|| Print ||
Originally published in The Journal of College Student Psychotherapy, Vol. 10(2) 1995, pp. 55-72
The Hazards of Treating "Attention-Deficit/Hyperactivity Disorder" with Methylphenidate (Ritalin)
by Peter R. Breggin, M.D. and Ginger Ross Breggin
ABSTRACT. The criteria for Attention-Deficit/Hyperactivity Disorder focus on behaviors that adults find frustrating and disruptive. Conflicts between children and adults are redefined as diseases or disorders within the children. Treatment with stimulant drugs such as methylphenidate (Ritalin) will produce greater docility in any child (or animal) without actually improving conduct or academic performance. Parents are not informed that they are trading behavioral control for toxic drug effects. The label ADHD is attached to children who are in reality deprived of appropriate adult attention These children require improved adult attention to their basic needs. [Article copies available from The Haworth Document Delivery Service: 1-800-342-9678.]
Few mental health professionals can recite the American Psychiatric Association diagnostic criteria as delineated in the Diagnostic and Statistical Manual of Mental Disorders-lV (DSM-IV) (American Psychiatric Association, 1994), even for the diagnoses they routinely use. But the diagnostic standards are important in setting clinical and research trends. Their existence creates a strong, if potentially misleading, impression of validity for psychiatric diagnosing in general, as well as for the individual diagnostic categories. The prescription of medication to children, for example, is largely justified on the basis of these diagnoses.
The existence of the diagnoses also influences how millions of parents and teachers view the children in their care. Most teachers and many parents of young people have heard of "hyperactivity" and, more specifically, Attention-Deficit/Hyperactivity Disorder (ADHD). Many non-mental health professionals believe they can diagnose it.
The disruptive behavior disorders (DBDs)
Along with Conduct Disorder and Oppositional Defiant Disorder, ADHD was originally considered one of the Disruptive Behavior Disorders in the DSM-III-R (American Psychiatric Association, 1987). In the DSM-IV, an attempt is made to separate ADHD from the other two disruptive disorders at least when ADHD manifests itself primarily as inattention rather than hyperactivity. The DSM committee found that while disruptive behavior and attention problems "often occur together," "some" ADHD children are not hyperactive and disruptive (Fasnacht, 1993).
Despite any attempt to separate them, the three diagnoses often overlap with each other and research projects often refer to them as one group, the DBDs. The DSM-IV observes that "A substantial portion of children referred to clinics with Attention-Deficit/Hyperactivity Disorder also have Oppositional Defiant Disorder or Conduct Disorder." A National Institute of Mental Health (NIMH) study similarly observes, "'Pure' conduct disorder or 'pure' opposition disorder are relatively rare in clinical samples, with most cases also qualifying for an attention-deficit disorder diagnosis" (Kruesi et al., 1992).
The DSM-IV does not discuss the definition of Disruptive Behavior Disorder, DSM-lll-R states that DBD children are "characterized by behavior that is socially disruptive and is often more distressing to others than to the people with the disorders." The "illness" consists of being disruptive to the lives of adults-a definition that seems tailored for social control.
Attention deficit/hyperactivity disorder
The DSM-IV distinguishes between two types of ADHD, one marked by inattention and the other by hyperactivity-impulsivity. The official standard for ADHD requires any six of nine items under each category. For hyperactivity-impulsivity the first four items in descending order include:
The first four items in the list for diagnosing the inattention form of the disorder include:
Those who advocate medicating children often view ADHD as a specific "mental illness" with a genetic and biochemical cause. But as the list of criteria demonstrates, it is one more DBD-another way a child gets labelled as a source of frustration or disruption. This is true even in regard to some of the criteria for the inattention aspect of the disorder. As Gerald Golden (1991) observes: "The behavior is seen as being disruptive and unacceptable by parents and teachers, and the child is socially handicapped as a result."
