Pre-School Children on Ritalin 2/13/02

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Prescribing Ritalin for Pre-Schoolers

FYI

A Feb. 4, 2002 press release by The National Institutes ofHealth (NIH) announces a new "finding" by researchers from theNational Institute of Environmental Health Resources (NIEHR). They claim that"more than 15 percent of boys in grades one through five had been diagnosedwith ADHD and about 10 percent (or two-thirds of those diagnosed) were takingmedication for the condition."

Until now, estimates by the National Institute of MentalHealth (NIMH) and the American Psychiatric Association have claimed 3% to 5%.

This stunning, but unexplained precipitous rise in thislucrative epidemic affecting American children has no scientific explanation.The press release (below) states that the "findings" are based onreports by parents in rural North Carolina. The press release may be a signalthat the ADHD-Ritalin industry is looking toward minority children as its nexttarget: "Only two percent of Hispanic children were taking medication totreat ADHD."

An article about this subject by Jonathan Leo, Ph.D.,"American Preschoolers on Ritalin," appears in the Jan / Februaryissue of Social Science and Modern Society.

The article addresses the underlying promotional hype thatis being passed off as "science" by the promoters of Ritalin. Althoughthere are no agreed-upon replicable diagnostic criteria for ADHD, eventhree-year olds are being targeted as drug testing subjects by the government.Three-year olds are being forced to ingest a stimulant drug that may alter theirdeveloping brain without any evidence that it is for their benefit.

Dr. Leo writes: "handing out more money toinvestigate the safety of Ritalin for even younger children is exactly the kindof thinking that has created the current mess, and more money will only makemore of a mess."

He describes the response by the Clinton White House in2000, the pro-Ritalin advocates, and the drug companies, to news reports thatchildren were prescribed Ritalin and amphetamines without any medicaljustification. Their response was "nothing but a face-saving move todeflect a potential public relations nightmare."

"In light of the fact that there seems to be acorrelation between the amount of time, effort, and money that NIMH devotes toADHD and the rising numbers of American children using Ritalin, it is easy tosee why a study estimating that a quarter-million American preschoolers are onRitalin could be a PR disaster. The political reasoning coming out of Washingtongoes something like this: a group of doctors has been prescribing medications tovery young children; this group of doctors is now exposed; so, now we are goingto give money to this same group to investigate the safety of what they havebeen doing. Why? So they can continue doing what they are already doing."
——————————————————————————————–NATIONAL INSTITUTES OF HEALTH National Institute of Environmental HealthSciences
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FOR IMMEDIATE RELEASE Monday, February 4, 2002 NIEHSContact: Tom Hawkins (919) 541-1402

Parental Report: Impact of Attention Deficit-HyperactivityMay Be Underestimated

The public health impact of AttentionDeficit-Hyperactivity Disorder may be greatly underestimated by school andpublic health officials, scientists at the National Institute of EnvironmentalHealth Sciences said today.

The NIEHS scientists and colleagues at the University ofNorth Carolina School of Medicine in Chapel Hill reported that when they queriedparents in a "typical" county of rural and suburban homes — JohnstonCounty, N.C. — the parents reported more than 15 percent of boys in grades onethrough five had been diagnosed with ADHD and about 10 percent (or two-thirds ofthose diagnosed) were taking medication for the condition. Asking the parentswas a key to the higher figures, the researchers thought, because school nursesmight not be aware of children who are receiving medication treatment entirelyat home.

"Treatment rates are usually viewed as abnormallyhigh if they exceed the three to five percent prevalence estimate for ADHD citedin an American Psychiatric Association manual in 1994," the authors said."Therefore, the national public health impact of ADHD may be greatlyunderestimated by both educators and public health officials."

The information gathered from parents also indicated thefollowing:

About five percent of the girls were diagnosed with ADHD,compared to 15 percent of the boys. Also three times as many boys as girls takemedication to treat the condition.

Overall, over nine percent of all fourth and fifth gradechildren in Johnston County were taking medication to treat ADHD. In these twogrades, parents reported over 15 percent of white boys were taking stimulantmedication.

