Kids on Pills
Julia Green Elementary School is one of Nashville's most respected public schools. Test results consistently indicate that students at the Hobbs Road school received a superior education. What's more, Julia Green has a reputation as a school that takes a particular interest in the individual needs of its students.From time to time, for example, a student may have difficulty focusing on his schoolwork or concentrating on tasks assigned to him. When a child demonstrates such "off-task" behavior, the principal, Imogene Brown, usually arranges a conference with the child's parents. "We sometimes suggest to the parents that they talk to their pediatrician about their child's condition," Brown says. But sometimes, she says, the child comes back with a prescription for methylphenidate, the drug popularly known as Ritalin, in hopes that his ability to concentrate on his schoolwork will improve.He will not be alone. Every day after lunchtime at Julia Green, 12 of the school's 507 students walk to the principal's office. There, the school secretary gives each student his midday dose of Ritalin. Usually, it will be his second dosage of the day, the first having been administered at home earlier in the morning. As is the case at all other Metro schools, each child's Ritalin is kept in an envelope with his name on it, and school officials stress that distribution of the drug is carefully monitored. Parents must sign release forms before their children can take the drug at school. School officials do not relish the idea of school secretaries administering Ritalin. A decade ago, school nurses were available to perform such tasks. But, ever since the school system suffered severe financial cutbacks during Mayor Bill Boner's administration, school nurses have virtually disappeared from Metro schools. "We would feel more comfortable if school nurses were distributing" the Ritalin, says Craig Owensby, spokesperson for Metro schools. "We would like to relieve teachers and secretaries of that responsibility, but without school nurses, how are you going to do it?" To make the best of a difficult situation, Owensby says, the secretaries are "very careful to make sure the medicine gets matched up with the child." Julia Green's Imogene Brown says she is "not one for medication," but she admits that she has seen "wonderful changes among children who are now on Ritalin. It does help them focus and be a regular part of the classroom. There have been some dramatic improvements among children, and I think it helps a lot of kids." This year, Brown says, the number of Julia Green students taking Ritalin has dropped slightly from last year, but only because a number of the children taking the medication have moved on to other schools. In Metro schools overall, as in the rest of the nation, however, the use of Ritalin has risen astonishingly in the 1990s, educators say. "I have observed a marked increase in the use of Ritalin that schools are asked to dispense," says Barbara Gay, a social worker in Metro Schools. Meanwhile, it is hard to get exact figures on the number of students who take the drug at Metro's 127 schools. According to Owensby, that is the sort of data school nurses would have collected.Ritalin is most commonly used to treat conditions such as Attention Deficit Disorder (ADD) and Attention Deficit/Hyperactive Disorder (ADHD). According to Children and Adults With Attention Deficit Disorder (CHADD), a Florida-based not-for-profit organization, some 3 to 5 percent of all American children -- or up to 3.5 million children -- suffer from ADD. Ninety percent of those diagnosed with the condition are white boys. According to figures from the Tennessee Board of Pharmacy, the consumption rate in Tennessee is higher than the national average. For every 100,000 people in the country, an average of 1,693 grams of Ritalin was consumed in 1995. In Tennessee, the figure was 1,868 grams per 100,000 people. (These figures include consumption of Ritalin in both children and adults.) In Tennessee alone, chapters of the CHADD organization have been founded in Knoxville, Chattanooga, Dayton, Johnson City, McMinnville, Murfreesboro, Dyersburg, and Paris. As a nation, the United States leads the world in prescribing Ritalin to treat various behavioral problems. According to a March 1996 story on Ritalin in "Newsweek", the drug is consumed in the United States at a rate at least five times higher than in the rest of the world. Because so much Ritalin is consumed in Tennessee, the Health and Human Resources Committee of the state House of Representatives has scheduled a meeting next week to explore the high rates of the drug's usage here. "We plan to study the usage and effects from the child's perspective," says state Rep. Tommie Brown, D-Chattanooga, who was encouraged to start investigating the drug when parents began approaching her about