The use of Ritalin to calm hyperactive students in Baltimore County fell sharply between 1989 and 1991 after a two-decade climb that provoked an emotional debate and made the county one of the nation's leading consumers of the drug.
Writing in today's Journal of the American Medical Association, two doctors with the Baltimore County Department of Health say the decline followed a flurry of media reports that aroused fears over the drug's alleged side effects.
Dr. Daniel J. Safer, a psychiatrist with a county mental health center, said yesterday that the drug's popularity peaked, then fell in the late 1980s when media reports publicized concerns about a drug he thinks helped thousands of local children focus on their school work.
"I think the medication was used appropriately, and some of the children who were taken off became more problematic in their school adjustments," said Dr. Safer, who treats children at a mental health center in Rosedale.
During the 1970s and 1980s, the percentage of students taking Ritalin in the county's public elementary schools doubled every four to seven years, to the point where one out of every 17 children (5.9 percent) was taking the drug in 1987.
This was two to three times the national rate, and helped propel Maryland into the top four states in Ritalin use.
But the trend was not to last. Between 1989 and 1991, the Ritalin use across the county's elementary, middle and high schools fell 37 percent -- placing the county much closer to the mainstream.
At the peak of the drug's use in 1987, about 2,811 children enrolled in county schools were taking Ritalin, the largest number in the elementary schools, where problems of hyperactivity and inattentiveness tend to surface. By 1991, the number had dropped to 1,795 children.
Overwhelmingly, the downward trend resulted from fewer children's being started on Ritalin, rather than youngsters' being taken off the drug. Dr. Safer said he didn't know whether hyperactive children who could have benefited from Ritalin were falling behind or disrupting classrooms because they never got the medicine.
That would require a look at students' personal files, which are off limits to researchers, he said.
But school nurses reported frequent problems among students who were taken off Ritalin after responding well to the drug. Ritalin is prescribed for children who are physically restless and may also have problems focusing on tasks for any length of time.
The drug actually is a stimulant. Many experts believe it helps spur a chemical reaction that normally enables people to refrain from getting distracted or acting without thinking.
In the late 1980s, considerable publicity was given to the rising rates of Ritalin use, and to threats by a Washington lawyer affiliated with the Church of Scientology to file a class-action lawsuit against Baltimore County over what he characterized as the inappropriate use of Ritalin.
But the controversy was wider than that: Many parents questioned whether Ritalin was being used as a "crutch" to calm youngsters who really needed counseling and closer attention from their teachers.
Some charged that teachers were aggressively suggesting Ritalin, a practice that would be outside their field of expertise since only doctors can legally recommend and prescribe a drug.
School officials insisted that teachers, school nurses and psychologists can alert parents to a child's problems and perhaps recommend taking the youngster to a doctor. But they cannot recommend the use of any drug, officials said.
Most of the parents who took their children off Ritalin said they were concerned about side effects and the concept of giving medication to control hyperactivity. And most said their concerns were based partly on television and newspaper accounts of the issue.
Dr. Safer said side effects were rare, and can include upset stomach, headaches, nervous ticks and sleeplessness. Most of the side effects are minor and disappear with time.
"There's been a heightened concern that in many cases I think was unwarranted," said Linda Schuerholz, a psychologist at the Kennedy Krieger Institute who evaluates children with behavior and learning disabilities. "There are probably a number of kids who should have been on medication and were not on medication."
But Dr. Paul Lavin, a Catonsville psychologist who is an outspoken Ritalin critic, said the decline shows that parents have become better educated about other methods of controlling hyperactivity. He said these include behavior modification, a program based on rewards and incentives, and a dietary regime based on the elimination of food additives.
"It's not just a backlash against Ritalin," said Dr. Lavin, an assistant professor of psychology at Towson State University. "A lot of people were looking for other alternatives."