The percentage of children diagnosed with ADHD was similaramong African-American children and white children, but eight percent of whitechildren in the sample were receiving medication treatment compared to fivepercent of African-American children. Only two percent of Hispanic children weretaking medication to treat ADHD.

The study utilized parental and teacher reports of 6,099children in 17 public elementary schools in the semi-rural county. BecauseJohnston County has a racial/ethnic and educational profile similar to NorthCarolina as a whole, the authors of the study said they feel that medicationtreatment rates are probably similar in many other counties in North Carolinaand elsewhere. The researchers said similar data needs to be collectednationally to better understand ADHD medication treatment patterns.

Authors of the study are Andrew S. Rowland, Ph.D.; DaleP.Sandler, Ph.D.; and David M. Umbach, Ph.D., of NIEHS, which is part of theNational Institutes of Health but located in Research Triangle Park, N.C., nearJohnston County;
A. Jack Naftel, M.D., of the department of psychiatry, University of NorthCarolina School of Medicine, Chapel Hill;
and Lil Stallone, M.P.H., and E. Michael Bohlig, both of the private researchfirm CODA/Westat of Durham, N.C.

The research appears online in the February issue of the AmericanJournal of Public Health, a publication of the American Public HealthAssociation. The journal is accessible at www.APHA.org.

The principal investigator, Dr. Rowland, may be reachedfor interviews at (505) 272-1391. Dr. Sandler, the senior investigator, isavailable at (919) 541-4668. (Dr. Rowland is now with the University of NewMexico Health Sciences Center.)

The National Institute of Environmental Health Sciences isa component of the National Institutes of Health, U.S. Department of Health andHuman Services.

Below are excerpts from Dr. Leo’s article.
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AMERICAN PRESCHOOLERS ON RITALIN
By Jonathan Leo, Ph.D.

At the start of the twenty-first century, it has becomeapparent that the American medical community’s most controversial legacy tothe science of child development and child rearing is a potent psychotropicdrug. Ritalin is the drug of choice for ADHD and every year, more of ourchildren are taking it. American physicians, who prescribe 90% of the Ritalinproduced worldwide, believe this is all based on “science.” As an example ofa child who the ADHD experts think should be medicated take Sarah. Sarah’sstory is on the New York University Department of Psychiatry’s web site.

“Sarah chooses to sit in the back of the classroom andmuch of the time she’s doodling in her notebook or staring out of the window.She seldom completes assignments and often forgets to bring the right books toclass. Her desk is a mess and she generally can’t find what she’s lookingfor. Then she gets weepy and says that nobody understands her.” According tothe experts at NYU her diagnosis is Attention-Deficit Hyperactivity Disorder(ADHD), and the treatment of choice for her is Ritalin. This little girl iscrying out, “Please understand me” and the American medical community’sresponse is, “Medicate her.” Sarah is a fourteen-year old but we arecurrently prescribing Ritalin for children as young as two.

The ADHD experts are quick to point out that ADHD is oneof the most thoroughly investigated and well-studied pediatric diseases. It iscertainly true that millions of dollars, countless hours, and tremendousresources have all been consumed in an enormous effort to investigate ADHD. Yet,fundamental questions about ADHD are still vigorously debated. There is no proofof any underlying neurobiological deficit, it is not clear what the propertreatment should be, and it is not clear that the label “ADHD” is evenvalid. Even the American Psychiatric Press Textbook of Psychiatry,which overwhelmingly supports the idea that ADHD is a biological disease, hasstatements such as, “With unclear diagnostic boundaries, it is difficult todefine or even conceptualize a unitary concept of ADHD or its etiology (p. 838)”,or “there remains considerable uncertainty about the validity of ADHD as adiagnostic entity (p. 827).”

The issue of medicating children has recently taken on newimportance because the National Institute of Mental Health (NIMH) has juststarted an unprecedented study on the use of medications to treat ADHD inpreschoolers (three-year olds). This is the single most important moral questionthe scientific community will face in the next decade. The ethics of geneticallyaltered tomatoes, health care rationing, organ transplants, prescription drugreimbursements, and even assisted suicide are just a walk in the park comparedto the ethics of exposing a developing brain to a psychotropic drug. Givingthree-year-olds medications to help them be better nursery school students is agiant leap across an ethical threshold that will have profound consequences forour society. The responsibility, or as some would say, the irresponsibility, isenormous.

