Reprinted from April & May 1999 Heritage Foundation Article
Why Ritalin Rules
By MARY EBERSTADT
here are stories that are mere signs of the times, and then there are stories so emblematic of a particular time and place that they demand to be designated cultural landmarks. Such a story was the New York Times’ front-page report on January 18 appearing under the tame, even soporific headline, "For School Nurses, More Than Tending the Sick."
"Ritalin, Ritalin, seizure drugs, Ritalin," in the words of its sing-song opening. "So goes the rhythm of noontime" for a typical school nurse in East Boston "as she trots her tray of brown plastic vials and paper water cups from class to class, dispensing pills into outstretched young palms." For this nurse, as for her counterparts in middle- and upper-middle class schools across the country, the day’s routine is now driven by what the Times dubs "a ticklish question," to wit: "With the number of children across the country taking Ritalin estimated at well over three million, more than double the 1990 figure, who should be giving out the pills?"
"With nurses often serving more than one school at a time," the story goes on to explain, "the whole middle of the day can be taken up in a school-to-school scurry to dole out drugs." Massachusetts, for its part, has taken to having the nurse deputize "anyone from a principal to a secretary" to share the burden. In Florida, where the ratio of school nurses to students is particularly low, "many schools have clerical workers hand out the pills." So many pills, and so few professionals to go around. What else are the authorities to do?
Behold the uniquely American psychotropic universe, pediatrics zone — a place where "psychiatric medications in general have become more common in schools" and where, in particular, "Ritalin dominates." There are by now millions of stories in orbit here, and the particular one chosen by the Times — of how the drug has induced a professional labor shortage — is no doubt an estimable entry. But for the reader struck by some of the facts the Times mentions only in passing — for example, that Ritalin use more than doubled in the first half of the decade alone, that production has increased 700 percent since 1990, or that the number of schoolchildren taking the drug may now, by some estimates, be approaching the 4 million mark — mere anecdote will only explain so much.
Fortunately, at least for the curious reader, there is a great deal of other material now on offer, for the explosion in Ritalin consumption has been very nearly matched by a publishing boom dedicated to that same phenomenon. Its harbingers include, for example, Barbara Ingersoll’s now-classic 1988 Your Hyperactive Child, among the first works to popularize a drug regimen for what we now call Attention Deficit Disorder (ADD, called ADHD when it includes hyperactivity). Five years later, with add diagnoses and Ritalin prescriptions already rising steeply in the better-off neighborhoods and schools, Peter D. Kramer helped fuel the boom with his bestselling Listening to Prozac — a book that put the phrase "cosmetic pharmacology" into the vernacular and thereby inadvertently broke new conceptual ground for the advocates of Ritalin. In 1994, most important, psychiatrists Edward M. Hallowell and John J. Ratey published their own bestselling Driven to Distraction: Recognizing and Coping with Attention Deficit Disorder from Childhood to Adulthood, a book that was perhaps the single most powerful force in the subsequent proliferation of add diagnoses; as its opening sentence accurately prophesied, "Once you catch on to what this syndrome is all about, you’ll see it everywhere."
Not everyone received these soundings from the psychotropic beyond with the same enthusiasm. One noteworthy dissent came in 1995 with Thomas Armstrong’s The Myth of the add Child, which attacked both the scientific claims made on behalf of ADD and what Armstrong decried as the "pathologizing" of normal children. Dissent also took the form of wary public pronouncements by the National Education Association (NEA), one of several groups to harbor the fear that add would be used to stigmatize minority children. Meanwhile, scare stories on the abuse and side effects of Ritalin popped out here and there in the mass media, and a national controversy was born. From the middle to the late 1990s, other interested parties from all over — the Drug Enforcement Administration (DEA), the Food and Drug Administration (FDA), the medical journals, the National Institutes of Health (NIH), and especially the extremely active advocacy group chadd (Children and Adults with Attention Deficit Disorder) — further stoked the debate through countless reports, conferences, pamphlets, and exchanges on the Internet.
To this outpouring of information and opinion two new books, both on the critical side of the ledger, have just been added: Richard DeGrandpre’s iconoclastic Ritalin Nation: Rapid-Fire Culture and the Transformation of Human Consciousness (Simon and Schuster, 1999), and physician Lawrence H. Diller’s superbly analytical Running on Ritalin: A Physician Reflects on Children, Society and Performance in a Pill (Bantam Books, 1998). Their appearance marks an unusually opportune moment in which to sift through some ten years’ worth of information on Ritalin and add and to ask what, if anything, we have learned from the national experiment that has made both terms into household words.
