July 30, 1995 in Nation/World

Raised On Ritalin Raised On Ritalin Teachers, Parents Embrace Growing Use Of The ‘Sit-Still Pill’

Carla K. Johnson And Susan Drumheller S Staff writer
 

(Clarification from Monday, July 31, 1995): Cooper Brislain has been prescribed a stimulant known as Cylert to treat Attention Deficit Disorder. His blood is tested twice a year to make sure the medicine isn’t causing liver damage. Although the drug is similar to the drug Ritalin, liver tests are not required for Ritalin users. A photo caption in Sunday’s newspaper may have given an incorrect impression about when the tests are needed.

First of three parts

Exasperated with her son’s playground fights, crying fits and flaring temper, Sandy Brislain told her doctor, “You either give him drugs or you give me drugs.”

The doctor prescribed Ritalin for the kindergarten child.

Spokane’s Sandy and Al Brislain believe the decision to put Cooper, now 13, on the rigidly controlled stimulant was right.

Their son has a controversial condition called Attention Deficit Disorder, or ADD. They believe their medicine cabinet plays a key role in helping him succeed.

A rapid rise in Ritalin use in the last four years shows that many parents, doctors and teachers are turning to drugs to modify children’s behavior. Some become passionate Ritalin champions as they watch the drug calm rowdy children.

Recently, more doctors are trying Ritalin on adults, too, raising the prospect of children staying on it for decades when its long-term impact on developing brains remains unknown.

The exploding use of Ritalin, a drug under the same control as morphine and cocaine, creates a national debate.

On one side, some experts worry Ritalin’s reputation as a panacea for family and classroom problems causes too many children to be drugged.

Teachers who see Ritalin work with one child are too quick to recommend it for others, these experts say. Doctors hastily label children with Attention Deficit Disorder without the extensive evaluation needed for a good diagnosis.

“People are looking for some quick fix,” said Bill Womack, a child psychiatrist with Seattle’s Children’s Hospital and Medical Center. He is trying to rein in runaway Ritalin prescriptions.

“I think that because adults are taking more medication for the stresses of our culture we are asking doctors to put our kids on medicines also.”

On the other side, the drug’s advocates push for deregulation. They say it’s cruel to keep it from children who would fail in school and be social outcasts without Ritalin.

“Working with ADD can be one of the most rewarding things a pediatrician can do,” said Coeur d’Alene doctor Terrence Neff.

“Each year, we have at least six children who go from (special education) classes to accelerated classes within a year’s time.”

On average, one child in every classroom in Spokane and Coeur d’Alene takes Ritalin or some other drug to control the frantic behavior associated with the disorder. Ritalin is the most common drug passed out in schools.

“It makes me nervous,” said Connie Johnson, a Post Falls elementary school secretary, who hands out Ritalin to several children every lunch hour. “It’s a part of my job I wish I didn’t have to do.”

So many Idaho children are on the drug that the state ranks No. 1 in the nation for per capita consumption. Washington ranks 20th. Use of the drug in Idaho and Washington more than doubled from 1990 to 1993.

This year, the U.S. government plans to allow drug companies to make more than 11 tons of the drug - five times the amount produced in 1990 and enough to keep 1.5 million children medicated for an entire year.

Worse than Dennis the Menace

Parents of ADD children tell stories that make Dennis the Menace look like a model child.

Karen Blaine’s son filled the other children’s shoes with tempera paint at day care. He slashed a couch at home with a knife, not out of anger, but because he couldn’t control his urge to do it.

All children are impulsive and inattentive sometimes. But children with the disorder show those characteristics to the extreme.

Before the disorder can be diagnosed, a child must have a problem with behavior before age 7 and in more than one setting, usually, home and school.

The entry for the disorder in the psychiatrists’ diagnostic handbook is so subjective, so everyday, it reads like a bad school report card.

Careless mistakes, messy work, fidgeting, excessive talking and dislike for homework all are mentioned. Paying attention in class is particularly difficult for these children.

“It’s like trying to run a race car on regular gasoline,” explained Coeur d’Alene child psychologist Craig Stempf. “The power is there, but it’s not getting the right fuel.”

Boys with ADD outnumber girls 3 to 1. But it takes less abnormal behavior for a girl to be diagnosed.

Girls appear more prone to a type of ADD that does not include hyperactivity but instead leaves them lost in space. Often these girls are overlooked because they aren’t discipline problems for teachers.

The disorder’s cause is a mystery.

The brains of people with the disorder may metabolize sugar differently. Or the fault may lie in the neurotransmitters, chemicals that normally allow electrical impulses to travel through the brain. Yet, these hypotheses aren’t backed up with repeated scientific studies.

