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.