Doing Ritalin right, By Susan Brink

Doing Ritalin Right,
By Susan Brink

Sure, it works - but there are big flaws in the way it's being given

In schools across America, as many as 1 million children line up every day for a glass of water and a little yellow pill called Ritalin. Doctors prescribe it, parents hesitantly agree to it, and school nurses supervise the ritual of handing it out because they believe the pill will calm children down and stop them from clowning around or goofing off. The ultimate reward, they hope, will be academic and social success.

A long-awaited study by the National Institute of Mental Health shows that drugs like Ritalin calm kids down even better than previously thought–as long as the children continue taking them. But there's no proof that in the long run the drugs help kids get better grades or build better lives. Children with what is now called attention deficit hyperactivity disorder, or ADHD–the most common reason for taking Ritalin and similar stimulants–are at higher risk than their peers of dropping out, of becoming smokers, of abusing alcohol or drugs, even of spending time in prison. This study provides stronger evidence than ever that medication can shift troubled kids to a better track. But it echoes the frustrating finding of earlier studies that a little yellow pill is not enough, by itself, to keep them there.

Lost potential

The study also suggests that society could do much better by the children diagnosed with ADHD. One way to interpret its findings is this: Assuming a million kids have ADHD, 690,000 of them will get better the way they're typically treated, though many will still have symptoms of the disorder. But if those 1 million kids were treated in the most effective way science has devised, 850,000 of them could get better.

The study, as yet unpublished, was presented last month at the annual meeting of the American Academy of Child and Adolescent Psychiatry in Anaheim, Calif. It is based on the largest clinical trial ever conducted by the National Institute of Mental Health, or NIMH. It is NIMH's first clinical trial involving children and the longest active treatment study of ADHD.

Its strongest finding is that drugs work. Closely monitored treatment with stimulant drugs (Ritalin is one of four commonly prescribed, and its use has increased 700 percent in this decade) can erase enough symptoms of ADHD to eliminate the diagnosis for 82 to 85 percent of children. That may reassure parents who are giving their children the typical twice-daily dose, but the study also suggests that three times a day works better, with a nighttime dose about half the size of the first two. Researchers monitored the effect of the drug closely, through talks with both parents and teachers–first weekly, then monthly–altering the dose or changing drugs as necessary.

How often does that happen in everyday cases? Hardly ever, says William Pelham, one of the principal investigators of the NIMH study and director of the Attention Deficit Hyperactivity Disorder Program and Summer Treatment Program at SUNY–Buffalo. (There are 16 such state-of-the-art summer treatment camps; for information, call 716-833-2143.) "That kind of prescribing is an extreme rarity," says Pelham. "If one tenth of 1 percent of kids are getting medicated like this, I'd be astonished. It should be 100 percent."

Straight A's

Doctors also got a daily behavioral report card from teachers to help them decide whether a drug was working and the dosage was right. That kind of communication rarely happens in the real world. But "without that report card, it's like asking a physician to manage a diabetic without data on blood sugar," says Mark Wolraich, director of Vanderbilt University's child development center.

Few things are clear about this disorder–not even what to call it, despite the fact that it's the most commonly diagnosed behavioral disorder in children. One early term was minimal brain dysfunction; another was hyperkinesis. Then it was called attention deficit disorder, or ADD–a term that still has wide currency. The behavior associated with it seemed essentially disruptive and impulsive; kids with the disorder, it was thought, would jump from Legos to Matchbox cars, from a hula hoop to a Superman doll, shoving their best friends to the ground in the process. Many children with the disorder are disruptive and impulsive. But others are more quietly distracted, their attention diverted by something as innocuous as a blowing leaf, which they then lose interest in if a bird flies by.

Two New York children illustrate the difference between the hyperactive and the inattentive. Faith Harris, now 7, was a whirlwind even as a baby. She'd shake a rattle once, throw it down, then grab a ball. She'd push the ball, but before it stopped, she'd pick up her teddy bear. And she'd forget about that if she saw a shadow move across the wall. "She was the busiest baby I ever saw," says her mother, Jean.

