The use of ritalin and other drugs to treat Attention Deficit Hyperactive Disorder (ADHD) in children remains controversial, with parents, patients, physicians, and the media taking different stances. Lucie Robson examines the debate around medicating our children.

Ritalin. Image: hipsxxxhearts

Ritalin (Image: hipsxxxhearts)

Clinical Associate Professor Michael Kohn is not impressed. “Terrible,” he says. “It was beyond the scope of what was reasonable to believe.”

“This is the latest in a series of articles blaspheming the use of Ritalin in the treatment of behavioural disturbance in children,” he says, exasperated. “It is motivated, I believe, as I said, through the beliefs of the people rather than their own objective journalistic integrity.”

What the head of department of Adolescent Medicine at Westmead Children’s Hospital is referring to is an article that exploded on October 13, first in The Daily Telegraph and then on news websites around Australia. There were follow-up reports on television, and everyone started talking about ADHD again.

Adorned with the headline ‘We’re turning our kids psychotic’, the piece claimed that the Telegraph had obtained adverse event reports from the Therapeutic Goods Administration, and these reports detailed extreme reactions to ADHD medications, such as psychotic episodes and suicidal ideation, reactions that had increased over recent years.

When the story broke, it wasn’t really news to Martin Whitely, a member of the West Australian parliament and long-time activist against what he calls the ‘ADHD industry’. “None of that surprised me, in fact I’ve spoken about it at length in the West Australian parliament,” he says. “I’ve known about them for donkey’s years.”

Living with ADHD

Meanwhile, Alexander Catts, 23, took his dose of Ritalin, as he has done regularly for the last seven years. “I didn’t read it, I heard bits and pieces. I heard on, I think the health report or something on radio national, I overheard a bit about the psychotic episodes and things that were brought on, but I didn’t get into depth. I think I didn’t pay that much attention.”

These three voices represent three different sides of the same long-winded, sprawling, complex and sometimes heated story of Attention Deficit Hyperactive Disorder and the low-dosage stimulants used to treat it in children and teenagers. These drugs are among the most studied and discussed in the world, as is the condition they are prescribed to treat.

ADHD is characterised by dysfunctional levels of hyperactivity (fidgeting, talking and moving incessantly), inattention (easily distractable, disorganised) and impulsivity. Stimulants such as Ritalin and dexamphetamine have been the standard treatment for over 50 years. They are prescribed to improve impulse control and concentration.

The adverse event reports, which are voluntarily submitted by doctors, are not readily available to the media from the TGA. And those supplied by Whitely do not make a compelling read. While there are details of some disturbing reactions experienced by very young children, such as suicidal thoughts, psychotic episodes, they are sparse. And there is no indication either way of how prevalent they are among the large amount of children who take the drugs.

Which means, probably, that the sensationalised reports in the Daily Telegraph have brought Australia no closer to a consensus on the issue. But they are telling, in the way they characterise the way people speak about ADHD.

“In their journalistic writing they are exclusively one-sided,” says Professor Kohn, about the Telegraph article. “I think that there needs to be some counter for a campaign of fear. We saw that with children overboard, we’ve seen that in a number of other political contexts.”

Same old story

Concerns about side effects have, however, been raised before. One example is a 1996 academic article co-written by David Evans, Associate Professor of Special Education at the University of Sydney.

“The purpose of the article was I suppose to pose a cautionary note at that time, about what had become an epidemic of prescriptions being written for students who had trouble attending in class,” he says. “We felt from our research that there was little evidence to say what the long-term effects of some of these drugs were on young children. I think there were tentative findings to suggest that students, young children, suffered sleep problems, there were question marks over their development, what effect it had on their development, in terms of bone growth and just growth in general.”

It is not only the side effects of the drugs that fuel the arguments against children being prescribed them in the first place. The diagnostic criteria themselves have sparked controversy, because between the words on the page are many potential ambiguities.

