The Religion of Ritalin
In the Lake Washington High School cafeteria there are about 100 adults, and three kids, including the one in the Green Day T-shirt who's helping his mother sell books. Their books all pertain to one topic: Attention Deficit Disorder (ADD)."Everyone's white," says Tiffany, the friend I've brought along. She's right. They're all white, except Tiffany. We're in Kirkland, at a meeting of Children and Adults with Attention Defcit Disorder, better known as CH.A.D.D. There are at least three CH.A.D.D. chapters in the Seattle area: one on the Eastside and two in South King County. There are over 650 chapters, with more than 35,000 members, nationwide.As soon as we sit down, Tiffany pulls an ATM receipt out of her wallet and writes me a note: Is ADD real? Or is this the hot new disorder of the '90s?I whisper, "Doctors call it a chemical imbalance of the brain. It's genetic. Ritalin supposedly fixes it." Tiffany shakes her head in confusion.I make her a short list of statistics: According to CH.A.D.D., ADD affects five percent of all kids under 18 in the U.S. Ninety percent of them are white boys. The next big market will be girls and adults. There are other stats, too, but the piece of paper isn't big enough to list them: At least 1.3 million kids in the U.S. are currently on Ritalin. The number of Ritalin prescriptions has increased 390 percent in the last four years. Ritalin use is five times higher in the U.S. than in the rest of the world, and out of the 10 tons of Ritalin produced each year, 90 percent is consumed in the U.S. Even the DEA thinks Ritalin is overprescribed.The evening speaker has arrived. He's a psychiatrist from Virginia Mason Medical Center who specializes in adolescents. He starts by trashing alternative methods of treating ADD, specifically homeopathic and herbal remedies. He encourages parents to be "advocates" for their teenagers. He wants them to help their kids "regulate car safety and date safety, given their disability."During the question-and-answer period, one woman claims that her 200-pound, six-foot-tall son has decided to go off Ritalin, and she's not going to argue with him. Since he's gone off the drug his grade point average has dropped from 3.8 to 2.4."If he's still symptomatic and he has ADD, then he needs to be on medication," the doctor advises. He suggests that the mother let the son keep and analyze his own data. "I can't tell you how many ADD adults return to my office and want to go on medication again," he says.Another woman in the front row explains that her ADD son said he could regulate himself just fine on marijuana, and hinted that she too could benefit from smoking weed. The doctor postulates that ADD kids who grow up untreated will probably turn into substance-abusing adults.Liz Brown, NonbelieverIf most of the people at the CH.A.D.D. meeting in Kirkland are Ritalin believers, Liz Brown has lost the faith. A few years ago, when Brown's son Dylan was in the third grade, he was diagnosed with ADHD (the H stands for Hyperactivity). Liz described her son as being "very sensitive, creative, and visual."We're talking in a coffee shop at the Pike Place Market; I've asked her to tell me about her experience with this prevalent but elusive brain dysfunction. "Dylan's no monster, or even excessively active," Liz confided, "he's just distractible. I've accepted it about his personality." She cups her hands around her mug, leans forward, and adds, "You know, there's no such thing as a bad kid."When Liz first learned about Dylan's "condition," she was concerned, cautious. "Everyone was already looking at the child like something was wrong," she remembers.At the urging of Dylan's teacher, she took Dylan into his doctor, who diagnosed him with ADHD and prescribed five milligrams of Ritalin daily. Dylan took Ritalin in the morning at school. On weekends he had drug holidays. Weekends free from Ritalin, according to Brown, are typical for most kids, in order to offset some of the side-effects. Ritalin can stunt growth and cause loss of appetite. Other reactions include nervousness, insomnia, hypersensitivity, anorexia, blood pressure, pulse changes, and headaches. Some of the rarer side-effects are Tourette's Syndrome, toxic psychosis, and possibly hair loss."I thought Ritalin was something Dylan needed." Brown scrapes invisible crumbs from the table. She remembers driving all the way to her son's school to call him out of class when he forgot to take his pill one morning.Brown's pill-pushing days were short-lived. She had a change of heart when she read a Seattle P-I article by Dr. Keith Hoeller that criticized Ritalin culture. That was the beginning of an exhaustive search for reading material, ending with the book Toxic Psychiatry by Dr. Peter Breggin. After educating herself about the drug, Brown immediately took Dylan off Ritalin."Don't get me wrong," Brown says, "I think some people have ADD and ADHD, but not to the extent that it's being diagnosed now." She estimates that there are 800 doctors in one white-dominated Eastside area she asks me not to name. "Professionals are making a living off of ADD. They write books, write