Should We Give Our Children Ridelin?

Great Debates
21

If anything, my mother kept me from sugar and caffeine as a kid, because she noticed my tendency towards hyperactivity.

I was almost NOT diagnosed-because at the time I was, my sister had just been born, and my parents and my teacher thought I was acting out because of jealousy issues. Nope. Then my cousin was diagnosed. My mom talked to my aunt, and took me to a therapist. I don’t remember all that happened (it was a long time ago-I was only six), but I had to go through a whole battery of tests.

I never thought about going off my Ritalin, until once missed my pill a few times in high school. I NOTICED the difference. I was all over the place, concentration was a nightmare, my appetite was HUGE (I mean, out of control where I was thinking of food and couldn’t concentrate on class), etc.

It isn’t like not wanting to behave. It’s that you literally cannot focus. It’s near impossible. And then on the other extreme, you sometimes get so involved that you HYPER focus, to the point of shutting everything else out.

It’s not fun.

22

2 things I want to mention:

  1. FWIW, the doctors of various sorts I’ve encountered in the recent past are far more reluctant to hand out a 'scrip for Ritalin than you might beleive. OTOH, this is what I’m seeing from my perspective as an adult – and I understand doctors are much more reluctant to encourage people past a certain age to ingest amphetamine on a daily basis.

  2. I think there is a common misconception that ADD == Bouncing off the walls. It does not. That can be a symptom, but the disease is much more complex. I think Magiver hit it on the head. I’ve always described it as “I can feel the thoughts floating around in the back of my brain, but I can’t get them to my mouth or my fingers”. This results (for me) in a very short attention span, because it’s next to impossible to accomplish anything in a reasonable amount of time unless I’m VERY into it to begin with. This can be very frustrating. And in adulthood, this typically manifests itself as irratability, anxiety, or depression. I wasn’t diagnosed with ADHD as a child (although I probably would have been - my parents just never took me to the doctor), but I imagine that this frustration was manifesting itself in the form of acting out, and generally being a little s***. Some people might characterize my behavior back then as “bouncing off the walls”, but I wasn’t exactly a spaz.

I agree that if you pump your kids full of sugar and caffeine, it probably won’t end in positive results. I also think that some kids are more likely to… well, bounce of the walls. But just because somebody is hyper in no way means that they have ADHD.

I think this is more or less what you were trying to say, but I wanted to reiterate because I think this is a common misperception among a lot of people.

23

Interesting note: I take an over the counter medication that has the exact opposite side affect from my sister’s experience. I get a “mellow” effect and my sister gets nervous. I’ve asked other people how they feel when they take the drug and it is usually one reaction or the other. As of late, the drug has been repackaged with specific selling restrictions, so I assume it is being abused. Unlike ritalin, this drug affects my memory and specifically my speech, in a bad way.

24

Exactly-it wasn’t always like bouncing around, it was more like being squirmy. I remember pacing the floors mumbling to myself while we were standing up in the front of the room for our vocabulary lesson. One day I sat down and started to lay down. I wasn’t bouncing, I was fidgeting. I couldn’t get comfortable.

And my thoughts came too fast-my mouth was always five steps ahead of my brain. OY!

25

I distinctly remember having problems getting words out. My parents would ask me a question and were often miffed at my silence when I was really only trying to compose a sentence. It would be interesting if a questionnaire could be made to see how many common experiences ADD kids had and how they changed over time.

In 1st grade I could read fluently (aloud) from our storybooks and was surprised at how other kids struggled. Advance in time and my vocabulary maintained pace but my comprehension went down.

26

I take medication for ADHD every day (Concerta, 54mg). I can see a difference when I forget to take my medication. I can’t focus any one thing at a time, making it extremely difficult to concentrate. Conversely, once or twice I have accidently taken an extra pill (I am not a morning person). To agree with scotandrsn, I was a zombie. It took me forever to respond to questions asked of me, not because I couldn’t answer them, but because I mulled over the answer I was going to give in my head for a good 20 seconds before I said anything. I guess it would give the appearance of me being a zombie to anyone watching, though I was fully aware and awake in my head.

