Chapter Index: Ritalin: An Iatrogenic Drug Epidemic
Ritalin: An Iatrogenic Drug Epidemic The most commonly prescribed drugs for children are the psychostimulants, especially Ritalin (methylphenidate). Ritalin is commonly given to children diagnosed as ADD or hyperactive while attending public schools. It also is dispensed to quiet children in institutions. And Ritalin usage is escalating. The FDA was forced to double its proposed ceiling on the production of Ritalin, according to William Schmidt's "Sales of Drug Are Soaring for Treatment of Hyperactivity," in the May 5, 1987, New York Times. Estimates on the use of Ritalin usually exceed 500,000 children a year in the United States, and reach as high as a million. In "Medical News and Perspectives," in the May 6, 1988, Journal of the American Medical Association, Virginia Cowart estimates the 1988 total at 800, 000 children. The title, "The Ritalin Controversy: What Made This Drug's Opponents Hyperactive?" facetiously dismisses concerns about the problem. A January 16, 1989, Time magazine report puts the figure for Ritalin-treated children at 750,000 and cites NIMH predictions of one million by the early 1990s. Time also cites an NIMH estimate that one in ten boys suffers from hyperactivity. From this and other more inflated claims (see chapter 12) it is possible to envision the eventual Ritalin drugging of an even larger percentage of America's male children. [To a great extent, widespread Ritalin use is an American phenomenon. On a recent trip to Scandinavia I found little evidence of drugging children. In their more child-oriented schools and culture, it was considered abhorrent. But there was fear that Scandinavian psychiatrists would try to "catch up" with their American counterparts.] Although there are some differences among them, the psychostimulants can be discussed as a group. Dexedrine (dextroamphetamine), produced by Smith Kline and French, accounts for a small share of the market, as does the stimulant Cylert (pemoline). The lion's share goes to Ritalin, a product of CIBA. The Effects of Ritalin on the Brain and Mind of Children The actual impact of stimulants on the brain and mind of children are poorly understood and, despite administering the drug to millions of youngsters in the past several years, psychiatry shows little interest in the question. In none of the many standard and even specialized textbooks I consulted could I find any interest in how children feel when taking stimulants. The subjective experience of the child is ignored. It is as if we are putting coins (instead of pills) into one end of a black box (instead of a child) and getting an output at the other end. What happens inside the box is of no concern; all we care about is the behavioral end product. This disregard for the person's subjective response is due in part to the dual stigmatization of the patients: not only are they "mental patients," they are children. That they are involuntary patients makes it all the easier, and in some ways necessary, to ignore their feelings. [We rarely want to know the real feelings of people we are coercing or abusing. I discuss this in The Psychology of Freedom (1980) and in the forthcoming Beyond Conflict.] Indeed, one of the few references I could find to the child's subjective experience of Ritalin was one voiced by Paul Wender, who observes in The Hyperactive Child (1973) that "they never like the medication." In the American Psychiatric Press's Textbook of Psychiatry, Mina Dulcan observes that children report feeling "funny" on the drug. [In fact, there is little evidence for an improvement in attention span, and as we shall see, prolonged use tends to disrupt attention span.] The youngsters I have talked to have felt that Ritalin put them "out of touch" and made them "feel weird," blunting their feelings and subduing them. In adults we know that stimulants energize and cause a hyperalert feeling, not unlike drinking a lot of coffee, but more so. In increasing doses they create agitation, an artificial high, psychotic euphoria or mania, and, finally, convulsions. In large enough doses they would have the same effect on children of any age. But those who prescribe the drug are certainly not aiming at producing a high in already "hyper" children. When the child in the classroom sits still, stops fussing, and becomes more obedient-the desired drug effect has been achieved. And children on Ritalin often do look as if they are taking a "downer" rather than an "upper". They are emotionally suppressed or flattened. [Frequently the clinical effect is mixed, quieting the child during the day but causing insomnia at night, or producing up-and-down cycles. Also, Ritalin can make a child more irritable rather than calmer.] Children do seem to react differently to uppers and downers compared to adults. For example, phenobarbital, a reliable sedative for adults, is