prescriptions, teach seminars."Sweet Chunks of LogicAnother source that influenced Brown was a television show she watched: a 1995 Merrow Report about Ritalin and ADD. The Merrow Report is a quarterly PBS documentary series about children and education."This is a copy of The Merrow Report," Liz says, indicating the video tape on the table. "CH.A.D.D. doesn't like this tape one bit."It's easy to understand why. The Merrow Report reveals for the first time that Ciba-Geigy, the main manufacturer of Ritalin, sunk about $900,000 into CH.A.D.D. organizations over 10 years. That's just the beginning. The Merrow Report is packed with haunting facts and images. There's a shot of little boys queued up at lunchtime for their daily ritual of Ritalin. Pills are handed out communion-style by the school nurse.In another segment, a doctor from CH.A.D.D.'s board gives a heartfelt pitch for the miracle of Ritalin. "Kids who can't finish work finish work," he says in sweet chunks of logic. "Kids who forget homework bring it back. Kids who leave their desk a mess are better organized."The Merrow Report features interviews with well-meaning parents, all of whom wish for their children to be "normal and successful." In the opposite corner are interviews with adults who felt coerced into putting their children on Ritalin. One mother reported that 80 percent of her friends had a teacher ask them to consider Ritalin. She thought it was because the schools were trying to cut budgets and fit more kids in classes."If you don't conform to the system, you'll be out of sync," said one disillusioned mother.There are also interviews with ADD kids who hate taking Ritalin. "When I'm not on Ritalin I take in more information," one high school skater admits, "and then life is so much greater and more interesting. Ritalin focuses everything down to fine-point. You're not the same person you were."Dr. Peter Breggin, the physician, author, and psychiatric-abuse watchdog from Bethesda, Maryland, talks in The Merrow Report about attention-deficit hysteria. He says, "CH.A.D.D. likes to claim that kids are stigmatized in school-but I'd much rather do bad in school. There's nothing worse that you can do to an human being in America today than give kids a 'mental illness' label and tell them they need drugs."Breggin reads aloud from the Diagnostic and Statistical Manual of Mental Disorders. He cites examples of criteria for diagnosing children as suffering from ADD or ADHD: "The broad criteria are: Inattention: for example, often fails to give close attention to details or makes careless mistakes in schoolwork. Hyperactivity: for example, often fidgets with hands or feet or squirms in seat. Impulsivity: for example, often blurts out answers before questions have been completed."Breggin believes these categories more accurately represent "kids who would rather be doing something else. The kids are bored and frustrated," Breggin says. "There's no evidence that it's a disease or medical conflict. It's a childhood conflict."Street RitalinRitalin, or methylphenidate, is essentially identical to amphetamines. This accounts for its status as a Schedule II regulated substance. Only doctors can dispense it, because there's a high potential for abuse. Last year, the Ritalin brand of methylphenidate allegedly earned manufacturer Ciba-Geigy $373 million in sales-a number Novartis' public relations department refused to confirm (in December 1996 Ciba-Geigy merged with Sandoz Pharmaceuticals to become Novartis). Though Ritalin and generic methylphenidate account for 70 percent of all ADD prescriptions, Dexedrine, Cylert, and anti-depressants are also prescribed for ADD.There has been a significant rise in the illegal trafficking of Ritalin in the past several years, both in the schoolyard and on the street. Most street Ritalin comes from Mexico; schoolyard Ritalin comes from enterprising kids. One kid claimed he could get about $10 per pill at his school; a bottle of 100 pills costs around $45.00 generic, $65.00 for the Ritalin brand.Dr. Matthew Speltz of Seattle Children's Hospital says of Ritalin's popularity, "I would like to try to debunk the myth that stimulants just work on kids who have problems." Speltz says Ritalin has the capability of improving the concentration of 60 to 70 percent of the population."I Do Malicious Mischief"Joseph believes Ritalin is helping him, and that he hasn't lost any control over his life: "I could stop taking Ritalin whenever I want to," he says.A few months ago, Joseph, a sophomore, was suspended from Roosevelt High School for writing on a telephone pole with chalk. He was also recently diagnosed with ADHD. The school sent a classroom observer in to evaluate another kid's behavior. "They watched me instead," Joseph says, swiveling around in his chair while he talks."I have ADHD on top of ADD. It makes a lot of sense," he says. "It would take me two hours to write half a page on the computer. I was always stopping. All I could see were the obstacles in front of me." Like if I was typing, I'd start noticing how the sunlight was falling on the computer. Now I can type a whole page no problem"On the other hand, Joseph has never