MEDICATION 
Epilepsy Information Medication Watch
on the link:
IDEA 2004: Medications Statute
Administration of Medication to Students with Disabilities
Treatment Methods for ADHD
The Natural Approach-Focus
Adderall
Atomoxetine: A New Medication Treatment for AD/HD
Concerta - methylphenidate
Ritalin
Brain Gym
Why Ritalin Rules
Depakote
Inositol
It's Academic endorses none of the treatments listed on this page or anywhere else on this site.
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IDEA 2004: Schools Cannot Require Kids to Take Medications....
Section 1412 - State Responsibilities (the "catchall" statute) includes subsection (25) that prohibits school
personnel from requiring children to take medication as a condition of attending school, being evaluated, or receiving special education services. The statute says:
(25) PROHIBITION ON MANDATORY MEDICATION -(A) IN GENERAL - The State educational agency shall prohibit State and local educational agency personnel from requiring a child to obtain a prescription for a substance covered by the
Controlled Substances Act (21 U.S.C. 801 et seq.) as a condition of attending school, receiving an evaluation under subsection (a) or (c) of section 614, (see 1414(a)(c)) or receiving services under this title. (Section 1412 - State
Responsibilities)
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Administration of Medication to Students with Disabilities
Overview
Recent years have given rise to a proliferation of litigation over the school district's role in administering medication to students with disabilities, greatly
clarifying the law with respect to this important issue.
Key Points
These key-point summaries cannot reflect every fact or point of law contained within a source document. For the full text, follow the link to the cited source.
General Policies Regarding Administration of Medication
A general policy of refusing to administer medication to all students will not pass muster for students with disabilities. If a student must take medication during the school day to effectively participate in his educational program,
then administration of such medication may be a related service under IDEA or
Section 504. See, e.g., Berlin Brothersvalley (PA) Sch. Dist., 353 IDELR 124 (OCR 1988); Conejo Valley (CA) Unified Sch. Dist., 20 IDELR 1276 (OCR 1993); San Ramon Valley (CA) Unified Sch. Dist., 18 IDELR 645 (OCR 1991);
Fairfield-Suisun (CA) Unified Sch. Dist., 353 IDELR 205 (OCR 1989).
Administration of Medication in Excess of Recommended Dosage
Courts have recognized that a school district may refuse to administer medication to a student with a disability on the basis of a district policy
prohibiting administration of medication in excess of the physicians' recommended daily dosage. See DeBord v. Board of Education of the Ferguson-Florissant School District, 26 IDELR 1133 (8th Cir. 1997) and Davis v. Francis Howell School District, 25 IDELR 212 (8th Cir. 1997).
Ritalin
A school district cannot condition the receipt of special education and related services on administration of Ritalin or any other medication. Nor can a school
district condition placement decisions on an agreement to permit administration of Ritalin. However, the appropriate placement for a student may vary,
depending upon whether or not she is taking Ritalin, if prescribed. Casey J. v. Derry Cooperative Sch. Dist., 17 IDELR 1095 (D. NH 1991).
Parental Right to Refuse Administration of Medication
School districts have no right to compel parents to administer medication to their children because parents have a right under state and federal
constitutional law to choose not to medicate their children. However, these constitutional rights may be abridged when failure to medicate or otherwise seek medical treatment jeopardizes the life of a child or endangers others.
Niewendorp v. American Family Home Ins. Co., 22 IDELR 551 (WI 1995).
PARENTS SHOULD ALWAYS CONSULT THEIR
PHYSICIAN ABOUT MEDICATION AND BEFORE THEIR
CHILD TAKES ANY MEDICATION.
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Treatment Methods for ADHD......Gee-Have we missed any?
Click on this link to access information about the following treatment methods.
Acupuncture-Chinese Healing Method involving long needles inserted in specific locations of the body.
Alexander Technique-Mental practice that focuses on improving movement
and balance to achieve optimal health.
Animal Assisted Therapy-Any treatment using the interaction with animals to improve the mood or health of an individual.
Applied Kinesiology-Designed to measure how well messages are transmitted by the nerves in your brain and central nervous system.
Aromatherapy-Aromatherapy is the use of essential oils to improve the mind and body.
Ayurveda-The practice of utilizing natural items to overcome illness and strengthen the body and mind.