Russell Barkley (1991, p. 13) states, "Although inattention, overactivity, and poor impulse control are the most common symptoms cited by others as primary in hyperactive children, my own work with these children suggests that noncompliance is also a primary problem." It is not surprising that some children are noncompliant with Barkley. He not only wants to medicate them, he blames the child for conflicts that the child is having with family and school. As he puts it, ". . . there is, in fact, something 'wrong' with these children" (p. 4). He does not make a similar indictment of the authorities in the child's life, such as parents or teachers, although they have much more control over the conditions that determine the child's life and mental condition.
A disease that goes away with attention
The symptoms or manifestations of ADHD often disappear when the children have something interesting to do or when they are given a minimal amount of adult attention. This is agreed upon by most or all observers and indirectly finds its way into the DSM-III-R and DSM-IV The DSM-IV specifies that the symptoms may become apparent when the child is in settings "that lack intrinsic appeal or novelty" and may be minimal or absent when "the person is under very strict control, is in a novel setting, is engaged in especially interesting activities, is in a one-to one situation," including being examined by the doctor. Most advocates of ADHD as a diagnosis also note that it tends to go away during summer vacation.
Who's got the problem?
If the list of criteria for ADHD has any use, it identifies children who are bored, anxious, or angry around some of the adults in their lives or in some adult-run institutions, such as the school and family. These "symptoms" should not red flag the children as mentally ill. They should red flag the adults as requiring new efforts to attend to the needs of the children.
When a small child, perhaps five or six years old, is persistently disrespectful or angry, there is always a stressor that child's life-something over which the child has little or no control. Sometimes, the child is not being respected, because children learn more by example than by anything else. When treated with respect, they tend to respond respectfully. When loved, they tend to be loving. While the source of the child's upset may turn out to be more complicated than that-perhaps the parent is too afraid or distracted to apply rational discipline and lets the child run wild, or perhaps the child is being abused outside the home-the source always lies in the larger world. Children do not, on their own, create severe emotional conflicts within themselves and with the adults around them.
Children aren't bored, inattentive, undisciplined, resentful or violent by their individual natures; but the stigmatizing label ADHD implies that they are. These children are usually more energetic and more spirited, or more in need of an interesting environment, than their parents and teachers can handle. One of the early advocates of hyperactivity as a diagnosis describes them as unusually dynamic bundles of energy (Weeder, 1973). Yet they are being diagnosed with a mental illness-a label that can follow them into adulthood to ruin their future lives.
Dad attention deficiency disorder (DADD)
In my clinical experience, most so-called ADHD children are not receiving sufficient attention from their fathers who are separated from the family, too preoccupied with work and other things, or otherwise impaired in their ability to parent. In many cases the appropriate diagnosis is Dad Attention Deficit Disorder (DADD) (Breggin, 1991).
The "cure" for these children is more rational and loving attention from their dads. Young people are nowadays so hungry for the attention of a father that it can come from any male adult. Seemingly impulsive, hostile groups of children will calm down when a caring, relaxed, and firm adult male is around. Arlington High School in Indianapolis was cancelling many of its after-school events because of unruliness, when a father happened to attend one of them (Smith, 1993):
Since then the school has begun to enlist volunteer dads for its after-school events.
At other times, the so-called disorder should be called TADD: Teacher Attention Deficit Disorder. Due more to problems in our educational system than to the teachers themselves, few students get the individualized educational programs that they need.
In 1993 neurologist Fred Baughman, Jr. noted that studies have failed to confirm any definite improvement from the drug treatment of these children. Baughman cites estimates of the frequency of ADD that vary from 1 in 3 to 1 in 1000. He therefore asks, "Is attention-deficit hyperactivity disorder, after all, in the eye of the beholder?"
The eye of the beholder theme echoes Diane McGuinness who has systematically debunked ADHD as the "emperor's new clothes." According to McGuinness in a chapter in The Limits of Biological Treatments for Psychological Distress (1989):
According to Richard E. Vatz (1993), "Attention-deficit disorder (ADD) is no more a disease than is 'excitability.' It is a psychiatric, pseudomedical term."