had a problem focusing on artwork or television. He can spend hours doing hands-on projects or drawing cartoons. Joseph takes drug holidays on weekends because he wants to be more alert when he's skating But he notices a need to sleep more, when he adjusts to going off the medication on weekends.The term "hyperactivity" makes sense to him: he seems to be trying on language as he talks. He's hopeful. "I'm a troublemaker," he says at the end of the interview. "I do malicious mischief."Learning Disabled?If a student is diagnosed with ADD, they can take standard entrance exam tests untimed; that would include GEDs, SATs, LSATs, MCATsÉ you name it. Some claim that wealthy white parents are trying to buy their kids a better chance for the college of their choice. Schools also benefit from kids being diagnosed with ADD as a learning disability. The federal government gives schools approximately $420 per ADD kid; state funds are also available for learning-disabled students. At a time when school budgets are being slashed to the bone, disabilities are valuable for school funding.There is one truth you can't avoid when you start looking into Ritalin, ADD, and ADHD: Their histories are intimately linked to the modern history of education.Dr. Keith Hoeller, a professor of psychology at several area community colleges and editor of The Review of Existential Psychology and Psychiatry, draws a convincing parallel between the end of corporal punishment in the schools in 1965 and the advent of Ritalin. The U.S. Food and Drug Administration (FDA) approved Ritalin in 1961, for kids with neurological problems."In experiments that were done prior to FDA approval, half the kids showed improvement on the psycho-stimulant," said Hoeller. "Long-term testing of the drug was not done then, nor has it been done since then. Go pick up an insert for Ritalin at any pharmacy and see for yourself."After Ritalin received its patent and an FDA blessing, Ciba-Geigy started advertising in the schools. "You'll note that this is also around the time that school psychologists came on staff in the schools," Hoeller says.Hoeller also points to certain cultural shifts since the '60s as a reason for Ritalin's rise: "Teachers and parents have been given tools for social control. They have set up a system whereby, when teachers have problems with kids, kids have a learning disability. The teachers send kids to counselors and then psychologists."A disturbing footnote to Hoeller's history of diminishing tolerance for differences in schools is a 1971 quote from William M. Cruikshank, a special education expert from the University of Michigan. Twenty years ago he complained that the "learning disabled" label was being applied to "children, who stuttered, teased the family cat, had night terrors, couldn't swim, masturbated, didn't like to go with girls, bit their nails, had poor eating habits, didn't keep their rooms neat, wouldn't take baths, or didn't brush their teeth."One Referral a WeekSchool psychologists and some medical specialists-tell a different story. Sharon Costello, a psychologist for the Seattle School District, explains that children are carefully scrutinized for an ADHD by a special team. "The team consists of psychologists, teachers, and hopefully parents, who review the child's case and write up an intervention plan," Costello says. "We do about one referral a week."The team can suggest ways to monitor the child in the classroom, or they can send the child on for further medical evaluation. They try to get a broad overview of the child's behavior in several settings.If the child turns out to have ADHD, and is qualified, he will be tagged "learning disabled," which entitles him to special classes and "learning accommodations" (including extra federal and state funds). If the ADHD child can't be placed in the special education program, they are still entitled to learning accommodations under Section 504 of the 1973 Rehabilitation Act.I ask Costello how the team determines whether a child's behaviors have to do with brain dysfunction, or whether they're the result of physical or sexual abuse in the home. She draws a blank. She says, with a naivet that borders on absurdity, "If parents are supported by the schools, we feel like they will disclose more about what's going on in the home."Costello is reluctant to let me look at the tests used for evaluating children's behavior. The documents are official school property. But another frontline operator, Patti Varley, a Psychiatric Clinical Nurse Specialist from Children's Hospital, offers me copies of her evaluation tests, and talks openly and persuasively about her work. "In the last month I've interviewed 12 kids to see whether they have ADD or not," says Varley. "Only two have the disorder. But it's a real diagnosis." Varley wants to make sure it's clear that a sufficient number of a child's behaviors must be inappropriate in two settings, like home and school.Varley looks like a sophisticated Ricki Lake. "People want answers the first few minutes they meet me," Varley says, but she takes her time making a diagnosis.Varley's frustrated with professionals who look at a kid for only