its increased presence in schools. Participants in the meeting will include psychologists, parents, pediatricians, and others who have experience with the drug. "We just want to know why the rates are higher here than elsewhere," says Brown. "We want to know how it is being administered in school. And we want to know the causes that may exist in society to cause the condition to begin with." The use of Ritalin to curb behavioral problems among children is controversial. Many professionals believe that the drug helps children with ADD or ADHD to become more focused and to pay better attention in class. In a number of cases, medical doctors, psychiatrists and counselors have seen dramatic improvements, especially among children with serious behavioral problems. Others, however, believe that ADD is an over-diagnosed condition. Ritalin's critics contend that parents and doctors often opt to prescribe the drug when the problem may simply be one of bad conduct. Rather than taking tough measures to discipline a child, critics say, parents often just take the easy way out. Critics also point out that the drug is so often prescribed for boys, who are more prone to demonstrate bad conduct than girls. That fact, the critics say, indicates that society prefers to dope up its children rather than set tough limits for them. "I think this is about drugs instead of parenting," says Julia Landstreet, a mother and former Julia Green PTA president who has been active in Metro education issues. "I absolutely believe some kids need [Ritalin]. But the nature of our culture is to take a pill to fix things. This seems in keeping with everything else that is going on." Enormous advances have taken place in the medical community over the last decade with the introduction of "mood-settling" drugs. Millions of Americans take a variety of medications to combat depression, anxiety, fatigue, and other psycyhologically related illnesses. But because Ritalin is administered to children, and because schools are often ill-equipped to handle the rise in its usage, the debate over Ritalin has taken center stage. Is Ritalin simply a drug that medicates problems rather than solves them? Or is it a valuable tool that helps children behave better and learn more in the classroom? The answer is not a simple one. Ritalin is only one of a number of drugs prescribed to treat ADD and ADHD. The stimulants Adderall and Dexedrine, as well as anti-depressants such as Norpramin, Prozac, and Ludiomil, are also administered to treat the conditions. But Ritalin appears to be the drug of choice. According to a news story in "The Tennessean", Ritalin accounts for approximately 60 percent of all prescriptions in the country written by doctors for individuals suffering from ADD/ADHD. Ritalin can only be prescribed by a doctor. It is not addictive for children, but Dr. Mark Wolraich, a professor of pediatrics and director of the Child Development Center at Vanderbilt University Medical Center, notes that it is addictive for adults. He also cautions that "its prescriptive use needs to be closely regulated." Wolraich points to a recent study conducted between normal 14-year-old boys with hyperactivity and 21-year-old hyperactive males. In that study, he says, "None of the group of 14-year-olds reported feelings to want to take the medication, while some of the 21-year-olds did." Wolraich says children do not report "pleasurable" feelings from the drug. Thus, the risk of children abusing the drug is minimal. Ritalin's effect seems paradoxical: It is a stimulant, and yet it helps hyperactive kids settle down. Because it stimulates the central nervous system, however, it creates a calming, mood-leveling effect. Thus, the person taking Ritalin is less easily distracted from a particular activity. That benefit "has been documented in hundreds of studies with control," Wolraich says. There are side effects, however. The most common, which can be controlled by adjusting the dosage, are suppressed appetite and sleep loss. Other side effects can include nausea, headaches at the outset of therapy, and a letdown, or mood change, when the medication wears off. Ritalin may also cause users to be jittery or nervous, but these effects can be minimized by an additional medication, such as a beta-blocker that takes the edge off. Because the typical dose of Ritalin lasts for about four hours, it is usually administered several times a day. It is common for children to take "drug holidays" from their Ritalin on weekends or in the summertime, when they do not have to be as focused. "You use it in the situations where children need it," Wolraich says. "For some of the children with ADHD, their problems are primarily in the school setting and not at home. In that case, they don't necessarily need Ritalin on the weekends and in the summertime." Ritalin's public image has been far from favorable. Because