Treatment in Search of Justification
To examine the rationale for these experiments a good place to start is with anarticle titled, "Trends in Prescribing Psychotropic Medications toPreschoolers". This article received a tremendous amount of coverage in themainstream press because of one simple straightforward statistic. According tothe authors, the number of preschoolers taking medications for ADHD increased300% from 1990 to 1995. “Shocked”, “concerned”, and “surprised” werejust some of the reactions from the American medical community. In fact, whileboth sides of the Ritalin debate expressed significant concern about thisstatistic, the reasons for their concern could not have been more different.

The problem, even for those who endorse the use ofRitalin, is that Ritalin has never been officially approved for children undersix. Although prescribing these medications to children in nursery school may belegal, doctors are entering new territory when they do so because there havenever been any experiments on the effects of Ritalin in such young children.According to Dr. Steven Hyman, the director of NIMH, “Without good clinicaldata, every child who receives this medication represents an uncontrolledexperiment – that is entirely unacceptable.” The White House, Hillary Clinton,and NIMH immediately stepped into the fray, and amidst great fanfare, announcedthe allocation of five million dollars to investigate the safety and efficacy ofthese drugs for preschoolers.

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For those who oppose the escalating use of Ritalin in suchyoung children, the appropriate response to statistics documenting toddlers onRitalin is, “Stop – Enough is enough.” As Drs. Michael McCubbin and DavidCohen put it, “That public education and health systems permit the massivedrugging of children despite the lack of knowledge should set off alarm bells.”There is no reason for any child under six, much less three, to be taking anykind of medication for hyperactivity. Investigating the safety and efficacy ofthese drugs in toddlers will have one result: ten years from now even morethree-year-olds will be taking medication for ADHD.

The MTA Study If one had to pick a “landmark” study inthe history of ADHD research it would certainly be Treatment Strategies forAttention-Deficit/Hyperactivity Disorder written by the “MTA Cooperative Group”.The fanfare surrounding the publication of this article was nothing short ofextraordinary. In a segment titled, “Ritalin’s Redemption” ABC Newsdeclared, “The early results of a large national study indicate that drugtherapy for children with attention deficit and hyperactivity disorder is notonly effective, but much better than psychological counseling alone.” Notethat ABC News did not quote an expert; they just declared it as fact. In anotherarticle announcing the results of the study, one of the authors, James Swanson,was quoted as saying, “ Treatment can mean the difference between a kid endingup at Berkeley or ending up in prison.” In the ADHD literature, you would behard pressed to find a single scientific study that has been more responsiblefor the huge number of Ritalin prescriptions written in this country. Anybudding sociologist out there who would like to investigate why Americanphysicians lead the world in passing out Ritalin should look no further than theMTA study. According to the authors, the most important goal of the study was toanswer the question, “How do long-term medication and behavioral treatmentscompare with one another?” It might seem like a fairly straightforwardquestion, but it’s loaded. A major point of contention in the Ritalin debatecenters on answering the question of whether to treat an ADHD child withmedication or psychosocial interventions.

The Ritalin proponents believe that a child with ADHD is“at risk” and will continue to fail at school, and if left untreated longenough the child will probably develop a more serious condition. Without somesort of medication, the child is doomed to a life of frustrations, failures andpossibly even incarcerations. Talk therapy might sound good, but in the view ofthe Ritalin advocates withholding medication from these kids is irresponsibleand even verges on child abuse.

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The primary goal of the MTA study was to supposedly answerthe question “to medicate or not to medicate.” However, it needs to bementioned that the study’s authors never entertained any doubt about theanswer to this question themselves. In their previous writings, most of the MTAinvestigators have made it very clear that they strongly favor the use ofmedications. Their goal in creating this study was obvious: To bring thoseskeptics who do not quite share the MTA philosophy of raising children into thePro-Ritalin fold.