Let’s put the question bluntly: 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"?What is methylphenidate?
he first thing that has made the Ritalin explosion possible is that methylphenidate, to use the generic term, is perhaps the most widely misunderstood drug in America today. Despite the fact that it is, as Lawrence Diller observes in Running on Ritalin, "the most intensively studied drug in pediatrics," most laymen remain under a misimpression both about the nature of the drug itself and about its pharmacological effects on children.
What most people believe about this drug is the same erroneous characterization that appeared elsewhere in the Times piece quoted earlier — that it is "a mild stimulant of the central nervous system that, for reasons not fully understood, often helps children who are chronically distractible, impulsive and hyperactive settle down and concentrate." The word "stimulant" here is at least medically accurate. "Mild," a more ambiguous judgment, depends partly on the dosage, and partly on whether the reader can imagine describing as "mild" any dosage of the drugs to which methylphenidate is closely related. These include dextroamphetamine (street name: "dexies"), methamphetamine (street name: "crystal meth"), and, of course, cocaine. But the chief substance of the Times’ formulation here — that the reasons why Ritalin does what it does to children remain a medical mystery — is, as informed writers from all over the debate have long acknowledged, an enduring public myth.
"Methylphenidate," in the words of a 1995 dea background paper on the drug, "is a central nervous system (CNS) stimulant and shares many of the pharmacological effects of amphetamine, methamphetamine, and cocaine." Further, it "produces behavioral, psychological, subjective, and reinforcing effects similar to those of d-amphetamine including increases in rating of euphoria, drug liking and activity, and decreases in sedation." For comparative purposes, that same dea report includes a table listing the potential adverse physiological effects of both methylphenidate and dextroamphetamine; they are, as the table shows, nearly identical (see below). To put the point conversely, as Richard DeGrandpre does in Ritalin Nation by quoting a 1995 report in the Archives of General Psychiatry, "Cocaine, which is one of the most reinforcing and addicting of the abused drugs, has pharmacological actions that are very similar to those of methylphenidate, which is now the most commonly prescribed psychotropic medicine for children in the U.S."
Such pharmacological similarities have been explored over the years in numerous studies. DeGrandpre reports that "lab animals given the choice to self-administer comparative doses of cocaine and Ritalin do not favor one over another" and that "a similar study showed monkeys would work in the same fashion for Ritalin as they would for cocaine." The dea reports another finding — that methylphenidate is actually "chosen over cocaine in preference studies" of non-human primates (emphasis added). In Driven to Distraction, pro-Ritalin psychiatrists Hallowell and Ratey underline the interchangeable nature of methylphenidate and cocaine when they observe that "people with add feel focused when they take cocaine, just as they do when they take Ritalin [emphasis added]." Moreover, methylphenidate (like other stimulants) appears to increase tolerance for related drugs. Recent evidence indicates, for example, that when people accustomed to prescribed Ritalin turn to cocaine, they seek higher doses of it than do others. To summarize, again from the dea report, "it is clear that methylphenidate substitutes for cocaine and d-amphetamine in a number of behavioral paradigms."
All of which is to say that Ritalin "works" on children in the same way that related stimulants work on adults — sharpening the short-term attention span when the drug kicks in and producing equally predictable valleys ("coming down," in the old street parlance; "rebounding," in Ritalinese) when the effect wears off. Just as predictably, children are subject to the same adverse effects as adults imbibing such drugs, with the two most common — appetite suppression and insomnia — being of particular concern. That is why, for example, handbooks on add will counsel parents to see their doctor if they feel their child is losing too much weight, and why some children who take methylphenidate are also prescribed sedatives to help them sleep. It is also why one of the more Orwellian phrases in the psychotropic universe, "drug holidays" — meaning scheduled times, typically on weekends or school vacations, when the dosage of methylphenidate is lowered or the drug temporarily withdrawn in order to keep its adverse effects in check — is now so common in the literature that it no longer even appears in quotations.
Just as, contrary to folklore, the adult and child physiologies respond in the same way to such drugs, so too do the physiologies of all people, regardless of whether they are diagnosed with add or hyperactivity. As Diller puts it, in a point echoed by many other sources, methylphenidate "potentially improves the performance of anyone — child or not, add-diagnosed or not." Writing in the Public Interest last year, psychologist Ken Livingston provided a similar summary of the research, citing "studies conducted during the mid seventies to early eighties by Judith Rapaport of the National Institute of Mental Health" which "clearly showed that stimulant drugs improve the performance of most people, regardless of whether they have a diagnosis of adhd, on tasks requiring good attention." ("Indeed," he comments further in an obvious comparison, "this probably explains the high levels of ‘self-medicating’ around the world" in the form of "stimulants like caffeine and nicotine.")
