THE RITALIN CONTROVERSY

Once hailed as the miracle medicine for hyperactive kids, Ritalin is under increasing attack from parents who claim that it is overused. Is it a wonder drug? Or are we treating childhood as if it were a disease?

FROM THE BEGINNING, NANCY AND BRUCE CORNISH SUSPECTED their son was different. Though he was their first child, the new parents knew most babies slept more than Jason. He was awake and active most of the day and night. He cried when he wasn’t being held. They took turns rocking him hour after hour. “I needed more sleep than the baby did,” remembers Nancy.

As a toddler, Jason required vigilance. Nancy learned that she couldn’t leave the energetic infant alone for more than a few seconds. Even after child-proofing their Piano home, Jason discovered new ways to do damage-sometimes to himself. And he needed his mother’s constant attention. “He figured God put me on earth as his entertainment center,” says Nancy.

So Nancy and Bruce weren’t surprised in 1979, when their four-year-old became a preschool dropout. The school asked them to remove their son because he couldn’t sit in a chair, play with toys or other children, or listen to stories. Jason seemed distracted, restless, impulsive.

Doctors began to run tests. They learned that Jason had an I.Q. of 140 but couldn’t learn in a regular classroom. The official diagnosis was minimal brain dysfunction (MBD). The prescribed therapy was Ritalin, a stimulant that, paradoxically, calms down a restless child.

For the next seven years, Jason swallowed the tablets in the morning, at lunch, and sometimes in midafternoon. The drug seemed to help him settle down so that he could listen and learn. Jason received special education support until fourth grade when state rules changed and he was no longer classified as a special ed student. When the special ed support ended, Jason once again became embroiled in battle with his teachers.

The Cornishes wanted to file a lawsuit to force their local school district to put Jason back into special education, but they decided it would cost too much money. They looked into special schools. They saw more doctors, including a pediatric neurologist. Then Jason’s diagnosis changed. He was pronounced depressed. The doctors deemed Ritalin partially responsible for the depression, so Jason was taken off the drug. He went into therapy and was given new drugs to combat his depression.

Children like Jason are enigmas to educators, physicians, parents, and therapists who are locked in a heated-and at times hysterical-battle over when and how to medicate young “hyperactive” patients in general, and over the use and misuse of Ritalin in particular. Families like the Cornishes feel trapped in the middle of a confusing debate marked increasingly by buck-passing from one group of experts to the other.

The controversy over Ritalin is particularly sharp because of what some perceive as a growing intolerance, especially in crowded classrooms, toward kids who can’t learn reading, writing, and arithmetic by conventional means. Many of those children have been diagnosed with “attention deficit disorders” (a more specific form of minimal brain dysfunction) and given Ritalin to help them focus on their school tasks for longer and more consistent periods of time. But more and more, parents and doctors are beginning to question whether the drug is being used for sound medical purposes or simply as a means of subduing unruly students in an effort to maintain orderly classrooms. Other critics believe that the use of Ritalin is an outgrowth of the pressure-packed Eighties, with its focus on achievement and good grades.

Some parents who have opted out of the Ritalin controversy are turning to special private schools and other methods of learning. In some parts of the country they have gone further, looking to the courts for help. Lawsuits against school districts have been filed in Georgia and New Hampshire by parents who oppose drug therapy for their children and hold their children’s teachers accountable for its increasing use. And doctors are being blamed too: at least eight medical malpractice suits have been filed, five of them in Massachusetts. To date, none have been filed in Texas.

The latest wave of public furor over Ritalin may also be a reaction to its increasing use. Some 800,000 to 1,000.000 school children, or 3 percent to 5 percent of the elementary and junior high school population, are treated with drugs for attention deficit disorders (ADD). The drug seems to help about 80 percent of them, while the remaining 20 percent who try Ritalin show no improvement or suffer side effects too severe to continue with the drug therapy. In Texas, the number of Ritalin prescriptions reported to the Department of Public Safety has almost doubled since 1983.

