Sunday, April 20, 1997
Ritalin
By Carol Robidoux
A stunning increase in the use of the mood-alterning drug in Bucks County classrooms is just a hint of the national controversy over the treatment of ADD.
Have you visited your child’s school lately? If you stop by around lunch time, you might be startled at what you see going on.
This year, an estimated 250,000 doses of Ritalin will be distributed by school nurses across Bucks County to kids with Attention Deficit Disorder and Attention Deficit Hyperactivity Disorder.
"People would be amazed to see the daily parade of students lining up to get their Ritalin." says Dr. Alan Sohn, psychologist for the Bucks County Intermediate Unit.
"I would not be surprised, no matter how high you told me the numbers were in the county," says Sohn, who oversees programs and objectives for all ADD/ADHD students in the county’s school districts.
Consider the following:
- At Neshaminy, 360 daily doses of the drug are administered, totaling 64,800 for the year, according to the district health services office.
- In the Centenniel district, annual daily doses of Ritalin have more than tripled since 1991, up from 10,000 to 36,000 last year, according to district health coordinator Betty Kautz.
- And while data on Ritalin in Bristol Township are not available or computerized, Ellen Gecker, who oversees health services for the district, says she wouldn’t be surprised if doses administered daily in Bristol Township fall in the same range as other districts.
Clearly there are a lot of students being treated for ADD and ADHD. But below the surface there is some confusion as to how students with these disorders should be identified, lending to what many experts believe is misdiagnosis and over-diagnosis of deficit disorders, asserts Sohn.
"The question as to whether it’s an educational or medical problem has never been answered. That’s why many parents are getting bounced around between the schools, their family doctors and the insurance industry. I think the answer needs to come down from the state and federal levels."
What’s happening locally is just one chapter in the national story that’s unfolding in ADD and Ritalin.
Consumption of the drug in the United States has quadrupled in the last five years, from 100 million daily doses in 1991 to more than 350 million doses last year.
It is no wonder that Ritalin has become a cause for concern. Experts disagree over its usefulness. Parents struggle to untangle the mixed message being sent to their kids in their safe, "drug-free" school zones: Just say no to drugs. And by the way—don’t forget to take your Ritalin.
Ritalin, generically known as methlyphenadate, is an amphetamine in the same class as cocaine and speed. Some of its known side effects are muscle tics, Tourette’s syndrome, stunted growth, sleeplessness, loss
of appetite and long-term dependence.
Even those experts who endorse the use of Ritalin as a last resort are well aware of the implications of what may appear to be a society exerting drug-induced control over its children.
"Appropriate diagnosis is crucial. People are saying ADD is the hot diagnosis of the '90s. I disagree," says psychologist Scott Alfgren, one of many local medical professionals fielding the barrage of inquiries into ADD, and offering referrals for screening and counseling.
There are many children struggling in school, observes Alfgren, and all too often they’re labeled BAD—for bad—by teachers.
"They are inattentive, distractible and impulsive. The difference is, when teachers understand what ADD is really all about, it puts a whole new light on a particular student." Alfgren, of the Family Guidance Association in Yardley, works with schools helping educate teachers, administrators, guidance counselors, coaches—anyone who has contact with kids—in understanding what ADD is really about.
"That’s why I go to schools. There’s not enough information circulating about what the needs of ADD kids are, beyond giving them a daily dose of Ritalin. They need certain classroom accommodations—more time for tests, more one-on-one instruction," says Alfgren.
"Ritalin is no silver bullet."
Others in the know tend to agree with that assessment of Ritalin.
So much so that they will go so far as to discredit Ritalin as the panacea many within the medical community have made it out to be.
Pat Dunn of Lower Makefield, the parent of a 13-year-old ADHD child, says the approach doctors take is all wrong.
"First, do no harm. That’s what I say. Medical doctors have been educated to use pharmaceuticals. Western medicine doesn’t associate what we eat with our health," says Dunn, an advocate for the Feingold Diet, devised by the late Dr. Benjamin Feingold.
Her son was diagnosed with ADHD at age 5 and was put on Ritalin. But Dunn didn’t feel right about giving him such a potent drug.
She groped for answers until she stumbled upon the Feingold Diet. Focusing on diet, not drugs, turned her son’s life around.
"I was insisting he eat a healthy breakfast before school everyday, cereal, milk, orange juice. What I found out was that my son was allergic to all three components of that diet—corn, dairy products and oranges. I was feeding him three major no-nos right off the bat. On an empty stomach, he was in full reaction by the time he got to school," says Dunn.
"I was setting him up for disaster."
Feingold’s philosophy is described as a time-honored food elimination diet, hinging on the idea that kids today are fed phony food with little nutritional value.
"The incidence of food additives has paralleled the rise in ADD since World War II," says Feingold spokesperson Patricia Palmer.
She cites three major food additives, BHT, BHA and TBHQ, as found in certain foods, including breakfast cereals, potato chips and other processed items. These additives put the body’s natural functions in a
precarious situation, contends Dunn.
"Diet is the least expensive, least invasive, least risk factor. To say there’s not validity to nutritional research is a falsehood," adds Palmer.