27

Where to start, where to start. For one, it seems that we have dispensed with the notion that children with ADHD simply need their parents to look after and control them. If this were the case, it seems to me that they would not appear any different than children with other behavioral disorders, namely ODD and CD. However, all three of the disorders are distinct from one another (Loeber, Burke, et al., 2000; J Am Acad Child Adolesc Psychiatry). Additionally, the symptoms of the disorder would also suggest that Parkerz explanation simply could not account for meeting these criteria. Finally, first hand observation and clinical experience suggests qualitative differences for these children compared to their peers. (We also have testimonials within this thread that argue against this explanation).

Secondly, does anyone have empirical data regarding the “overprescription” of stimulant medications? For this, one would need to demonstrate a significant increase in the misapplication of stimulant medications, either in terms of being prescribed when other therapies might be more effective, or when the condition at hand is not actually ADHD. Safer (2000; Ann Clin Psychiatry) reviews existing literature to suggest that the observed 3 fold increase between 1990 and 1996 in the prescription of stimulants (note that this does not equate to erroneous or inappropriate prescriptions) is not notably higher than during similar durations of time between 1971 and 1990. He also cites a finding that one quarter of those diagnosed with ADHD were not prescribed medications.

The conceptualization of ADHD has undergone vast reworkings since the mid-1900’s, including its original formulation in the first DSM in 1968. Originally it was regarded as “minimal brain damage” or “minimal brain disfunction.” The term ADHD is not “in vogue,” it is the diagnostic label for the condition. The symptoms are not tentative research criteria, Goodbeam. It must have been a while since your “work” in the field. The criteria remain largely unchanged from DSM III-R in 1987 (we are now in DSM-IV, since 1994) (nor were they drastically different in DSM III (1981). The only real changes from III-R to IV were the deletion of the “acts in dangerous ways” criterion, and the organization of the symptoms back into inattentive and hyperactive-impulsive dimensions. Interestingly, recent research by Frick et al (2000) suggests that symptoms that were left out because they were not sensitive enough, those denoting a “sluggish cognitive tempo” (daydreams, seems lost in a fog) should be reintroduced.

Goodbeam, I also need to point out that your links are junk. The first does not rely on empirical data, and the side effects link is to a site that is peddling a competing substance!

As a side note, I published findings in 2001 (Journal of Child Psychology and Psychiatry) that boys with ADHD in childhood were at greater risk for tobacco use in adolescence, even when controlling for ODD and CD. I speculated that the cognitive effects of nicotine served to ameliorate the attentional deficits the boys experienced.

Beagle, do you have questions about ODD?

28

I forgot to include this summary of diagnosis and treatment.

Root, RW, Resnick, RJ (2003). An Update on the Diagnosis and Treatment of Attention-Deficit/Hyperactivity Disorder in Children. Professional Psychology: Research and Practice, 34, 34–41

29

I’ve been diagnosed with ADD in the past, and prescriptions shoved at me. I’ve also had a therapist say “No…borderline, maybe, but definitely not at the point where medication is useful.”

My experience with Ritalin: bad. It did help me focus a little more in the classroom (this was in 6th-7th grades), as I was distracted by less. It also rendered me completely inable to write. My mind worked too slowly to do it: when I write, I get in a zone not dissimilar to an athelete in a hugely important game/meet/match. Outside stimulus is muffled, and your body (in this case, my mind) leads you. When I was on Ritalin, this just didn’t happen - I couldn’t help but stop and think about what I was writing, which made it sound forced. Writing was (always has been) my main emotional release, as I’ve always (always have, always will) been extremely introverted. Talking things out is painful for me to the point of being counter-productive. I ended up as an angsty pre-teen with no way of getting the ‘bad stuff of my mind’ out in a constructive form. This was a Bad Thing. The Ritalin also noticably slowed down my reaction time at TKD, which was also a Bad Thing.

