LEAD STORY
Readin', Writin' and Ritalin
Thousands of kids are taking drugs in Portland schools every day--with the blessing of parents, educators and doctors.
BY NIGEL JAQUISS
njaquiss@wweek.com
Although frequently used to treat hyperactivity, Ritalin is a stimulant, essentially a form of speed, not a depressant.
Late last year, a National Institutes of Health panel
concluded that ADHD is indeed real, though it couldn't conclusively state much about the causes of the
disorder.
Scientists are not exactly sure how Ritalin works, but most now believe that Ritalin stimulates receptors in the frontal lobes of the brain that allow people to filter various stimuli instead of reacting ceaselessly to each one.
Nobody knows why most ADHD sufferers are male. Girls with ADHD often display the reverse of the excessive energy boys exhibit.
Rather than being hyperactive, they tend to be
withdrawn.
Oregonians ranked 19th in the nation in per capita Ritalin consumption in 1997, according to DEA statistics.
ADHD has been
recognized for 100 years under a
variety of names and symptoms. The name of the disorder was changed to ADHD in 1987, but many people still call it ADD.
A number of drugs similar to Ritalin, including Dexedrine, Adderall and Cylert, are also used to treat ADHD.
Some children
experience side effects from Ritalin, such as loss of appetite, insomnia and, in rare cases, stunted growth. Doctors say all are easily corrected if the dosage is adjusted properly.
The largest nationwide support group for families of ADHD sufferers is called Children and Adults with Attention Deficit Disorder, or CHADD.
CHADD has about 300 active families in the Portland area and can be reached at (503) 294-9504 or chaddpdx@
aracnet.com.
KGW News Channel 8 recently aired a three-part story on Ritalin use in Portland.
Three weeks ago, the state released a survey showing that kids' use of marijuana, cocaine and speed has leveled off over the past two years.
What the survey didn't show is the extraordinary increase in the school-age use of another drug--a stimulant so powerful that, like morphine, it is classified as a Schedule II controlled substance.
While kids have been learning to say "no" to drugs, their parents have been learning to say "yes" to Ritalin.
Drug Enforcement Agency figures show that Ritalin use in this country has soared more than 700 percent in the '90s. Although city-by-city breakdowns aren't available, experts in Portland estimate that nearly 5 percent of all school-age children take Ritalin or similar drugs--that's more than 4,000 kids in Multnomah County alone.
The rise in Ritalin use, as many know, is a response to the increasing number of kids--mostly boys--who are diagnosed with attention deficit hyperactivity disorder. According to a physician who has seen perhaps more cases of ADHD than any doctor in the city, the boom is far from over. "I think it [ADHD] is under-treated and under-diagnosed," says Dr. David Bell of the HealthFirst Medical Group.
Because Ritalin is so effective at treating the symptoms of ADHD, it has come to be viewed as one of the pharmaceutical industry's success stories of the '90s, a drug that, like Prozac and Viagra, has helped millions of people deal with chronic disorders.
But in Portland a growing number of psychologists, doctors and educators believe that something more complicated is afoot, that the rapid growth in the diagnosis of ADHD and in the use of Ritalin is masking a far greater problem--a culture that is becoming less tolerant of kids who act like kids.
"ADHD is much more a symptom of things that are going wrong with our society," says Dr. Mark Ruggiero, a specialist in developmental and behavioral pediatrics at Oregon Health Sciences University. "We're a medically oriented society that likes simple, quick responses to complex problems."
Although ADHD afflicts people of all ages, almost 80 percent of the nearly 5 million Americans who take medication for the disorder are under 18, according to researchers. Of those children, nearly 80 percent are boys.
The situation in Portland mirrors national trends. Every year more and more boys are lining up in school offices for their doses of Ritalin. (Although timed-release medication is available, most kids take Ritalin at regular intervals; they aren't allowed to medicate themselves, so nurses and school secretaries dispense the drugs.) In fact, at one westside Portland middle school, the number of kids showing up for their medication every lunch hour so overwhelmed the secretary that she recently demanded a transfer to a high school, where Ritalin is less prevalent. "It was ridiculous," says the secretary, who wishes to remain anonymous. "I spent all my time passing out pills."
