Children, ADHD and Ritalin

This evening the BBC1 Panorama programme is showing a documentary on the prescription of Ritalin to children diagnosed with Attention Deficit Hyperactivity Disorder.

This seems an appropriate time to reproduce an article of mine that was published in Open Mind magazine (issue 123, October/September 2003) four years ago.

Always on the Go

A psychologist I know gives her last lecture of each year on a paper entitled ‘The aetiology and treatment of childhood’. It describes a worrying condition, with symptoms like short stature, emotional immaturity and a reluctance to eat vegetables – or ‘legume anorexia’. The good news is that when sufferers are investigated 10 years later they have almost all got better.

Yes, it’s a joke – a clever American satire on the way professionals turn normal human behaviour into a medical problem. But a lot of notes get taken before her students realise this.

Inspired by my friend, we could invent another spoof diagnosis. Let’s imagine a condition which largely affects boys between the ages of 6 and 12, and manifests itself in symptoms like not doing homework, fidgeting and being ‘always on the go’.

Unfortunately, this one is not a joke. It is a shorthand description of Attention Deficit Hyperactivity Disorder (ADHD), the most commonly diagnosed psychiatric condition in American children today. There is more to diagnosing it, but not a great deal. Children must display these behaviours in more than one setting (say, at home and at school) and they must be evident before the child is seven. It is often diagnosed by teachers or school counsellors with no medical training.

In the USA, at least 10 per cent of children – 5 or 6 million out of 50 million – are taking medication to treat ADHD; 90 per cent of them boys. In some classroom in prosperous New England states, as many as one boy in three can be on drugs.

Not only are the numbers diagnosed enormous, they are rising rapidly. The most commonly prescribed treatment for ADHD is methylphenidate, better known under its brand name Ritalin. Back in 1988, one million American children were taking it: in 1975 the figure was 150,000.

The same trend can be seen this side of the Atlantic. Department of Health figures show that National Health Service prescriptions of Ritalin in England rose from 2,600 in 1992 to 186,000 in 2000.

ADHD is no joke at all when you know more about the medication used to treat it. Besides Ritalin, children can be prescribed dextroamphetamine (Adderall or Dexedrine) or methamphetamine (Desoxyn or Gradumet). These drugs share an ability to calm children down and make them more manageable in classroom settings.

To some, it is paradoxical that drugs known as stimulants make ADHD children calmer. They see it as proof there is something different about their brains. But the American psychiatrist Peter Breggin says this effects has long been known. He describes what happens when ADHD medication is given to laboratory animals:

instead of struggling to escape a cage, the animal will sit relatively still, carrying on rote, useless behaviours, such as grooming, chewing on its paws, or staring into the corner. If the drugged animal does move about, it will pace a restricted area in a purposeless manner.[1]

To Breggin, the therapeutic effect of Ritalin and its rivals is better seen as an adverse reaction. He quotes a study where more than half the children treated displayed obsessive-compulsive behaviour. They played the same game over and over again, or exhausted themselves raking up leaves. It is nice when children want to help in the garden, but when, as in a case I have heard Breggin describe, a boy waits under the tree for a leaf to fall, something is very wrong.

Sometimes the side-effects are more serious: children become ‘zombie-like’ or suffer from hallucinations. Often they will end up taking cocktails of drugs to treat these reactions. And there can also be serious effects on physical health: high blood pressure, palpitations, stomach cramps, blurred vision and much else.

Why are so many children being diagnosed with ADHD and put on drugs? Or, as the Washington writer Mary Eberstadt asks:

How has it come to pass that in fin-de-siècle America, where every child from preschool onward can recite the “anti-drug” catechism by heart, millions of middle- and upper-middle-class children are being legally drugged with a substance so similar to cocaine that, as one journalist accurately summarized the science, “it takes a chemist to tell the difference”?[2]

One explanation is that America has got it right. Perhaps millions of children across the world are suffering from ADHD but going untreated. But if this were the case, as Leonard Sax points out, you would expect American children to be racing ahead in their school work. As it is, ‘France, Germany, and Japan continue to maintain their traditional lead over the United States in tests of math and reading ability’.[3]

It is the same with juvenile crime. ADHD is diagnosed more often in Britain than the rest of Europe. But a recent survey found that ‘the United Kingdom arrests a higher proportion of young people than the average for the countries of the Council of Europe for all categories of crime except rape and murder’.[4]

If we set aside the idea that ADHD is a real condition, there are many other explanations for the rise of the diagnosis. Some say that children’s behaviour really is getting worse and emphasise the role of chemical additives in food. They claim great improvements from a change in diet.

