RITALIN DEBATE

This powerful little pill can transform a hyperactive child into a
little angel, but is it being used appropriately?

Ritalin - the popular child medication that can transform a handful of
trouble into a little angel - is experiencing unprecedented popularity
in Canada.

Prescriptions have jumped more than 500 per cent throughout the '90s,
raising concerns that disruptive or highly energetic children are
being inappropriately drawn within the drug's net.

Doctors stress it is to be used only when there is a proper diagnosis
of attention deficit hyperactivity disorder (ADHD), but it is possible
some children who don't clearly fall into this category are receiving
Ritalin.

Is Ritalin a wonder drug or just a handy tool we've developed to stop
kids from bothering us?

How much Ritalin use is too much? Or not enough?

``This is a fascinating issue that goes way beyond the efficacy of a
drug,'' says Dr. Russell Schachar, senior scientist and staff
psychiatrist in the department of psychiatry at the Hospital for Sick
Children.

``It says something about our society's approach to behaviour, how to
manage it and our expectations of medicine.''

If we want immediate results and are less willing to spend time and
money on longer-term therapies such as counselling, Schachar says,
it's not surprising parents and doctors are opting for a simple pill.

While he says he has seen some children who have been incorrectly
diagnosed by family physicians as having ADHD and are receiving
Ritalin, it is not an unusually high number given the differences of
opinions among professionals.

Schachar's biggest concern about Ritalin is that it is so successful
at stopping ``bad'' behaviour that many other problems, such as
learning or language disorders, psychological or family issues are
left untreated.

``These issues get much less attention than they deserve,'' says
Schachar, adding the real danger of an early labelling of a child with
ADHD is that other therapies are not tried.

``I'm not saying for a minute that handling a child with ADHD is
simple. Anyone going to do that will need the advanced course - a
Ph.D. in child management. But there are non-drug interventions.''

However, not everyone leaps to the drug solution, he says. About 25
per cent of the parents he deals with at Sick Kids refuse the drug
alternative.

``They have no intention of giving a pill to a kid, for moral, ethical
or other reasons, no matter how bad he's behaving.''

And this is the reason controversy has raged around Ritalin during the
past 40 years: It is a drug used to change the behaviour of children.

Children with ADHD, a condition affecting about 5 per cent of the
population, have trouble sitting still, paying attention and
completing tasks. They are impulsive and easily frustrated.

Ritalin is the brand name for methylphenidate hydrochloride, a drug
that stimulates the central nervous system.

Taken orally on average three times a day, the drug can reduce
hyperactivity and impulsiveness and increase the time children can
stay focused on an activity. Their school work improves, as do their
relationships with family and peers.

The social isolation that accompanies the disorder is one of its
biggest tragedies, says Dr. Marsha Rappley, a Michigan pediatrician,
who tells the story of a father's anguish when his son was turned away
from Cub Scouts.

``I've had a father crying because he had to admit he never wanted to

spend a whole day with his child.''

When Ritalin works, as it does in the majority but not all cases of
properly diagnosed ADHD, the change in the life of the child is
wonderful to see, Rappley says.

``I have seen time and time again where it has been successful. It
changes the quality of life for a child not just at school but with
parents and friends.''

However, Rappley is deeply concerned about a study she just completed
of 222 children on social assistance. It showed children as young as
age 2 being diagnosed with ADHD and given Ritalin.

Anyone familiar with the willfulness and energy level of a child going
through the ``Terrible 2s'' will question diagnosing a child of that
age with an attention deficit disorder, says Rappley.

``It gives everyone pause,'' she says.

Dr. Bill Mahoney, associate professor of pediatrics at McMaster
University and chairperson of the Canadian Medical Association's
psycho-social pediatrics committee, says we might be seeing the
increased willingness of parents to come forward with their children.

It wasn't very long ago that parents were blamed for this condition in
their children, Mahoney says.

``At one time, it was thought if a child had a problem with behaviour
in school, it was a problem in the family,'' he says, ``That's been
the model for years for physicians, teachers and other
professionals.''

In a ``double-blind'' study where neither the children, their parents
nor professionals working with them knew if they were given the drug
or a placebo, the children who actually got Ritalin received more
positive comments about their behaviour, he reports.

Sometimes the impact of the drug is astonishing in its rapidity and
effectiveness, he says. ``Within half an hour of the first dose, a
child can be normalized and you say, `My God, this is fantastic.' ''

Using therapy and counselling to modify behaviour and treat learning
disabilities make it a much longer process, says Mahoney, adding,
``Ritalin can be seen as an easy out.''

Since it is a prescription drug, it is imperative doctors act as
``neutral observers'' of the behaviour and not get rushed into trying
Ritalin as a first option, he says.

``We are dealing with a diagnosis that is behavioural. We see children
where the explanation is that they are being bullied, they have a
subtle learning disability or the family situation (is a problem).''

Dr. Abel Ickowicz, acting psychiatrist-in-chief at the Hospital for
Sick Children, says the increased popularity of Ritalin is not just a
Canadian phenomenon, but similar increases are being seen in the
United States and Europe.

He gives many reasons for the recent sharp jump in its
use:

* As many as two-thirds of people diagnosed with ADHD do not grow out
of it, as earlier thought, and need medication for many, many years.

* The explosion in medical information to the public means that more
people are aware of the disorder and its treatment, and will seek help.

* While it used to be given primarily to control children during
school hours, now there is increased willingness to prescribe it for
evenings, weekends and holidays to help a child live normally outside
of school.

* Many girls had the disorder but were never diagnosed. Where once
girls accounted for only 10 per cent of all ADHD cases, they are now
close to 40 per cent. They were missed because girls can display their
symptoms less overtly.

``There may also be some less positive reasons,'' he warns. ``It is
easy to take a pill. It is not a panacea. It is not poison, either.''

Dr. Chris Turner, manager of Health Canada's continuing assessment
division with the Bureau of Drug Surveillance, says his department has
asked for government funding to conduct a study of the increased
prescription use of the drug.

Alerted to the recent, sharp increase, the department is setting out
to find the reasons why.

Until the report of who is prescribing the drug and for what reasons
is completed, says Turner, he will have no comment.

- -- Dave Haans - Graduate Student, University of Toronto WWW:
http://www.chass.utoronto.ca:8080/~haans/

Checked-by: "Rich O'Grady"