Is Ritalin Overprescribed? No

by Dr. Jerry Wiener

This article is from drkoop.com

ADHD does exist

In defending the current use of Ritalin for treating ADHD, it is important to first emphasize that the disorder really exists.

Discovering that a child has ADHD is more complicated than a diagnosis of the mumps or chickenpox, but the diagnosis of ADHD can still be valid. An analogy would be multiple sclerosis: As with ADHD it is a distinct disease, yet we don't know what causes the problem and have no laboratory test for diagnosing it.

Since the 1950s, what we now call ADHD has been a well-recognized syndrome involving, as all syndromes do, a group of signs and symptoms that occur together. Years of research have documented that some children differ from their peers in being inattentive and hyperactive as well as impulsive. Extensive field trials and numerous studies have established that hyperactivity is at the core of the diagnosis, with inattention a consequence of the other two, especially in school-age boys.

Adding to the evidence that ADHD is a legitimate clinical problem are recent results of magnetic resonance imaging (MRI) studies showing that children diagnosed with ADHD have subtle but significant anatomical differences in their brains compared with other children.

Furthermore, studies of families suggest there is a genetic component for many cases of ADHD. More specifically, recent research has found a possible link between ADHD and three genes that code for receptors (proteins that just form the surface of cells) that are activated by dopamine, a neurotransmitter (chemical that conveys messages from one nerve cell to another). Defects in these genes could mean a reduced response to dopamine signals, perhaps accounting for the uninhibited behavior observed in ADHD.

Diagnosing ADHD

A child suspected of having ADHD should be evaluated by a trained and experienced clinician who takes the time to assess the child's development, family history, and behavior at school and at home. The clinician should require that the criteria set forth in the current Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) are met before concluding that a child has ADHD.

To receive the diagnosis of ADHD, a child should display a significant number of symptoms and behaviors reflecting hyperactivity, impulsivity, and inattention -- and the symptoms and behaviors must be more persistent and severe than normally occur in children of that age. In addition and importantly, there must be impaired functioning in school, home, and/or social relationships.

Are mistakes made in diagnosing ADHD? Of course. They usually occur when the clinician is rushed, inexperienced, untrained, pressured, or predisposed either to "find" ADHD or to overlook it. As a result, there is both overdiagnosis and underdiagnosis of ADHD. A reported six-fold increase in Ritalin prescriptions over the past five years is reason to reflect about possible overusage.

However, repeated findings of a three percent prevalence rate of ADHD among school-age children gives as much cause for concern about underdiagnosis as for overusage; these prevalence rates mean that up to 30 percent of children with ADHD may not be receiving sufficient treatment.

Treating ADHD

While there is no cure for ADHD, there is a very effective treatment to minimize its symptoms -- through the use of stimulant medications such as Ritalin. Such drugs are by far the most effective treatment for moderating and controlling the disorder's major symptoms -- hyperactivity, inattention, and impulsivity -- in 75 to 80 percent of children with this disorder.

The safety and effectiveness of Ritalin and other stimulant drugs, including Dexedrine (dextroamphetamine) and Cylert (pemoline), have been established more firmly than any other treatment in the field of child and adolescent psychiatry. Literally scores of carefully conducted blind and double-blind controlled studies have repeatedly documented the improvement -- often dramatic -- in symptoms of ADHD following the use of stimulant medication, with Ritalin the most common choice. By contrast, no other treatment, including behavior modification, compares with stimulant medication in efficacy; and in fact, no treatment besides these medications has had much success at all in treating ADHD.

Stimulant medication is so effective that a parent with a child diagnosed with ADHD should receive an explanation if the clinician's judgment is not to prescribe medication. Appropriate considerations for not opting for Ritalin and similar drugs include a history of tic or Tourette's syndrome, the presence of a thought disorder, significant resistance to such medications in the patient or family or insufficient severity of the symptoms or dysfunction. Other classes of drugs, such as antidepressants, can be effective and used when there is concern about the use of a stimulant medication or when side effects occur.

The issue should not be whether stimulants are overprescribed but where they may be misprescribed. The most common example: children who are described as overactive or impulsive but who do not meet the criteria for the diagnosis of ADHD. Another example is use of stimulants as a diagnostic "test" in the hands of a rushed or inexperienced clinician who may not consider that a favorable response was due to the placebo effect and therefore mistakenly assumes that the diagnosis of ADHD has been confirmed.

As effective as Ritalin can be for treating the symptoms of ADHD, it should rarely if ever be the only treatment for someone with the problem. The child or adolescent may also benefit from remedial work for any identified learning disability, family therapy, or psychotherapy for problems of self-image, self-esteem, anger, and/or depression.

Is Ritalin overprescribed? Not when it's used for children who meet the criteria for the diagnosis of ADHD, including the requirement that the child's ability to function must be "significantly impaired." All too often, the mistakes in prescribing Ritalin are errors of omission, where children who could benefit from the drug never receive it. Instead, they go through school labeled as troublemakers, or as unmotivated or hostile. They'll have missed out on the opportunity for at least a trial on a medication that could have significantly improved their symptoms and allowed for improved academic performance, self-esteem, and social interaction.

Jerry Wiener, M.D.
American Council on Science and Health
http://www.acsh.org/

Founded in 1978, and directed and advised by the world's leading scientists, physicians, and policy advisors -- ACSH is is a nonprofit, consumer education organization dedicated to providing the public with mainstream scientific information on issues related to food, nutrition, chemicals, pharmaceuticals, lifestyle, the environment and health.