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Ritalin -- A Position Statement
The use of stimulants such as Ritalin (methylphenidate) and Cylert (pemoline) and Dexedrine (dextroamphetamine) as well as anti-depressants such as Tofranil (imipramine) is generally accepted in the United States for use with Attention Deficit Hyperactivity Disorder (ADHD). It is estimated that some 5-10% of children in elementary school meet the clinical criteria for ADHD, and are therefore candidates for the administration of stimulants or anti-depressants. Many of these children may outgrow some of their symptoms, such as hyperactivity, and yet may have the essential attention deficit condition survive into adulthood. These children may benefit from continuing medical management of their condition into adulthood.
In the ideal case, medication would be administered only after a thorough medical evaluation to rule out confounding factors such as anxiety conditions, childhood depression, sleep disorders, or other medical conditions such as thyroid disorders, nutritional deficits, possible food allergies, or heavy metal toxicities. Also, medication would ideally be part of a multi-faceted approach which would include psychotherapy, parent training, and behavioral management.
Testing needs to be done to assure the proper titration of the medication, and side effects need to be monitored. In practice, enthusiasm for stimulant administration in many areas of the United States is such that as many as 40% of some elementary classroom populations are on stimulant medications. First of all, such large-scale medication of children appears to be beyond any justification based on clinical criteria. Moreover, it appears to be occurring without the complementary services recommended by authorities in the field. Stimulant administration has become monotherapy in most cases. Additionally, there seems to be an under-recognition of certain ADHD subtypes which are more appropriately addressed with anti-depressant and anti-convulsant medication rather than stimulants.
The practitioners acquainted with EEG biofeedback have become aware that behavioral normalization and improvement in attentional skills can be learned even by those identified with ADHD, so that they no longer satisfy the diagnostic criteria for the condition. Also, children (and adults) so trained will no longer require medication for ADHD. Practitioners recognize the value of medication in those cases where children are in crisis, and where short-term remedies are appropriate. However, for the chronic condition of ADHD, the learning of improved control--with its promise of permanen ce--is considered preferable to the continual administration of medication. EEG biofeedback should be considered as an alternative to all the medications currently used for ADHD.
The indiscriminate resort to medication of our children has drawn concern from unusual quarters. Richard M. Restak, M.D., entered the field of neuropsychiatry before the time when biological psychiatry was fashionable. He was a pioneer, therefore, in the field of psychopharmacology. Hence, his present caution is particularly significant:
"From the tardive dyskinesia experience neuroscientists have learned an unsettling lesson: Not only can brain-altering drugs sometimes cause permanent harm, they may act like a time bomb that goes off a decade or more after exposure to them. Could something similar happen with the milder tranquilizers and anti-depressant agents that are now used by millions of people? What about medications like Ritalin that are now almost routinely prescribed to control hyperactivity in children? This latter possibility is particularly troublesome since a child's brain is still undergoing development and may thus be at greater risk. Unfortunately, neither neuroscientists nor anyone else can provide reassurance about the long-term safety of present and future mind- and brain-altering drugs."
Richard M. Restak, M.D., Receptors, Bantam Books, New York 1994 (p.198)
Restak's concern is reflected also in recent statements from the American Psychiatric Association, which has cautioned against the prevailing excessive resort to medication of children, against the casual diagnosis of ADHD, and against neglect of complementary interventions.
Siegfried Othmer, Ph.D.
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