Others point to drug companies’ financial support for groups of parents of ADHD children. These publicise the diagnosis and challenge the media when they question its validity. And it is a good investment: in 2001, American companies made $600 million in profits on ADHD drugs.

But marketing a product is not as easy as that. If it were, we would all be millionaires. So there must be something about modern American and British society that makes it so receptive to the idea of ADHD.

A clue to what it might be lies in the figure we gave earlier: 90 per cent of the children prescribed Ritlalin are boys. What has changed for boys in recent decades?

One development has been the rise of feminism. At one time boys were pretty much expected to fidget and lose things. If you said a boy was ‘always on the go’ in the 1950s, it was praise. The feminist demand was for girls to be treated with the same indulgence as their brothers. They should have the same freedom to play out, tear their clothes and get dirty.

Today, things are different. So entrenched is the belief there are no intrinsic differences between boys and girls that few professionals would dare say ‘boys will be boys’ when discussing a client. Yet the same people, as parents, will say to one another: ‘You know, boys are different.’

And if they are different, perhaps they should be treated differently. Penny Holland has just published a book suggesting that banning play with guns in schools and nurseries does more harm than good. She told the Guardian:

We noticed an impact on the half a dozen boys who were persistently interested in weapons and superhero play. We started to notice the effects of our constant negative attention. They became more withdrawn – and set on a behaviour train. They became dispirited.[5]

And playing in the street has been redefined as ‘anti-social behaviour, with all sorts of police and council powers developed to deal with it. Yet you do not have to be so old to remember your mother asking you as a child, ‘Why are you indoors on a nice day like this?’

If boys’ energy is finding fewer outlets at home, the position in school is worse. Although there is little research to back the idea, it is now agreed between all parties that education is the key to improving Britain’s economic performance. The result has been a grinding emphasis on basic skills and government targets.

Margaret Hodge, now Minister for Children, announced in 1999 that ‘the days of toddlers colouring, cutting and pasting are over’. Meanwhile, league tables of older children’s test results are printed in every newspaper, and GCSE and A-level results are treated as a barometer of the nation’s health.

When you add to this the fact that the government wants half of all children to go to university – and how few children from poor homes get there – it is clear that it is almost impossible for a middle-class child to step off this conveyor belt. A great number of children with no aptitude for it are forced to study until they are 21. No wonder they have behavioural problems.

Over the same period, schools have become less structured, with more onus put on individual pupils to organise themselves. Recent research from the Office for Standards in Education says this does not suit boys. They do better when teachers set clear limits and in schools with good discipline, close monitoring and a sense of community.[6]

Of course, some children’s behaviour is difficult and the parents do need help – although it would be a relief to see some alternative to the chemical cosh of Ritalin. But it is clear that the ADHD diagnosis is hoovering up all sorts of boisterous, bored and unhappy children. It is not their brains that are faulty, but the way we adults treat them.

References

1. P. Breggin (2001). What people need to know about the drug treatment of children. In C. Newnes, G. Holmes & C. Dunn (Eds.) This is madness too. Ross-on-Wye: PCCS Books.
2. M. Eberstadt (1999). Why Ritalin rules. Policy Review, 94, April–May, Washington DC: Heritage Foundation.
3. L. Sax (2000). Ritalin: Better living through chemistry? The World and I, November, pp. 287–299.
4. G. Buckland & A. Stevens (2001). Review of effective practice with young offenders in mainland Europe. Canterbury: European Institute of Social Sciences.
5. P. Curtis (2003). Why toy guns are back in the classroom. The Guardian, 12 July. (Penny Holland’s book, We don’t play with guns here, is published by Open University Press).
6. Office for Standards in Education (2003). Boys’ achievement in secondary schools. London: Ofsted.