Research with adopted children, twins and siblings points to a genetic cause.

One out of four ADD children has a biological parent with the disorder. Some experts guess the condition is a genetic throwback to our hunter ancestors. Quick reactions were more important to hunters than long attention spans.

“That’s all nonsense,” countered Dr. Peter Breggin, a psychiatrist and author of “Toxic Psychiatry,” “Talking Back to Prozac” and “The War on Children.”

“There is no diagnosis of ADD or conduct disorder. They’re all simply descriptions of things children do that annoy or frustrate us.”

Breggin argued that blaming behavior on psychological disorders masks the true problem.

“These children are like canaries in a mine shaft,” he said. “They signal that there are problems in a family, in a school, in society.”

Instead of telling children they are misbehaving, society tells them they have malfunctioning brains. The latter is more demoralizing, he argued.

Breggin may be at odds with his profession, but he’s not alone in his skepticism.

A number of teachers and special education professionals doubt hyperactivity and distraction are actual disorders. They worry about the tendency to blame bad behavior on a forgotten pill rather than a child’s will.

“If it isn’t your fault, you’re not going to take responsibility for the cause or the cure,” said Ted Marshall, Coeur d’Alene school psychologist.

“It was accepted at one time that the earth is flat. Just because it (ADD) is well-accepted doesn’t mean diddly.”

Drug of the week

Defending tight restrictions on Ritalin, government officials tell stories of cocaine addicts shooting up the drug and welfare mothers selling their children’s pills.

Its current status means the government controls production and prescriptions cannot be refilled. A doctor must OK a new prescription each month.

Ritalin is in bad company. Drugs in the same category include cocaine, speed and morphine.

Boise police reported this spring that some kids snort their Ritalin at school to get high. “It’s like the drug of the week,” said narcotics detective Tony Taylor.

Ritalin is the brand name for methylphenidate, also available in generic form.

A typical one-month prescription costs about $30. Children usually take one pill in the morning and one at lunch. Some seem to outgrow their need for the drug with puberty; others keep taking it through their teenage years and beyond.

No one knows exactly how it works. Scientists speculate that it stimulates parts of the brain necessary for concentration - perhaps by mimicking brain chemicals.

Although dogs tremble, twitch and slobber when given the drug, Ritalin oddly has a calming effect on children at the right dosage.

Reports are extremely rare of children becoming addicted or displaying the drug’s more serious side effects: stunted growth and Tourette’s syndrome, a disorder characterized by behavior such as barking and outbursts of profanity.

More typical side effects are decreased appetite, sleep problems and stomach aches.

For their part, advocates say the drug is the most studied medication on the market and most doctors consider it relatively safe.

Research is scanty on its long-term effects, however.

Scientists admit they still need to study whether prolonged use may alter the development of the brain’s control centers for planning and concentration.

Many parents hesitate to try the drug on their children.

A University of Idaho study found they would prefer to treat their children’s hyperactivity and distraction problems without drugs.

Leslie Gillies of Coeur d’Alene was one. A teacher first suggested the drug for her son Tom, now 9. The family doctor agreed.

“I was very sensitive to the idea,” Gillies said. “It took me a year and a half before I put him on medication.”

Yet, the results sometimes are so dramatic that once parents try Ritalin, they are loathe to give it up. Their feelings about the drug can change as quickly as their child’s performance in school.

After a year on Ritalin, Tom’s grades are now average or above average, instead of near failing. He loves writing so much he’s working on a book of spooky stories.

“I write better,” Tom said. He also isn’t as distracted by other children when he’s on Ritalin.

“It’s unfair for me to keep him off his medicine,” his mother said.

Experts say medication works 75 to 80 percent of the time. But the definition of “works” varies from study to study.

Ritalin alone does not improve long-term school performance and social skills or reduce delinquency, studies show.

Living with an ADD child

Parents are as confused as the professionals. And they have to handle the emotional trauma of raising a difficult child.

Sandy Brislain recalled taking Cooper to the beach when he was a baby.

“I envied the parents who were sitting there with a book while their children were sitting happily beside them with a bucket of sand. Cooper would be crawling down the beach and stealing everybody else’s toys.”

As the boy got older his mother tried offering rewards for good behavior. Then, instead of fighting about cleaning his room, they would fight about the rewards.

Cooper could sit for hours playing with Legos or drawing, but switching to a new activity sent him on a tirade. He blew up at children who teased him. He hated kindergarten.

“He would come home and sob for hours and I would cry. Then we all would cry,” Brislain said.

Ritalin smoothed Cooper’s life a bit, but he never became a model student.