By the time Faith was 4 years old, she had been diagnosed with ADHD. A doctor recommended Ritalin, and before she was 5, Faith was taking the drug twice a day. But after six months, Harris and the child's doctor agreed the drugs were having no effect. Faith is one of a minority of children for whom such drugs don't work. She struggles mightily to sit still, pay attention, and get her schoolwork done.

Jimmy Reinicke, 11, is primarily inattentive (actually, boys are more often hyperactive than inattentive, whereas most girls with ADHD are primarily inattentive). When Jimmy was in first grade, the bell rang for lunch and the teacher asked the class to line up. The noisy 6-year-olds scrambled out of their desks and marched out into the hall; the teacher slammed the door shut behind her. But Jimmy didn't notice. His mother doesn't know exactly what he was doing–maybe examining his new crayons. Suddenly, he looked up and realized the class had left without him. "His classmates called him Jimmy from Outer Space," says his mother. Jimmy started on Ritalin and switched to a newer drug, Adderall, after showing side effects like anxiety and insomnia. (Other stimulants prescribed are Dexedrine and Cylert.) Jimmy has just started junior high school, a point at which many ADHD children run into trouble because of added academic pressure and personal responsibility. He's doing well so far.

A scientific debate over whether this is one disease with subtypes or two entirely different diseases will take place this week as the National Institutes of Health hosts a consensus conference on ADHD. (A consensus conference draws together the best minds in a field to hash out medical disagreements among them.) The NIMH study looked only at children who were both hyperactive and inattentive, because researchers reasoned they should study children with the most severe form of the disorder. It's not yet clear if the positive findings about the benefit of medication for these children will also apply to children like Jimmy. But children like Faith, if prescribed drugs under such close scrutiny, could increase their odds of getting better.

Zero absolutes

What is clear, from studies of twins and of patterns within families, is that children inherit a tendency toward ADHD. In fact, multiple genetic components contribute to an array of symptoms; so do a child's surroundings. But there's no biological marker, no brain scan, no blood test, no definitive psychological test that absolutely diagnoses ADHD. Some doctors and teachers see it in every child who misbehaves; others don't even believe it exists.

Scientists think ADHD occurs in part because certain receptors in the brain involved in focusing attention and reining in impulsiveness fail to respond to the brain's natural chemicals, dopamine and norepinephrine. The interactions between the chemicals and the receptors help most of us stick with tedious chores like balancing the checkbook (they also prevent most of us from blurting out spontaneous observations about the boss's ideas). Medications like Ritalin are thought to increase those chemicals and to stimulate the inhibitory receptors, producing the odd result of a stimulant drug's acting to increase inhibition. The drugs enter the body quickly and leave just as quickly, curing nothing but letting a child focus on the important work of learning.

The NIMH study, which lasted 14 months, looked at 576 children in six cities, sorting them into four groups. One received drugs. One got "psychosocial therapy," which meant parent training, teacher counseling, and intensive work on the children's social skills, and a third got both drugs and therapy. A fourth group, used as a control, received whatever treatment happened to be available. Drugs alone worked; slightly better were drugs in combination with other therapy. Both approaches worked far better than psychosocial treatment alone or standard outside treatment.

Researchers fear the results will be misinterpreted as evidence that all ADHD children need is a good, mind-altering drug. But it's not that simple. The children getting nondrug therapy received intensive treatment for nine months, including eight weeks at a special summer camp, but then treatment leveled off. The children on drugs, by contrast, got their doses like clockwork for the full period of the study, three times a day, seven days a week. "There are few, if any, psychosocial researchers who would say that five months after you stop treatment, children would do as well as those children still taking drugs," says Pelham. "Everybody knows that, in the short run, medication has a whopping effect."

It's the long run that's uncertain. The study's finding that medication alone has no long-term benefit on how children do academically is frustrating. And an observation that the children receiving combination therapy (drugs plus behavior modification taught at school, at home, and with other kids their age) did slightly better than those on drugs alone was also inconclusive: It remains to be seen how each group of children, 7 to 9 years old when the study began, fares in adolescence.