Biofeedback Method-where an individual can control bodily functions such as brain activity, muscle tension and heart rate in order to improve their health.
Bonny Method-Uses Guided Imagery and Music to explore and awaken the mind in order to improve the individuals emotional, spiritual, physical and mental
well-being.
Chiropractic Medicine-The practice of manipulating the spine in order to improve health.
Coloring Therapy-Coloring Therapy uses the activity of coloring as a self help medium. While coloring (with felt tipped markers, colored pens, pencils, etc) a
state of consciousness similar to meditation occurs.
Creative Arts Therapy-Provides patients with different ways to express themselves than are available through traditional therapies.
Deep Relaxation Therapy-Technique in which an individual relaxes both the mind and body to a state where healing can occur.
Dream Interpretation-Based on the idea that dreams are a way to view underlying issues that an individual has.
Ecopsychology-Ecopsychology is the belief that the needs of the planet and community are the same as the needs of the individual. By helping the planet,
you help yourself, and vice versa.
Environmental Medicine-Based on the understanding that the human body is constantly coping with its dynamic environment by means of a number of
complex biological mechanisms and that problems with the environment can affect the workings of these systems.
Food and Mood-An exploration of the relationship between diet, nutrition and emotional and mental health, and an attempt to educate others about these
findings.
Guided Imagery Also called Visualization Therapy-this method uses mental imagery to focus and direct the users imagination to affect their actions.
Holistic Medicine-This technique focuses on addressing the whole person - body, mind, and spirit. The practice integrates conventional and alternative therapies to prevent and treat disease, and promote optimal health.
Homeopathic Medicine-This method relies on "letting like s cure likes" meaning that illnesses are treated by minute quantities of substances that have
similar effects.
Hypnosis-The use of hypnotism to plant suggestions to change behavior and improve well being.
Macrobiotic Approach-This approach uses dietary, lifestyle and environmental changes in an attempt to improve an individuals physical and
mental state.
Magnetic Stimulation Therapy-The use of powerful magnets in an attempt to correct problems within the body or mind of an individual.
Meditation-This process attempts to create a state of consciousness that brings serenity, clarity, and bliss in order to improve overall well being.
Neuro-Linguistic Programming-A method of examining the way an individual thinks and acts through their language and using this knowledge to
affect change.
Past Life Therapy-Examines current issues an individual faces and attempts to correlate these with past existences.
Play Therapy-A method where children can, through play, communicate issues and request assistance in a comfortable and safe environment.
Polarity Therapy-This technique involves working with the Human Energy Field in order to improve the functioning of both the mind and body.
Rubenfeld Synergy Method-This method attempts to release memory and emotion stored in the users body and mind by removing energy blocks and
imbalances.
The Trager® Approach-This method relies on gentle movements to rid the body of negative mental patterns.
Thought-Field Therapy Method-using light pressure on specific points of the body to improve functioning by unblocking the flow of energy.
Vision Therapy-Correcting problems with an individual's vision can improve their ability to learn and have a dramatic impact on their mental well-being.
Yoga Focuses-on using breath, mind and body controlling techniques to improve overall health and well being.
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The Natural Approach- Focus
Naturopathic approaches to the treatment of ADHD and ADD take a holistic look at the individual and take into account diet, lifestyle, personality type,
surroundings and emotional factors.
Natural remedies are used to gently and effectively treat the symptoms, while at the same time helping the person to heal and to reach a state of balance and health.
Focus ADHD Formula is a 100% safe, non-addictive alternative treatment for ADHD.
Focus is a proven, complex herbal remedy, specially formulated by a practicing Clinical Psychologist to safely and effectively treat the symptoms of ADHD.
In combination with a healthy lifestyle and diet which excludes excess sugar, stimulants, artificial preservatives and colorants, Focus acts as a calmative
remedy which can focus the mind and improve concentration.
What are the ingredients of Focus?
Ginkgo Biloba, is a powerful herb from the Far East and has been grown in temple gardens for millions of years. Its medicinal properties have only been
discovered by the West during the last 20 years, where clinical studies have indicated its effectiveness in restoring the functioning of the circulatory system
and improving blood flow to the brain. Active ingredients include flavone glycosides (including ginkgolide), bioflavins, sitosterol, lactones and anthocyanin.