Ironically, although Ritalin use has soared, there is still no definitive test for ADHD. It's unclear whether its causes are genetic or environmental, and the symptoms look different in each case. "You have to approach each child individually," says Dr. Robert McKelvey, director of child and adolescent psychiatry at OHSU.
To make diagnoses, doctors rely on information from families and teachers, as well as their own observations and standardized lists of behavioral patterns. The grab bag of symptoms that now describe the disorder has sometimes led to criticism that ADHD is a catchall for difficult behavior.
The mountain of research available does suggest that careful prescription of Ritalin improves concentration and allows children to attack challenges more effectively, particularly when used in concert with various behavioral modification strategies.
Nobody has to convince Diana Brown of the benefits of Ritalin.
From the time her son was born 12 years ago, it was clear to Brown that he had special needs. "He was extremely difficult," she says. He talked ceaselessly, was highly energetic and distractible and didn't sleep through the night until after his second birthday.
As is the case for many children, Brown's son's problems really became an issue when he was exposed to the stimulation of a schoolroom full of students. He was a bright child. In first grade, he barely missed the cutoff for entry into the Talented and Gifted program. But it was his increasingly inattentive and disruptive behavior that got him noticed.
One day when her son was in second grade, Brown was summoned to school. She knew something was seriously wrong when she was confronted by a small army of Gresham-Barlow District special-education experts. The assembled group of 12 told Brown that her son needed to see a doctor: He was probably suffering from ADHD, they said.
"I was overwhelmed," Brown recalls. "I was just stunned."
The family pediatrician made a diagnosis and suggested medication. "Boy, I was not thrilled with that," Brown says. Instead, she and her husband first tried changing their son's eating habits. (Some researchers believe that processed foods exacerbate ADHD symptoms.) "We tried the Feingold Diet," Brown says, referring to a diet of natural foods with no artificial additives. Already a picky eater, the boy could find nothing in the diet he liked, which made life even more difficult. "It was insane," Brown recalls.
Next, they tried a series of naturopathic remedies, all the while attempting various behavioral modifications. Nothing worked. Brown's attempts to parent her son seemed increasingly futile. "I felt completely ineffective," she says. "No matter what I did, I couldn't communicate with him."
A recent study completed by OHSU researcher Judy Kendall notes that living with a child who suffers from ADHD can be "chaotic, conflictual, and exhausting." One mother Kendall interviewed describes caring for a child with ADHD this way: "It's like death. Nothing is like I expected, nothing is ever the same," she says. "Future dreams and day-to-day life is always disrupted."
Desperate for a solution, the Browns finally resorted to medication. Life got a little better. Ritalin enabled the Browns' son to concentrate, and finally he began to learn.
Still, reconciling Brown's hopes with her son's reality has been painful.
"For me, it's been a major challenge because I have very high expectations," says the 49-year-old mother of two. "This was going to be the child who discovered the cure for cancer or brought world peace. He may still, but he may not."
ADHD has taken a toll on Brown's marriage, family and health--and nearly every other facet of her daily life. Brown compares the adjustment to having prepared for years to go on a trip only to wind up in the wrong place.
"When you find out your child has a disability, it's like you think you're going to Holland to see the beautiful tulips," she says. "Instead, you wind up in Italy. It's beautiful there, too, but you can't speak the language, and you don't understand anything anybody says to you."
Stories like Brown's explain the surge in Ritalin use as parents have reached for pharmaceutical solutions to their children's problems. At the same time, though, Ritalin's explosive growth in the '90s is a fundamentally different phenomenon than those of other "wonder" drugs. Viagra, for instance, represents a novel treatment of an age-old disorder. Similarly, after its introduction in the late '80s, Prozac filled a gaping need for sufferers of depression. But Ritalin has been used for children's behavioral problems for nearly 50 years. So why the sudden jump in prescription rates? Part of the answer, doctors say, is that only in the last decade has there been conclusive evidence of the drug's effectiveness. Diagnostic techniques and the precision of dosage have also improved.