Meanwhile, about 25 percent of parents adamantly refuse to give their children drugs for the disorder, says Peter Jensen, associate director for child and adolescent research at NIMH and one of the lead investigators on the study. "Probably about 1 in 3 children with ADHD is getting treated with a drug," says Jensen. "There is probably dramatic undertreatment with drugs."

But some experts think there is overtreatment as well. "What's maddening is that I see it in both directions," says Glen Elliott, director of child and adolescent psychiatry at the University of California–San Francisco. He sees children who could benefit from drugs but whose families refuse medication. He also sees families for whom an ADHD diagnosis is "getting them off the hook. They've got a kid who's a pain in the rear and they want a drug."

Problem child

The pressure doesn't always come from parents; sometimes the school system insists on a brain-disorder label. A Midwestern professor, for example, who wants to protect his daughter's privacy by not using his name, talks about endless phone calls from teachers about his child, who as a preschooler liked to play by herself. Now 7, she grew up the only child in a quiet, academic household, and when she went to school she had trouble getting along with kids her age. She'd play alone, quietly working a puzzle, say, and her teachers were alarmed. Boys would bully her, and she'd retreat.

"First it was the teacher. Then the school counselor. Then the heavies in the school, the principal, start to show up. You go to meetings, and everybody thinks your child has a problem," he said. Doctors and therapists each had a different diagnosis–ADHD, anxiety disorder, obsessive-compulsive disorder, depression–and each diagnosis called for a different drug. But at home, his daughter did well; her grades and reading skills were so good that she was able to advance directly from kindergarten to second grade. The professor continues to refuse drug treatment, and his greatest concern is that his daughter has been labeled "abnormal." "Social conformity and mental health are becoming the same terms," he says. "The person with a different perspective is seen as a candidate for medication."

Lawrence Diller, a San Francisco pediatrician who specializes in ADHD, often prescribes stimulant drugs for children but believes that treating a disorder has become confused with enhancing performance in an increasingly competitive society. Diller wrote Running on Ritalin: A Physician Reflects on Children, Society, and Performance in a Pill (Bantam, 1998, $26), and he lays the blame for a lot of children's behavioral problems on social conditions: Parents are away from home too much, large classes demand conventional behavior, and quirky kids get labeled and lost. "I just don't believe a pill is the moral equivalent of good parenting and good schooling," says Diller. "I prescribe it because I recognize I can't change the larger social and cultural factors. My job is to relieve suffering, and Ritalin, in the short term, will ease suffering."

It may ease suffering, but Ritalin will never cure in the way an antibiotic cures an ear infection. The symptoms of ADHD retreat only for as long as those diagnosed with it keep gulping down the little yellow pills. Parents of 1 million children are pinning their hopes on the theory, as yet unproven, that the respite their children get through Ritalin will buy them the attention span they need to develop.


To drug or not to drug

Testing a child for attention deficit hyperactivity disorder (ADHD) means working with a pediatrician, a child psychiatrist, a child psychologist, or a pediatric neurologist. The specialty matters less than does experience. Beware of therapists who either push drugs immediately or dismiss drugs completely.

About two thirds of children don't outgrow the disorder, so be wary of advice to wait and see. Most experts agree that medication can help, but it isn't the only solution - parents and teachers need to learn new ways (through rewards and consequences, for example) to teach their kids how to follow rules and sit still. And don't go to the doctor and accept a prescription after a 15-minute office visit; an evaluation should include medical, psychological, behavioral, and educational assessments. The doctor or therapist should talk both to parents and the child, and get information from teachers before coming to a conclusion.

Once your child is diagnosed, beware of unproven therapies. Sugar doesn't cause ADHD, and a special diet won't cure it. Many children are still treated with traditional one-on-one therapy, with play therapy in a therapist's office, or with biofeedback, none of which has been proven effective in treating ADHD. Previous studies have proven only three approaches to be effective: medication, behavior therapy (in which parents and teachers are taught how to work with children), and a combination of both.