not generally used to quiet children, because it tends to excite them. These confusing results in children are rarely mentioned anymore in psychiatric textbooks, which simply recommend the drug because it "works." The idea that Ritalin or other stimulants correct biochemical imbalances in the brain of hyperactive children, although promoted by Wender and others, is false on two counts. First, there is no known biochemical imbalance in these children, and second, it generally is accepted that Ritalin has the same effect on all individuals, regardless of their psychiatric diagnosis or behavior. Frequently listed as side effects are sadness or depression, social withdrawal, flattened emotions, and loss of energy. Consistent with the braindisabling principle of biopsychiatric treatment (chapter 3), 1 believe that these subduing effects are not side effects but the primary "therapeutic effect," rendering the child less troublesome and easier to manage. Other negative effects of Ritalin include growth suppression (both height and weight), tics, skin rashes, nausea, headache, stomachache, and psychosis. Abnormal movements, such as tics and spasms, sometimes develop. Many cases of full-blown Tourette's syndrome are reported, characterized by both facial and vocal tics. Sometimes these neurological disorders do not subside after termination of treatment, and tragically, neuroleptics may be prescribed to control them, increasing the risk of further neurological disorders. Pemoline frequently is associated with involuntary movements at commonly used doses. Parents should be warned about this risk and experts should recommend stopping the drugs as soon as any abnormal movements are noted. While there is some growth rebound when Ritalin is stopped, the degree of growth recovery is not known. Although little concern is shown in the literature, it seems unlikely that the negative impact on the body is limited to the loss of a few inches or pounds. Such a gross effect likely would be associated with more subtle and difficult-to-ascertain developmental abnormalities. The cause of the growth inhibition is unclear, but it is not due to loss of appetite alone. The stimulants also produce a chronically elevated heart rate and blood pressure in many children. The long-term impact of chronically revving up the cardiovascular system is unknown. Some drug advocates claim that the psychostimulants do not cause addiction in the doses typically prescribed to children. Meanwhile, we do know that stimulants are highly addictive and often abused as illegal drugs, called speed and uppers. The Drug Enforcement Administration (DEA) puts Ritalin and other psychostimulants in Class II, along with morphine, barbiturates, and other prescription drugs that have a high potential for addiction or abuse. Goodman and Gilman's The Pharmacological Basis of Therapeutics (1985) points out that Ritalin is "structurally related to amphetamine" and says simply, "Its pharmacological properties are essentially the same as those of the amphetamines" (p. 586). It considers Ritalin among the highly addictive drugs. The APA's DSM-III-R (1987) has special categories for abuse and dependence involving amphetamine and "amphetamine-like" drugs, specifically including Dexedrine and Ritalin. The pattern of abuse for Ritalin and related medications is described as "very similar to those of Cocaine Dependence and Abuse." The DSM-III-R then observes, "Controlled studies have shown that experienced users are unable to distinguish amphetamine from cocaine." Ironically, the DSM-III-R description of Ritalin abuse exactly parallels the enforced "treatment" of children: Chronic daily, or almost daily, use may be at high or low doses. Use may be throughout the course of the day or be restricted to certain hours, e.g., only during the working hours or only during the evening. In this pattern there are usually no wide fluctuations in the amount of amphetamine used on successive occasions, but there is often a general increase in doses over time.Yet this is the pattern imposed by physicians on as many as one million children annually. Causing Inattention, Memory Problems, and Hyperactivity with Ritalin It seems to have escaped Ritalin advocates that long-term use tends to create the very same problems that Ritalin is supposed to combat - attentional disturbances" and "memory problems" as well as "irritability" and hyperactivity." When children are prescribed Ritalin for years because they continue to have problems focusing their attention, the disorder itself may be due to the Ritalin. A vicious circle is generated, with drug-induced inattention causing the doctor to prescribe more medication, all the while blaming the problem on a defect within the child. As Ritalin treatment is continued, its calming or subduing effects can diminish, requiring increased medication. It can become more and more