it is associated, in some people's minds, with Dexedrine, also a stimulant and an "upper," or cocaine, Ritalin is sometimes described as "kiddie speed," or "crack for children." There have been reports of parents abusing their children's Ritalin, as well as instances of children selling their pills to friends who don't have prescriptions. The media has contributed its share of erroneous reports about the drug, embellishing its side effects and risks. "I think Ritalin has an image problem," Wolraich says matter-of-factly. "Particularly, there was a large media campaign by Scientologists to try to discredit the use of Ritalin in the late '80s. The campaign exaggerated the side effects and potential risks," he says, adding that its potential side effects are less severe than aspirin. What "is" important to understand about Ritalin is that it does not cure a child's hyperactivity or distractibility. Rather, it only treats the symptoms of the disorder. And that disorder may be hard to define. Some refer to it simply as ADD, while others prefer to throw hyperactivity into the mix, calling it ADHD. Doctors say ADD and ADHD are neurological syndromes with symptoms that can include impulsiveness, distractibility, hyperactivity, and excess energy. No scientific evidence exists to show that ADD is a disease. Rather, it is an incurable, complex disorder. "Unfortunately, we can't draw blood or look at an X ray and say, `Yeah, they have ADD,' " says Dr. Cynthia Briggs, a child psychiatrist at Vanderbilt. "Kids have symptoms to an extreme, more on the exaggerated end." Briggs, whose own daughter has been diagnosed with ADD, points out that other conditions may actually be at the root of the problem. "I think it's easy to miss other things," says Briggs. "There are other reasons that kids are restless. It's tough to attribute it all to ADHD. I have had kids come in and say they have been diagnosed with ADHD; then I do a little digging to see if something else may be going on. Depression in kids and post-traumatic stress disorder can sometimes get misdiagnosed as ADHD." Barbara Gay, a social worker for Metro schools, agrees that diagnosing the condition is not easy. "It's a very complex disorder," she says. "There may be so many other factors involved, like neglect, abuse, and broken families, that can cause the same symptoms." But Gay says that, for 3 to 5 percent of the school-age population, "there's a biochemical imbalance that means that they can't sit still in school." For those children, she says, Ritalin may be an appropriate drug. But Gay maintains that parents must be involved in the decision-making process, when it comes to deciding whether their child should be taking the drug. "Some parents are willing to let their kids take drugs at the drop of a hat," she notes. "Others say, `No way.'" One school of thought holds that ADD/ADHD is actually a smoke screen, dreamed up to explain unacceptable personality traits. According to this line of thinking, ADD/ADHD is simply a cop-out, a way of telling people that their behavior is not their fault. When people have a "disorder," after all, they are not responsible for their actions. One child neurologist, Fred A. Baughman Jr., recently posted on the Internet an article entitled "What Every Parent Needs to Know About ADD," in which he raised questions about the disorder. Baughman charged that it may be diagnosed simply by a "teacher checking any eight of 14 behaviors on a pencil and paper checklist," that it needs "no physician, laboratory, X ray, or brain scan conformation," and that the root problem with the diagnosis is that "there is no confirmation." He mocked the tendency of medical professionals to refer to ADD/ADHD as "a brain disease" owing to a "chemical imbalance of the brain," when science does not support those statements. He advises that everyone approach the subject of ADD/ADHD with "skepticism." To diagnose the disorder, doctors and counselors do administer a variety of tests to children. One is the Achenbach Childhood Behavior Checklist, which asks parents to rate, in terms of severity, whether the child bites his fingernails, is secretive, sleeps more or less than others, threatens people, sucks his thumb, wishes to be the opposite sex, or worries excessively. Vanderbilt's Wolraich says the diagnosis of the disease is usually based on reports from parents and teachers, not from a doctor's first-hand observation of the child. He says that observing only small samples of the child's behavior in an office setting does not provide "good enough examples to go on in terms of their behavior." The key question, of course, is whether ADD/ADHD is simply over-diagnosed, leading Ritalin to be over-prescribed. Experts differ on that question. "The core issue with ADD is that it is far too easily and quickly diagnosed," says Howard Morris, president of the National Attention