Every year at the school open house, the Brislains could pick out their son’s desk. It was the one spilling papers in the corner 10 feet from the rest of the class.

Sandy Brislain recalled what her son’s third-grade teacher said when she moved him away from the distraction of his classmates: “You’re still part of the United States, Cooper. You’re Alaska.”

Drugs have not changed Cooper’s personality, his parents say.

They have not dulled his creativity in art or his interest in computers, the two redemptions in his school day. They do seem to calm him, making him more willing to follow directions and finish jobs.

Diagnosis can be guesswork

Cases like Cooper’s convince many people the disorder is real.

Even so, mainstream doctors and researchers worry about the rapid rise in new cases, suspecting more and more children are misdiagnosed.

There is no biological test for the disorder. Diagnosis is usually based on questionnaires filled out by teachers and parents. Questions deal with how often a child squirms, daydreams and fails to finish work.

“I don’t see it as some sort of conspiracy or laziness on the part of teachers, parents or physicians,” said Laurie Wilson, a University of Idaho psychology professor. “People are just going to try what works.”

Wilson’s research found that teachers often mistake ADD for other psychological disorders.

Spokane therapist Pat Sharp has seen school officials jump to conclusions about children.

One boy referred to Sharp for suspected ADD was angry and disruptive, but didn’t have a history of that behavior.

After several weeks of working with the boy, Sharp learned his secret: An older child was torturing small animals and forcing him to watch.

The child saw the older boy snatch a puppy from a neighbor’s yard, shove it into a trash can and set it on fire. With a less meticulous diagnosis, the boy might have been dosed with Ritalin.

Doctors share the blame for knee-jerk diagnoses. Some don’t test for lead poisoning and thyroid problems - which can cause hyperactivity. Some pass up a computer program that tests attention levels.

In many cases, “they do a wham-bam-thank-you-ma’am kind of diagnosis,” said school psychologist Marshall. “It’s Russian roulette whether they consider all the factors.”

If they’re not sure, some doctors try Ritalin to see if it helps. That’s wrong, researchers say. In 1978, researchers showed most children respond to stimulants, whether they have the disorder or not.

“If the physician doesn’t take a lot of time sorting out what’s going on, that’s the first mistake,” said Womack of Seattle Children’s Hospital.

Only half the children referred for possible ADD to Children’s Hospital turn out to have it, Womack said.

Neff, a pediatrician who handles a large number of cases in Kootenai County, described a higher rate of positive diagnosis. He estimated he medicates about 75 percent of the children who come to him.

“Sometimes we will treat a child to the best of our ability, knowing we can’t reach the parents” with family therapy, he said. Often that treatment involves Ritalin.

Some professionals use comprehensive diagnosis procedures.

Sharp does 5-1/2 hours of testing and observation when she evaluates a client for possible ADD, a much longer process than the short doctor’s office visit described by some parents.

She also does a four-week study where only the pharmacist knows which week the child takes Ritalin and which week he or she takes a placebo, a pill that looks like the real thing but contains no medicine. Teachers and parents then fill out questionnaires about the child’s behavior. About 85 percent of the children in the studies end up taking Ritalin, Sharp said.

Concern about misdiagnosis spurred a Washington task force to write a handbook for teachers and doctors. The book, distributed last year, discourages teachers from referring students to doctors without first checking with a school psychologist, school nurse and school counselor.

Womack would like to see post-graduate classes on ADD for doctors.

“How can we go about making sure people understand this disorder so that it’s not just a parent preoccupation (or) pop medicine?” he asked.

Sandy Brislain reacts to the skeptics with a challenge: “If you don’t see there’s a problem would you please take my child and live with him for a week? And live with him without his pill.”

, DataTimes ILLUSTRATION: 7 Photos (3 Color)

MEMO: These 2 sidebars appeared with the story:

1. A POPULAR DIAGNOSIS AND DRUG In 1993, the United States accounted for 85 percent of worldwide consumption of Ritalin. New ADD patients doubled in the last four years. Of every 10 people who see a doctor, nine walk out with a drug prescription. By last year, more than 5 percent of school-age boys and 1 percent of school-age girls across the nation were diagnosed with the condition. Most take Ritalin. The popularity of the diagnosis drives up the cost of education. Washington taxpayers now pay more than $23.7 million for special services given to ADD children as required by law.