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The investigators have pre-selected a group of parents whobelieve that it is acceptable to medicate children; in this lack of randomsampling, we find the experiments main shortcoming. According to the MTAinvestigators, this is how they found the parents: “ In all instances, thechild’s parents contacted the investigators to learn more about the study,after first hearing about it through local pediatricians, other health careproviders, elementary school teachers, or radio/newspaper announcements.” TheMTA investigators have ended up with a group of parents who accept the very ideathat ADHD is a disease – which in and of itself is a biased group. Even as thestudy progressed, built-in mechanisms guaranteed the formation of a biased groupof parents.

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The bias of the MTA experiment could be compared todesigning a study to determine if teachers should continue to use corporalpunishment in the classroom. Imagine taking a group of teachers who believe incorporal punishment for their students and asking them if it works. Would therebe any doubt about their reply? Obviously not. Their opinion however, in no wayconstitutes proof that corporal punishment is good for children. Physicalintimidation will certainly work as a means to force children (and adults forthat matter) to obey orders. We do not ban physical punishment in the classroombecause it does not work in the short run. We ban it because of its negativelong-term effects and society’s acknowledgement that children are people, too.

Is Ritalin quick, easy, and cheap? Yes. Will it work?Probably, if all that is meant by work is that the children are easier tocontrol. But the real question is, will it help children? No one is going todisagree that Ritalin will make kids easier to control or that it improves theirability to pay attention. What we don’t know is how Ritalin affects a childfrom within. Children cannot tell us what it is like to live with Ritalin.

However, an insightful, first-hand account of Ritalin’seffects was written by Walter Kirn, an editor for GQ magazine who startedtaking Ritalin when he was thirty-one. For the first several months, he thoughtit was a wonder drug that gave him incredible powers of attention, but when hestarted to notice that it was fundamentally changing his personality he tookhimself off Ritalin. Besides lamenting the fact that children will not have theluxury of taking themselves off the medication, Kirn is also concerned aboutwhat constitutes success when it comes to evaluating the effects of Ritalin. InKirn’s words, “ The pills are a kick. They’re uppers. Get it? Uppers. Theyact like downers on kids who truly need them, according to the experts, but whatdo they know? The experts are on the outside looking in, monitoring behavior,not emotion. All they see are rows of little heads sitting obediently at littledesks.”

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The PATS Study: How Young is too Young?
Based on the success of the MTA experiment, the Ritalin experts are nowinvestigating the use of Ritalin in preschoolers. The study is referred to asPATS, which stands for “Preschool ADHD Treatment Study.” A recent article inScience magazine entitled: “Planned Ritalin Trial for Tots Heads intoUncharted Waters”, addressed some of the ethical issues surrounding theupcoming experiments on the use of medication in such young children. The end ofthe article holds a surprising paragraph about the laboratory classroom that Dr.Lawrence Greenhill, with funding from NIMH, is planning. In response to aquestion about how researchers will know whether a three-year old is functioning“on task”, (one of the goals of giving Ritalin) Dr. Greenhill explains:

"We’re going to set up a laboratory classroom, andwe’ll observe common tasks done in nursery school, such as stacking blocks andstringing beads on a thread. Children will be asked to sit in a circle and takepart in group events. The test will be whether the child is compliant andparticipates or attends for a few seconds before drifting away and doingeverything else in the room.

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When the PATS investigators see a child who does not wantto stack blocks, they see a disease that needs to be medicated. When educatorslike Holt and Montessori see a child who does not want to stack blocks they lookto the environment. It needs to be mentioned that the people who believe thatnon-compliant three-year-olds have some sort of neurobiological disease are thesame people who are largely responsible for the epidemic of Ritalin use in thiscountry. These are the same people who for years have said the following: ADHDis a “disease”; these children have a malfunctioning cerebral cortex; 3% to5% of our children have this disease; and the best treatment for these childrenis Ritalin.

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When a preschooler does not want to stack blocks or takepart in group activities can we really be sure that she suffers from a disease?Kohn continues, “Parents and teachers who defend the use of control withoutreservations do not, as a rule, pause to ask these sorts of questions. Ifsomeone persists in controlling others, something else may be at work – a setof values and a view of relationship that no argument or evidence will sufficeto challenge.” Our society is leading the world in Ritalin consumption and wecannot ignore the fact that this is partially due to the value system in thiscountry. Sure, Ritalin will help us control our kids, but as a society maybe weneed to take a step back and reevaluate this issue of “control.”

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