difficult to prevent rebound hyperactivity, talkativeness, and other signs of euphoria. [The 1990 PDR has a special box on "Drug Dependence" for Ritalin, including warnings that drug withdrawal can be accompanied by "severe depression" and hyperactivity.] This drug rebound effect is easily confused with the child's original hyperactivity, again causing the doctor to mistakenly continue or to increase the medication. We have seen similar patterns with the use of neuroleptics, minor tranquilizers, and antidepressants. As with any addictive drug, withdrawal from psychostimulants, even in routine use, can be very difficult. Again we are educated by the official DSM-III-R, which has a special category for withdrawal reactions caused by amphetamine and amphetaminelike drugs, including cocaine and Ritalin. After "several days or longer" of medication, withdrawal from the drug can produce depression, anxiety, and irritability as well as sleep problems, fatigue, and agitation. The individual may become suicidal in response to the depression. Again, no distinction is made between children and adults. In the 1960s and early 1970s an epidemic of psychostimulant abuse spread over America and a number of other industrial nations. In response the National Institute of Drug Abuse, a branch of the U.S. Department of Health, Education and Welfare, published a large compendium of 150 studies dealing with the abuse of amphetamines and related drugs, including Ritalin, making clear the seriousness of the then-rising epidemic and the government's concern about stemming it. I Yet estimates of the size of that epidemic of drug abuse do not approach the highwater mark of up to one million children now taking Ritalin. One study in the compendium, authored by P. H. Connell and reprinted from the 1966 Journal of the American Medical Association, states that the regular ingestion of only two or three tablets a day constitutes abuse and that the self-abuser "would certainly be better off without them." This limited use of the medication, described as abuse, is exceeded frequently in the routine treatment of children. Despite these warnings, little or nothing is said about addiction and withdrawal problems by the profession in its textbooks, popular books, and media statements. Why would a profession's ethics consider a pattern of abuse a serious epidemic disease, except when it is called a "treatment" for children? Why would it describe serious withdrawal symptoms after only a few days of self-abuse with a drug, but dismiss the same potentially bad outcome when prescribing the same drug for years at a time to children? There is reason to be concerned about brain tissue shrinkage as a result of long-term Ritalin therapy, similar to that associated with neuroleptic treatment. A 1986 study by Henry Nasrallah and his colleagues of "Cortical Atrophy in Young Adults with a History of Hyperactivity," published in Psychiatric Research, found the brain pathology in more than half of twenty-four young adults. Since all of the patients had been treated with psychostimulants, "cortical atrophy may be a long-term adverse effect of this treatment" (p. 245). One study is suggestive rather than conclusive, but there remains a cause for concern. It bears repeating that the use of any potent psychoactive drugs is not good for the brain. Combining antidepressants and psychostimulants increases the risk of cardiovascular catastrophes, seizures, sedation, euphoria, and psychosis. Withdrawal from the combination can cause a severe reaction that includes confusion, emotional instability, agitation, and aggression. Combining neuroleptics with Ritalin causes a much-increased risk of sedation, stupor, and emotional flattening as well as adding the withdrawal problems associated with neuroleptics. Moral and Psychological Harm From Giving and Taking Ritalin In the American Psychiatric Press Textbook of Psychiatry (1988), Mina Duican summarizes some of the harmful psychosocial effects on children who are given Ritalin: ... indirect and inadvertent cognitive and social consequences, such as lower self esteem and self efficacy; attribution by child, parents, and teachers of both success and failure to external causes, rather than the child's effort; stigmatization by peers; and dependence by parents and teachers on medication rather than making needed changes in the environment. (P. 993)The "stigmatization by peers" is worth underscoring. Often children are ridiculed and rejected by their peers as a result of taking psychiatric drugs, in contrast to taking illegal drugs, which may have a certain glamor or status associated with them. Being a "mental patient" who needs "medication" is anything but a status symbol among the young. A recent unpublished report confirms that taking Ritalin badly affects a child's self-esteem as well as the attitudes of parents, teachers, and doctors. The