A third myth about methylphenidate is that it, alone among drugs of its kind, is immune to being abused. To the contrary: Abuse statistics have flourished alongside the boom in Ritalin prescription-writing. Though it is quite true that elementary schoolchildren are unlikely to ingest extra doses of the drug, which is presumably kept away from little hands, a very different pattern has emerged among teenagers and adults who have the manual dexterity to open prescription bottles and the wherewithal to chop up and snort their contents (a method that puts the drug into the bloodstream far faster than oral ingestion). For this group, statistics on the proliferating abuse of methylphenidate in schoolyards and on the street are dramatic.
According to the dea, for example, as early as 1994 Ritalin was the fastest-growing amphetamine being used "non-medically" by high school seniors in Texas. In 1991, reports DeGrandpre in Ritalin Nation, "children between the ages of 10 and 14 years old were involved in only about 25 emergency room visits connected with Ritalin abuse. In 1995, just four years later, that number had climbed to more than 400 visits, which for this group was about the same number of visits as for cocaine." Not surprisingly, given these and other measures of methylphenidate’s recreational appeal, criminal entrepreneurs have responded with interest to the drug’s increased circulation. From 1990 to 1995, the dea reports, there were about 2,000 thefts of methylphenidate, most of them night break-ins at pharmacies — meaning that the drug "ranks in the top 10 most frequently reported pharmaceutical drugs diverted from licensed handlers."
ecause so many teenagers and college students have access to it, methylphenidate is particularly likely to be abused on school grounds. "The prescription drug Ritalin," reported Newsweek in 1995, "is now a popular high on campus — with some serious side effects." DeGrandpre notes that at his own college in Vermont, Ritalin was cited as the third-favorite drug to snort in a campus survey. He also runs, without comment, scores of individual abuse stories from newspapers across the country over several pages of his book. In Running on Ritalin, Diller cites several undercover narcotics agents who confirm that "Ritalin is cheaper and easier to purchase at playgrounds than on the street." He further reports one particularly hazardous fact about Ritalin abuse, namely that teenagers, especially, do not consider the drug to be anywhere near as dangerous as heroin or cocaine. To the contrary: "they think that since their younger brother takes it under a doctor’s prescription, it must be safe."
In short, methylphenidate looks like an amphetamine, acts like an amphetamine, and is abused like an amphetamine. Perhaps not surprisingly, those who value its medicinal effects tend to explain the drug differently. To some, Ritalin is to children what Prozac and other psychotropic "mood brightening" drugs are to adults — a short-term fix for enhancing personality and performance. But the analogy is misleading. Prozac and its sisters are not stimulants with stimulant side effects; there is, ipso facto, no black market for drugs like these. Even more peculiar is the analogy favored by the advocates in chadd: that "Just as a pair of glasses help the nearsighted person focus," as Hallowell and Ratey explain, "so can medication help the person with add see the world more clearly." But there is no black market for eyeglasses, either — nor loss of appetite, insomnia, "dysphoria" (an unexplained feeling of sadness that sometimes accompanies pediatric Ritalin-taking), nor even the faintest risk of toxic psychosis, to cite one of Ritalin’s rare but dramatically chilling possible effects.
What is methylphenidate "really" like? Thomas Armstrong, writing in The Myth of the ADD Child four years ago, probably summarized the drug’s appeal best. "Many middle and upper-middle class parents," he observed then, "see Ritalin and related drugs almost as ‘cognitive steroids’ that can be used to help their kids focus on their schoolwork better than the next kid." Put this way, the attraction to Ritalin makes considerable sense. In some ways, one can argue, that after-lunch hit of low-dose methylphenidate is much like the big cup from Starbucks that millions of adults swig to get them through the day — but only in some ways. There is no dramatic upswing in hospital emergency room visits and pharmacy break-ins due to caffeine abuse; the brain being jolted awake in one case is that of an adult, and in the other that of a developing child; and, of course, the substance doing the jolting on all those children is not legally available and ubiquitous caffeine, but a substance that the dea insists on calling a Schedule II drug, meaning that it is subject to the same controls, and for the same reasons of abuse potential, as related stimulants and other powerful drugs like morphine.More.....
What is CHADD?