2. TRACING STIMULANT USE A brief history of Attention Deficit Disorder and Ritalin:

1902 - British pediatrician George Still blames subtle brain damage for “passionate” behavior of 20 children in his practice. 1917-1918 - Viral encephalitis outbreak leaves children with impaired attention and impulse control. This lends credibility to Still’s theory that brain damage can cause behavior problems. 1937 - Rhode Island pediatrician Charles Bradley first uses stimulants on children. His subjects are institutionalized children with behavior problems. Half improve in their school work. “I feel peppy,” says one. 1955 - Ciba-Geigy Corp. introduces Ritalin to treat condition called minimal brain dysfunction. It is also recommended for lethargy and narcolepsy, a disorder characterized by attacks of deep sleep. 1960 - New York child psychiatrist Stella Chess writes an influential paper on hyperactivity. The condition is thought to be relatively benign, and that children outgrow it at puberty. 1961 - National Institute of Mental Health awards first of many grants for research on stimulants and children. 1968 - The psychiatric diagnostic manual lists a new disorder called Hyperkinetic Reaction of Childhood, a forerunner of Attention Deficit Disorder. 1970 - Ritalin becomes the primary stimulant used in the treatment of hyperactive children. 1971 - The government designates Ritalin as a “schedule II” drug, reserved for hard narcotics. 1977 - Generic form of Ritalin, methylphenidate, is approved for production. 1980 - Attention Deficit Disorder shows up as a new name for hyperactivity in the psychiatric diagnostic manual. Later edition changes the name again, to Attention Deficit/Hyperactivity Disorder. 1987 - Ritalin reviewed by Food and Drug Administration and found safe and effective for treating ADD. 1987 - Children with Attention Deficit Disorder of Florida is founded as a support and advocacy group. In 1993, name changes to Children and Adults with Attention Deficit Disorder. CHADD becomes a major player in changing federal education regulations to benefit children with ADD. 1990 - U.S. Department of Education begins to encourage research on education for ADD children. 1990 - Social Security Administration recognizes disorder. People with it can get disability payments. Children suffering from ADD are eligible for up to $458 per month. 1991 - Department of Education says children with the disorder are eligible for special education services.

These 2 sidebars appeared with the story:

1. A POPULAR DIAGNOSIS AND DRUG In 1993, the United States accounted for 85 percent of worldwide consumption of Ritalin. New ADD patients doubled in the last four years. Of every 10 people who see a doctor, nine walk out with a drug prescription. By last year, more than 5 percent of school-age boys and 1 percent of school-age girls across the nation were diagnosed with the condition. Most take Ritalin. The popularity of the diagnosis drives up the cost of education. Washington taxpayers now pay more than $23.7 million for special services given to ADD children as required by law.

2. TRACING STIMULANT USE A brief history of Attention Deficit Disorder and Ritalin:

1902 - British pediatrician George Still blames subtle brain damage for “passionate” behavior of 20 children in his practice. 1917-1918 - Viral encephalitis outbreak leaves children with impaired attention and impulse control. This lends credibility to Still’s theory that brain damage can cause behavior problems. 1937 - Rhode Island pediatrician Charles Bradley first uses stimulants on children. His subjects are institutionalized children with behavior problems. Half improve in their school work. “I feel peppy,” says one. 1955 - Ciba-Geigy Corp. introduces Ritalin to treat condition called minimal brain dysfunction. It is also recommended for lethargy and narcolepsy, a disorder characterized by attacks of deep sleep. 1960 - New York child psychiatrist Stella Chess writes an influential paper on hyperactivity. The condition is thought to be relatively benign, and that children outgrow it at puberty. 1961 - National Institute of Mental Health awards first of many grants for research on stimulants and children. 1968 - The psychiatric diagnostic manual lists a new disorder called Hyperkinetic Reaction of Childhood, a forerunner of Attention Deficit Disorder. 1970 - Ritalin becomes the primary stimulant used in the treatment of hyperactive children. 1971 - The government designates Ritalin as a “schedule II” drug, reserved for hard narcotics. 1977 - Generic form of Ritalin, methylphenidate, is approved for production. 1980 - Attention Deficit Disorder shows up as a new name for hyperactivity in the psychiatric diagnostic manual. Later edition changes the name again, to Attention Deficit/Hyperactivity Disorder. 1987 - Ritalin reviewed by Food and Drug Administration and found safe and effective for treating ADD. 1987 - Children with Attention Deficit Disorder of Florida is founded as a support and advocacy group. In 1993, name changes to Children and Adults with Attention Deficit Disorder. CHADD becomes a major player in changing federal education regulations to benefit children with ADD. 1990 - U.S. Department of Education begins to encourage research on education for ADD children. 1990 - Social Security Administration recognizes disorder. People with it can get disability payments. Children suffering from ADD are eligible for up to $458 per month. 1991 - Department of Education says children with the disorder are eligible for special education services.

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