so many educators, doctors and parents have formed a cult around this drug, despite the huge weight of scientific evidence that it has limited powers and is usually applied to the wrong children. THE DRUG Case History #2: Alice K. took her son off Ritalin and put him on a placebo, despite the fact that her son's principal called her up and screamed at her when the druggist admitted to the scam. "Daniel wasn't doing any better with the drug that without it," she told me, "and the drug was making him sick. He lost 17 pounds when he went off the drug. He started to sleep at night. The headaches went away. The trouble he had focusing his eyes went away; so did the pains in his stomach." Ritalin is technically a "psychoaffective stimulant," chemically similar to benzedrine (methamphetimine, casually known as "speed"). It is classified as a "mild central nervous system stimulant" by the Physician's Desk Reference on Prescription Drugs (PDR). According to the PDR, "There is neither specific evidence which clearly establishes the mechanism whereby Ritalin produces its mental and behavioral effects in children, nor conclusive evidence regarding how these conditions relate to the central nervous system." In layman's terms, no one understands how it works -- which is odd, given that Ritalin will be prescribed for as many as 7.5% of all school-age children at some point during their schooling. Besides the side effects suffered by Daniel W., the PDR lists 28 additional problems caused by Ritalin, including failure to grow, high blood pressure, irritability, psychotic reactions, withdrawal symptoms, seizures and lethargy. As you would expect, some of these symptoms are similar to those of the "speed freak" who abuses stimulant drugs. The PDR recommends "drug" holidays during weekends, school breaks and "challenges" (brief periods when Ritalin is discontinued to see if it is still necessary). These "drug holidays" are supposed to control the side effects; but there is no evidence that most physicians build "drug holidays" into Ritalin prescriptions. The first doctor to treat misfit kids with stimulants was Charles Bradley, who began by giving them Benzedrine in the 1930's. In the words of one Ritalin apologist, "Nobody knows for sure why he gave stimulant medication to [hyperactive] children, but the important thing is that he did." This sort of ruthless and muddled thinking -- "Let's go ahead and suspend the usual rules of scientific research and proof!" -- is typical of the Cult of Ritalin. The same apologist, writing in the U.S. Department of Education's official research digest, admits elsewhere that " . . . studies that have attempted to determine if treated children actually learn more have generally been discouraging. For example, although hyperactive children score a little better on achievement tests when taking medication and the amount of gain increases with time, the overall effect is rather small. When medication is stopped for a period of time, the gains disappear." In other words, Ritalin has proven to be effective in getting some children to comply with the requirements of the classroom, such as sitting still and controlling aggression, but it has only had a minimal success in helping them to learn. Ritalin, when it works, serves the interests of the teacher and the school system, not the needs of the child. A computerized search of the scientific literature on Ritalin and the hyperactivity diagnosis turned up 60 articles published between 1960 and 1990, of which 35 cast strong doubts on the validity of the hyperactivity label, the use of Ritalin to treat children labeled hyperactive, or both. The scientific literature confirms that Ritalin is almost never prescribed except at the instigation of school officials, reports that many parents and physicians have had more success with behavior management strategies and the Feingold Diet than they have had with Ritalin, and documents the phenomenon of "Ritalin abuse" described below. THE DIAGNOSIS Case History #3: Warren T. was suspended three times for striking other children and his teachers complained that it was all they could do to keep him "settled down." His mother Suzy, an old hippie who believed strongly in an organic lifestyle and fed all her children a meatless, chemical-free diet, admitted that she usually "couldn't cope" with him at home, either. She agreed to try him on Ritalin, but when he complained of feeling depressed and "stupid" she stopped giving him the drug. Warren's experiment with Ritalin did not last long enough for anyone to be sure it helped him, but his teachers initiated several punitive administrative measures to force Suzy T. to put him back on the drug. There are some children who are "helped" by Ritalin, but they are probably only a small fraction of the ones who are given the drug. To benefit from Ritalin, a child must have what the American Psychiatric Association Diagnostic and Statistical Manual (known as the DSM-IIIR) calls "Attention-deficit