Pubdate: Sun, 14 Feb 1999 Source: Chicago Tribune (IL) Copyright: 1999 Chicago Tribune Company Contact: http://www.chicagotribune.com/ Forum: http://www.chicagotribune.com/interact/boards/ Author: Carolyn Alessio and Bob Condor GETTING A GRIP ON ADD Ritalin pills come in a range of chalky colors according to their strength--lemon yellow for 5 milligrams; pale green for 10; light yellow for 20; and white for 20-SR or "sustained release." Scott Holmes, 35, takes 10 milligrams, and sometimes the pills remind him of baby aspirin, "only thinner." He believes the stimulant helps him to concentrate and screen out distractions. Holmes began taking Ritalin two years ago when a psychiatrist diagnosed him with attention deficit disorder (ADD). But lately a note of sheepishness creeps into his voice when he mentions his medication. For the past six months, since he lost his job, Holmes has been rationing his supply. "Sometimes I guess I have this little struggle with it--I'm not one to readily take medication," he says. "In all honesty I suppose I should, so I don't put things off, like resumes and cover letters. I don't make the phone calls like I should during the day." Price also is an issue for Holmes. At about $1.50 per 10-milligram tablet, the cost of Ritalin adds up quickly, especially when a patient doesn't have reliable insurance coverage. Holmes, a former health care product manager who lives in Schaumburg, is one of an estimated 750,000 to 2 million American adults who take Ritalin or its generic equivalent, methylphenidate, to combat symptoms of inattention and hyperactivity. These adults join a growing number of children. IMS Health, a research firm that studies the pharmaceutical industry, says that about 9.4 million prescriptions for Ritalin or its generic form were written for U.S. children under 18 during 1998, up from 6.1 million five years ago. Experts estimate that these numbers translate to 3 million to 4 million children taking the drug. The true believers in Ritalin hold that, like Prozac, the drug of the '90s, Ritalin seems to clear symptoms once thought immovable and immobilizing. But, on the other side, the newfound faith in Ritalin's power to rescue people from the turmoils and anxieties of life has spurred controversy about the American quest for perfection. The increasingly vocal opponents of the drug are asking a pressing question: Do our rigid ideas about appropriate behavior and intolerance of individuality result in a Stepford society? "ADD is a product of the hurried and hectic society in which we live," said Richard DeGrandpre, a psychologist and author of the new book "Ritalin Nation" (W.W. Norton). "If Ritalin or other stimulants didn't exist, we'd be left with trying to find a real solution to (these) problems." DeGrandpre and other critics challenge the supercharged popularity of Ritalin. They express concern about doctors overprescribing the stimulant to children and adults with attention problems that don't qualify as ADD or ADHD (the "h" stands for hyperactivity). And, as the disorders cut across more sectors of the population, some are suggesting alternative therapies. At the heart of the ADD debate is the diagnosis. Current guidelines of the American Psychological Association describe people with attention deficit and hyperactivity as those who often have difficulty with behaviors such as organizing tasks or waiting their turns. Though ADD and ADHD often are used interchangeably, scientists distinguish between the two. According to Dr. Mina Dulcan, head of child and adolescent psychiatry at Children's Memorial Hospital, youngsters with ADHD are "like Dennis the Menace"--always running around and fidgety, but also exhibiting "inattentive" behavior by making careless mistakes and not listening. People with ADD, she said, suffer from the latter group of symptoms without the hyperactivity. If you think these behaviors sound universal, you're not alone. "We all have days when we can't focus or initiate a task," said Dr. John Krawczyk, a child psychiatrist at the Neuropsychiatric Clinic at Illinois Masonic Hospital. "But we shouldn't jump to conclusions. Not everyone is ADHD." What separates attention deficit behavior from ordinary frustration or rambunctiousness, says Krawczyk, is that it is a chronic condition beginning in childhood. To make a diagnosis, he consults clinical checklists and gathers information from parents, teachers and family physicians. There is no definitive test for attention deficit disorders. The American Psychological Association looks for "clinically significant impairment" in two or more settings at work, home, school and social situations. "About three out of every 10 patients referred to us have ADHD," said Krawczyk. "The other seven may have some other problem like depression, an anxiety disorder or organic illness." Increasing numbers of adults also are being diagnosed with attention deficit disorders. Scott Holmes was more relieved than shocked to find he had a condition typically associated with children. "If you're diagnosed as an adult, it's not like finding out you have cancer. It's more like a big revelation that helps to explain so many things," said Holmes, who is between jobs while he searches for a more creative and suitable position. Ritalin has been deemed effective by a National Institutes of Health consensus panel for short-term use in patients with attention deficit and hyperactivity problems. But experts warn against diagnosing someone with ADHD who is suffering from other mental illnesses adversely affected by