Scuttellaria Laterifolia (also known as Skullcap), is a relaxing nerve tonic and anti-spasmodic, which reduces excitability and relieves depression. Active
ingredients are flavonoids, tannins, bitter, volatile oil and minerals.
Matricaria Recutita (also known as German Chamomile), is traditionally used to promote calm and to soothe nervous tension. Its active ingredients include
volatile oil, flavonoids, valerianic acid, coumarins, tannins, salicylates and cyanogenic glycosides.
Centella Asiatica (also known as Gotu Cola), is found wild in moist areas throughout Africa and Asia. Centella Asiatica is used to re-vitalize the brain and
nervous system, increase attention span and concentration and combat ageing.
Avina Sativa (Green Oats), also called Hawer, is a remedy traditionally used in folk medicine as well as in modern herbalism to treat nervous exhaustion and as a general nerve tonic. Active ingredients are saponins, flavonoids,
minerals, alkaloids, steroidal compounds, Vitamins B1 , B2, D, E, carotene and wheat
protein.
Urtica Urens, called Umbabazane in Africa is used traditionally and in modern herbalism as a circulatory stimulant and to lower blood sugar levels. Active
ingredients are histamine, formic acid, acetylcholine, serotonin, glucoquinones, minerals, Vitamins A, B and C and tannins.
Aspalathus linearis (also know as Rooibos) Many children with ADHD symptoms suffer from hypoglaecemia or they are hyperglaecemic due to
incorrect diet. This means that their blood sugar levels will fluctuate a lot, leading to mood swings, irritability and restlessness as well as lack of
concentration. Rooibos contains Magnesium, zinc and iron which are all essential to a healthy nervous system. Zinc and iron in particular are important
for brain unctioning and concentration. Deficiencies in these elements will cause problems in concentration, memory and mood. Rooibos also has calmative properties and is known to soothe and decrease nervous tension (although this
effect is not as strong as the two above ingredients. Many
children with ADHD symptoms also suffer from various allergies and food intolerances. Rooibos is of great benefit in the management of allergies and to
build up the immune system. Rooibos improves overall liver functioning, which helps the body to eliminate toxins and improves overall body functioning
thereby increasing the efficiency of all organs of the body. Rooibos is endemic to the Cedarberg Mountains of the Cape and is not found anywhere else in the world.
How do I use Focus?
Children up to the age of 15:Take one drop per age year of the child or adolescent in a little water or juice every morning and evening after meals.
Adults: Take 20 drops in a little water every morning and evening after meals.
Focus may be also be combined with BrightSpark homeopathic ADD/ADHD remedy, MindSoothe or MindSoothe Jr (ages 3-15).
How long until I see results?
While an immediate calming effect is usually noted, it takes a little longer for improvements in concentration, distractibility and memory to be noted.
Best results are achieved when Focus is used consistently and the recommendations regarding diet and consistent discipline are followed.
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Common Misspellings for Adderall and Adderall XR
Are you looking for information about Adderall or Adderall XR?
Aderol, Aderall and Aderal are common misspellings for this stimulant medicine used to treat ADHD in kids. Like Ritalin, Adderall is a stimulant, but instead of
being made of methylphenidate, Adderall is a mixture of different amphetamine salts. It can help to reduce or improve the symptoms of ADHD, including having a short attention span and/or being hyperactive and impulsive.
Adderall is a short acting stimulant and is generally given twice a day.
Adderall XR is a long acting form of this stimulant that can be given just once a day, so that children don't have to take a lunch time dose. It usually lasts 10-12 hours in many children.
Dosage
As with other stimulants, the usual philosophy is to start with a low dosage and then work your way up as needed, either until it is working well or the child is
having intolerable side effects.
In general, the dosage of Adderall is about 1/2 that of methylphenidate (Ritalin) containing products, so 20mg of Ritalin would be about equivalent to 10mg of
Adderall.
Adderall is approved for use in children over age 3 years.
It is generally started at a dose of 2.5mg in children under age 5 and gradually increased as necessary. Older children often start with a 5mg dose. These
double scored tablets are available in sizes of 5mg, 7.5mg, 10mg, 12.5mg, 15mg, 20mg, 25mg and 30mg.