Hyperactivity Disorder", known as "ADHD" for short. ADHD involves more than just difficulty in learning and getting by in the standard classroom. If a child truly has ADHD, he or she must constantly be in motion and is totally unable to sit still or concentrate for more than a few moments. Children with ADHD are not just in conflict with their environments, they are aggressively engaged in attacking and injuring others, both children and grownups. They are impervious to rewards or punishments; their behavior doesn't change from one environment to the next. Such children are much rarer than those who are casually diagnosed "hyperactive" because they resist the demands placed on them in a typical classroom. Aggression is the key to determining whether a child can or cannot be "helped" by Ritalin. The clinical evidence on Ritalin overwhelmingly indicates that without the presence of aggression, the child does not have a disorder that can be helped by Ritalin. The standard references on medical diagnosis and treatment instruct physicians making a diagnosis of ADHD to proceed with caution; their warnings are usually ignored. The Merck Manual of Diagnosis and Therapy, the most conservative standard reference in medicine, warns that, "Rating scales and checklists, the predominant mode of identification, are often unable to distinguish ADD from other behavioral disorders. Such data often are based on subjective observations made by untrained personnel." The DSM-IIIR says, "Children in inadequate, disorganized or chaotic environments may appear to have difficulty in sustaining attention and goal directed behavior.". The DSM-IIIR includes a separate "disorder" for misfit kids who do not show the constant activity and aggression of ADHD: "Attention-deficit Disorder, Other" (or "ADDO"). ADDO is described as a "residual diagnosis" created to include "daydreamers," "absent-minded kids" "underachievers" and other children who disdain their surroundings in ways that make adults angry. Children with ADDO are passive, rather than aggressive, and the symptoms of the two disorders are so different that the DSM-IIR doesn't even bother to caution physicians against mistaking one disorder for the other. Remember ADDO; it will come up again. RITALIN ABUSE Case History #5: Donny's teachers always described him as a "nice, quiet" boy, but they reported having a good deal of trouble with him nonetheless. His classwork was never up to their standards. He was slow to follow instructions, and sometimes didn't follow them at all. He had few friends and spent a great deal of time daydreaming by himself, wrapped up in his own world. Sometimes he seemed to have trouble understanding what was expected of him. One of his teachers recommended to his parents that they get a prescription for Ritalin. When they told the family pediatrician that Donny's teacher wanted him to try Ritalin, she wrote out the prescription at once. Ritalin abuse begins with "diagnosis abuse." First, a child who does not have ADHD has to be labeled "hyperactive," whether or not he or she has the relentless motor behavior and aggression that are necessary symptoms of ADHD. In the sort of circular thinking that supports the Cult of Ritalin, a prescription for Ritalin "proves" the validity of the hyperactivity diagnosis -- and automatically exonerates the teachers, the classroom environment and the whole school bureaucracy from any charges that they have failed to do an adequate job of serving the labeled child. How can you help a child who just can't fit in? Unlike Valium, Librium, Darvon or any of the tranquilizing "happy pills," Ritalin is abused by the physicians who prescribe it, not by the people who take it. Ritalin abuse is a chemical dependency of inadequate systems and failed officialdom. Like other forms of substance abuse, Ritalin abuse involves denial and codependency. Ritalin abusers deny that they abuse the drug; the parents of children who were wrongly placed on the drug are co- dependents who enable the abusers and are afraid to confront them. Donny's experience is common. Hundreds of thousands of children who do not fit the diagnosis of ADHD take Ritalin despite the clinical evidence that it cannot help them. They are almost always put on the drug because someone in the school system recommended it; the proper diagnostic procedures are almost never followed, and doctors usually write prescriptions for Ritalin without challenging the appropriateness of the drug. (Ciba-Geigy, the Fortune 500 drug giant that produces Ritalin, spends millions of dollars a year to promote the drug, which no doubt encourages doctors to prescribe it.) Despite the weight of medical research and the warnings of medical authorities, Ritalin continues to be abused because it helps perpetuate the myth that there are some children who just can't be taught properly because they have something wrong with them. If Ritalin were used only to treat children with ADHD and aggression, there would still be serious ethical