OTOH, a good friend of mine also has ADD. Amazingly, it went undiagnosed for a long time. She finally got a correct diagnosis, takes Ritalin, and the change is astounding. She went from struggling through basic-level or remedial classes to getting all A’s in advanced-level classes and being in the top 15% of our class. The change in her self-confidence is really amazing as well.

Ritalin (and other drugs) can be useful in some situations. They’re grossly over-used, though, and they are used as a crutch for behavioral issues. In 6th grade, I couldn’t pay attention in class because I was bored and naturally get distracted easily. These two fed on each other, and I ended up missing homework being assigned, not being able to focus on tests, etc. My standardized test scores were always high (I got an 1180 on the SAT in 7th grade), nothing else was. The reason: there were distractions in the classroom, and I was bored, because I read most of the reading list 3 years previous, when my sister was in that grade. The solutino to this problem was assumed to be "ritalin so she focuses’’, which ended up being ‘ritalin so she can’t do anything.’

I’ve got very mixed feelings on the topic.

30

“Harrison Bergeron” by Kurt Vonnegut, Jr.

31

Harrison Bergeron by Kurt Vonnegut
As my profile says, I also have ADD. IIRC I was put on Ritalin back in the third grade. I needed it. At the time, the average person had never heard of ADD.

While medicating children unnecessarilly is a bad thing, not medicating kids with ADD/ADHD is like not giving insulin to diabetics. It is not a matter of bad parenting. lack of something constructive to do or anything similiar. My neurochemistry does not function normally. My current psychiatrist (Dr Amy Brodky, marvellous doctor) wanted to make sure that my medications were needed and were not causing problems. She eased me off my pills. Nasty, nasty things happen to my brain when there’s no methylphenidate in it.

32

The last time I did much thinking about child psych was three or four years ago, when I had a class with a very well-respected prof in the field. His contention was that ADHD was not overdiagnosed in the population as a whole. Estimates were that about 5% of kids had ADHD symptoms to the degree that they could benefit from medication, and about 5% of kids were on medication at that time. Trouble is, they weren’t the same kids. Among middle- to upper-class white boys, it was very liberally diagnosed, less so among white girls and boys from minority groups, and practically unheard of in minority girls.

Of course, there are plenty of parents out there in the “we’ve tried nothing, and we’re all out of ideas!” camp, who will inquire about ADHD rather than trying to impose any structure. And yes, docs will usually err on the side of prescribing the medication–but why shouldn’t they? Side effects are generally mild and self-limiting, so the downside of treating those who will not benefit is minimal. Those people can simply stop the medication and/or try something else. Those who do benefit–well, they benefit. From a game theory standpoint, it makes sense to err on the side of a medication trial.

The “diagnosis by therapeutic trial” is not unheard of. My most common example is GERD; if you have heartburn symptoms that sound attributable to GERD but not quite classic, I can send you for expensive tests, or I can try you on Pepcid or Prilosec for a month. If you get better, you get better; if not, we try something else.

What about diet? Studies like this one suggest that the link between sugar and hyperactivity in kids is not well-established. Caffeine can, of course, cause some hyperactivity, but it also stimulates some of the same areas of the brain as Ritalin, and can thus be beneficial in the same way. Indeed, many adults with untreated ADHD self-medicate with massive quantities of coffee. (I certainly did.)

Can exercise help? Well, I’m not about to start telling my patients to exercise less. If nothing else, exercise improves sleep, which makes anyone feel more alert, ADHD or not.

The bottom line, though, is that two things are necessary to treat ADHD (in the words of a psychologist I’ve worked with): 1.) structure, structure, structure, and 2.) taking the damn medication. Either of those things without the other will help some, but not nearly so much as the combination. It does a disservice to a kid to put him on medication that doesn’t help (or helps marginally) without making any other changes, but it does an equal disservice to a kid to put him on a Feingold diet and make him do laps around the yard every night when Ritalin would be vastly more effective.

Dr. J

33

Back in my college student days I tried Ritalin recreationally. In me it produced a more than mild euphoria and a sense of heightened perception. I could have stared for hours at a Cheez-it in endless fascination.