Adding to the commotion about Ritalin is the Church of Scientology, a dogmatic quasi-religious organization with a long history of opposition to psychiatry. The Scientologists have fueled fears about Ritalin with dramatic stories of its abuses and its effects. The group’s offshoot, the Citizens Commission on Human Rights (CCHR), which investigates and exposes what it sees as psychiatric violations of human rights, has assisted in research and lawyer referrals in almost two dozen lawsuits involving Ritalin over the past two years. CCHR has even set up a “Ritalin Hotline” in its Los Angeles office. From there, “information letters” are sent out by the thousands claiming Ritalin to be as dangerous as cocaine and labeling it a cause of delinquency, crime, and suicide. According to a CCHR pamphlet, the “countless children in this country on very dangerous psychiatric drugs. . .are the unwitting guinea pigs of an experiment which is turning into a nightmare of monstrous proportions.”

Locally, the Church of Scientology has staged several protests over the past few years. CCHR’s Dallas spokeswoman, Sherri Randall, says she is documenting Ritalin abuse for future lawsuits. She also is starting a group called PADRE, Parents Against Drugs Replacing Education.



THE DIAGNOSIS



HOW CAN PARENTS TELL WHEN A child crosses the line from normal, boisterous behavior into the realm of a disorder that might require medication?

Since there is no single test to detect ADD, its diagnosis continues to create debate among professionals. There are few accepted shortcuts to identifying it. Milton Cardwell, M.D.. a developmental pediatrician with offices in Las Colinas. says he normally spends an hour with his new patients and their parents before attempting diagnosis. Extensive interviews with parent and child about home life are key, Cardwell explains, because attention deficit disorders often have a genetic root. Some simple neurological tests can also help diagnose children seven or older-such as asking the child to stand on one foot for fifteen seconds, walk heel to toe in a straight line, and touch each finger to the thumb in succession several times. But if the child tails below expectations in these motor skills tests, Cardwell says, a doctor should see the physical limitations merely as a part of the diagnostic puzzle, not an answer automatically calling for Ritalin. And, Card-well adds, a child can do fine on the tests and still have ADD.

The most widely used diagnostic tool is the Diagnostic and Statistical Manual of Mental Disorders, issued by the American Psychiatric Association as a catalogue of criteria for diagnosing psychiatric conditions. According to the manual, signs of ADD range from fidgeting, difficulty in playing quietly, and interrupting others to losing things necessary for school tasks, such as pencils and books-hardly uncommon traits of elementary school kids. But other criteria-engaging in physically dangerous activities without thinking about consequences, shifting from one uncompleted activity to another-may help doctors rule out questionable cases. And, according to the manual, one sign must be present for a reliable diagnosis of ADD: difficulty sustaining attention during school tasks or routine chores,

Some doctors have been critical of the criteria set up by the manual. Dr. Warren Weinberg of Children’s Medical Center of Dallas at The University of Texas Southwestern Medical Center doesn’t use it in his diagnosis of attention deficit disorders. Through Weinberg’s own research as a pe-diatric neurologist, he has come to believe that “all behavior has a biological basis.” In the early Seventies, Weinberg shocked the psychiatric world with his studies about depression in young schoolchildren. “It was a heretical concept. It was unacceptable. Now it’s a widely studied condition,” Weinberg says.

Though he is reluctant to second-guess any doctor’s diagnosis of ADD, Weinberg questions whether some ADD cases aren’t really children who are depressed and should be treated with special counseling, stress reduction, positive support from parents and teachers, and depression-controlling drugs-but not Ritalin. “The label [ADD] has no meaning to me. It’s like saying someone has fever.1’ Weinberg asks, “What’s causing the fever? What is the cause of the infection?”

Weinberg uses a different system of classifying attention deficit disorder, which includes terms such as “primary disorder of vigilance.” He defines this disorder by describing its victim as the kid who chronically tails asleep or daydreams in class, and believes that such children may suffer from a mild form of narcolepsy. At other times the child is busy, constantly moving, fidgeting, and talking. According to Weinberg, in many instances the child is just trying to stay awake.

