This article was originally published in Maclean’s magazine on March 11, 1996. Partner content is not updated.Obscure and poorly understood two decades ago, when it was known as hyperactivity, ADD is now one of the most commonly diagnosed behavioral disorders in children. Researchers believe it is inherited, and grown-ups - especially the parents of ADD children - are being diagnosed in large numbers, too.
Ritalin DebateIn most ways, Ian Sanders-Rifle is a regular kid. He thinks some of his Grade 11 classes in Richmond Hill, just north of Toronto, are "OK" while others are "horrible." His favorite sports are baseball and basketball, and when he gets together with friends, they indulge in the usual teenage pastimes - hanging out, watching TV. He is an accomplished cartoonist, who hopes to make a career in computer animation. But the 17-year-old also grapples with an unseen burden: Ian has attention deficit disorder, a condition that afflicts between three and five per cent of Canadian children - especially boys. When he forgets to take his medication, the stimulant Ritalin, he can hardly sit still. "I get very, very hyper," he says. "And I get very stupid. I'll know something is wrong, like shouting, but I'll do it anyway." The drug imparts a welcome inner calm, he says. "There's a pretty big difference - when I'm on it, I can sit still for 30 to 40 minutes, instead of two, max."
Obscure and poorly understood two decades ago, when it was known as hyperactivity, ADD is now one of the most commonly diagnosed behavioral disorders in children. Researchers believe it is inherited, and grown-ups - especially the parents of ADD children - are being diagnosed in large numbers, too. New clinics have sprung up to treat ADD, and experts are in constant demand as speakers. Often, they describe kids who seem like classic troublemakers. Many children with ADD are too fidgety to tie a shoe properly, much less listen to a teacher. They are wildly impulsive and easily distracted, pushing adult patience to the limit. Yet many are also brimming with imagination and enthusiasm - and, surprisingly, a significant number can focus on certain tasks with laser intensity. "This is an elusive and complex disorder," says Denise Fruchter, a former special education teacher who now runs a summer camp for ADD children in the Muskokas, about 150 km north of Toronto. "These kids can be very challenging, but they can also be absolutely wonderful."
Some experts, on the other hand, argue that the flurry around ADD is overblown. For one thing, some cases seem so mild that they cause little disruption. And while few skeptics dispute the existence of the condition, first thoroughly documented by McGill University psychologist Virginia Douglas in the 1970s, they point out that ADD is simply a label for a set of symptoms that non-ADD kids may also display from time to time. For instance, children enduring neglect or abuse may exhibit ADD-like symptoms, such as poor attention span. And adults unable to keep a job or a spouse could seize on the disorder as an excuse. "Right now," says Russell Schachar, a psychiatrist at the Hospital for Sick Children in Toronto and a longtime researcher in the field, "there are a lot of people who require an explanation for the failures they are experiencing."
The questions have spilled over to Ritalin, a drug commonly prescribed for ADD. Between 1993 and 1994, prescriptions for Ritalin in Ontario jumped by 45 per cent, to 125,000. Prescriptions in Alberta in the first nine months of 1995 rose by 22 per cent - to 27,501 - compared with the previous year. Some experts believe that doctors and even teachers are too quick to recommend Ritalin - which can have powerful side-effects - as a way of subduing unruly children. "It's diagnosis by prescription," says Patrick Baillie, a psychologist at the Calgary General Hospital. "I'm not against Ritalin, per se, but adequate assessments of children are not being done." Last week, the Vienna-based International Narcotics Control Board - acting at the request of U.S. officials - released a report documenting a dramatic increase in the use of Ritalin to treat American children, and warning of its overuse. The drug's manufacturer, Ciba Pharmaceuticals of Summit, N.J., responded that the drug has proven safe in more than 40 years of use, and that, in any case, prescriptions for Ritalin should always be preceded by a thorough medical evaluation, usually over a period of weeks or months.
How did ADD get to be so prominent, so fast? Television played a part, with segments on such popular U.S. shows as 20/20 and Oprah sparking waves of interest. And Driven to Distraction, a 1994 best-seller by Boston-area psychiatrist Edward Hallowell, convinced many that they are afflicted. In his sympathetic, easy-to-read book, Hallowell notes that ADD children are often viewed as social misfits. Without realizing it, they miss basic conversational cues, blurt out tactless comments, and shout or shove over minor frustrations.
Some - often nurtured and encouraged by parents or teachers - do manage to grow into bright and energetic adults, excelling in creative, high-risk professions such as the arts, sales and business. But others, after a childhood pockmarked by academic failure, parental anger and social isolation, turn into resentful, discouraged adults. "I have one patient who had 52 jobs over a 30-year period," says Umesh Jain, head of the 18-month-old Adolescent and Adult ADD Program at the Clarke Institute of Psychiatry in Toronto. "Boredom and poor interpersonal relations can sabotage them."