Some experts, however, think that a big part of the Ritalin revolution has to do less with medicine than with society--particularly American society. In this country, according to a 1995 United Nations study, we produce and consume 90 percent of all the Ritalin used in the world.
Jeff Sosne is widely recognized by educators and doctors as one of Portland's leading authorities on ADHD. Perhaps no other facility in the metro area sees more ADHD sufferers than the Children's Program, a clinic Sosne and his partners run in Multnomah Village. While Sosne agrees with the conventional wisdom that a combination of medication and behavioral training can help nearly anybody with ADHD, his explanation for the disorder's prevalence is radical--and unsettling.
Speaking to a roomful of anxious parents in an airless meeting room at his clinic recently, the 46-year-old child psychologist offered his theory of what's changed since he began seeing patients 20 years ago. Expectations are higher, life is more intense and kids get in trouble for behavior people formerly ignored, he said. The criteria by which children are judged have gotten tougher. "There aren't more people with ADHD," he told the parents. "It's that the bar has been raised."
With his blue jeans, disheveled hair and scruffy salt-and-pepper beard, Sosne comes across as pretty laid-back. But when he talks about what's gone wrong for the thousands of children who've been referred to the Children's Program, the soothing cadence of his voice can't hide his profound and harsh criticism of the "sound-bite nation," as he calls modern America. "Expectations have been raised without an increase in resources," he says, referring to the notion that each student will perform brilliantly, go to college and earn lots of money. "As a result, kids on the margin have been affected the most."
In Oregon, nowhere has the pressure on kids increased more than in schools. Bigger class sizes, an emphasis on standardized tests and even proposals to link teacher pay to student performance weigh on kids. "The day is gone when marginal kids could just skate along and go get a job in a factory," says Dr. David Bell, who estimates he's treated 1,500 kids with ADHD in his 25 years of practice.
School personnel say parents share the blame for the explosion in ADHD. "A lot more kids are coming to schools unprepared," says Ty Okamura, a counselor at Hosford Middle School. Okamura cites several possible causes, ranging from prenatal exposure to toxic substances to broken homes to poor parenting skills. Others point to television, video games and a culture of instant gratification.
Kids today are often scheduled from the minute they wake until the time they go to sleep. "[ADHD] has always been there," says Chris Jones, a counselor at Chapman Elementary in Northwest Portland, "but years ago people weren't as busy."
William Brant, a psychologist at Gray and Jackson middle schools, thinks the pressure-cooker atmosphere in schools may exacerbate the symptoms of ADHD. Student-teacher ratios continue to worsen, standardized tests are more frequent and everybody is expected to excel. "The school board, superintendent and legislators are acting as though nobody below the 50th percentile exists," Brant says. "If the system ran differently, some kids could cope without medication."
But these days, there's little tolerance for kids who learn differently. "If my son has enough time, he can do anything any other kid can do," Diana Brown says, "but that's not acceptable in our society."
"More and more," Sosne says, "the question parents ask is not 'How do we understand what a kid needs?' but instead, 'Is he ADHD?'" In fact, parents often want this diagnosis because federal laws include ADHD in the list of disabilities that qualify students for such considerations as extra time on tests and individualized attention. "There's more and more pressure to label kids so they can get support and resources," Sosne says.
For Brown, her son's ADHD diagnosis, while traumatic, brought a kind of relief. "Without the label, he wouldn't have any accommodations," Brown says, "and he needs those." Resources range from the high-tech, such as electronic spelling devices, to the homemade. For instance, Brown's son focused better if he couldn't see other kids, so when he was in fourth grade, his mother built cardboard study carrels for him and all the other kids.
Extra resources won't help students with ADHD overcome the obstacle posed by Oregon's Educational Act for the 21st Century. Starting this spring each 10th grader must pass a series of tests to earn what's know as a Certificate of Initial Mastery, which is ultimately envisioned to be the true benchmark of an Oregon student's abilities.
