Though some forms of behaviour that might be termed “hyperactivity” or “social maladaption,” especially in boys, has been documented since the 19th century, it is only in recent decades that such symptomatic behaviour has been clinically diagnosed, labelled as disorder, and treated with medication, usually amphetamines. The diagnosis and psychopharmacological treatment of Attention Deficit Disorder (ADD) or Attention Deficit Hyperactivity Disorder (ADHD) has in recent years become widespread, especially in North America. The organization CHADD (Children and Adults with ADD) in its internet “Fact Sheets” gives us a menu of degrees of disorder and estimated percentages of occurrence, claiming that 1% to 3% of school-aged children have full-blown ADHD, and that 5% to 10% exhibit a partial set of symptoms with “other problems, such as anxiety and depression present” (CHADD, 1999c). They also note that “another 15% to 20% of the school-aged population may show transient, subclinical, or masquerading behaviors suggestive of ADHD.” One writer (Millar, 1996) claims that the number of people in the United States diagnosed with ADD or ADHD had risen from 900,000 in 1960 to over 2,000,000 at the time of writing. He also asserts, “It is estimated that 10 to 12% of all American boys between the ages of 6 and 14 are using the drug (Ritalin)” (Millar, 1996, p. 1). In 1987, Paul Wender stated categorically in the introduction to his book that “there are probably five million ‘hyperactive’ children in the United States.” Patti Johnson, a member of the Colorado State Board of Education, writing in 1999, makes the claim that “between 10 percent and 12 percent of U.S. boys are being treated with Ritalin” (Johnson, 1999). Another author, Peter Breggin, appears to agree with Wender’s earlier estimates: “While estimates vary widely, the total number of children on Ritalin has probably increased to 4-5 million or more per year” (Breggin, 1998 as cited by Barkley, 1999). In a review published on the internet by CHADD, the well-known researcher and expert on ADHD Dr. Russell Barkley (Barkley, 1999) objects to the figures cited by Breggin, saying, “We are asked to take Breggin’s subjective and biased impressions over the available scientific research on the matter” (Barkley, 1999). The “scientific research” to which Dr. Barkley has reference is a study reported by Daniel Safer (Safer et al, 1996) five years earlier. This study concludes that between 1990 and 1995 methylphenidate (Ritalin) treatment increased, on best-estimate average, by 2.5 times, meaning that in the U. S. some 1.5 million youths between the ages of 5 and 18 were being treated with Ritalin in 1995.
While it is not clear from what sources Dr. Breggin draws his conclusions, it is also not clear what Dr. Barkley thinks would have happened between the Safer study of 1994-1995 and his review of Breggin’s book in 1999. Anecdotal evidence, a multiplicity of articles, books, and web pages suggests that public awareness of the diagnosis of ADHD and the use of Ritalin and other amphetamines as treatment has increased dramatically in recent years. When I mentioned to friends and acquaintances that I was writing a paper ADHD, just about everyone had some comment to make. The general feeling is that the disorder, if it can be called that, is over-diagnosed and that amphetamines are over-prescribed. Whatever the truth of these opinions may be, it is obvious that there is a high level of public awareness, probably reflecting increased instances of diagnosis and Ritalin prescription. Almost everyone I spoke to either has a child on Ritalin or knows someone whose child is on Ritalin. In his book Ritalin Nation, Richard DeGrandpre presents us with the following alarming information: “The U.S. Drug Enforcement Administration estimates that by the year 2000, 15 percent of all school-age children (8 million) will go on to use Ritalin. Welcome to Ritalin Nation” (DeGrandpre, 1999)
It also seems that psychotropic drugs (drugs that are designed to affect mental processes, such as tranquilizers) are being administered to younger and younger children. A more recent study (Zito et al, 2000), published in the Journal of the American Medical Association, notes that “psychotropic medications prescribed for pre-schoolers increased dramatically between 1991 and 1995” (p. 1025). Like the Safer study mentioned above, this study deals only with the first half of the decade and only involved children enrolled in state-operated programs. Nevertheless, the conclusions are striking: “Stimulant treatment in preschoolers increased approximately 3-fold during the early 1990’s” (p. 1028). This means that approximately 1.5% of children age 2 to 4 years in the two U.S. Medicaid programs studied were receiving some form of stimulant medication. The authors account for this increase in four ways. They note that the criteria for ADHD diagnosis have expanded since 1980, that more girls are now being treated for the disorder, that medication treatment has become more widely accepted, and that school and preschool health personnel have become more active in identifying medical needs.
In an editorial article following the report of the above-mentioned study, Dr. Joseph Coyle refers to several other studies regarding children and psychopharmacological interventions:
Several recent studies provide additional evidence that the prescription of psychotropic drugs to very young children has increased during the last decade. In a review of information from the Intercontinental Medical Statistics Study, Minde [Minde, 1998, “The use of psychotropic medications in preschoolers: Some recent developments.” Canadian Journal of Psychiatry 43: 571-575] described a 3-fold increase in methylphenidate prescriptions in Canada and a 10-fold increase in the prescription of selective serotonin reuptake inhibitors in the United States for children 5 years old and younger between 1993 and 1997. This article also summarized findings from Strasbourg, France, showing that 12% of children beginning school were receiving psychotropic medications. (Coyle 2000 p. 1059)
According to Dr. Fred Baughman (1999) a Michigan study reported that 223 children, from 1 to 3 years old, who were in the federally funded Medicaid program had been diagnosed with ADHD and were on one or more psychotropic medications.