Frank Putnam (1990), a director of one of NIMH's research units, recently applauded "the growing number of clinicians and researchers condemning the tyranny of our psychiatric and educational classification systems." Putnam finds that it is "exceedingly difficult to assign valid classifications" to children, and yet "children are by far the most classified and labeled group in our society." He warns against "the institutional prescriptions of a system that seeks to pigeonhole them." (p. I)
A physical basis to ADHD?
A study led by NIMH's Alan Zametkin (Zametkin et al., 1990) received a great deal of publicity for finding increased brain metabolism in positron emission tomography (PET scans) of adults with a history of ADHD in childhood. However, when the sexes were compared separately, there was no statistically significant difference between the controls and ADHD adults. To achieve significance, the data was lumped together to include- a disproportionate number of women in the controls. In addition, when individual areas of the brain were compared between controls and ADHD adults, no differences were found. It is usually possible to massage data to produce some sort of statistical result and Zametkin's study is a classic illustration.
Since ADHD is not a disorder but a manifestation of conflict, we doubt that a biological cause will ever be found. Golden (1991) put it simply: "Attempts to define a biological basis for ADHD have been consistently unsuccessful. The neuroanatomy of the brain, as demonstrated by neuroimaging studies, is normal. No neuropathologic substrate has been demonstrated . . ." (p. 36)
Meanwhile, the emphasis on possible genetic and biological causes of upset behaviors in children obscures the growing body of research confirming their psychosocial origins (reviewed in Green, 1989; Breggin, 1992).
No specific drug treatment
Contemporary experts agree that methylphenidate affects all children in the same way and is in no way specific for children diagnosed ADHD. Golden (1991) observes, ". . . the response to the drug cannot be used to validate the diagnosis. Normal boys as well as those with ADHD show similar changes when given a single dose of a psychostimulant" (p. 37).
Within an hour after taking a single dose of a stimulant drug, any child tends to become more obedient, more narrow in focus, more willing to concentrate on humdrum tasks and instructions. Parents in conflict with a little boy can hand him a pill, knowing he'll soon be more docile.
It is commonly held that stimulants have a paradoxical effect on children compared to adults, but these drugs probably affect children and adults in the same way. At the doses usually prescribed by physicians, children and adults alike are "spaced out," rendered less in touch with their real feelings, and hence more willing to concentrate on boring, repetitive schoolroom tasks.
At higher doses, both children and adults become more obviously stimulated into excitability or hyperactivity. There is, however, great variability among individuals and a number of children and adults will become more hyperactive and inattentive at the lower doses as well.
The British are much more cautious about using stimulants for children. Grahame-Smith and Aronson (1992), authors of the Oxford Textbook of Clinical Psychopharmacology and Drug Therapy, suggest that stimulants may work in children the same way they impact on rats, by "inducing stereotyped behavior in animals, i.e., in reducing the number of behavioural responses . . ." (p. 141). Stereotyped behavior is simple, repetitive, seemingly meaningless activity, often seen in brain damaged individuals. The textbook states somewhat suggestively, "It is beyond our scope to discuss whether or not such behavioural control is desirable" (p. 141).
One way to understand the routine effect of any psychiatric drug is to look at its more extreme or toxic effects (Breggin, 1991). The clinical or "therapeutic" effect is likely to be a less intense expression of the toxic effect. In discussing methylphenidate's "cognitive toxicity," James M. Swanson (1992) and his coauthors summarized the literature:
"In some disruptive children, drug-induced compliant behavior may be accompanied by isolated, withdrawn, and overfocused behavior. Some medicated children may seem 'zombie-like' and high doses which make ADHD children more 'somber,' 'quiet,' and 'still' may produce social isolation by increasing 'time spent alone' and decreasing 'time spent in positive interaction' on the playground.!"
Meanwhile, as Swanson et al. (1992) confirm, there's no evidence that methylphenidate improves learning or academic performance. This is confirmed in various reviews (Breggin (1991); Coles (1987); McGuinness (1989); and Swanson et al. (1992)).
