Chapter Five

No Worse than Aspirin?

The generic name of the drug known as Ritalin is methylphenidate. Everybody knows it as Ritalin because the manufacturer CIBA (now Novartis in Canada) has almost got the market cornered. You can ask them if you like, but they won't release their sales figures. Still, they did have enough in their kitty to donate nearly a million dollars to CHADD.

(Who or what is this CHADD I keep referring to? As mentioned earlier, CHADD is the acronym for Children and Adults with Attention Deficit Disorder, the principal parent-support group for Attention-Deficit/Hyperactivity Disorder. CHADD has over 20,000 members and 600 branches in the United States. The organization is expanding rapidly into Canada where many child psychiatrists serve on their boards. CHADD recruits members and distributes literature about the “disease” ADHD. They assisted in a drug company effort to get the national quota on the manufacture of methylphenidate (over seven tonnes in 1994) increased. They were concerned that a shortage might develop and leave parents and children high and dry.)

I have chosen to deal with the subject of this chapter in two parts. First, let’s consider whether Ritalin actually works. Then, let’s see if it is really no worse than aspirin, as some doctors say.

Does Ritalin work?

As we shall see, the answer to this question depends on what you mean by “work.” If you mean does it quiet children down, the consensus is that it does. About 80 percent of children who receive the drug experience this effect.

This similar to saying aspirin helps headaches. It is important not to equate this settling down with a cure of the child’s behavior problem. Let me cite an interesting study which will put this difference into perspective.

Granger et al, from the Department of Psychology of the University of California at Los Angeles report a study in which they enlisted ninety-six undergraduate college students to view and make judgments about videotaped play sessions. These were videos of two different ADHD boys playing an interaction game with three normal peers. One of the target boys was on Ritalin and one wasn’t. (See Grander, DA, et al., Social Impressions of Methylphenidate Effects on Hyperactive Children’s Peer Interactions,” Journal of Abnormal Child Psychology 21: 67-81.)

The observations of these undergraduates were evaluated and more negative than positive behaviors were detected. The interesting thing is that the negative behaviors reported were strikingly different.

The negative ratings for the placebo child (the one not getting Ritalin) reported three behaviors:

• non-compliance
• aggression
• disruption.

The negative ratings for the Ritalin child also reported three behaviors:

• social inhibition
• passivity
• submissive behavior.

The question arises: When a child is reported to be better on Ritalin does “better” mean more compliant, less aggressive, and less disruptive?

I have no doubt that, for a teacher trying to run a classroom, these qualities equate with “better.” But are submissiveness, passivity, and social inhibition qualities we want to generate in children?

In another study, three covert antisocial behaviors were measured: stealing, destroying property, and cheating. Ritalin was found to reduce the incidence of the first two, but it increased the incidence of cheating. The authors speculate that this is because Ritalin enhances task involvement. (See Hinshaw, SP, Heller, T, and McHale, JP, “Covert Antisocial Behaviour in ADHD,” Journal of Consulting Clinical Psychology April 1992 (60/2): 274-81.)

What is the lesson for parents from these findings? When it is reported that a child is much improved on Ritalin, it is best to find out, if you can, exactly what the reporter means when he or she reports “improvement.” It may be simply calming. It may, however, involve changes you or I would not see as improvement.

Later, when I come to discussing my own retraining approach for children, you will see that Ritalin contributes little to promoting the adaptive growth of the child. The drug may calm the child, but it does not help change his or her behavior problems so that they eventually disappear in the way such behaviors normally do when children grow up.

Does Ritalin have Side Effects?

According to the head of psychiatry at the Vancouver Children's Hospital, Ritalin is not even as dangerous as aspirin. (See the report in the Vancouver/Lower Mainland area newspaper the Tri-City News, 26 August 1990.) Few advocates of the drug take so extreme a position as this. The fact is that Ritalin, like most drugs, has many known side effects. Some of them are rare; some of them are common; and some of them just are a nuisance. Some of them are serious, and there are some equally serious possibilities that are as yet unclear.

Here is a short table of side effects originally published under the auspices of the US Department of Justice, Drug Enforcement Administration (DEA). The title of the publication is Methylphenidate (A Background Paper) October 1995, and it is available through the DEA.

The five most regularly reported effects are: insomnia, decreased appetite, stomachache, headache, and dizziness. When decreased appetite leads to weight loss, discontinuing the drug may be necessary. If the child avoids taking the drug late in the day insomnia can be reduced, but using night time sedatives along with Ritalin is not a common nor a recommended practice.

