If the emphasis among researchers on biology crowds out work on prevention, environmental causes, and alternative forms of therapy, a similar pattern occurs among clinicians. The most striking consequence of assuming that an unusually distractible or impulsive child is suffering from a disease is the tendency to turn to medication to solve the problem.
"Assumptions of organicity have often been used, in practice, as a justification for prescribing drugs," Jacobvitz and Sroufe have written. In an interview Sroufe adds, "The majority of hyperactive kids today are treated only with Ritalin—the vast majority.
Ritalin is the brand name for methylphenidate, which was approved for use with children in 1961. Like Dexedrine (dextroamphetamine), another stimulant sometimes prescribed for hyperactivity, Ritalin is classified as a Schedule II drug, meaning that among substances with legitimate medical use it is regarded as having the highest potential for abuse, and its manufacture is regulated by the Drug Enforcement Administration. (Other drugs in that class include morphine and barbiturates.)
The best available figures on the use of drugs for ADHD come from a careful biennial survey of Baltimore County schools by the psychiatrist Daniel Safer. In 1987 among public elementary school students in that county 5.9 percent were taking stimulants. Extrapolating to the nation as a whole, and correcting for the fact that Maryland doctors are a bit freer with their prescription pads than their counterparts elsewhere, Safer estimates that three quarters of a million children nationwide are now receiving stimulants. "It's been increasing steadily since we first took a look, in 1971, and it'll go over one million in the 1990s if the present trend continues," he says.
Indeed, about four out of five children diagnosed as hyperactive are put on stimulants at some point, making drug therapy far and away the treatment of choice in the United States. (This does not seem to be true elsewhere; in most of Western Europe, for example, children rarely or never receive medication for hyperactivity.)
In the early 1970s, media coverage of Ritalin use seeded a storm of controversy, culminating in the publication of a widely read book by Peter Schrag and Diane Divoky: The Myth of the Hyperactive Child. This period also saw the publication of Benjamin Feingold's Why Your Child Is Hyperactive, which argued that drugs were unnecessary because hyperactivity could be cured by restricting the amounts of sugar and food additives in the child's diet. (Subsequent studies have been unable to demonstrate that diet can bring about any significant improvement in the great majority of hyperactive children.)
Lately the medication controversy has been heating up again, largely because an arm of the Church of Scientology, which calls itself the Citizens Commission on Human Rights, is picketing professional conferences and helping to sponsor a series of legal actions charging physicians with malpractice. But if the church group's claim that "psychiatry is making drug addicts out of America's school children" is, understandably, not taken seriously by those in the field, neither does the drug deliver the benefits claimed by some proponents.
While the idea that stimulants can have a quieting effect may seem peculiar, the fact is that these drugs don't so much slow down activity as redirect it. A child on Ritalin may move around just as much as a nonmedicated child over the course of a day, but he will be better able to sit still for tasks that require concentration. His activity is more goal-directed, less aimless, more likely to be "on-task" than it was before. Besides being less distractible and better able to sustain attention, the medicated child typically becomes less aggressive and less apt to get into trouble, less obnoxious to his peers, easier for his teachers to handle, and generally more compliant. Unsurprisingly, parents and teachers are often pleased with the change they see in a child who is put on Ritalin.
That's the good news. The bad news has to do with side effects—about which more in a moment—and with the drug's efficacy, which is probably the greater of the two problems. The evidence shows, first, that drugs do absolutely nothing for 25 to 40 percent (depending on whose estimate you trust) of hyperactive children. Kenneth Gadow, in his book-length contribution to a series called Children on Medication, reported, "Some youngsters even become worse on medication! Unfortunately, there is no way to tell whether medication is going to work other than to have the child take it."
Second, a large proportion of the children who do respond to Ritalin also improve on a placebo. After weeding out the nonresponders, the pediatrician Esther Sleator followed a group of medicated children for two years and then began slipping some of them sugar pills. Of twenty-eight subjects for whom definite data were available, eleven continued to behave as if they were getting the real thing. Russell Barkley's review of several hundred studies indicates that about 40 percent of children are rated as improved when they're on a placebo, although the magnitude of the improvement generally isn't as great as it is for children receiving Ritalin.
Third, even for children who respond well to stimulants, the effect is a temporary suppression of symptoms, not a cure. A child may have been taking Ritalin for years, but within hours of the last dose he will be indistinguishable from a hyperactive child who has never taken Ritalin. Or almost indistinguishable: in what is known as a rebound effect, when the drug wears off the child will briefly become a little worse than he was before.
Fourth, although some children on stimulants are able to do more work and thus receive better grades, drugs do nothing to enhance actual academic achievement. Beneficial effects on concentration had long been assumed to translate into achievement, but an analysis that Russell Barkley and Charles Cunningham made of seventeen studies in the late 1970s, and a subsequent analysis by Kenneth Gadow of another sixteen studies in 1985, were uniformly discouraging. "Certain behavioral interventions are clearly superior to stimulant medication in facilitating academic performance," Gadow concluded.
On reflection, this doesn't seem so strange. Drugs do not remedy cognitive deficits or create skills. And if hyperactivity is the result of learning problems rather than the cause, two psychologists pointed out in a 1988 article, "interventions directed toward suppressing [hyperactive] behaviors will have no long-term effects in reducing either the [hyperactivity] itself or learning difficulties unless the latter are specifically treated."