stimulant drugs. "There is evidence that a small number of physicians diagnose a troubling percentage of ADHD cases in children that don't meet the diagnostic criteria and then prescribe Ritalin to see if it helps," said Benjamin Lahey, a psychologist and ADHD researcher at the University of Chicago. At the same time, "there are doctors who almost never diagnose ADHD or prescribe Ritalin," Lahey said, adding that one extreme is no better than the other. Now, he says, most primary-care physicians respect the issue enough to seek more information or make referrals to specialists rather than simply write a prescription. "The federal government estimates about 4 percent of U.S. children meet the criteria for ADHD (or ADD) based on reliable, highly standardized interviews. Only about one-third of those kids appear to be taking Ritalin," Lahey said. "That doesn't mean every child who meets the criteria will benefit from the drug--some don't--but if the child is not diagnosed, then you can't consider a treatment with overwhelming evidence of effectiveness." Possible side effects for Ritalin include insomnia, decreased appetite (at least during early treatment), tics and, in children, a slowed growth rate. Ritalin, or methylphenidate, is a Schedule II drug on the federal Drug Enforcement Agency's list of controlled substances, which means it has therapeutic uses but is also potent enough to cause psychotic reactions in some patients. There is little research about any long-term effects, although such stimulants have been available for more than four decades. Chicago Police Officer Janine Renault considers any side effects of Ritalin unacceptable. Six years ago, she refused to start her son, Brandon, on the drug even though his school and a psychiatrist recommended it. "This is speed," said Renault. "At work I see kids all the time who use speed and coke and I won't do that to my son." Brandon was diagnosed with ADHD after his prekindergarten teacher said he rarely focused on tasks. At age 4, Brandon was barely able to sit still. During dinner, he would take a few bites, then stand up and announce that he had to go to the bathroom. "You could tell him no, you could try more discipline, but he'd stand right up again," said his mother. Renault balked at treating her son's behavior with a pill. After Brandon was diagnosed, Renault met with the principal: "There were tears coming out of my eyes, and I said if ever there's a mother who will prove you guys wrong it will be me because I will never put my child on Ritalin." Renault, who describes herself as health-conscious and generally averse to medications, remembered a newspaper article she had read about an alternative treatment center. Founded in 1989 by scientists from Argonne National Laboratory and medical professionals, the Carl Pfeiffer Treatment Center in Naperville treats behavior disorders and learning disabilities with biochemical therapy. Renault took her son to the Pfeiffer Center, where tests indicated that Brandon had several chemical imbalances, including a zinc deficiency, his mother said. Doctors prescribed a regimen of customized vitamins and minerals, plus regular checkups. Within three weeks, Renault said, Brandon's teachers reported an improvement in his behavior. Now 10, Brandon still takes his vitamins twice a day. He's doing well at school, getting A's and B's. "No C's," his mother emphasized. He attends a special reading class to help with the learning disabilities that frequently occur alongside ADD. Other than that, Renault says her son is a "typical" 3rd grader. "Nobody would guess he was ADD," she said. Specialists differ in their assessments of the Pfeiffer program and similar treatment approaches. While many researchers remain unconvinced that nutritional approaches can address the symptoms of ADD, NIH panelists suggested some children might benefit from nutritional intervention, such as avoiding certain foods. The NIH did hedge that additional studies are needed before any guideline could be established. The scientific evidence is more sparse for such therapies as biofeedback and herbal treatments. The Children and Adults With Attention Deficit Disorders (CHADD) organization, which counts more than 30,000 members nationally, dismisses most alternative-type treatments and warns against "exaggerated or misleading claims." It should be noted, however, that in the past CHADD has received hundreds of thousands of dollars in donations from pharmaceutical companies, including Ciba-Geigy, now Novartis, which manufactures Ritalin. But in recent years, the overall donations from pharmaceutical companies have decreased, according to John Heavener, chief executive officer of CHADD. Less contentious and endorsed by organizations like CHADD are behavioral modification techniques to treat ADD or complement the use of Ritalin. Adults with ADD, for instance, can benefit from structuring their environment to address shortcomings associated with ADD. They are advised to use a tape recorder to record messages to themselves, make lists of tasks, post schedules around their homes and offices. Similarly, one option for children is "contingency management," known better as timeouts and reward systems. If the child completes a task, a token, star or checkmark is placed on a chart. A specific number of tokens earned can be turned in for privileges, such as increased TV time or a small toy. Failure at the task results in a timeout in a nonstimulating environment. If the process proves difficult, experts recommend breaking the task into smaller