The long-term effects "remain in doubt"
As the National Institute of Mental Health succinctly stated, "The long-term effects of stimulants remain in doubt" (Regier and Leshner, 1992). The FDA-approved information put out by the drug company, Ciba-Geigy, admits "Long-term effects of Ritalin in children have not been well established" (Physicians' Desk Reference, 1994, p. 836). Yet methylphenidate is typically advocated as a long-term treatment.
NIMH further states that studies have demonstrated short-term effects such as reducing "class room disturbance" and improving "compliance and sustained attention." But it recognizes that the drugs seem "less reliable in bringing about associated improvements, at least of an enduring nature, in social-emotional and academic problems, such as antisocial behavior, poor peer and teacher relationships, and school failure."
While estimating that ". . . between 2 and 3 percent of all elementary school children in North America receive some form of pharmacological intervention for hyperactivity," (p. 3) NIMH continues to encourage giving methylphenidate to increasing numbers of children.
Methylphenidate and cocaine
Parents are seldom told that methylphenidate is "speed" — that it is pharmacologically classified with amphetamines and causes the very same effects, side effects, and risks. Yet this is well-known in the profession. For example, Treatments of Psychiatric Disorders observes that cocaine, amphetamines, and methylphenidate are "neuropharmacologically alike" (American Psychiatric Association 1989, p. 1221). As evidence, the textbook points out that abuse patterns are the same for the three drugs; that people cannot tell their clinical effects apart in laboratory tests; and that they can substitute for each other and cause similar behavior in addicted animals (American Psychiatric Association, 1989, p.1221. Also see Breggin, 1991, and Breggin and Breggin, 1994a&b). The DSM-IV confirms these observations by lumping cocaine, amphetamine and methylphenidate abuse and addiction into one category. The Food and Drug Administration (FDA) classifies methylphenidate in a high-addiction category, Schedule II, which also includes amphetamines, morphine, opium, and barbiturates (Goodman et al., 1991).
Before it was replaced by other stimulants in the 1980s, methylphenidate was one of the most commonly used street drugs (Spotts and Spotts, 1980). In our home town of Bethesda, youngsters nowadays sell their prescribed methylphenidate to classmates who abuse it along with other stimulants.2 In working with community groups, we often hear anecdotal reports of individuals who have graduated from using medically prescribed methylphenidate to alcohol or street drugs. One of the authors (P.B.) has seen some cases in his own practice.
Like any addictive stimulant, methylphenidate can cause withdrawal symptoms, such as "crashing" with depression, exhaustion, withdrawal, irritability, and suicidal feelings. Parents will not recognize a withdrawal reaction when their child gets upset after missing even a single dose. They will mistakenly believe that their child needs to be put back on the medication.3
More facts withheld from parents
Parents are not told that methylphenidate, as a stimulant, can cause the very disorders it is supposed to cure-inattention, hyperactivity, and aggression. When the child becomes worse while taking the medication, he or she is likely to be given higher doses of the drug, or an even stronger medication, such as the neuroleptics thioridazine (Mellaril) or haloperidol (Haldol). This can result in a vicious circle of increasing drug toxicity (side effects of methylphenidate are further discussed and documented in Breggin, 1991).
Rarely are parents informed that methylphenidate can cause permanent disfiguring tics. One of us (PB) has recently consulted in the case of a young boy in whom routine dosage produced disfiguring muscle spasms and tics of the head, neck, face, eyes, and mouth.
Parents are sometimes told that methylphenidate can suppress growth (height and weight), but the explanation is usually given in a manner calculated not to frighten them. Much of the brain's growth takes place during the years in which children are given this drug; but doctors don't tell parents that there are no studies of the effect of this growth inhibition on the brain itself. If the child's body is smaller, including his head, what about the contents of his skull? And if size can be reduced, what about more subtle and perhaps immeasurable brain deformities?
Parents are infrequently informed that like any form of speed, methylphenidate can often make children anxious and sometimes cause them to behave in ways that seem "crazy." Most surely, parents will not be told about any danger of permanent brain damage from long-term exposure to methylphenidate. While no consistent brain abnormalities have been found in children labelled ADHD, one study has found brain shrinkage in adults labelled ADHD who have been taking methylphenidate for years (Nashrallah et al., 1986). The authors of the study suggested "cortical atrophy may be a long-term adverse effect of this [methylphenidate] treatment."