study, "Why Johnny Can't Sit Still: Kids' Ideas on Why They Take Stimulants," was conducted by physicians Peter Jensen, Michael Bain, and Allen Josephson. Jensen is an experienced researcher from the Division of Neuropsychiatry at Walter Reed. Using interviews, child psychiatric rating scales, and a projective test entitled "Draw a Person Taking the Pill," the authors systematically evaluated twenty children given Ritalin by their primary care physicians. Many of the children thought they were taking the pill to "control them" because they were "bad." They often attributed their conduct to outside forces, such as eating sugar or not taking their pill, rather than to themselves. The researchers conclude that taking the drugs produced (1) "defective superego formation" manifested by "disowning responsibility for their provocation behavior"; (2) "impaired self-esteem development"; (3) "lack of resolution of critical family events which preceded the emergence of the child's hyperactive behavior" and (4) displacement of "family difficulties onto the child." Jensen and his colleagues warn that the use of stimulant medication "has significant effects on the psychological development of the child" and distracts parents, teachers, and doctors from solving important problems in the child's environment. While psychostimulants can blunt a child sufficiently to make him more amenable to control in a classroom or at home, at least for a few weeks, there is little or no evidence of any beneficial long-term effect on academic or psychosocial life. Surprisingly, this rather negative conclusion is confirmed in standard textbooks. As Dulcan observes in the American Psychiatric Press Textbook of Psychiatry, "Stimulants have not yet been demonstrated to have long-term therapeutic effects. . . ." Furthermore, "it is clear that medication alone is not sufficient treatment" (p. 990). In addition, the PDR and other sources make clear that the long-term negative effects of taking Ritalin have not been evaluated. The 1990 PDR specifically warns that "sufficient data on safety and efficacy of long-term use of Ritalin in children are not yet available." Statements such as these are hair-raising in view of the frequency with which children are subjected to long-term Ritalin treatment. There is general agreement, even among advocates, that Ritalin never should be given to a child as the primary or sole treatment. Psychosocial interventions are also required in the school and home. James H. Satterfield, executive director of the National Center for Hyperactive Children in Encino, California, coauthored a follow-up study of medicated children in the 1987 Journal of the American Academy of Child and Adolescent Psychiatry. The inclusion of counseling for both the child and his parents in the treatment program resulted in fewer arrests and lower rates of institutionalization. Drugs alone produced no long-term beneficial effects on school performance or socialization. Satterfield sees psychotherapy as the chief modality, with the medication required in the short run to help some children settle down for therapy. What about psychotherapy alone? Sadly, the Satterfield study didn't give any children counseling by itself. In evaluating the impact of Ritalin, the importance of the placebo effect must be taken into account. As the American Psychiatric Press Textbook of Psychiatry points out, while as many as 75 percent of children are rated improved during the initial treatment (and subduing) phase with Ritalin, 40 percent of placebo or nondrug controls are rated similarly. This suggests that placebo may account for more than 50 percent of the supposed Ritalin effect. McGuinness's review chapter in The Limits of Biological Treatments for Psychological Distress (1989) confirms that there is no convincing evidence that the medications help learning or attention problems. While Ritalin sometimes can reduce "fidgety behavior," it does so in all children regardless of any diagnosis. Beyond temporarily calming children, says McGuinness, "the data consistently fall to support any benefits from stimulant medication. " She also warns that "stimulant medication is a drastic invasion of the body and nervous system," with potentially adverse effects that we cannot anticipate. McGuinness concludes by calling for the abandonment of diagnoses such as ADD and hyperactivity as well as the mass medicating of these children. It may be a painful admission to recognize that one has spent 10 to 20 years studying something that doesn't exist, but when considering the accumulated amount of human suffering, the substitution of medication for otherwise remedial behavior problems, then it is time to stop and think.In The Learning Mystique, Gerald Coles similarly concludes that there is no scientific evidence that Ritalin helps hyperactivity or ADD. Ritalin is advertised heavily by the pharmaceutical