components and using a timer. Parent training is another widely endorsed psychosocial intervention. It is a formalized attempt at educating parents on how to work with an ADD-diagnosed child at home. "The first step is reconnecting a relationship with your child," said David Bucknam, a counselor at the Arlington Center for Attention Deficit Disorder in Arlington Heights. "It tends to have a calming effect." Bucknam said he asks parents to "think about jobs you've had with a really good boss," then glean the best of the manager's traits for the parental repertoire. One of his suggestions is a structured dinner time that is not long but has built-in incentives for interaction and proper manners. "There's a phrase--I didn't come up with it--rules without a relationship equals rebellion,' " he said. For parents whose children suffer from the disorder, these techniques may not be enough. Amy Cameron chokes up when she talks about making the decision to medicate her daughter Cate. "You live with the guilt, you live with the pressure of society telling you you shouldn't medicate your child," she said. Cameron can tell you a lot about patience in parenting. Three of her four children have been diagnosed with attention deficit problems, but only Cate, 10, is also hyperactive. Cate has been taking stimulants since kindergarten. She was diagnosed after a teacher told Cameron, who lives in the western suburbs, that Cate had behavior problems in the classroom. "Pieces began to fall into place," Cameron said. "Cate wouldn't ever sit down. At the movies, she was the kid running up and down the aisles." A psychiatrist put Cate on Ritalin, but she had some initial problems with the medication. Ritalin affects the body for only a short time and when the three daily pills wore off, her mother said, Cate experienced mood swings. Cate's doctor tried another stimulant, but she grew subdued. "She was very within herself," Cameron said. "I was constantly saying, `You OK? You OK?' I felt she was overmedicated." The Camerons switched doctors and Cate began to take a new, time-release form of Ritalin made available by her participation in a University of Chicago clinical trial. According to her mother, the results were astonishing. Cate began to focus at school. Her handwriting improved, as did her long- and short-term memory. Away from school, she was less frantic. When they went shopping, an activity that used to send Cate into near-hysteria, she was much more "in control." "You can tell her no," Cameron said, "and she doesn't go out in a huff and sit on the curb." Cate's sister, Alex, 11, and brother Scott, 8, were diagnosed more recently. In the near future, Cameron said, she and her husband may have to consider medication for these children, too, but Cameron is not as frightened as she was with Cate. "Some parents think, `Dear Lord, this is the worst thing that could happen to me.' But I don't look at it that way at all," Cameron said. "Their minds just work differently." In fact, preliminary findings by researchers at Stanford University and others have found that brain imaging scans of children with ADD and ADHD might suggest different levels of activity in the frontal cortex of the brain. And two genes have been associated with ADHD, the second confirmed in December. Although scientists do not agree on whether attention deficit disorder is a singular condition or a variety of maladies, the most common belief is that the brain suffers from a lack of the biochemicals dopamine and norepinephrine. No one quite knows how the stimulant methylphenidate works in the brain to help the inattentive or hyperactive person, though the drug itself increases dopamine levels. In a recent development, a Duke University Medical Center study published in January hypothesizes that balancing dopamine and serotonin--the neurotransmitter boosted by Prozac and antidepressants--might be the critical link to improving focus and calming hyperactivity. To date, doctors and researchers have been unable to distinguish the mild cases from the more severe ones that would benefit from medication because there are no blood tests or other biochemical signals. "Genetics research will be used to tailor the drugs and other treatments," said Dr. Edwin Cook, a University of Chicago child psychiatrist who led a team of researchers credited with discovering one of the ADHD genes. "But it won't help us diagnose ADHD anytime soon. Perhaps always doctors will have to take a careful history of the patient, sit down with parents and teachers, know how the home and school settings are affecting a child." All of which prompts the notion of understanding more about ADD and Ritalin rather than reaching a snap judgment. "What this issue needs," Lahey said, "is more light, not more heat." GETTING A GRIP ON ADD There is no medical test for ADD or ADHD, but here is a sample of the clinical guidelines listed in the Diagnostic and Statistical Manual of Mental Disorders. A few Warning signs for ADD - - Often fails to give close attention to details or makes careless mistakes in work or schoolwork. - - Often does not seem to listen when spoken to directly. - - Often loses things necessary for tasks or activities. - - Often fidgets with hands or feet or squirms in seat. - - Often leaves seat in classroom or in other situations in which remaining seated is expected. - - Often blurts out answers before questions have been completed. - - Often has difficulty awaiting turn. - - Often talks excessively. - - Often forgetful in daily activities. - --- MAP posted-by: Don Beck