But if the CIM is modified in any way for kids with learning difficulties, the results don't count. According to state guidelines circulated by Portland Public Schools, "In grade 10 students who take a modified assessment cannot earn a CIM." Parents of children with ADHD are furious at this inflexibility, which they consider blatant discrimination.
Not surprisingly, as the educational system has become more Darwinian, many veteran school personnel have begun to embrace Ritalin. "I've changed from being a person who thought drugs were very negative to seeing how they can be the right thing for people," says Kathy Jaffe, principal at Chief Joseph Elementary in North Portland. Chapman principal Bob McAllister shares Jaffe's outlook. "For the most part I'm not favorably disposed toward medication," he says, "but I've seen too many success stories."
Some school officials see a dark side to the current emphasis on the drive for higher results. "I think the impact of the business sector on education has become phenomenal," says Brant, a school psychologist with 20 years of experience in the district. "We're spending far too much time getting students to a skill level so they can be of use to companies instead of making them into good citizens, which I thought was the point of education."
In Portland, district superintendent Ben Canada is the man who must balance children's varied needs with Salem's demands for measurable results. Just how highly charged the issue of raising standards can be was evidenced at a town-hall meeting last month. Facing a barrage of criticism from parents over plans to increase the requirements for high-school graduation, Canada literally tore a copy of his plan to pieces.
In the mania to implement higher standards, Canada concedes that some kids will inevitably suffer. "That's a great concern to all of us," he says. "We're not sure how to handle that."
There's another culprit in the rush to label kids and prescribe Ritalin--the managed-care industry. Although drugs have proven effective for a majority of kids with ADHD, research suggests the most beneficial treatment is a combination of medication and behavioral training. But psychologists and psychiatrists are expensive; one 45-minute visit can easily cost more than the $50 that will buy an entire month's prescription of Ritalin for most kids. "Managed care has had a profound impact on medical practice," says OHSU's McKelvey. "The idea is to try to get everything done quickly, use more drugs and use them faster."
The president of the Oregon State Pharmacists Association, Mike Douglas, assesses the relationship bluntly: "Doctors write too many prescriptions because HMOs don't want to pay for any other type of treatment."
Managed-care officials dispute such criticism. Medication is the most effective therapy for ADHD, says Dr. Joseph Intile, medical director of the Oregon Health Plan; if doctors aren't spending more time on therapy, it's because they think drugs alone are more effective.
For the kids themselves, taking medication for ADHD can be fraught with emotional baggage. School officials claim there's little stigma attached to lining up for Ritalin every day, but what doctors see doesn't always correspond to that rosy assessment. Sosne says that for various reasons a large percentage of kids decide to stop taking their medication at some point, although most of them start back up again. Brant believes it's sometimes difficult for the kids to decide whether they like the way Ritalin affects them. "Behaviorally, there's a change," he says. "Kids aren't as wild and crazy or maybe as fun. That may cause some to stop taking the drugs."
Just when--if ever--kids can or should stop taking Ritalin nobody knows. The NIH says there's no evidence that careful use of Ritalin and other ADHD drugs is harmful or addictive. But that doesn't mean people aren't dependent on them. Many doctors now believe that for most kids ADHD never goes away. "People increasingly regard ADHD as chronic and think it will last throughout patients' lives," says McKelvey.
Many commentators suggest, as did a writer in The New Yorker last week, that the best solution to the ADHD epidemic is simply to just say "yes" to Ritalin. Drugs work, the argument goes, and trying to slow down our better-faster-cheaper culture is futile.
That sentiment is implicit in HMOs' strategies and a Legislature hell-bent on standardizing education. But slowing down and embracing kids with different styles of learning doesn't mean a lowering of standards--it means an elevation of consciousness.
Labels are everything in our society, convenient boxes that lead to quick fixes but not always the best solutions. OHSU's Ruggiero worries that the current rush to slap the ADHD tag on kids obscures greater disorders that ail us all.
"The diagnosis," Ruggiero says, "misses the bigger picture."
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Willamette Week | originally published February 17, 1999