company CIBA in psychiatric journals. The irony of pushing psychiatric drugs for children is graphically portrayed on a page of the April 1987 Clinical Psychiatry News. Across the top of the page is a headline, AMA INITIATES PROGRAM TO IMPROVE HEALTH OF ADOLESCENTS. The report laments that two-thirds of all high school students have tried an illicit drug before graduation, that one in five smoke cigarettes daily, and that many abuse alcohol. But the report takes up less than half the page. The dominant display on the page, sporting a large picture of a child doing his school work, is an ad for Ritalin entitled "ADD therapy that's easy to live with." Within the ad, a small box of fine print is labeled "Drug Dependence." In a 1988 letter to me psychologist David Keirsey, the author with Marilyn Bates of the best-seller Please Understand Me (1984), excoriates those who prescribe Ritalin for children: The people who prescribe chemotherapy for inattention and restless action have no idea of how damaging it is. . . . As for mental effects, such as the child coming to see himself as a damaged person, these prescriptors remain quite oblivious. And the claim that these chemically abused children pay more attention to the teacher and learn better remains undocumented, the teachers' reports that they are less restless and more docile hardly constituting evidence of learning. Who wouldn't be docile if spaced out on speed or crashed from sleepless nights from speed? And as for the unavailability of alternative interventions, well, just because physicians are not trained to treat behavior is no reason for them to assume that others aren't.The drugging of children seems to garner far more public sympathy than the forced drugging of adults. On June 10, 1988, Ted Koppel's "ABC News Nightline" estimated that 800,000 children were taking Ritalin and that its production had doubled in recent years. The subject of the show is nine-year-old Casey jesson, whose school system told him to take Ritalin as a part of its "educational plan." When Casey's parents protested, the New Hampshire Department of Education upheld the school's decision. The superintendent of schools appeared on "Nightline" to affirm the school's right to insist on medication. What other alternative did Superintendent Brown offer the parents? "They have the right to withdraw their child from school." Intimidating parents into drugging their children is a common practice around the United States, especially among the poor and minority groups. There are cases in which schools have obtained Ritalin and given it to children without parental knowledge or permission. Psychiatry Ignores the Controversy The controversy surrounding Ritalin has been going on a long time. Two decades ago, on September 29, 1970, the Committee on Government Operations of the U. S. House of Representatives held hearings entitled "Federal Involvement in the Use of Behavior Modification Drugs on Grammar School Children." Already 200,000 to 300,000 children were being drugged, and the subcommittee correctly summarized that eventually the figures would "zoom." The subcommittee noted the irony that "each and every school child is told that 'speed kills,' " while many other children are being forced to take speed in the form of Ritalin. It warned about the effect of this on "our extensive national campaign against drug abuse." It further condemned "a certain glibness about the experimentation on young children in this country, used as guinea pigs." Testimony was received about a pattern of teachers and school administrators intimidating parents into giving Ritalin to their children. Commenting on the diagnosis of hyperactivity, educator John Holt's presentation told the committee: We consider it a disease because it makes it difficult to run our schools as we do, like maximum security prisons, for the comfort and the convenience of the teachers and administrators who work in them.... Given the fact that some children are more energetic and active than others, might it not be easier, more healthy, and more humane to deal with this fact by giving them more time and scope to make use of and work off their energy? . . . Everyone is taken care of, except, of course, the child himself, who wears a label which to him reads clearly enough "freak," and who is denied from those closest to him, however much sympathy he may get, what he and all children most need - respect, faith, hope, and trust.Largely outside of psychiatry, the controversy around school-related diagnoses and Ritalin has continued to simmer over the years. As reported in the May 7, 1975, Psychiatric News, at the annual meeting of the American Orthopsychiatric Association physician Larry Brown, director of the Massachusetts Advocacy Center, pointed out that drugging children distracted attention away from the faults of the school system. He finds this "blaming