With so many potential pitfalls, relief in the form of a pill can be appealing. And there is no question that methylphenidate, manufactured under the trade name Ritalin, has salvaged the lives of many children with ADD. In moderate doses, stimulants like Ritalin can have the surprising effect of calming children with ADD. The whirling inner chaos of constant distraction abates and they are able to focus on particular tasks and complete them. Impulsive, aggressive behavior declines, leading to an improved social life: some parents report that their children begin receiving party invitations for the first time in their lives.
But Ritalin is a powerful drug with properties similar to amphetamines, or "uppers," and many doctors are cautious about its use. Side-effects can include a racing heart, nausea, headaches and insomnia. A recent study by the National Toxicology Program of the U.S. department of health and human services also found that massive doses of Ritalin may cause cancer in mice, although the link in humans is unsubstantiated. U.S. health authorities said the findings do not justify taking Ritalin off the market, but in January, the manufacturer agreed to inform doctors about the study results.
Although not a true amphetamine like Dexedrine, Ritalin in large doses can lead to dependence. In Canada, Ritalin has been a controlled substance under the federal Food and Drug Act since 1984, making it more difficult to obtain. Still, it has been a favorite with drug abusers in cities where more popular narcotics like cocaine and heroin are unusually expensive. In Saskatoon earlier this year, police sounded the alarm over a rash of break-ins in homes where a family member was on Ritalin. Frequently, only the pills were taken. Teenagers on Ritalin may sell their pills - they bring $10 to $20 a tablet. Worse, younger children on the drug may be terrorized by teens looking for a hit.
Just as troublesome is the suggestion that a diagnosis of ADD is sometimes too convenient. Calgary psychologist Baillie believes that teachers facing program cuts and bigger classes may be tempted to suggest Ritalin as a way of obtaining peace in the schoolroom. But in many cases, he says, children who are depressed or anxious because of troubles at home can display all the hallmark symptoms of ADD: undirected energy, impulsive behavior and poor attention spans. "Maybe teachers are not saying it directly," he says, "but many parents feel they are being pushed to try Ritalin."
Teachers counter that they tend to be more cautious than either parents or doctors in medicating children. Home, they say, is where most behavioral disruptions originate. "From time immemorial, there has been at least one kid in the class who hangs from the chandeliers," says Bauni Mackay, president of the Alberta Teachers' Association. "But society labels everything now and ADD is one of the common labels."
Confronted with a definitive diagnosis of ADD, but determined to stay clear of drugs, some parents, doctors and teachers are looking for alternatives. Psychiatrist Bud Rickhi, executive director of the Research Centre for Alternative Medicine in Calgary, says he began looking for a drugless treatment for ADD after encountering children who complained that Ritalin left them feeling agitated or lethargic. In conjunction with the University of Calgary and the World Health Organization, he is exploring the use of biofeedback to "rewire" the brains of ADD children. Researchers believe that ADD is caused by an imbalance among brain chemicals known as neurotransmitters. Rickhi's method uses lights and sounds to stimulate the chemical pathways that ADD children lack. The board of education in Medicine Hat has already expressed interest in participating in the study. "The effects of this technique are permanent," Rickhi says. "Children get better grades and adults get better compliance."
Most doctors agree that even patients who respond well to Ritalin require large doses of encouragement and help with modifying behavior. And sometimes, a no-drug approach is all a child can tolerate. When Ben Fox started Grade 1 at age 6, school authorities in a community near Saskatoon advised his mother to put him on Ritalin. Judy Fox refused and instead fought for a teacher's aid. "I think they were just looking for an easy way out," she says. "They told me I was wasting taxpayers' money, but I think saying no to Ritalin was the best thing I ever did."
Finally, when Ben was 9 and in Grade 4, school authorities in the Vancouver Island community where the family now lives demanded that Ben be put on Ritalin or removed from school. "He was throwing things, disrupting the class," Fox says. "A change in the wind can set him off." She reluctantly agreed, and tried Ben on Ritalin for about 10 days. "It was terrible," she says. "I could hear the doors slamming at school. He was sobbing, having night terrors." Ben was taken off the drug and enrolled in a six-week, residential program at the Queen Alexandra Centre in Victoria, where he learned new techniques for staying focused and controlling his anger. Now 11, he attends regular classes and is supported by a full-time teacher's aid. "This is an awful, awful burden," acknowledges Fox. "But Ben is also an imaginative, affectionate child and he is always very remorseful. And he has a great sense of humor. Without that, I don't know what we'd do."
Maclean's March 11, 1996