Adderall XR (extended release) is approved for children over age 6 and it is available as a once a day capsule. It is available in sizes of 5mg, 10mg, 15mg,
20mg, 25mg and 30mg. For children switching from regular Adderall to Adderall XR, you usually just add up the dosage they take throughout the day and that is their single dose of Adderall XR. So kids taking 10mg of Adderall twice a day
would take one Adderall XR 20mg in the morning.
Side Effects
Although generally well tolerated, the main side effects of Adderall and Adderall XR include anorexia (loss of appetite), insomnia, weight loss, emotional lability, abdominal pain (stomachache) and depression.
If side effects don't improve with time, your Pediatrician may have to lower your child's dosage or consider changing to another medication, such as Concerta or Strattera.
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Atomoxetine: A New Medication Treatment for AD/HD
Carol E. Watkins, M.D.
Atomoxetine, brand name, Strattera, was approved by the FDA for distribution in November 2002. It became available in US pharmacies in early 2003. Despite its hefty price tag, it is becoming widely used for adults and children with
Attention Deficit Hyperactivity Disorder. (AD/HD) It is a non-stimulant medication approved for the treatment of AD/HD in both children and adults. The stimulants include methylphenidate (Ritalin, Concerta and Metadate CD) and
amphetamine (Dexedrine, Dexedrine Spansules, and Adderall XR). Stimulants are FDA approved for the treatment of AD/HD in children and adolescents, but most physicians consider them the first line medication treatment for AD/HD in
adults too.
How Does It Work?
Atomoxetine is a selective norepinephrine reuptake inhibitor. This means that it strengthens the chemical signal between those nerves that use norepinephrine to send messages. Atomoxetine does not appear to affect the dopamine systems
as directly as do the stimulants. Atomoxetine does not seem to cause an increase in brain dopamine levels in the nucleus accumbens or the striatum areas of the brain. The stimulants appear to cause an increase in the availability of
dopamine in these areas. The effect on the nucleus accumbens is believed to cause euphoria and to be responsible for the stimulants’ abuse liability. Dopamine increases in the striatum may be associated with the risk of motor tics. (1)
Although Atomoxetine’s direct effect only seems to be with norepinephrine, it appears to cause a secondary increase in dopamine levels in the prefrontal
cortex area of the brain. (the brain area behind the eyes.) This part of the brain is associated with the ability to mentally rehearse responses, and inhibit
impulsivity. The area is also associated with working memory.
Atomoxetine’s chemical structure bears some similarities to the tricyclic antidepressants although it is actually a phenylpropanolamine derivative. The
tricyclic antidepressants include desipramine and imipramine. These two medications have been shown to be effective treatments for AD/HD in adults and
children but do not have FDA approval for this use. The tricyclics affect norepinephrine but are not as specific as atomoxetine. It is the tricyclics’ effect on neurotransmitters other than dopamine and norepinephrine that appear to
cause their drawbacks. Their anticholinergic effects can cause constipation, dry
mouth and dry eyes. Their antihistaminergic effects can cause weight gain and tiredness. Their alpha adrenergic effects can cause tremor and changes in blood pressure. The tricyclics can cause a delay in cardiac conduction. This effect
can cause minor—and in rare cases—serious changes in heart rhythm. Investigators have evaluated atomoxetine carefully for cardiac rhythm and blood pressure changes. Minor, but insignificant, increases in pulse and blood
pressure were noted. Atomoxetine did not appear to cause changes in cardiac conduction
Can you abuse atomoxetine?
Some physicians have been reluctant to prescribe stimulants for adults because they are Schedule II and are officially listed as having a significant potential for addiction. Although stimulants can indeed be abused, their use does not
seem to cause abuse individuals who do not already have a substance abuse
problem. (3) However there are other ways in which stimulants can be abused. Because they decrease sleepiness and cut appetite, individuals might use them to cram for exams or lose weight. Atomoxetine appears to have minimal abuse
potential. Thus, it is not as highly controlled as the stimulants. It can inhibit sleep or appetite but does so much less than the stimulants. Thus, it is less likely to be passed around.
Does atomoxetine have side effects?
The side effects of atomoxetine may include many of the side effects seen with stimulants. These common effects include appetite suppression, sleep
disturbance jitteriness and irritability. Since there is a small increase in pulse and blood pressure, these should be monitored in patients with cardiac disease. However, these effects are often milder than those of the stimulants.