Growth suppression has been reported in children receiving Ritalin a year or more, especially if the dose is high. Does growth bounce back when the drug is discontinued? Most findings indicate that it does, but some authors seem to be hedging a bit when they say not to give the drug during the child’s time of “normal growth spurt.” The fact is, these are the years when Ritalin is most often prescribed.

A less common but serious side effect has been identified by Lipkin, who reports that of 122 kids treated with Ritalin, nine percent developed tics, (repetitive contractions of functional muscle groups as in eye blinks, neck thrusts, or sniffs) and that these tics were “mostly transient.” What in this connection does he mean by “mostly”?

One child in his series developed Gilles de la Tourette’s syndrome, a chronic condition of multiple shifting body tics and occasional vocal symptoms which can become a very serious handicap, as any member of the National Gilles de la Tourette’s Association can confirm. (See Lipkin, PH, Goldstein IJ, Adesman AR, “Tics and Dyskinesias Associated with Stimulant Treatment in Attention-Deficit Hyperactivity Disorder,” Archives of Pediatric and Adolescent Medicine, 148:859-861, 1994.)

Reports of psychotic reactions are rare but have occurred. Leukopenia, caused by poisoning of the bone marrow, is equally rare. The only deaths from Ritalin that I have seen reported resulted when teen-agers crushed Ritalin pills and injected them intravenously. I have heard they some adolescents have now taken to snorting Ritalin. Who says it is not addictive?

Another issue medical papers rarely include in their discussion of the negative effects of Ritalin is the topic of how the children who take the drug feel about it. Though some doctors say that children don’t even notice they are taking the drug, such doctors cannot have interviewed the children.

Children don’t like taking Ritalin and they say so. Some hide their pills, other pouch them in their cheeks and spit them out later. School nurses have learned to stand over the children until they are sure the pill has been swallowed. Older children say things such as: “I hate taking Ritalin… When I take Ritalin nothing’s fun anymore… When [you’re] not on Ritalin you take in more… When not on it, life is greater… My dad [a doctor] says there are no side effects. It says there are, right here on the box… I don’t like myself on Ritalin… It’s totally not me. I become a false person.”

These interview quotes are from the video documentary, The Merrow Report ADD, which was produced by South Carolina ETV in Columbia South Carolina. View it if you want some firsthand data.

Is Ritalin Addictive?

Now we come to the unanswered question most everybody is worried about. Does Ritalin set the child up for later substance abuse? Almost all of the literature put out by the various ADHD support groups, and even some physicians who promote Ritalin, say there is no reason to be concerned about later drug abuse. Here is a quote from a letter which expresses one opinion on this subject. In response to a column I had written, Derrick H Smith, a CHADD consultant and child psychiatrist, writes:

“A number of well controlled studies have also shown, contrary to Millar’s opinion, that the use of methylphenidate [Ritalin] or other medication has not predisposed teen-agers to addiction and other drug problems.” (See “Letters,” Vancouver Province, 29 March 1996.)

I know of no such studies, and I have been keeping up with this literature. On the other side we have the following data: CIBA says that the long term effects of Ritalin are as yet unknown. The US Department of Justice, DEA Report of 1995, previously cited, has this to say on the subject:

“a number of recent studies, drug abuse cases, and trends among adolescents from various sources indicate that methylphenidate use may be a risk factor for drug abuse.”

In another part of this report the authors say, “children are abusing methylphenidate and abuse can lead to dependency and addiction.”

In his letter Smith goes on to recommend parents turn to CHADD for more accurate information than I provide about the subject. The DEA report has this to say about CHADD’s information for parents. “Of particular concern is that most of the ADHD literature prepared by CHADD and other groups and available to parents, does not address the abuse potential of methylphenidate.”

I am impressed that Ritalin has become a street drug, and it is often found to have been the entry drug to serious addictions such as to cocaine and heroin. I am of the opinion that giving kids Ritalin to improve their home and school behavior may help to make them more tractable, but at the same time it teaches them to look to drugs for the solution to life’s problems. Further, I believe Ritalin may habituate them and make them dependent.

The question that now arises is this. If ADHD is a nonsense diagnosis, as I say it is, what, then, is wrong with these children? If Ritalin is a “no no,” what is the right way to deal with the difficult behaviors these children exhibit? In the next chapter I shall outline my alternative to diagnosing them ADHD and treating them with stimulant drugs.

Since I have written two books for parents on the subject of child rearing, I will touch on this topic only lightly, and guide readers to these other books for more information. They are The Omnipotent Child and Rearing the Preschool Child, and information about both books can be found on the Palmer Press website at www.omnipotentchild.com.