[First appeared in the Western Journal of Medicine, December 2000]
Ritalin, the drug used to treat Attention Deficit Hyperactivity Disorder (ADHD), cannot stay out of the news. Last week, class action suits filed in New Jersey and California allege a conspiracy between the pharmaceutical industry, medical doctors and the ADHD leading self help group to unnecessarily medicate American children with a dangerous drug. This news comes at the same time two hundred child mental health experts met in Washington for a two day conference sponsored by the Surgeon General on children's mental health. This and another conference in two weeks at the National Institute of Mental Health (NIMH) are a direct response to national concerns raised by a report last spring of an alarming increase in the use of Ritalin in toddlers. Hillary Rodham Clinton, was only the most conspicuous voice asking questions. And when the first lady asks a question, you better have some answers. But what's the parent of a school age child who is struggling in school to think about the Ritalin.
Ritalin is the best known of the stimulant class of drugs that have been used for over sixty years to treat childhood hyperactivity, now called ADHD. Myths abound about Ritalin and the debate over the drug quickly verges on hyperbole. For example, few know that Adderall, a purportedly ìnewî concoction of amphetamine, has surpassed Ritalin (trade methylphenidate), as the most widely prescribed medication for ADHD in annual prescriptions in America. All the stimulants (including methamphetamine) used for ADHD have essentially the same effects and side effects differing primarily only in length of action.
Most people continue to believe that stimulants, like Ritalin, work paradoxically or the opposite on hyper kidsócalming them down. Many studies have proven otherwise: stimulants like Ritalin work the same in children and adults, ADHD or not, to improve focus and staying on tasks that are difficult or boring. Therefore, prescribing Ritalin as a way to diagnose ADHD is absurd since everyone will do better. Higher doses of Ritalin ìspeedî up children as well as adults. Children, however, donít like the higher doses nor do they self medicate. On the other hand, adults do and therefore are at risk for stimulant abuse and addiction. Children never become addicted.
What about this civil class action suit? The attorneys are patterning their charges to conform to successful litigation against the tobacco companies. There is a major difference with Ritalin, however. Unlike tobacco, the medical establishment, most notably the American Psychiatric Association along with the main professional child psychiatry association solidly back if not promote the use of Ritalin for ADHD. The vast bulk of scientific literature supports the short term effectiveness and safety of Ritalin. Is the pharmaceutical industry suppressing information to the contrary? Rumors aboundóincluding a counter rumor that this action is terribly reminiscent of Scientology inspired suits in the late 1980s that temporarily led to decreases in Ritalin use in certain parts of the country.
Only the disclosure that comes with discovery will determine whether a Ritalin conspiracy really exists but even without a conscious plan, the influence of pharmaceutical industry dollars for research support and advertising, first to physicians and now directly to families has been profound. The market forces of Adam Smithís ìinvisible handî operate within the world of childhood mental health and illness. American psychiatryís infatuation with the brain coincides with a drug industry more than happy to contribute funds for research that only counts symptoms and pills. If only family counseling or special education rewarded stock holders the same way Ritalin or Prozac does.
Practically every researcher in ADHD now accepts drug company money as do the self help groups for at least a part of their work and projects. They would say that they are not influenced by the source of their funding. However, many worry otherwise, from the doctors at local hospital grand rounds listening to a lecture ìsupported in part by the (fill in the blank drug company)î to the editors of the august.
New Journal of Medicine reviewing the latest research findings. Add further the influence of the economics of managed care which drive doctors towards Ritalin as ìquick fix.îótalking to parents and working with schools simply takes too much time.
The success of Adderall, which was vigorously marketed to doctors, is more a sign of ìhypeî activity than any real medical breakthrough. The advertising for the new stimulant product for ADHD, Concerta, crosses boundaries as the first prescription drug for a childhood psychiatric condition marketed directly to parents. The picture of a smiling boy holding a pencil surrounded by his happy parents and sister tells you theyíre pleased because the boy is now being treated for ADHD, a biological disorder best rxíed with a pill. Such presentations can only further promote a brain based view of behavior, e.g., an aspect of nature, at the expense of nurtureófamily, school, neighborhood and cultureófactors that many still feel are important to a childís healthy emotional development.
The conference at the NIMH in two week plans to set out a course to specifically study ADHD and Ritalin use in toddlers. Virtually every researcher at that conference receives funds from the pharmaceutical industry. At the Surgeon Generalís Conference it was clear that non-drug approaches to children are egregiously underfunded. What about taking yet another cue from the tobacco wars and develop a tax on either pharmaceutical profits or the drugs themselves that wound be directed back to other effective interventions for ADHD like parent and teacher behavioral management training? Specific tax incentives and disincentives are the most likely way the public, through government action, will be able to influence otherwise powerful economic forces which push towards only medicating for childrenís problems.
Parents should still feel that they can choose Ritalin safely for their child after theyíve fully explored issues of family, learning, and school. These new civil suits will only confuse and frighten undecided parents. Unfortunately given the massive effort to convince America that their childrenís brains are bad, only such extreme countermeasures like the Ritalin suit may get the publicís attention.
Lawrence Diller, M.D., practices behavioral pediatrics in Walnut Creek, California and is the author of
Running on Ritalin: A Physician Reflects on Children, Society and Performance in a Pill.