Dr. Coyle also indicates that the prescription of psychotropic medication is rarely accompanied by any other form of treatment: “While only a quarter of these children received psychological services, nearly 60% received psychotropic medications, and almost half of these were prescribed 2 or more psychotropic medications” (Coyle, 2000, p. 1059). In a recent talk, Dr. Gabor Maté, author of the book Scattered Minds claimed that 80% of children diagnosed with ADHD were prescribed Ritalin and no other treatment (Maté, 2000).
At the same time, it is important to note that there is a growing backlash to the widespread use of psychotropic medications, particularly on the very young. Several books published in the last few years are highly critical of the ADHD epidemic and the widespread medication of children. In addition to Breggin and DeGrandpre, who were previously referred to, there are The Hyperactivity Hoax (Walker, 1998), Running on Ritalin (Diller, 1998), and The Myth of the A.D.D. Child (Armstrong, 1995). In addition to books, there are numerous popular articles and internet sites criticizing or condemning current practices in child medication.
Following the release of Dr. Zito’s study mentioned above, U. S. senatorial candidate Hilary Rodham Clinton launched an initiative to question the use of drugs with children. As reported in The Christian Science Monitor:
The Clinton administration’s effort, while limited to younger children, sharpens questions about how much children of all ages are being medicated for disruptive behaviors. Recently, a United Nations panel criticized doctors in the United States for over prescribing psychiatric drugs. The panel reports that 80 percent of the world’s Ritalin is consumed in the US (Feldman, 2000).
It’s 90 percent according to a recent study by the Center for Science in the Public Interest (Jacobson & Schardt, 1999). This figure is also mentioned by Ms. Johnson of the Colorado State Board of Education (Johnson, 1999).
Quite a stir occurred recently (November, 1999) when the Colorado Board of Education passed a resolution discouraging teachers from recommending the use of psychotropic medications like Ritalin. Reporting in The New York Times, Michael Janofsky writes:
The resolution, the first of its kind in the country, carries no legal weight. But it urges teachers and other school personnel to use discipline and instruction to overcome problem behavior in the classroom, rather than to encourage parents to put their children on drugs that are commonly prescribed for attention deficit and hyperactive disorders (Janofsky, 1999).
Before leaving, for the moment, the question of widespread instances of ADHD diagnosis, there are two disturbing sidebars to note. Both of these are mentioned in Dr. Coyle’s article cited above. Based upon the study by Zito et al (2000), he notes: “As 3 of the 4 data sets are derived from Medicaid populations, the findings suggest that poor children are experiencing these changes in drug prescribing practices.” (Coyle, 2000, p. 1059) Dr. Coyle undertook an informal survey to confirm his suspicions:
To ascertain whether the prescribing practices documented by these recent reports represent informed practice, I surveyed the editorial board (48 physicians) of the Journal of Child and Adolescent Psychopharmacology by facsimile about their prescribing of stimulants, clonidine, antidepressants, and antipsychotics for 2- to 4-year-old children (unpublished data, November 24, 1999). … Seventy-two percent of the physician board members responded. Most (28 or 35) reported either no use or very rare prescribing of these medications in this age group, and only 3 reported prescribing clonidine on rare occasions. … The rarity of the use of psychotropic medications in very young children reported by experts in pediatric psychopharmacology suggests that they are much more reticent than the physicians treating the children in these studies. (Coyle, 2000, p. 1060)
The sociological implications of Dr. Coyle’s statements can only be regarded as alarming. However, that’s not all. Dr. Coyle goes on to say that there is “virtually no clinical research” on the effects of such medications on young children. Since there are a number of critical brain development events that occur between the ages of three and ten years, there might be concern surrounding the influence of medications which are designed to affect brain function. Animal experimentation has shown that the use of psychotropic drugs does indeed have long range effects on brain development including “persistent decrease in cortical synaptic density and in memory deficits in adulthood” (Coyle 2000, p. 1060).
As Dr. Coyle concludes, “Thus, it would seem prudent to carry out much more extensive studies to determine the long-term consequences of the use of psychotropic drugs at the early stage of childhood.” Perhaps it would be equally prudent to examine the effects of psychotropic medication on growing children of any age. But as we shall see later, it is probably unlikely that such research will be done in the near future.
Erica Goode (2000), commenting on the Zito study in The New York Times, notes the serious lack of data regarding the effect of medication on young children. “And even when doctors prescribe medication in a last-ditch attempt to help a very disturbed child,” she writes, “they are operating in a vacuum: little or nothing is known about the effects of psychiatric drugs on the developing brain or the long-term impact on social relations, academic achievement or personality in young children who take such drugs” (Goode 2000).
Please see the next page, ADHD Part Three, for continuation.