questions about drugging children, not for their own benefit (because Ritalin doesn't improve their ability to learn), but for the benefit of others. However, the weight of scientific research suggests that most children that are given the drug do not have ADHD with aggression. ADVICE FROM A RITALIN SURVIVOR Case History #6: John W., the author of this article, was placed on Ritalin at age 9. His parents were well-meaning people with an exaggerated respect for authority. Ritalin was recommended to them by a zealous pro-Ritalin teacher who, at one point, had nearly a quarter of the children in her class on the drug. In the typical pattern of Ritalin-abuse and codependency, they arranged for John W.'s pediatrician to prescribe the drug without any independent evaluation to determine whether John W. had ADHD with aggression or not. In fact, what John W. had would now be described as ADDO, the daydreaming, inattentive behavior that is specifically not treatable with Ritalin. John W. was not told about the drug or its purpose; he was simply given his "pay-attention-pill" every morning along with his breakfast vitamins. At about this time in his life, John W. began to experience frequent confusion and forgetfulness that he now associates with the drug. At 11, he "took himself off Ritalin" by concealing the pills instead of taking them. A few months later, he began selling them to other kids, in the expectation that he would be caught, and no longer given the drug. He was caught, but -- in a typical example of the collective denial practiced by families with a substance abuse problem -- everybody pretended nothing had happened. Eventually he switched to throwing the pills away instead of selling them, and somewhat later was taken off the drug. I don't recommend anybody else handle their Ritalin problem the way I did. Instead, I suggest that parents, children and professionals who get caught up in the Cult of Ritalin take the following steps: 1) Get a second opinion from a neutral and qualified third party to be sure that the child truly has ADHD with aggression in the narrow medical sense. Remember: if the child does not really have ADHD with aggression, Ritalin won't help the child at all. 2) Learn all you can about ADHD, Ritalin, the side effects of Ritalin and the alternative treatments for the disorder. Consult the Physicians Desk Reference on Prescription Drugs, the Merck Manual on Diagnosis and Therapy and Dr. Doris Rapp's excellent book on the subject, Is This Your Child?. You can also contact the Feingold Association of America, a volunteer group dedicated to keeping the ideals of Dr. Ben Feingold alive, at (703) 768-3287. 3) Even if the child truly has ADHD with aggression, insist that alternative classroom strategies be tried before you agree to medication. Remember, medication improves classroom behavior, not learning. The child receives no direct benefit from Ritalin, which is given to him or her for the sake of improving conditions in the classroom. Is there any evidence that teachers and school officials have competently tried to manage the child's problems? What kind of special attention or assistance give to the child would mitigate the need for Ritalin? Before agreeing to sacrifice the health and autonomy of the child, you can insist that every possible means of helping the child to learn be exhausted. 4) If, in the end, you decide to try Ritalin because it seems to be the only possible solution, use a minimum dose of the drug and insist on every possible assistance to help the child learn. Ritalin doesn't "fix" the child and eliminate his or her need for additional help in the classroom. If you have agreed to try Ritalin because of pressure from school officials, don't just give in. Make a contract with the officials that the child will use Ritalin only as long as they are willing to provide the child with extra help and support. You have the right to insist on this under new U.S. Department of Education guidelines for enforcing the Individuals with Disabilities Education Act (IDEA). In technical terms, your contract with the school officials would be spelled out in an Individual Education Plan (IEP). Any time you are subjected to a major medical intervention, you owe it to yourself to become an active and informed health care consumer, instead of passively letting medical experts "fix you." After all, you might not be broken! It is doubly important to be an active consumer when psychoaffective drugs are involved, since their effects on your body and spirit are so profound. Children, alas, are rarely in a position to become informed health care consumers, and grown-ups have an extra responsibility to look out for their interests. It is bad enough to have trouble functioning in school; it is much worse to start out in life with a label that tells officialdom you are a person who has to be drugged into submission. Reprinted with Permission from MOUTH, April 1993 This doucment may be distributed freely in electronic format.