Finally, parents will not be told by their doctor that there are almost guaranteed non-drug methods to improve the conduct of nearly all so called DBD children-through more interesting, engaging schools and through more rationally managed, loving family relationships.
Is ADHD an Americans' disease? A boys' disease?
ADHD is rarely diagnosed in countries with more evident concern for children, such as Denmark, Norway, and Sweden, where psychiatric drugs of any kind are much more rarely given to children. A doctor working in England's National Health Service is not allowed to give methylphenidate in routine practice because it is not on the approved drug list. The doctor could prescribe amphetamines, which have a similar effect, but this is discouraged and relatively rarely done.
Males are far more frequently given DBD diagnoses than females. According to the DSM-IV, ADHD occurs in boys up to four to nine times more frequently than in girls and Conduct Disorder is "much more common in males" in whom the rates vary from 6% to 16%. Aside from feeling bored or in conflict with adults, why would boys ordinarily tend to act resentfully and rebelliously toward the authority of their mothers and female teachers? The simplest answer is that they are trained to be that way toward women in general. In fact, most grown men in the world today resent being told what to do by women.
A multiplicity of factors contribute to the conflicts and confusion in little boys: How boys are trained to suppress their tender ("feminine") side and encouraged to be competitive, dominating and hostile toward women; how these lessons are imprinted through TV and the entertainment media, and reinforced in sports and on the playground, as well as in the family and almost everywhere else in society.
In our modern society, in which girls receive increasingly confusing messages about assertiveness, more and more young girls are being diagnosed with one or another DBD. Often they are girls with special gumption.
Children with Attention Deficit Disorders (CH.A.D.D)
Founded in 1987, Children with Attention Deficit Disorders (CH.A.D.D.) is an organization of parents who have children labelled with attention deficit disorders. CH.A.D.D.'s official policy views these children as suffering from genetic and biological problems. In the words of CH.A.A.D. president Sandra F. Thomas (1992), "Our kids have a neurological impairment that is pervasive and affects every area of their life, day and night."
CH.A.D.D. leaders claim that their children's emotional upset and anger is in no way caused by family conflicts, poor parenting, inadequate schools, or broad social stressors. A recent CH.A.D.D. brochure, Hyperactive? Inattentive? Impulsive?, headline announces: "Dealing with parental guilt No, it's not all your fault" (CH.A.D.D., undated). After stating that ADHD is a neurological disorder, the brochure goes on to explain: "Frustrated, upset, and anxious parents do not cause their children to have ADD. On the contrary, ADD children usually cause their parents to be frustrated, upset, and anxious." (p. 1)
There could be no better example of child-blaming and parental exoneration.
CH.A.D.D. has followed the model of its adult counterpart, the National Alliance for the Mentally Ill (NAMI) (Breggin, 1991). NAMI parents usually have grown offspring who are severely emotionally disabled, and they promote biochemical and genetic explanations, drugs, electroshock, psychosurgery, and involuntary treatment. NAMI also tries to suppress dissenting views by harassing professionals who disagree with them (Breggin, 1991). Now NAMI has developed an affiliate, NAMI-CAN-the National Alliance for the Mentally Ill; Child and Adolescent Network (Armstrong, 1993). NAMI-CAN, like CH.A.D.D. believes in BBBD-biologically based brain diseases.
CH.A.D.D. and NAMI parents have developed enormous influence by joining forces with biologically-oriented professionals, national mental health organizations, and the drug industry. But where is the money coming from to support high-pressure lobbying, media campaigns, and upscale national conventions a hotels like the Chicago Hyatt Regency? CH.A.D.D.'s convention program, "Pathways to Progress," states (CH.A.D.D., 1992): "CH.A.D.D. appreciates the generous contribution of an educational grant in support of our projects by CIBA-Geigy Corporation."
