Ritalin: Child Abuse on Prescription?

A Convenient Diagnosis", default", Does Ritalin Work? Potentially Toxic, Cancer in Mice. Is this a real improvement, or is the child simply drugged?

Family doctors are these days frequently under pressure (usually from teachers and social workers who know nothing about drug therapy and probably understand nothing about the way the international drug industry operates) to prescribe the drug called Ritalin for children who are accused of behaving badly, reported as not doing well at school and `diagnosed' as suffering from something called Attention Deficit Hyperactivity Disorder (known as ADHD).

For several decades now Ritalin, and other amphetamine type drugs, have been prescribed for children diagnosed as suffering from various types of brain dysfunction and hyperactivity. (Other psychostimulants which have, at one time or another, been regarded as competitors to Ritalin have included Dexedrine).

In my view the first problem is that Attention Deficit Hyperactivity Disorder (and other variations on the hyperactivity theme) is a rather vague diagnosis which is often leapt upon by teachers, social workers and parents to excuse and explain any unacceptable or uncontrollable behaviour.

Parents of children whose behaviour is in any way regarded as different or unusual are often encouraged to believe that their child is suffering from a disease for two simple reasons. First, it is more socially acceptable to give a child a pseudoscientific label than to have to admit that he or she may simply be badly behaved.

Second, when a child has been given a label it is possible to offer a treatment. Commonly it will be one, such as a drug, which offers someone a profit. ADHD, which is also known as Attention Deficit Disorder (or ADD), hyperkinetic child syndrome, minimal brain damage, minimal brain dysfunction in children, minimal cerebral dysfunction and psycho-organic syndrome in children, is a remarkably non specific disorder. The symptoms which characterise the disorder may include: a chronic history of a short attention span, distractibility, emotional lability, impulsivity, moderate to severe hyperactivity, minor neurological signs and abnormal EEG. Learning may or may not be impaired.

Read that rather nonsensical list of symptoms carefully and you'll find that just about any child alive could probably be described as suffering from ADHD.

What child isn't impulsive occasionally? What child doesn't cry and laugh (that's what emotional lability means)? What child cannot be distracted?

One big worry I have is that Ritalin could be recommended for any child who seemed bored and restless or who exhibited unusual signs of intelligence or skill. Read the biographies of geniuses and you may wonder what we are doing to our current generation of most talented individuals.

`Is Ritalin a drug in search of a disease?' wrote one author, and it isn't difficult to see why.

First Used In The 1960s
Ritalin has been recommended as a treatment for functional behaviour problems since the 1960s. When CIBA first suggested this in 1961 they were turned down by the FDA but in 1963 approval was given for this use of the drug.

By 1966 the `experts' had come up with a definition of the sort of child for whom Ritalin could useful be prescribed. Children suffering from Minimal Brain Dysfunction (MBD), the first syndrome for which Ritalin was recommended, were defined as `children of near average, average or above average general intelligence with certain learning or behavioural disabilities ranging from mild to severe, which are associated with deviations of function of the central nervous system. These deviations may manifest themselves by various combinations of impairment in perception, conceptualization, language, memory and control of attention, impulse or motor function'.

Other symptoms which children might exhibit and which could be ascribed to MBD included: being sweet and even tempered, being cooperative and friendly, being gullible and easily led, being a light sleeper, being a heavy sleeper and so on and on.

Given that sort of list to work with it is difficult to think of a child who wouldn't benefit from Ritalin - though the official estimate seemed to be that only around 1 in 20 children were real MBD sufferers.

A Convenient Diagnosis
The bottom line is that it has become easy for social workers and teachers to define any children who misbehaves or doesn't learn `properly' as suffering from MBD or ADHD. Its a convenient diagnosis which excuses parents, teachers and social workers from responsibility or any sense of guilt. How can the parents or the teacher be accused of failing when the child is ill?

The head of the task force which identified and labelled MBD allegedly subsequently joined the company making Ritalin and produced their handbook for doctors on the condition. Commercially Ritalin and MBD became a huge success. By 1975 around a million children in the U.S. were diagnosed as suffering from MBD. Half of these were being given drugs and half of those on drugs were on Ritalin.

For the sake of completeness I should point out that Ritalin has not always been used exclusively in the treatment of badly behaved children.

When Dr Andrew Malleson wrote his book `Need Your Doctor Be So Useless' in 1973 he reported that the CIBA Pharmaceutical Company had suggested `to doctors the use of their habit forming drug Ritalin for `environmental depression' caused by `NOISE: a new social problem'.

Does Ritalin Work?
The next question which has to be asked is: `Does Ritalin work?'

Well, I'm afraid that I can't answer that question. And I honestly don't think anyone else can either. Novartis, the drug company which is now responsible for Ritalin in the UK, admits that `data on...efficacy of long term use of Ritalin are not complete'.

With one in twenty children said to be suffering from MBD (or ADHD or ADD or whatever else anyone wants to call it), with Ritalin having been on the market and used for this condition for over three decades, and with some experts saying that a million children a year are given Ritalin in the U.S. alone you might find this a trifle disappointing.