Other critics, including the Scientologists, go further in expressing skepticism over common methods of diagnosing ADD. All signs of the disorder, they charge, could fit all children at some time during their lives. “The truth,” writes Dennis Clarke, national spokesman for CCHR, “is that the vast majority of children who are being labeled “mentally ill’ have no mental disorder whatsoever but are suffering from very physical problems which have known medical treatments.” Clarke believes that chemical toxins, food coloring, preservatives, heavy metals such as cadmium and lead, and improper diet can contribute to a child’s behavior problems.

THE DRUG



LAST YEAR, 142,542 PRESCRIPTIONS for Ritalin, or more than twelve and a half million tablets, were prescribed by Texas doctors, who are required to document their prescriptions in triplicate. The ADD diagnosis accounts for 99 percent of the Ritalin sales, according to Ciba-Geigy, the biggest manufacturer of the drug.

Production of the drug also is increasing. From 1982 till 1987, with the exception of one year, the Drug Enforcement Administration has raised production quotas of Ritalin for Ciba-Geigy and a generic drug manufacturer. Since methylphenidate, the drug’s generic name, is classified under the Controlled Substances Act as a Schedule II stimulant, companies are limited by federal regulation. They must get DEA permission to increase quantities and specify why they are being increased. In the case of Ritalin, the reason was simply higher demand. A spokeswoman for Ciba-Geigy says that Ritalin production quotas for 1988 and ’89 are slightly lower.

Naturally, the more Ritalin, the more complaints from its critics. Stunted growth. Addiction leading to cocaine and heroin abuse. Suicide. Claims of these and other side effects attributed to Ritalin are being widely circulated by the Scientologists.

Doctors wince when they read the church-promulgated reports of Ritalin use and abuse. “I think a lot of the recent publicity has been based on emotionalism rather than on scientific data,” says Milton Cardwell. “A lot of what’s been published has been inflammatory and a disservice to these children and their families. I think it has needlessly upset people and they have been tempted to get information from the media instead of medical sources,” Cardwell adds.

There is little support in the medical community for the exaggerated claims of the Scientologists, although studies suggest that there may be some legitimacy in the charge that Ritalin can retard growth. In some cases where children were given more than 20 mg of the drug per day (two 10-milligram tablets a day are a typical dose), growth was impeded slightly. But doctors say that in most cases, a child will catch up after the drug is discontinued.

There are, however, numerous side effects, the most common being loss of appetite and insomnia. Some parents interviewed for this article say that they notice a “rebound effect” when the drug wears off late in the afternoon and a very hyperactive child sends the household into a frenzy. But other parents assert that behavior can be worse if the child has taken no drug at all.

Because of these side effects, and because diagnosis of ADD is difficult, medical experts suggest that Ritalin, even when properly prescribed, cannot be considered the whole of the treatment, but only a part. Individual or family counseling may be in order. “These children have all gotten to feel beaten down. They feel unsuccessful. They’ve gotten a lot of negative feedback. If they can have some successes, they can feel better about themselves,” says Cardwell.



THE SCHOOL ENVIRONMENT



IF THE MEDICAL COMMUNITY IS ATodds over Ritalin, it also is placing blameon educators who, some believe, are putting loo much stock in the medication’s ability to calm disruptive students. Schools areabout “sitting still, paying attention, and letting the teacher teach reading, spelling,writing, and numbers,” says Warren Wein-berg. He is critical of professionals whoprescribe medication for the sole purpose ofgetting the child to do those things. “Sure,there is grade improvement, because the student’s behavior gets belter. You are no longera nuisance,” Weinberg says. But, he adds,”There is no evidence that medication helpstrue learning, true memory, true reading andspelling.”

Weinberg is critical of schools that believe “more time on task, excessive emphasis, drill, or various teaching-training programs will speed up learning.” He says this approach actually promotes inattention. Weinberg believes that learning occurs as the brain develops. When the brain is ready to grasp new ideas, education of a child moves forward. He says a child diagnosed as ADD without hyperactivity, for example, may become a normal, healthy child when educators teach creatively rather than relying on “task-driven” methods.