CIBA-Geigy manufacturers Ritalin, the stimulant with the lion's share of the ADHD market.
The adult counterpart of CH.A.A.D., NAMI, has had equal success in its political efforts. It too is closely aligned with biological psychiatry and takes money from the drug companies.
A recent CH.A.D.D. Educators Manual was written with the collaboration of professionals, including Russell Barkley (Mary Fowler, 1992). It makes clear the intention to diagnose and drug children who fail to conform to strict discipline:
Like shining stars
Our children relate to us mostly through home and school. In both places we need a new devotion to their basic needs rather than to treating presumed psychiatric disorders. Above all else, our children need a more caring connection with us, the adults in their lives. This is now being realized in some school systems as they begin to abandon the large, factory-like facilities of the past in favor of "small is beautiful."
There are many advantages to smaller schools, but perhaps the most significant one is this: They allow teachers to get to know their students well enough to understand and to meet their basic educational and emotional needs. At the same time, small schools and classes meet the teachers' basic needs for a satisfying, effective professional identity. Conflict can be more readily resolved as it ideally should be-through mutually satisfying solutions-rather than through medical diagnosis and pharmacological suppression.
Some smaller, more child-oriented schools have shown that the DBDs virtually disappear. There is no better evidence for how the environment powerfully shapes the behavior that results in children being psychiatrically diagnosed.
In a July 14, 1993 New York Times report entitled "Is Small Better? Educators Now Say Yes for High School," Susan Chira reports: "[S]tudents in schools limited to about 400 students have fewer behavior problems, better attendance and graduation rates, and sometimes higher grades and scores. At a time when more children have less support from their families, students in small schools can form close relationships with teachers. "(p. 1)
Teachers in these schools have the opportunity for "building bonds that are particularly vital during the troubled years of adolescence."
Even students from troubled homes respond to small, more caring schools. "They are shining stars you thought were dull," said New York City teacher Gregg Staples. "If you're under a lot of pressure and stress, they help you through that," said student Joy Grimage. "They won't put you down or put you on hold."
Children respond so quickly to improvements in the way that adults relate to them, that most children can be helped without being seen by a professional person. Instead, the professional can consult with the parents, teachers, and other concerned adults.
Many psychotherapists, for example, routinely practice "child therapy" without actually seeing any children. They help their adult patients become more loving or disciplined parents through the routine work of psychotherapy, indirectly transforming the lives of their children. The children "get better" sight unseen. These therapists, many of whom work only with adults, may not identify themselves professionally as child psychiatrists or child therapists. But they are doing more good for children than the professionals who diagnose and medicate them.
Children don't have disorders; they live in a disordered world.
When adults provide them a better environment, they tend to quickly improve their outlook and behavior. But, children and teenagers can eventually become so upset, confused and self-destructive that they internalize the pain or become compulsively rebellious. They may need the intervention of a therapeutic-unconditionally caring adult to help them overcome their inner suffering and outrage. Sometimes these children can benefit from learning how to help ease the conflicted situation. But they should never be given the idea that they are diseased or defective, as the primary cause of their conflicts with their schools and families.
Children can benefit from guidance in learning to be responsible for their own conduct; but they do not gain from being blamed for the trauma and stress that they are exposed to in the environment around them. They need empowerment, not humiliating diagnoses and mind-disabling drugs. Most of all, they thrive when adults show concern and attention to their basic needs as children.
1. Citation numbers removed from the quote.
2. Fluoxetine (Prozac) with its stimulant effects is also becoming a drug of abuse (Breggin, 1994a).
3. Adverse drug reactions to methylphenidate are probably far much more common than the literature suggests (Breggin, 1991). Except when a drug is brand new, doctors almost never report or publish negative side effects. Many physicians do not know there is a mechanism for informing the drug companies and the FDA. Goodman et al. (1991. p. 78) observe "Over 40% of physicians are not aware that the FDA has a reporting system for adverse drug reactions . . ." In addition, advocates of psychiatric drugs for children have proven themselves especially unwilling to emphasize their dangerous effects (Breggin, 1991).