However atomoxetine can cause a significant problem with nausea. In my experience, this is the most common reason for individuals stopping the drug. Taking it with meals or splitting the dose may help. Atomoxetine is most commonly
given as a single dose in the morning. However there are some individuals who cannot tolerate this because they actually find the medication to be sedating. Atomoxetine can lead to urinary retention in some individuals. It can also
cause problems with sexual functioning. About 7 % of men experienced problems with erections and 3% experienced impotence. (4) Stimulants often cause the individual to feel more alert and less sleepy. Atomoxetine can occasionally do
this to a milder degree. In some individuals, however, Atomoxetine can actually cause sleepiness. I have several patients who prefer to take it at night. Atomoxetine does not usually have a rebound effect. Although the compound is
metabolized quickly, the clinical effects appear to last all day and even into the following morning. This can be a good thing for individuals who find that stimulants make them feel irritable in the evenings. However, people who need
to stimulant “kick” to help them focus may be disappointed in the new drug.
How Strong and How Fast?
Stimulants start to work in less than an hour. Because of this, one can rapidly determine the best dose. Atomoxetine has a more subtle, gradual onset. One
must increase the dose over several days or weeks. One may not see the maximum effect of a given dose for about three weeks. In some cases, I may do a cross over in which the individual takes a lower dose of the stimulant while waiting
for the atomoxetine to take its full effect. Limited studies have suggested that atomoxetine is equally effective to methylphenidate (Ritalin) for a variety of AD/HD symptoms. (2) In my own experience, this is not always true. Some
individuals experience even the highest recommended doses of the drug as less effective than the conventional stimulants.
Atomoxetine is metabolized through the cytochrome P-450 2D6 pathway. However the major metabolite is also active. The activity of the CYP 2D6 system
can vary widely in perfectly healthy people. Individuals who metabolize it slowly will build up a higher level faster than those who metabolize it rapidly. We often use blood levels to help us determine the proper dose of a tricyclic
antidepressant. However we do not have such a test widely available for atomoxetine. Because of this, we may not be able to achieve an effective dose in some individuals within the FDA dosage guidelines. Fluoxetine (Prozac) and
paroxetine (Paxil),, as well as other drugs affect the metabolism of atomoxetine. If one is taking atomoxetine it is important to check with the doctor or
pharmacist to make sure that they are not taking any other drugs that affect its metabolism.
A Double Edged Sword?
Some of the advantages of atomoxetine may be a double edged sword. Its lower abuse potential might make us more willing to prescribe it for individuals with a substance abuse problem. Its weak antidepressant effect might make us more
comfortable prescribing it for individuals who might have co-morbid depression. However this should not relieve clinicians from the responsibility for assessing and treating co-morbid substance abuse and mood problems. Atomoxetine is
more convenient because you can call in refills. However, one of the major reasons for failure for AD/HD medication treatment failure is inadequate follow up with infrequent dosage monitoring and adjustments. Medication management
visits can be therapeutic. Frequent visits also help pick up changes in the patient’s clinical condition.
So, Where Does Atomoxetine Fit In?
I still recommend the stimulants as the first-line drugs for AD/HD. They have stood the test of time. We are familiar with their strengths and their side effects. Their quick onset enables the clinician to more rapidly adjust the dose.
The stimulants—even the newer ones—are less expensive than atomoxetine. I have
found a number of patients who feel that even the higher doses of atomoxetine are not as effective as the stimulants. However there are many people who do not respond to stimulants or who cannot tolerate the side effects. I have
achieved excellent results in a number of individuals who felt jumpy or irritable on stimulants. For these people, atomoxetine can be an excellent medication.
Bymaster FP, Katner JS, Nelson DL, et al. Atomoxetine increases extracellular levels of norepinephrine and dopamine in prefrontal cortex of rat: A potential
mechanism for efficacy in attention deficit/hyperactivity disorder. Neuropsychopharmacology 2002; 27:699-711.Kratochvil CJ, Heiligenstein JH, Dittmann R, et al. Atomoxetine and methylphenidate treatment in children with ADHD: A
prospective, randomized, open-label trial. J Am Acad Child Adolesc Psychiatry 2002;41:776-84.Biederman, J, WIlens, T, Mick, E, Spencer, T, Faraone, SV, Pharmacotherapy of Attention-Deficit/Hyperactivity Disorder Reduces Risk for
Substance Use Disorder, Pediatrics, 104:2 1999 pe20.Michelson D, Adler I, Spencer T, et al. Atomoxetine in adults with ADHD: two randomized, placebo-controlled studies. Biol Psychiatry 2003;53:112-20.Michelson, D, Faries, D, Wernicke,
J, Kelsey, D, Kendrick, K, Sallee, FR, Spencer, T., Atomoxetine in the Treatment of Children and Adolescents with Attention-Deficit Disorder: A Randomized, Placebo-Controlled, Dose-Response Study, Pediatrics 2001, 108:5.