"We use a dietary program, but we are not anti-drug. Certainly there are those for whom drugs are necessary," says Palmer, "but parents and physicians should know their options."
While other controversial approaches to controlling ADD, such as brainwave biofeedback (see story below [sic]), blue/green algae supplements and dietary regimens, have been dismissed by leading attention deficit disorder support groups like Ch.A.D.D. (Children & Adults with Attention Deficit Disorders) and N.A.D.D.A. (National Attention Deficit Disorder Association), there is a growing momentum among parents to seek alternatives to drug therapy, says nutrition expert Patricia Grace Smith of Advanced Nutrition Services, Newtown.
"I work with children with ADD and most of them will respond to the addition of essential fatty acids to their diets," explains Smith.
"The hydrogenated foods we’re eating prevent the body from absorbing the essential fatty acids necessary for the brain, the immune system, the skin."
Hydrogenated foods are those that are over-cooked, fried and heavily processed. Hydrogenated food forms a bond that doesn’t allow the essential fatty acids that fire the brain to penetrate, says Smith.
And that would explain, at least to some degree, why a whole generation of children raised on fast food fare and highly-processed foods is suddenly exploding at the seams with disorders that affect one’s ability to think and focus, Smith believes.
But many parents are too eager to accept Ritalin as a cure, adds Smith. "It’s easier to give a pill than to feed kids right. It has a lot to do with fast food and fast lifestyle. The most powerful drug we have is our food, if we’d just use it right."
One Alternative
A Langhorne parent finds an answer through biofeedback
By Carol Robidoux
Jacob was a typical boy as far back as his mother, Connie, can remember.
"He was bubbly and enthusiastic. He was always an A/B student in Catholic grade school," recalls Connie Day of Langhorne.
Looking back now, Connie also sees that her happy-go-lucky, active son had a hard time paying attention in school.
"But because he was always with one teacher all the time, and because I spent a lot of time doing homework with him, we managed to get him through."
Something happened to Jacob during junior high school: His grades dropped, along with his self-esteem.
Despite her best efforts to rescue him, says Connie, Jacob was virtually drowning in the system.
"We tried everything we possibly could. No television on school days, my husband refused to take him hunting, something Jacob loves to do. Nothing worked."
Finally, a teacher at Neshaminy High School suggested Connie have Jacob tested for ADHD simply because she sensed Connie’s frustration, and because Jacob’s problems reminded her of another student who’d already been diagnosed with the disorder.
So the Days opted for screening outside the school system, to save Jacob the embarrassment of making appointments during the day with the school psychologist," says Connie.
Sure enough, her son had ADHD, according to an evaluation made at Southampton Psychiatric Associates.
"At first I was so grateful that a pill would solve the problem. Prior to that, I felt like a complete loser as a parent. No matter what I tried, nothing worked for him."
But after half a school year on Ritalin, little had changed.
In fact, by the end of the second marking period, Jacob’s grades had dropped.
"I was puzzled by the fact that everyone knew he had ADHD and was taking Ritalin. Yet no allowances were being made for Jacob. The teachers seemed clueless about what he needed," says Connie. Allowances such as extensions on project deadlines and more time for test-taking would have helped her son.
That’s when Connie started searching for information on alternative treatments. She found something interesting on brainwave biofeedback.
For years, biofeedback has been used to treat problems ranging from depression to chronic pain. Connie read about new studies supporting biofeedback as a drug-free way of countering symptoms, at a time when ADD experts were debunking it as of questionable worth.
She felt she had nothing to lose by trying—particularly since the Ritalin Jacob had been taking twice each day to keep him focused seemed to be losing its effectiveness.
Connie took her son off the drug completely and started him on biofeedback training the week he entered 11th grade at Neshaminy.
Jacob underwent therapy twice weekly for a total of about 30 sessions. Connie says her son’s performance in school has dramatically changed. Last year he was floundering in lowest-level courses. Today, at 16, he’s a B/C student in college-prep classes.
"I don’t give all the credit to biofeedback. He’s also got a tutor and he’s matured over the summer. Plus this year he has a wonderful group of teachers who recognize the (ADHD) and contact me at the first signs of a problem, " says Connie.
But she also believes Ritalin did little more than control her son’s behavior enough to keep him out of the disciplinarian’s office. It didn’t help him achieve better grades or feel better about himself."
"He’s calmer, less impulsive, more organized. He still has his moments, when he loses focus and concentration. But he quickly gets it back. He can recognize his behavior. I didn’t recognize how abnormal his behavior was until he’d calmed down," says Connie.
So why isn’t’ everyone riding the biofeedback bandwagon?
Children & Adult with Attention Deficit Disorder (Ch.A.D.D.), a national parent support network of more than 650 chapters, questions most alternative treatments—most fervently, biofeedback.
"Parents should be wary of investing time, money and their child’s interests in unproven, questionable treatments, such as EEG Biofeedback," according to a statement published by Ch.A.D.D.
Other alternative treatments discredited by Ch.A.D.D. as "seriously flawed" include diet and nutritional programs, removal of refined sugar from the diet and inner-ear disturbances.
