The Office of Drug Enforcement estimates that by 2000, fully 15 percent of school-age children will be taking ritalin for something. The question remains, "for what?" -- brattiness, boredom, reluctance, defiance? Whose attention is truly deficient -- kids' or parents'? (Or both?) Lately more adults are appropriating the diagnosis, using it to retroactively explain their own disappointments in life.
Few people familiar with ritalin are neutral about it. A milder form of speed and structurally kin to cocaine, ritalin is used to treat attention deficit disorder, a grab bag of unruly behaviors that interfere with some children's ability to learn and obey.
Once called ADD and now ADHD to include hyperactivity, the disorder is fully as controversial as its treatment. At one extreme are exhausted parents who believe family life would be unlivable without ritalin; their enthusiasm is shared by those who profit from the 700 percent increase in sales since 1991, including its manufacturer, which quietly contributed nearly $1 million dollars to ADHD support groups. Critics fear a generation of kids drugged into compliance instead of developing internal resources; they blame the psycho-medical establishment for pathologizing yet another human problem, and point to the lack of clear biological evidence that ADHD exists at all.
Between the opposing shores is a roiling sea of confusion. There's little doubt that ritalin works -- it is a powerful drug, after all -- but no one knows why. How can a stimulant calm a "hyperactive" child, anyway?
Advocates claim it's "paradoxical," that ritalin "activates the inhibitor," a vague calming mechanism presumed to reign in the seat of volition, the frontal cortex.
Detractors note that since ritalin increases focus in all kids, it's not treating any special disorder. The official psychiatric diagnosis requires a behavior checklist, including "not remaining seated when expected to do so" (Criterion A2b) and "having difficulty awaiting one's turn" (A2h).
Since the verdict turns on the perceived frequency of transgressions, it's easy for frazzled caretakers and sympathetic helpers to confer the subjective diagnosis -- and no laboratory tests to prove them wrong.
One thing is irrefutable: the suffering of families wrestling with their kids' maddening behavior. Many devoted, careful parents struggle for years to differentiate "can't" from "won't"; finally baffled by the self-defeating behavior of their otherwise good and intelligent kids, they're relieved to blame a neurological glitch.
In this they get passionate support from "Understanding ADHD" by Christopher Green and Kit Chee (Ballantine, 320 pages, $12.95), which claims to be "The Definitive Guide" but is packed with muddy assertions: "There is controversy only in the media, not in reputable professional circles," and "academics ... only see what they read in books, while we have to cope with the variables of real life." (One breezy heading is "Reality before Science.")
Stretching the loose diagnostic net to include "behavior out of step with parenting," the authors warn that, without ritalin, ADHD "can drag clever parents and children down the social and financial scale."
Such achievement concerns are indicted in the thoughtful "Running on Ritalin" (Bantam, 386 pages, $25.95), where pediatrician Lawrence Diller worries that ritalin is being cynically prescribed to narrow the gap between IQ and performance in a kind of "cosmetic psychopharmacology." Alarmed by the increasing demand for a drug whose long-term effects remain unknown, he demonstrates how contributing psychosocial factors -- family dynamics, attitudes toward free will and responsibility, marital dysfunction -- are trampled down in the stampede to make kids successful: "Should we, even with the best intentions, force kids into academic and career paths not well-suited to their personalities and abilities, and then medicate them to raise their motivation?"
It's true that, for a supposed medical entity, ADHD has curious demographics: largely a white, middle- or upper-class phenomenon, it's most prevalent in the South and rare among children of Asian immigrants (Virginia has the highest per capita ritalin use, Hawaii the lowest).
Moreover, it seems that a few doctors are doing most of the prescribing (in Michigan, 5 percent of the doctors write 50 percent of the scrips). Diller compares ritalin to "the canary in the coal mine," reflecting society's toxic obsession with achievement.
Pace, not pride, is the true architect of "Generation Rx" in the provocative "Ritalin Nation: Rapid-fire Culture and the Transformation of Human Consciousness" by Richard DeGrandpre (Norton, 284 pages, $23.95), where ADHD results "from our growing addiction to speed and excitement."
Constantly bombarded and increasingly jaded by ever-faster, brighter and bigger stimulation, and lacking the unplugged ability to amuse themselves and tolerate stillness, some kids need the bounce of ritalin just to maintain a basic level of interest: "Studies have documented how [ADHD] children turn into normal children under sensory-rich conditions... and how these children begin to fall apart when the sensory stream begins to fade."
Fidgeting, an official symptom of ADHD, can be interpreted as self-stimulation to jazz up slowness, an alien and uncomfortable state. An eighth grade teacher puts it simply: "Kids are restless because they don't have anything inside. They're so used to being entertained."
As a college professor seeking an updated Abnormal Psychology text, I received a dozen crackling new ones designed for the attention span of today's students. Full of jangly, Web-ish insets and colors, only one trusted readers to endure two paragraphs of text without a summary and perky sidebar about some celebrity, scandal, or psychological X-file -- which is a lot like TV news, when you think about it.
Meanwhile, adults are also drugging themselves to keep up with their frenetic lifestyles, ingesting mega-jolts of caffeine at fashionable coffee bars.
DeGrandpre addresses the harried hurried of every age when he asks, "Can you sit still, and if so, can you do it comfortably and regularly?" Claiming that "attention-deficit behavior is more prevalent and getting worse, but it's not because any brain disorder has been found," he prescribes "deliberate living" as the antidote. His suggestions for easing the daily pace are comprehensive and sensible, but will not satisfy those seeking a quick fix -- which is precisely his point.
As things stand, it appears that ritalin is medicating a host of character traits, rather than any biological disorder. The psychiatric bible, DSM-IV, cites "bossiness" and "stubbornness" as signs of ADHD, saving another affliction for the truly spiteful: ODD (Oppositional Defiant Disorder), which labels kids who "often deliberately annoy people" and "argue with adults."
Do we really need more personality "diseases"? Although psychologist Ross Greene says, "I'm not interested in inventing yet another syndrome," he describes what he calls "Inflexible Explosive Children" in "The Explosive Child: A New Approach for Understanding and Parenting Easily Frustrated 'Chronically Inflexible' Children" (Harper Collins, 342 pages, $24).
One more wobbly, vaguely neurological entity, its symptoms overlap with those of ADHD and ODD, as well as Tourette's, anxiety, learning, mood and language disorders. While Greene doesn't rule out ritalin, he emphasizes the skills deficits that parental and therapeutic management can remedy.
For example, breaking a tantrum down into its component stages -- "vaporlock, crossroads, and meltdown" -- he recommends intervening early. This is hardly news, but at least he respects the power of social context and significant others, which many ADHD advocates prefer to dismiss.
Somehow we survived 1984 without fulfilling every Orwellian prophecy (although public videocams do resemble telescreens, and afternoon TV get-'em shows are fully as cathartic as the Two-Minute Hate). But Huxley's prediction of universal drugging may be coming true, given the increasing popularity of instant physical solutions -- everything from jumbo lattes and Viagra to prophylactic antacids and liposuction. At this rate, ritalin may well become the soma of our brave new world.
Judith Schlesinger is a psychotherapist who holds a doctorate in psychology. A professor at Pace University, she wrote "Music and Madness," about the psychological and cultural impact of music, and a biography of Humphrey Bogart.
Pub Date: 01/17/99