Just how long does it take to find out whether or not a drug works? Am I being horribly cynical in suggesting that it might be against the drug company's interests to find out whether or not Ritalin really works? After all, if long term studies found that Ritalin didn't work a very profitable drug would, presumably, lose some of its appeal. Some research has been done. One five year study of hyperactive children who were given Ritalin at Montreal Children's Hospital found that the children did not differ in the long term from hyperactive children who were not given the drug. At least one investigator has reported that drugs like Ritalin may produce a deterioration in learning new skills at school and parents have reported that the symptoms of MBD have miraculously disappeared during school holidays.

The picture is confused by the fact that there may be a short term improvement in behaviour among children given Ritalin. But is this a real improvement? Or is the child simply drugged? Amphetamine type drugs reduce the variety of behaviour exhibited by children. A child taking Ritalin might have more focused behaviour. But although that might mean less disruption in the classroom does it really help the child? And should we give a child a powerful and potentially hazardous drug because they it keeps him quiet?

There is evidence suggesting that children who are genuinely hyperactive may have been poisoned by food additives or by lead breathed in from air polluted by petrol fumes. If this is so then is giving another potentially toxic drug really the answer to this problem?

Potentially Toxic
The next problem is that I believe that Ritalin can reasonably be described as potentially toxic. Ritalin has been described as `very safe' but for the record here is a list of some of the possible side effects which may be associated with Ritalin: nervousness, insomnia, decreased appetite, headache, drowsiness, dizziness, dyskinesia, blurring of vision, convulsions, muscle cramps, tics, Tourette's syndrome, toxic psychosis (some with visual and tactile hallucinations), transient depressed mood, abdominal pain, nausea, vomiting, dry mouth, tachycardia, palpitations, arrhythmias, changes in blood pressure and heart rate, angina pectoris, rash, pruritus, urticaria, fever, arthralgia, alopecia, thrombocytopenia purpura, exfoliative dermatitis, erythema multiforme, leucopenia, anaemia and minor retardation of growth during prolonged therapy in children.

Doctors who prescribe Ritalin, and who have the time and the inclination to read the warnings issued with the drug, will discover that Ritalin should not be given to patients suffering from marked anxiety, agitation or tension since it may aggravate these symptoms.

Ritalin is contraindicated in patients with tics, tics in siblings or a family history or diagnosis of Tourette's syndrome. It is also contraindicated in patients with severe angina pectoris, cardiac arrhythmias, glaucoma, thyrotoxicosis, or known sensitivity to methylphenidate and it should be used cautiously in patients with hypertension (blood pressure should be monitored at appropriate intervals). Ritalin should not be used in children under six years of age, should not be used as treatment for severe depression of either exogenous or endogenous origin and may exacerbate symptoms of behavioural disturbance and thought disorder if given to psychotic children.

The company selling it claims that although available clinical evidence indicates that treatment with Ritalin during childhood does not increase the likelihood of addiction chronic abuse of Ritalin can lead to marked tolerance and psychic dependence with varying degrees of abnormal behaviour.

Ritalin, it is warned, should be employed with caution in emotionally unstable patients, such as those with a history of drug dependence or alcoholism, because such patients may increase the dosage on their own initiative.

Ritalin should also be used with caution in patients with epilepsy since there may be an increase in seizure frequency.

And height and weight should be carefully monitored in children as prolonged therapy may result in growth retardation. (A child might lose several inches in possible height - though if treatment is stopped there is a generally a growth spurt). It is perhaps worth mentioning here my view that if a drug is powerful enough to retard growth it does not seem entirely unreasonable to suspect that the chances are high that it may be having other powerful effects upon and within the body.

Doctors are also warned that careful supervision is required during drug withdrawal, since depression as well as renewed overactivity can be unmasked. Long term follow up may be needed for some patients.

There have also been reports that children have committed suicide after drug withdrawal. And one study has shown that children who are treated with stimulants alone had higher arrest records and were more likely to be institutionalised. Long term use of Ritalin has been said to cause irritability and hyperactivity (these are, you may remember, the problems for which the drug is often prescribed). In a study published in Psychiatric Research and entitled Cortical Atrophy in Young Adults With A History of Hyperactivity brain atrophy was reported in more than half of 24 adults treated with psychostimulants (though I don't think anyone can say for sure whether or not the psychostimulants caused the brain atrophy the possible link should make prescribers, teachers and parents who are fans of Ritalin stop and think for a moment).

In Johannesburg a study of 14 children is said to have produced a response in only 2 children. One child showed some deterioration and another showed marked deterioration.

The final insult is, surely, the fact that the company selling Ritalin tells doctors that `Data on safety and efficacy of long term use of Ritalin are not complete.' For this reason they recommend that patients requiring long term therapy should be monitored carefully with periodic complete and differential blood counts, and platelet counts.

I regard this as an insult because Ritalin is not a new drug.

I have not, at the time of writing this, been able to find out exactly when it was first introduced but I have been able to trace it back to 1961.

Now, maybe I'm being rather demanding but it does seem to me that when a drug has been on the market for well over a quarter of a century it isn't entirely unreasonable for the drug company involved to have completed studying the data on whether or not it works and is safe.