Barry Belt, director of CEPD Services Inc. and one of the area’s only practitioners using brainwave biofeedback for ADD/ADHD, says getting the brain to regulate itself is a far more desirable goal than using drug therapy.
"Ritalin is taking the place of patience in schools," asserts Belt.
"Our brains are not equipped to do what we do in our society, working a 40-hour work week, handling the stresses that bombard us daily. In my opinion, Ritalin should be the last resort, only after other approaches have been tried. Medication ADD/ADHD only masks the problems that exist. We are, in essence, training a child to be a drug addict," says Belt.
Training one’s attention is the only way we have of manipulating our environment, says Belt.
"No one ever teaches you how to pay attention. Biofeedback does essentially what Ritalin does for the brain, it raises your arousal level. But with a difference."
That differences, says Belt, is the cumulative effect of biofeedback, administered in treatments of 30-60 sessions.
"Ritalin works for as long as it’s in the system. As soon as it wears off, the person with ADHD is back to where he started," explains Belt.
"The 'real world' requires black-and-white answers for something tat is actually many shades of gray. The pediatrician has to decide whether to medicate. The insurance company has to have a diagnosis before covering for expenses of treatment. The school district has to decide on special services for the child. Everyone involved has to act as if matters were black and white," says Belt.
What’s know is that in persons with ADD/ADHD, the brain is unable to focus, and there is a low threshold for distractibility.
Rob Kall, local counselor and co-editor of a book, "Biofeedback Theory and Practice," endorses the work Belt is doing with biofeedback for ADD/ADHD.
"There’s a model of ADD out there I really like by Tom Hartman, founder of an ADD forum on Compuserve. What he says is that ADD people function like hunters—ready for quick change. Others function like farmers: You plan ahead, plant seed, have a routine of behavior in which you best perform," explains Kall.
"If you look at it from a school’s perspective, you want everyone to behave. But kids are creative, distractible, full of theta brain waves, the lower frequency that correlate with dream state and
fantasizing," says Kall.
"Biofeedback helps you get better control of how you use your mind. It helps you learn how to produce brainwaves that are produced when you concentrate."
While the medical community regards attention deficit disorders as physiological and behavioral, Belt sees them as developmental and societal.
"If we want to begin to understand why it seems a whole generation of children are suddenly having this problem, consider the action-oriented existence in which they live," contends Belt. "We are mentoring hyperactivity in our kids."
Belt says there is a rash of misdiagnosis for ADD/ADHD out there. Proper diagnosis is the place to begin. "I start by finding out what’s going on at home, at school I check into the developmental and medical history of a child, their eating habits and discipline," says Belt.
A child’s maturity level is also a factor—will he or she grow into his or her behavior?—particularly those who are targeted in kindergarten or early elementary school for behavioral problems.
Belt consider himself a pioneer in what he describes as a growing treatment approach. While there are currently fewer than 1,000 practitioners across the country using brainwave biofeedback for ADD, there are thousands doing so in peripheral ways.
It’s a solution that goes much deeper than the potency of a four-hour pill. "There is something and relentless and immutable about a diagnosis of ADD/ADHD to a child. It says, 'This is who you are.' Our success with biofeedback demonstrates that children need not be the perpetual victims of their diagnoses."
What the Feds are saying about Ritalin:
Here's what the National Institute of Mental Health and the federal Drug Enforcement Administration have to say about Ritalin and its generic form, methlyphenadate:
For many children and adults with attention deficit disorders, these medicines dramatically reduce hyperactivity and improve ability to focus, work, and learn. The medicines may also improve physical coordination, such as handwriting and ability in sports.
Unfortunately, when people see such immediate improvement, they think medication is all that's needed. But the drugs don't cure the disorder; they only temporarily control the symptoms. After about four hours, they lose their effectiveness.
Although the drug helps people pay attention and complete their work, it can’t increase knowledge or improve academic skills.
The drug alone can't help people feel better about themselves or cope with problems.
There is not evidence of continuing relief of symptoms once the drug is discontinued.
The safety and effectiveness of long-term Ritalin and methlyphenadate treatment in children of all ages has not been determined in clinical studies.
Ritalin and methlyphenadate should not be used in children under six years of age.
Contrary to popular belief, stimulants like methlyphenadate will affect normal children and adults in the same manner they affect ADHD children. Behavioral or attentional improvements with methlyphenadate treatment therefore is not diagnostic of ADHD.
Weight loss and growth retardation are common side effects of chronic methlyphenadate therapy in youngsters, although drug "holidays" on weekends and summers can usually avoid these problems.
Serious side effects include facial ticks [sic] and muscle twitching. Other adverse effects, particularly at higher than therapeutic doses, include excessive central nervous system stimulation, euphoria, nervousness, irritability and agitation.
Although the drug is routinely portrayed as a safe and mild stimulant, a DEA study indicates addiction produced by methlyphenadate abuse is neither benign nor rare in occurrence, and methlyphenadate is more accurately described as producing severe dependence.
Methlyphenadate is a stimulant like amphetamine and methamphetamine (known on the street as "speed") and produces a number of effects, including dose-related increases in blood pressure, heart rate, respiration and body temperature, appetite suppression and increased alertness.
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