Deficit Disorder Association in Mentor, Ohio. "Lay materials, support groups, articles in the press, and all manner of other media attention have created an environment where parents are on high alert with respect to ADD. And ignorance and insurance issues have created a situation where professionals diagnose far too easily and where medication is too often used as the total solution." Wolraich, however, has a different opinion. "I don't think, in most cases, too many children are being treated with Ritalin," he says. "I think some children are being treated inappropriately -- in both directions. Some children who might well benefit from Ritalin are not receiving medication. But there are also children who don't have the diagnosis who are put on medication." The key issue, Wolraich says, is that ADD/ADHD is a legitimate condition that may require medication. "It has the same criteria and is as well-established as any other psychiatric diagnosis, like depression or conduct disorder," he insists. Jessica Golden, a second-year law student at Vanderbilt University Law School, speaks frankly, and rapidly, when she talks on the telephone. When she was a fourth-grader, Golden demonstrated symptoms of behavioral problems and was subsequently tested and diagnosed with ADD. She recalls being hyperactive and unable to concentrate or focus her attention on a specific task. She was prescribed Ritalin to control her inattention and restlessness. She recalls, however, that contrary to the success stories often noted by psychiatrists and pediatricians, she did not like the drug. "I took myself off Ritalin in the sixth grade," Golden says. "I didn't think it helped me. In fact, it gave me really bad headaches and made me very nauseous. When I took it, it made me focus too much; I could only concentrate on one thing at a time. There were things happening around me that I wasn't aware of." Golden has not taken Ritalin since the sixth grade, and she still has ADD. "I taught myself to get through the day," she says. "I may not be doing as well as I could be, but I think I'm doing just fine." Golden, whose brother has also been diagnosed as having ADD, faults her therapist for not supporting her when she balked at taking the medication. "He thought it was a very bad idea," she says. "When I did get off Ritalin, that was it -- he didn't try to help me get through it without drugs. It was pointless; he couldn't do anything for me." Now Golden argues that doctors "need to teach coping skills rather than prescribe the drug." Most medical professionals would agree that medication shouldn't be the sole treatment for ADD/ADHD. Medication lays the foundation for change but does not, by itself, eradicate the symptoms of the disorder. If positive change is to occur, the medication must be accompanied by exercises that improve self-esteem and reinforce good behavior. As the Ritalin issue moves to the forefront of the public consciousness, the conflict between the drug's critics and its advocates only seems to be growing louder. Those who discredit the drug highlight its potentially dangerous side effects but sometimes ignore the fact that it does have potential. Meanwhile, professionals in the medical field also say that use of the drug alone won't cure ADD/ADHD, and that it needs to be used in conjunction with other therapies. The Regional Intervention Program (RIP) provides training and support for parents who want to learn positive behavioral management skills. Danny Wheeler, RIP's national coordinator, runs his program out of an office on Belmont Boulevard. Families are referred to the center by pediatricians, day-care providers, and preschool teachers, among others. "It's really a situation where the parents are needing some training and support in interacting with their child's behaviors," Wheeler says. RIP began in 1969 as a model and demonstration project at the John F. Kennedy Center at George Peabody College for Teachers. Eleven RIP programs now exist in Tennessee, and it has expanded to Ohio, Connecticut, Washington, and Brazil. Wheeler's program has observed a number of children who have been diagnosed with ADD, and he is concerned that he is seeing more. "It's kind of scary, to me, for the diagnosing of children to be going lower and lower, as far as age is concerned, and it's kind of difficult to understand. This is a difficult diagnosis to make; it's pretty wide open."Wheeler believes that many parents are inclined to go for the quick fix, whether it is "Ritalin, or any other kind of medication." But he adds that Ritalin alone "is not going to do what needs to be done. The parent, the teacher, the providers, anyone who is in daily contact with the child needs to become more consistent in knowing and understanding what needs to be done and doing those things so that the child can succeed." Bruce Dobie contributed to this article.