Ritalin: Poison or opportunity for a kid?

None of us like poisons:
Stimulant medication, especially for children, often makes the news. We nationally learn about an infected hamburger in California; we also fret that we may be poisoning the kids. These reactions are "natural" and perhaps a reflection of evolution's biasing us to avoid risks. After all, being wrong about a real threat means that you're dead while being wrong about a bogus threat means that you're still alive although you could have missed an opportunity. Further, none of us like being poisoned, neither do bacteria. And as Margie Profet and Chris Sherman have taught us, pregnant women eat bland foods because the spicy ones often have substances that are toxic to developing brains.

Mistargeting Ritalin?
Eliot Marshall (Science, 8/4/00, 289, p. 721) draws our attention to a recent study in North Carolina and reported in the August issue of the Journal of the American Academy of Child and Adolescent Psychiatry. Adrian Angold and Jane Costello of Duke University collected a pool of 17,000 children, of ages 9, 11, or 13, and randomly sampled 4500 of them.

Parent interviews led to a smaller group of 1422 children of either high or low risk for ADHD.

-- 3.4% had ADHD according to DSM-III-R criteria. 5.3% of the boys and 1.5% of the girls met those criteria.
-- 6.2% had "ADHD-like behavior"
-- 7.3% actually received stimulants.

Although there is only a 1.1 % discrepancy between 6.2% and 7.3%, Marshall next remarks, "This fraction is in line with other findings of pervasive use of stimulants." Well. None of us like poisoning kids, if poisoning them is what we are actually doing.

Marshall mentions the only other study, one in 1992 by Peter Jensen (NY State Psychiatric Institute and Columbia University), that found only 12% of ADHD diagnosed children receive stimulant treatment. Jensen is quoted: "While we do have to be worried about pockets of overprescribing, there is good reason to think that only about one-half the children with ADHD are getting treated." Again, a shadow of our resistance to poisoning kids or labeling our own as handicapped --- parents don't like giving medicines to their own child.

What to do with teacher ratings?
Jensen reviewed the work by Angold and Costello and noted that some children who were rated by teachers as having ADHD were not given that diagnosis by Angold and Costello. Hooray for Angold and Costello! There are more than a few reasons to be suspicious of teacher reports, factors that easily would fill another essay or two and it's unfortunate that teacher ratings were given such prominence recently by the pediatrician's organization.

Some thoughts:
-- Kids livers crunch meds and usually do so more efficiently than most adults. Thus, child doses are often in "adult" ranges for many medications.
-- Maternal depression is associated with aggravation of oppositional and defiant conduct from their child. Treat the mother and the child likely behaves better. Could the same be true for prenatal treatment of maternal depression? There is certainly a pattern of evidence that an upset pregnant woman has cortisol changes that are reflected in her fetus. Stress to mother, familial conflict, and loss of resources tip her towards spontaneous abortion. Short of abortion, will these influences "tune" the child towards a more selfish, hyperactive, and predatory style? If so, there may be some developmental benefits to the child if medications were continued more often for expectant women but we may never assess this possibility.
-- Both mania and ADHD are advertised by high activity level. I've argued elsewhere that activity level is NOT a handicap; however, it serves to magnify other gaffs that the child may commit. If you are fast and loud male, socially adept, and never wrong then teachers defer to you and cheerleaders share with you. Bad timing at high volume simply means that you are a fool and not to be trusted with the car keys or with secrets.
-- Expect to see more anticonvulsants used for "ADHD" children. Divalporex is reported in the August issue of Journal Watch as effective for disruptive behavior in a group of 16 males and 4 females, aged 10-18 yrs, with explosive tempers and labile moods. (They are citing Donovan,S.J. et al., Divalporex treatment for youth with explosive temper and mood lability. Am.J.Psychiatry, 2000, May, 157, 818-820.)
-- Usually these medicines are handled by psychiatrists. However, pediatricians have given these medicines for a very long time and to young children who have seizure disorders. The doses and side effects are the same regardless of who writes the script and their purposes. Given the early and prominent role that pediatrics assumed in giving medicines (stimulants) for disruptive behavior (ADHD), there are a few writers who credit them for opening the field of child psychiatry to some interventions that actually work. Will they do the same for treating childhood mania? (Is a labile mood merely a seizure that has not spilled into convulsions?)
-- A good book, The Bipolar Child (1999) by Papolos, D. & Papolos, J. (NY: Broadway Books) describes bipolar children in language and format consistent with earlier books on ADHD.

Finally:
Stimulants in an appropriate dose range, produce more mature, cooperative, rational behavior even in normal children. Likewise for adults after their morning coffee. Stimulants not only make Joey calmer in math, they make him more active in volleyball. Thus, his behavior moves closer to the demands of his situation; Joey is NOT sedated into being quiet. What a strange culture, what a strange nature that we have. Medicines that abate our tears have the effect of making us less "responsible," and medicines that make us more alert, responsible (and in some citations, better learners) are given with such ambivalence. Especially if they are from a steel vat instead of a Chinese plant or a pond in Oregon!

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