of the victim" a "low point in professional ethics" and a political problem as well. He declares, "When drugs are used as a cheap alternative to reform of the schools, then the practice of drugging children must be seen as a political act." The year 1975 also marked the publication of Peter Schrag and Diane Divoky's pathfinding critique, The Myth of the Hyperactive Child, which includes criticism of the growing use of Ritalin. While the public controversy has been heated for more than two decades, psychiatry has remained impervious to it. Most textbooks of psychiatry don't bother to mention the controversy, and the drugging goes on at an escalating rate. Something other than media exposes will be required to stop this rampant abuse. Pressure must come from the public in the form of legislation and legal actions. Children: Our Most Vulnerable Citizens Children are our most vulnerable citizens. More than any other group, they need our love, our interest, our sympathy, and our protection. They also need us to create mutual respect between themselves and us. Out of mutual respect grows the most healthy kind of discipline. Raising children is the most difficult job in the world, requiring a balance of love and respectful limit setting that rarely comes easily to parents and caretakers. Being parents confronts us with our own personal problems, many of which stem from difficulties in our own childhoods that we cannot bear to face. Our preference for the company of adults, our preoccupations with adult concerns, our confusion over how to parent, mismatches of temperament between ourselves and our children, our impatience or tiredness - all of these compound to make parenting and teaching children difficult. Raising children is probably the easiest job in the world to botch, not only because it is so difficult, but because there's almost no one to hold us accountable. As parents we may at times feel baffled and impotent or even completely helpless; nonetheless, we exercise a degree of power and authority in the home that is unparalleled in the remainder of our lives. We never could lose our temper at the boss, or even at our employees, and get away with it so easily. We never could ignore the needs of our friends with such impunity. Nor could we hit or spank anyone else with whom we came into conflict. Our difficulty in raising children often is complicated by the stresses of our own adult lives. Many parents, especially single mothers, live in poverty; many families grow up amid racism; and all children and adults suffer from the effects of sexism and male supremacy. Many marriages are torn by conflicts that frighten and confuse the children. When our children finally go off to school, it is often to a more unsatisfactory situation than the one at home within the family. Typically children are forced to endure long, boring hours in regimented classrooms that give almost no attention to their personal needs or unique attributes. In many schools children are beaten and humiliated as a means of control. Child abuse and neglect are rampant. Instead of covering up this tragedy with diagnoses, drugs, and hospitals, psychiatry should be leading the society toward a more sympathetic understanding of the plight of children. Given what we've seen in this book, there's no chance that the profession can make such a turnaround in the imaginable future. An End to the Scapegoating of Children The schools virtually have given up on educational reform. Children who cannot or will not fit the mold are sent off to mental health professionals, frequently for stupefying and addictive medication. Parents similarly forsake their responsibility for raising their own children by handing them over to mental health specialists, not only injuring their offspring, but depriving themselves of the satisfaction of being good parents. The children are stigmatized and carry within themselves feelings of guilt and shame over problems that are almost wholly beyond their control. Which way shall we go - toward blaming our children for our own problems, including an epidemic of child abuse, or toward finding better family, educational, and social solutions? Modern psychiatry pushes us in one direction - toward blaming the victim and exonerating the adult authorities. It's the easy way out for all of the adults, including the child abuser; but it's a disaster for the child. We need a drastic turnabout in which we, as caring adults, retake responsibility for our children. Freeing ourselves from biopsychiatric mythology can become the single most important step in that direction. Suggested Reading List - Ritalin - ADD, ADHD, Hyperactivity, Learning Disabled, Impulsivity Order Toxic Psychiatry by Peter Breggin. M.D. Back to Main Ritalin/ADHD Page Back to Main SNTP Page Don't drug a child and . . . Say NO To Psychiatry!
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