But in a public school environment, where test scores and grades are a primary measurement of learning, many teachers say that they have little freedom to make school fun and less boring. With the Texas education reforms in place, some educators believe inat-tentiveness could reach new levels because students must spend most of their school time on “the basics.”

It is that emphasis on basic skills and testing that worries some professionals who fear Ritalin is being prescribed as a mental steroid. Mark Swanson, M.D., director of the University Affiliated Center for Devel-opmentally Disabled Children at UT Southwestern Medical Center, thinks that some parents and schools put too much pressure on children to make good grades.

“It’s our generation doing this. We were the first group to go to college in large numbers. So we see college as very important, the key to success,” says Swanson, who is thirty-eight and the father of three. “Some parents are looking for a little edge to improve grades. But if the kids get burned out in second or third grade, it may have lifelong effects.”

Swanson prescribes Ritalin only in the most severe attention deficit cases. In these cases, studies show, children are most likely to show dramatic improvement. In his work with the Dallas Independent School District, Swanson sees underprivileged children who exhibit signs of hyperactivity and inattentiveness, which frequently turn out to be responses to a chaotic home environment-not to school. “You can’t put every wild little boy on medication,” Swan-son says. He points out that most European countries use very little of the drug.

When a low-income child from a high-risk neighborhood is diagnosed with severe attention and hyperactivity disorders. Swan-son often recommends that the school administer Ritalin and that the prescription not be sent home, The fear is that prescriptions, or ’”scrips,” will be sold on the streets and used by someone other than the child-a fear that has been exploited by the Scientologists. But despite Swanson’s experience in low-income areas, he and others believe that Ritalin use may be highest not in the inner city but in the suburbs. William Fackler, M.D., who has practiced pediatrics in Richardson for twenty-seven years, thinks that some parents are looking for an easy solution with a Ritalin prescription. Fackler says parents in his area know which doctors will quickly prescribe Ritalin. “We all know who is willing to do this and who is not,” says Fackler. “In my own practice, I individualize every single case. I don’t give everyone Ritalin. That’s poor medicine.”

The coordinator for health services in Richardson schools, Forrest Skaggs. wishes there were time for her staff of school nurses to gather statistics about referrals and Ritalin use in RISD. “We’ve had some students show up on Ritalin with the teachers not knowing about any attention problems. We’ve been amazed,” says Skaggs, who says that most physicians don’t follow up with the school to see how the child is doing on the medication. “All we can do is monitor to make sure the proper dosage is given.”

Skaggs also observes that the competitive atmosphere of RISD puts kids under a lot of pressure. “In some communities, it [Ritalin] becomes a solution to other problems. But I see both sides. For some kids it makes all the difference in the world. I also see its abuse. I do think it’s overused.”

Tom and Karen Brown (their names have been changed at their request) can afford an expensive private school for their son Brad, an average student who makes mostly Bs and Cs. But Brad’s teachers have said he could make As if he weren’t so easily distracted. At age six, Brad was tested at Scottish Rite Hospital, but no learning disability or ADD was found. Still, for the next five years Brad’s “easy distractibility” was brought up at every teacher-parent conference. “There was a subtle encouragement to try Ritalin to improve academic achievement,” says Tom. “The national testing process at the school is very important.”

The Browns resisted, though they had many friends whose kids were on Ritalin at the time. They grew to resent their drug-free child being compared to other kids who were showing improved grades after taking the stimulant. But the Browns persevered without resorting to Ritalin. Brad made the fifth grade honor roll last year.

Both private and public schools are reluctant to publicize statistics about Ritalin use. Only the special schools for children with learning disabilities openly discuss the figures. At the Shelton School in Dallas, where tuition is about $8,000 a year, some 20 percent of the students are on Ritalin. But the school strongly discourages families from relying on drugs without other therapy.

“Some kids from public schools can go off medication in our smaller classes,1” says Sherrye Camp, executive director of Shelton, where the student/teacher ratio is seven to one. Camp believes that more three-dimensional learning, computers, field trips, and individualized instruction can help children who suffer from boredom in the conventional classroom.