Associate Professor Evans describes an ‘experiment’ in which several undergraduates were given the diagnostic criteria for ADHD, without knowing what they referred to. “I think more than half of them judged themselves to ADHD. They’re not trained in the use of the criteria, but when you do look at the criteria, they are fairly broad, and what actually constitutes ADHD requires somebody with very good skills to actually implement,” he says.

“ADHD is a condition that suits a very time-poor society, if you follow my meaning. In other words, it’s a quick fix, it’s a quick diagnosis with a sort of magical solution,” says Martin Whitely. “They’re all behavioural, and they include things like fidgeting in your seat, being easily distracted by external stimulus, losing pencils and other things that are necessary for completing tasks, running about, climbing incessantly – they’re all behavioural diagnostic criteria, and every kid displays them to some degree.

“Now, that has been turned into a disorder, if you like, or a disease, treatable with medications, because it suits so many interests. Obviously the pharmaceutical companies make a lot of money and invest a lot of money in the validity of the disease.”

Who does it benefit?

Whitely was formerly a teacher, and it was in the classroom that he became disheartened about the way that medicated children became more compliant, and this in turn made the teacher’s job much easier. The kids were being unfairly drugged, he believed.

“Very many of the kids, they don’t have a problem, it’s just that they are more boisterous and more distractible than others. Some kids do have real problems, you know, a host of things. From not being able to see properly or hear properly, or perhaps they’ve suffered abuse or trauma, or maybe they haven’t been taught how to behave properly, on occasions,” he says. “Those problems aren’t addressed because the medication gives the appearance of actually, well actually alters behaviour, it gives the appearance of addressing the ADHD.”

Whitely is a high-profile member of the West Australian support group Drug Free Attention Difficulties Support, and is working on a book, $peed Up $it $till, which will be released next year.

“It may be that there are some kids that are so out of control that you need to medicate them temporarily, to sort of introduce normality to their lives. That should be, you know, tiny handfuls. It should be very small numbers of kids,” he remarks. “You look at the diagnostic criteria, as I said, they’re all normal behaviours. We’ve medicalised this childhood, we’ve turned childhood into a disease. So I would argue that the diagnosis of ADHD is useless, it’s meaningless, it needs to be thrown out, and start again.”

Real impact

For some, though, the diagnosis definitely means something.

“I actually suffered from pretty severe depression for years,” says Alexander Catts about the events leading up to his diagnosis at the age of 16. “I was a pretty bright student in primary school, but then started skipping class a lot, and just found that I couldn’t concentrate at all at school. It was getting harder and harder, to sort of make it through a school day and perform at school. And I sort of suspected actually that I may be ADHD.”

He visited his regular psychiatrist and after filling out a questionnaire, was prescribed Ritalin on the spot. Besides initial weight loss (it is well documented that stimulants act as appetite suppressants) and the experience of mild comedowns, the effects were largely positive and he was able to get his life and education back on track.

“There’s a lot of anti-Ritalin fear-mongering that goes on. And some of it, it’s quite possible it’s overprescribed, but I sort of take a lot of it as it’s more a campaign against it. So people come up with really spurious claims. I’ve never experienced anything like it. I’m more like to lose the plot when I’m not on it!” he says. “I notice a stigma that I get around using it. Like people at uni sort of get the implication that I get an unfair advantage in my marks by being prescribed Ritalin. And I’ve noticed that attitude sort of in the media as well. It’s almost like people see it as a performance-enhancing drug. And I think that’s why there’s a lot of distrust towards it for that reason. I feel like I get treated like a drug addict at the chemist sometimes, when I pick it up.”

ADHD as a condition, as a disorder, as a misdiagnosis, false diagnosis or symptom of modern society will not escape being prodded, pulled apart or criticised any time soon. “The thing is, most of the public and most doctors and sceptical about it. Most teachers are sceptical about it,” says Martin Whitely. “But you just need a handful, you need a small passionate minority that believe fervently in it, to do a lot of damage.”