about 15 minutes before evaluating them. "It's much more complex than that," she says. "There are a lot of other childhood things. Anxiety looks like ADHD-so does post-traumatic stress."Varley's also frustrated with over-the-counter naturopathic medicines. She points east out her office window, in the direction of the freeway, where there are fields of foxglove growing. "Foxglove can damage your heart," Varley says. Varley believes it's unconscionable for naturopathic drug companies to offer a cure without advertising side-effects.I sit in the parking lot of Varley's Lake City office, reading through the 113 questions on the Achenbach Child Behavior Checklist, a behavior disorder evaluation tool for children aged four through 18. A few things that parents are asked to rate, in terms of frequency and severity, are whether the child bites their fingernails, is secretive, sleeps less than most kids, sleeps more than most kids, threatens people, sucks his or her thumb, wishes to be of the opposite sex, or worries.It's hard not to read checklists like the Achenbach and wonder where you fit in the behavior disorder continuum. I might have made a good ADD case study, but I'm glad I wasn't.I was taught by nuns who stubbornly continued to practice corporal punishment, despite inconvenient secular laws. I was ruler-slapped, and had my mouth taped shut. I liked to chew the metal ends off pencils. If my parents had a handy label for my excessive activity, and access to a popular pill like Ritalin, my teachers might have saved on their Valium prescriptions.But a pill or a label, then or now, wouldn't erase the twisted history of my family's drunks and perverts, or the underlying fact that I was exceedingly bored with sitting for hours.Adults and ADDThe next wave of ADD and ADHD patients won't be coming from the schools. More and more adults take comfort in believing all their problems can be traced back to these disorders, and with the help of doctors like Dr. Wren Hudgins, they're seeking out the Ritalin "cure."Hudgins started focusing on ADD in adults when he noticed that parents of ADD kids couldn't focus, and were jumping up during interviews. Hudgins says it's more difficult to diagnose adults. He needs to know how the adult functioned as a child-from school records, family interviews. For an adult to be properly diagnosed, the onset of ADD must have occurred before age seven. Would-be patients must also show that their adult lives have been adversely affected by the disability."It is a disability," Hudgins emphasizes. He's hopeful that in the next few years doctors will be able to uncover the chemistry of ADD. He thinks it will have something to do with dopamine and neurotransmitters. Hudgins cites statistics indicating that ADD is genetic, and is passed on from male parent to male child, three times more often than to female children.Overdiagnosis of ADD isn't a problem that concerns Hudgins. He draws an analogy between diagnosing for ADD and throwing out a net for crab. "You're likely to get other fish in the net too," he says sincerely.When I ask to be referred to an adult ADD patient, Hudgins sends me to Phyllis, a woman who talks five times faster than I can write. She skips associatively from one subject to the next. She's excited. She backtracks through the years, explaining all the curves her life took before she hit 39 and was diagnosed with ADD.She and her husband Larry were watching a TV show about adults with ADD, and he said, "Hey that's you." The unfinished projects. The forgetfulness. The flight of ideas. It took Phyllis 12 years of scattered major-changing to get through college.Phyllis remembers being overexuberant as a child, fidgety. During a high school British literature class, the teacher made Phyllis so angry she just got up and walked outÉ the window."I knew my way around the roof," Phyllis says. "I used to climb up the drainpipes all the time." She dropped out of school soon after that, got married and divorced, had a series of careers.She said she'd tried Ritalin but it made her angry at the far edge, when it wore off. Now she's on Dexedrine, which gets her through paperwork and meetings. On weekends she doesn't take the pills, because she doesn't need to focus as intensely.Phyllis claims she has external ADD. Her husband Larry has internal ADD. Internal ADD is about focusing so intensely that he can completely ignore considerations of time and space for hours. During our interview, Larry gets on the other phone line, and the conversation follows Larry's work history from the middle of the ocean (as a merchant marine) to the middle of a computer circuit board, then back out to sea again."I'd say a majority of people in the merchant marines are ADD," Larry says. He also believes that his new career in computers attracts ADD people. As we talk I realize I've been making huge associative leaps, interrupting, feeling small surges of anxiety. Larry and Phyllis claim that they have developed special antennae to detect people who have ADD; they talk about the ability like it's a gift. I wrap up the conversation and hang up the phone before their hyperactive antennae tune into me.