THE COPING



FOR TWELVE-YEAR-OLD BARBARA McNairy, relief came by way of a new way of learning, not medication. Her private school teachers had diagnosed Barbara as having attention problems. During class she would study the woodgrain on the top of her desk instead of listening to the teacher. When she did her classwork, Barbara sang to herself, disturbing other students and the teacher. By fourth grade, Jane and Jack McNairy had given up trying to change the school’s negative attitudes about Barbara, whose self-esteem was plummeting. They moved Barbara to Shelton. “She is so much more confident now. She has better coping skills,” says Jane.

As a girl, Barbara is in the minority at Shelton. The half dozen special schools in Dallas for children with learning problems have many more boys than girls. For every girl in a special school who has attention disorders or learning disabilities, there are four boys with similar problems. At the Winston School, assistant to the headmaster Ellen Davis describes the average Winston student as male, bright, often talented in art or drama, but unable to get organized. “It’s the child who gets in trouble for not turning in his homework, but he may be the next generation’s successful entrepreneur.”

Winston alleviates the organization problem by giving very little homework in kindergarten through sixth grade. Workbooks and a lot of “teacher-created” materials are used. “We show science, math, and reading in multisensory ways instead of learning with books ” says Davis. The educator adds that if parents object to the use of medication, the school will work with the child without the drug, but says the school always maintains the right to recommend medication.

On any weekday in her office on Royal Lane, Davis can receive a call from a parent looking into a special school for children with “learning differences.” The stress and strain of dealing with a child who is different affects the entire family. “I can often hear the frustration in the mother’s voice,” Davis says. “’And sometimes there are tears.”

Every parent of a child diagnosed with an attention problem suffers along with the child. And despite its drawbacks, many believe Ritalin offers an unparalleled solution. Without it marriages would have foiled, they say, families would split up. The child suffering from repeated failure finally can set goals and accomplish them while on the stimulant. They testify to the success of the drug when they see their children happy, better adjusted, and enjoying growing self-esteem.

“When ADD is diagnosed properly, Ritalin is the closest thing to a miracle drug we have,” says Dr, Michael Murray, a clinical psychologist who specializes in attention deficit disorders. “The medicine helps a child to do the things he was supposed to do. So good things start piling up. His self-esteem improves.”

There are ways of minimizing the drug’s deleterious side effects. Doctors can lower dosages or change the time of day the child takes the drug. Switching to a different stimulant such as Dexedrine or Cylert may give better results in some cases. Cardwell recommends a “drug holiday,” or a period in the summer or on vacation when the child is free of the drug. He also suggests that teachers monitor the child while he or she is off the drug to assess whether behavior problems are improving as the child matures.

But the real improvement comes with therapy, specialists say. Murray uses cognitive therapy to teach ADD children a sense of cause and effect. (If you don’t let him play with your toys, he won’t let you play with his toys.) He helps the child develop empathy. (How would you feel if a friend hit you?) He guides the child to find other ways’ to think and act. Then he dramatizes the situations by acting out roles.

Murray says Ritalin can help the impulsive child because it slows his responses and gives him time to reflect. “Once that’s built in, a therapist can teach him how to react to stimulus and ways to reason.”

Therapy for the parents can be found in Nancy Cornish’s group, Parents of ADD/ Hyperactive Children. One session is held the fourth Thursday of every month at Grace Presbyterian Church in Piano; a second group meets on the second Monday of each month at Good Shepherd Episcopal in Cedar Hill. Nancy started the group four years ago with seven parents. Since then, about 700 families have attended the sessions.

The parents cry and laugh together, The group does not believe in endorsing any one method of diagnosis or treatment, but parents give each other advice. Many of them feel they’ve been on a “referral merry-go-round’-seeing professionals from social workers to psychiatrists. Nancy calls on her own experiences now that Jason is thirteen and in eighth grade. Another son has been diagnosed with such severe learning disabilities that he qualifies for special education. “I believe reward instead of punishment works best with my kids,” Nancy says. “And 1 live my life according to the Gospel of Matthew: ’Do not worry about tomorrow, for tomorrow will worry about itself. Each day has enough trouble of its own.’”

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