Ritalin has a recreational history going back to the 60s, and was considered a choice recreational amphetamine.

I don’t know about doses, or if it affects people with ADD differently, and I am not qualified in any fashion except through my anecdotal experiences as a College student, but it does seem a scary drug to me.

34

Exactly. IMO, if medication significantly improves a kid’s symptoms, then he is not being “overprescribed”, and if it doesn’t, then he needs to stop taking it. “Overprescription” should not be an issue.

I won’t speak for him, but by “research criteria”, he may not mean “tenative”. It was drilled into my head when I did psych that DSM criteria are primarily for research purposes; they define specific populations so they can be studied.

Someone who falls just short of the DSM criteria for (say) depression may still benefit from an antidepressant. However, when we’re studying the effectiveness of antidepressants, we have to strictly define who we’re calling “depressed” so we can compare apples to apples. Thus, we know that people who meet DSM criteria for a disorder, as a group, benefit from treatment for that disorder, but we don’t know that other people don’t.

Dr. J

35

One of Dr. J’s laws of medicine–any drug can do anything. Benadryl, for instance, puts most people to sleep, except for some people who it wires up. Ritalin can freak some people out, while others can take it and barely notice any difference.

I can’t begin to tell you the difference in me since I started medication. I know for a fact I wouldn’t have gotten through medical school; my classes required me, for the first time ever, to think about things for more than ten minutes at a time, and it was trouble there that led me to a psychiatrist. It was like night and day.

Last year, not long after I started my internship, I went off the medication for a couple of months; despite my advocacy, I still have occasional fits of “Oh, you don’t need that stuff!” The result? A near-breakdown at the end of September, from the weight of the frustration and the inability to do anything right. I finally opened up to my program director and a few others about it, and they (good-naturedly) pronounced me an idiot–“What would you say to a patient who was taking a medication that improved his life considerably, who just stopped taking it for no good reason?” They were right, and I had to start the medication back to see just how right they were.

Those who fear Ritalin can rejoice at the arrival of Straterra, a completely different medication that apparently works just as well as Ritalin (as a whole). It isn’t a stimulant, and it isn’t even a controlled substance like Ritalin is, so it will be much easier to prescribe. IIRC, it’s also a once-a-day drug, so no more dosing at school. It’s going to change the face of ADHD, and the cries of “Overprescribed!” may only get worse.

Dr. J

36

Can you provide a non-biased link with Straterra info?

37

I am also very interested in anything that you have on Strattera. The majority of parents that I have seen for evaluations during the past month or two are aware of and interested in Strattera. I saw someone last week who reportedly had just started it that day. The effect was apparently stunning - greatly diminished hyperactivity, improved interactions with his brother, reduced noxious behaviors such as noise-making. I am particularly interested in any information regarding the effects of Strattera on comorbid tic disorders, which are often, it seems, exacerbated by stimulants.

38

Thanks Dr J That is indeed what I meant. This, as far as I know, is still the case today with DSM-IV.

I apologize for the mediocre links, Hector. Your references are indeed (I’m not being cynical here) more to the point. Thanks.

tomndebb Yes ADHD has its physical counterparts. For me, the question about the causality of the physiology of ADHD remains. Mind you, this is not an argument against medication. Again, when it does more good than bad, there’s no reason not to do it. I can still imagine a lot of parent being scared for giving their children medication that they might need to take the rest of their lives.

39

Well, he specifically described them as “tentative,” so that was how I took it. It seemed that he was suggesting that the DSM-IV criteria for ADHD are tentative and somehow not empirically supported or extensively tested yet. Clearly this is erroneous.

40

Whoops, I posted just a hair too soon. I don’t understand this assertion. DSM is the “Diagnostic and Statistical Manual for Mental Disorders.” These are the criteria that define mental disorders for clinical and research purposes. Clinical judgment is always at one’s discretion, but these criteria are the standard for practice. They are not restricted to research purposes. Unless I am missing the point you are both asserting.