Some children's behavior seems to improve only at relatively high dosages, around one milligram per kilogram of body weight. This much medication tends to have a detrimental effect on thinking skills, thus forcing the careful physician to choose between reducing hyperactivity and optimizing cognitive performance. What's more, "the [dosage] where teachers perceive the most improved classroom behavior is also associated with side effects," Gadow has reported.
These findings suggest hard questions about just why children are put on Ritalin in the first place, Even assuming that drugs make a difference, should they be prescribed to help a third-grader learn better? How about to reduce fidgeting, which, Safer points out, is "neither a disruptive influence nor highly unusual"? Or to establish docility, so that children will follow the rules and not annoy adults? At best the drug "may have much greater relevance for stress reduction in caregivers than intrinsic value to the child," Gadow has written. Gabrielle Weiss and her colleagues found that "children on the whole preferred being without the pills,'" and in a follow-up study of adults who had been medicated as children, Weiss's group found that slightly more listed medication as a hindrance than listed it as a help.
This reaction may be due in part to the social stigma of having to take pills every day, but part of it clearly has to do with side effects. Overall, research on these effects does not support the extravagant claims of some critics, including the Church of Scientology. Extreme adverse reactions are very rare and crop up occasionally with other medications as well.
If Ritalin stunts growth, the effect seems to be temporary. (It does seem possible that someone who continued taking medication straight into adulthood would be permanently affected, but no one knows for sure.) Other concerns, including reports of elevated blood pressure, facial tics, insomnia, and weight loss, have led specialists to recommend that younger children not be given stimulants. For older children, most of these side effects turn out to be either uncommon or controllable by modifying the dosage or the medication schedule.
Such adjustments may not, however, eliminate all the behavioral side effects. According to some studies, children on Ritalin sometimes become withdrawn and stare off into space, a behavior that critics call the "zombie" effect. While stimulants make these children less likely to annoy their peers or pick fights, they are also less likely to interact with others at all. And some investigators suspect that medication leads children and their parents to attribute any improvement to the pills rather than to social causes or to factors within their control.
Barbara Henker and Carol Whalen, psychologists at the University of California, have found that when someone is told that a given child is on medication, he or she is more likely to believe that the child's problems are serious and due to "nervous system dysfunction" than if told the child is in a behavioral treatment program. (Hence the circle is completed: assumptions of a biological cause lead to drugs, and drugs lead to assumptions of a biological cause.)
These concerns seem to have prompted little hesitation about prescribing stimulants. The number of prescriptions continues to rise, and more and more psychiatrists are talking seriously about keeping, or putting, adolescents and adults on stimulants too.
Ask professionals to name the most important finding relevant to hyperactivity within the past decade and they will tell you it is the discovery that the disorder doesn't disappear at puberty. Some hyperactive children continue to have problems with school and work, to be antisocial and otherwise troubled, as they get older.
But a closer look at these data suggests that something else is going on. One of the diagnoses that overlaps to a considerable extent with ADHD is "conduct disorder," which refers to aggressive, disobedient, troublemaking behavior; perhaps two thirds of hyperactive children also qualify for that diagnosis. Children who become delinquent in later life are primarily from the conduct-disorder group, rather than being a random sample of those who fidget and can't pay attention. Some of the non-conduct-disorder group, not surprisingly, may have trouble finishing school and may continue to be more distractible than most people when they grow up, but they apparently don't become mentally ill or get in trouble any more than the rest of us. The major revelation in the field during the past ten years, then, turns out to be this: if you were aggressive and antisocial as a child, you may also be aggressive and antisocial as an adult.
Even those researchers who are comfortable with both the diagnosis of hyperactivity and the use of Ritalin have urged that considerable care be taken in prescribing the drug and deciding who gets it. But virtually every common-sense recommendation offered in the professional journals is routinely ignored by physicians throughout the country.
Even though studies have shown that a child cannot be properly diagnosed on the basis of an office visit, a California survey of pediatricians revealed that the way children acted in front of them "seemed to be the most important characteristic in physician judgments." Doctors who seek further evidence to confirm their diagnosis may simply prescribe drugs and wait to see whether they work. According to a national survey done in 1987, three quarters of pediatricians continued to believe that a child's response to medication was helpful for purposes of diagnosis—this despite proof that many hyperactive children do nor respond to stimulants, and that many non-hyperactive children do.
According to studies conducted in several states, teachers often play little or no role in diagnosis or treatment of hyperactivity, even though their observations are critical. Moreover, against the advice of specialists, clinicians often prescribe unnecessarily high doses of Ritalin, fail to recommend counseling and other nonmedical treatments in addition to stimulants, and fail to schedule periodic "holidays" from the drug, as they should.
Much as the public outcry over Ritalin in the 1970s may well have "spurred a wave of better designed studies," according to the psychiatrist Mina K. Dulcan, so the newly filed malpractice suits, Russell Barkley concedes, may "motivate practitioners to bring their practices a little more up to date." Barkley emphasizes, nonetheless, that he believes that the practitioners being sued are not, strictly speaking, negligent. Negligence is judged according to customary practice in the field, not by the standards suggested by research. Put bluntly, this means that if most clinicians are diagnosing casually and prescribing irresponsibly, bringing legal action against any one of them will be difficult.
Diagnoses of other psychological disorders may be similarly arbitrary and subjective, made by committee and poorly defined, insensible of social factors and conducive to unfounded assumptions about biological causes. On the one hand, this may serve to excuse what goes on with hyperactivity, or at least to place it in perspective. On the other hand, it may provoke larger, more disturbing questions about the theory and practice of mental health in the United States.