The Ritalin Controversy Experts Debate Use of Drug to Curb Hyperactivity in Children by Gina Shaw Joshua, an adorable 5-year-old, has a personality that seems as impossible to control as his unruly blond hair. In his kindergarten class, heís up and down out of his seat every five minutes, never seems to follow the teacherís directions, and frequently can be found gazing out the window instead of paying attention. Whatís his problem? Does he just behave badly? Is he a normal, if overly energetic and easily distracted 5-year-old, or does he have the condition known as attention-deficit/hyperactivity disorder (ADHD)? It depends on whom you ask. ADHD, a disorder characterized by chronic problems with inattention and hyperactivity or impulsivity, was virtually unheard of 30 years ago, but now itís the most commonly diagnosed mental health condition in American children. According to the surgeon generalís report on mental health, ADHD affects between 3 percent and 5 percent of school children in any given six-month period. The American Academy of Pediatrics puts the numbers higher, perhaps between 4 percent and 12 percent. More boys than girls seem to be aff ected. The growth of the ADHD diagnosis, and the accompanying rise in the use of drugs, such as Ritalin, to treat the disorder, has led to a chorus of controversy. From books such as ìTalking Back to Ritalinî to Time magazine headlines, everyone seems to be asking: Are we overmedicating our children? Some scientists and public advocates think so. After all, there is no hard-and-fast test for ADHD. Dr. William Carey, a pediatrician at The Childrenís Hospital of Philadelphia, noted that the behaviors associated with ADHD in diagnostic manuals, such as the American Psychiatric Associationís DSM-IV (the gold standard of diagnosing psychiatric disorders), are difficult to distinguish from normal variations in temperament. ìThe current ADHD formulation, which makes the diagnosis when a certain number of troublesome behaviors are present and other criteria met, overlooks the fact that these behaviors are probably usually normal,î Carey said. The problem, he and others theorize, is not the childís condition but the incompatibility between the child and his settingósay, a ìbad fitî with a school. An editorial in the Wall Street Journal, ìAttention Deficit Disaster,î suggested that ADHD might not exist at all. ìRitalin is child abuse!î declared one Web site, while ìTalking Back to Ritalinî author Dr. Peter Roger Breggin warned of side effects from using Ritalin that can include neurological damage and addiction. In a study that appeared in the American Journal of Public Health, researchers in southeastern Virginia examined some 30,000 grade-school children and found that they took Ritalin and other drugs for ADHD at two to three times the rate you might normally expect. In other words, although ADHD is estimated to affect 3 percent to 5 percent of school-age children, some 8 percent to 10 percent of the children in the study took ADHD medication in school during the 1995-1996 school year. ìItís hard to believe this many children have the specific brain-related problem called ADHD,î said Gretchen LeFever, lead author of the Virginia study and assistant professor of pediatrics and psychiatry at the Center for Pediatric Research, a joint program of Eastern Virginia Medical School and Childrenís Hospital of the Kingís Daughters. But leading mental health organizations and child psychiatry specialists agree that there is such a condition as ADHD and that it can have very serious consequencesóincluding school failure and dropping out, substance abuse, failed relationships and depression, according to the American Psychiatric Association. In fact, the National Institutes of Healthís November 1998 Consensus Conference on ADHD found that ADHD is, if anything, underdiagnosed and undertreated. And despite the drumbeat of ìchemical generationî warnings, treatment with medication such as Ritalin, according to the largest ADHD clinical trial to be completed thus far, may be the most effective option for most children. The study, published in General Psychiatry in December 1999, found that kids on a well-managed medication program, or drug therapy alone, did much better than those receiving behavioral therapy alone. ìWe were surprised how much more effective medication was than even our intensive behavioral treatments in reducing ADHD symptoms,î said Dr. Peter S. Jensen, the principal collaborator from the National Institute of Mental Health (NIMH), which cosponsored the 14-month study with the Department of Education. Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD), a national advocacy organization, calls medication ìan integral part of treatmentî for ADHD. Most experts do concur that there are cases in which Ritalin is inappropriately prescribed. For example, to date the medication contains a label warning that it should not be prescribed to children under age 6, because safety and efficacy information has not been established for children that young, and there are concerns that the drug could affect their developing central nervous systems. But a study published in the Journal of the American Medical Association last year found a three-fold increase in the number of Ritalin prescriptions for children age 2 to 5. A three-year multi-site study funded by the National Institute of Mental Health, examining the safety and effectiveness of Ritalin in preschoolers, hopes to answer the questions that parents and physicians have about treating younger children with the drug. Gina Shaw is the medical writer for The Washington Diplomat.