Cancer In Mice
When early safety tests were done on mice researchers found that the drug caused an increased in hepatocellular adenomas and, in male mice only, an increase in hepatoblastomas (described as `a relatively rare rodent malignant tumour type'). The significance of these results to humans is unknown' say Novartis, the company selling Ritalin.

Here, once again, is yet more proof of the total worthlessness of animal experiments and the ruthless and cynical attitude shown by drug companies and those government departments which allegedly exist to protect the public from unsafe drugs.

I have frequently argued that when drug companies perform pre clinical tests on animals they do so knowing that if the tests show that a drug doesn't cause any problems when given to animals they can use the results to help convince the authorities that the drug is safe.

On the other hand when a drug does cause a problem when given to animals the results can be ignored on the grounds that `the significance of these results to humans is unknown'.

The question here is a very simple one: if the experiments on mice which showed that Ritalin causes cancer were of value why is the drug still available on prescription for children? And if the experiments can safely be ignored (on the grounds that animals are so different to human beings that the results are irrelevant) why the hell were the tests done in the first place?

Ignorance And Misplaced Trust
My own feeling is that the people who told you that Ritalin is 'very safe' are either unable to read or too lazy to do any research into the safety of a product which they are recommending with such enthusiasm.

Years of experience mean that I am not in the slightest bit surprised to find such crass stupidity exhibited by social workers. I am, however, more surprised to find school teachers showing such a potent mixture of ignorance and misplaced trust. Some observers claim that Ritalin can be considered for a children when tests and clinical examinations have shown the existence of a clear neurological disorder - with abnormal brain wave patterns.

Psychiatrist, psychologist, health visitor, teachers, GP and parents should, it is said, all be considered before considering treatment.

Even the company selling Ritalin says that `Ritalin treatment is not indicated in all children with this syndrome and the decision to use the drug must be based on the physician's evaluation of the child's history and the duration and severity of symptoms'.

However, despite this, when a team of researchers from the United Nationals International Narcotics Control Board examined the records of nearly 400 paediatricians who had prescribed Ritalin they found that half the children who had been diagnosed as suffering from MBD (or ADD or whatever) had not been given psychological or educational testing before being given the drug. The United Nations concluded that frustrated parents, teachers and doctors were too quick to stick a label of ADD onto children with behavioural problems (or, to be more accurate, to children whose behaviour was annoying the parents, teachers and doctors).

Less Than Enthusiastic
I am less than enthusiastic about this drug. In my view, the world would be a healthier place if all supplies of this wretched drug were wrapped in concrete and buried in the rubble of the headquarters of the company making the damned stuff.

You might have guessed by now that I wouldn't prescribe Ritalin for anyone - for anything.

But other doctors clearly don't agree with me. Some observers have described Ritalin as a drug that can unlock a child's potential. And although estimates about the number of children taking Ritalin vary in the U.S. alone it has been claimed that up to 12 % of all American boys aged between 6 and 14 are being prescribed Ritalin to treat various behavioural disorders. In 1990 the world wide production of the drug was less than three tonnes. By 1994 production of the drug had virtually trebled. It is now not unknown for schools to arrange for children to be treated with Ritalin without obtaining parental permission.

It is worth remembering that although doctors, parents and teachers have for over thirty years now been enthusiastically recommending the use of Ritalin (and similar drugs) in the treatment of MBD there are still a number of unanswered questions.

We still do not know whether the drug works and nor do we know whether it causes any permanent long term damage. We do not know whether the listed potential side effects do more damage than any possible good the drug might do. And, perhaps most astonishing of all, despite the fact that millions of children have been diagnosed as suffering from ADHD, ADD or MBD, and treated with powerful drugs, we do not even know whether any of these conditions - or hyperactivity - really exist.

Back in 1970 the Committee on Government Operations of the U.S. House of Representatives studied the use of behaviour modification drugs on children. At that time around 200,000 to 300,000 children a year in the U.S. were being given these drugs and the point was then made that hyperactivity is considered a disease because it makes it difficult for schools to be run `like maximum security prisons, for the comfort and the convenience of the teachers and administrators who work in them...'.

Since then the only thing that has changed is that the popularity of Ritalin has continued to rise and rise and rise inexorably.

Prescribing Ritalin is, in my view, authorised child abuse on a massive, global scale.

But it is clear that the prescribing of powerful mind altering drugs for small children is big business.

In the US the use of antidepressants and stimulants among toddlers aged between two and four tripled between 1991 and 1995. The period between birth and four years of age is a time of great change in the human body. Most importantly it is a time when the brain is maturing. Heaven knows what effect these drugs have on those tiny developing brains.

Ritalin is now widely prescribed for toddlers. So are many other antidepressants, stimulants and other powerful drugs. Remember: typical symptoms of this alleged disease include `restlessness' and `inattentiveness'.

I am delighted that my protests and complaints about these absurd and obscene prescribing habits have drawn a number of vicious complaints from doctors.

In my view every doctor who prescribes such drugs for children with alleged ADHD should be defrocked, given a good thrashing with genetically engineered stinging nettles and forced to emigrate to the USA.