PARENTS SHOULD ALWAYS CONSULT THEIR
PHYSICIAN ABOUT MEDICATION AND BEFORE
THEIR CHILD TAKES ANY MEDICATION.
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Concerta - methylphenidate
(meh thill FEH nih date)
Concerta, Metadate CD, Metadate ER, Methylin, Methylin
ER, Ritalin, Ritalin LA, Ritalin-SR
What is Concerta?
• Concerta is a mild stimulant to the central nervous system (brain and nerves). The exact way that Concerta works is unknown.
• Concerta is used to treat attention deficit disorder (ADD), attention deficithyperactivity disorder (ADHD), and narcolepsy.
• Concerta may also be used for purposes other than those listed in thismedication guide.
What should I discuss with my health care provider before taking Concerta?
• Do not take Concerta if you have taken a monoamine oxidase (MAO)inhibitor such as isocarboxazid (Marplan), phenelzine (Nardil), ortranylcypromine (Parnate) in the last 14 days.
• Do not take Concerta without first talking to your doctor.
if you have· an allergy to Concerta;
· severe tension, agitation, or anxiety;
· glaucoma;
· motor tics or have been diagnosed with Tourette's syndrome;
· depression;
· a psychotic condition such as schizophrenia;
· epilepsy or another seizure disorder;
· high blood pressure (hypertension);
· a history of alcohol or drug abuse; or
· a narrowing or blockage of your gastrointestinal tract (esophagus, stomach, or intestines).
• You may not be able to take Concerta, or you may require a dosage adjustment or special monitoring during treatment if you have any of the conditions listed above.
• Concerta is in the FDA pregnancy category C. This means that it is not known whether Concerta will be harmful to an unborn baby.
Do not take
Concerta without first talking to your doctor if you are pregnant or could become pregnant during treatment.
• It is not known whether Concerta passes into breast milk. Do not take Concerta without first talking to your doctor if you are breast-feeding a baby.
How should I take Concerta?
• Take Concerta exactly as directed by your doctor. If you do not understandthese directions, ask your pharmacist, nurse, or doctor to explain the
instructions to you.
• Take each dose with a full glass (8 ounces) of water.
• Take each dose of Ritalin or Methylin 30 to 45 minutes before a meal.
• The sustained-release forms of methylphenidate (Ritalin-SR, Metadate ER,Metadate CD, Methylin ER, Concerta) can be taken with or without food.
• Do not crush, chew, or break the sustained- or extended-releaseformulations of methylphenidate (Ritalin SR, Ritalin LA, Metadate ER,
Metadate CD, Methylin ER, Concerta). Swallow these whole with water or another beverage. They are specially formulated to release medication
slowly in the body. Alternatively, the Ritalin LA and Metadate CD capsules may be opened and the contents sprinkled onto a tablespoon of
applesauce (not warm), and the mixture swallowed immediately. Do not save the mixture for later use. The capsule contents should be swallowed
whole and not crushed or chewed.
• If you are taking Concerta, do not be alarmed if you see in your stool what looks like a tablet. This is the outer shell of the tablet, the medication has
been absorbed by your body.
• Store Concerta at room temperature away from moisture and heat.
What happens if I miss a dose?
• Take the missed dose as soon as you remember. However, if it is almost time for the next dose, skip the missed dose and take only the next regularly
schedule dose unless otherwise directed by your doctor. Do not take a double dose of this medication.
What happens if I overdose?
• Seek emergency medical attention.
• Symptoms of a Concerta overdose include agitation, tremors (shaking), muscle twitches, seizures, confusion, hallucinations, sweating, flushing,
headache, fast or irregular heartbeat, large pupils, and dryness of the mouth and eyes.
What should I avoid while taking Concerta?
• Use caution when driving, operating machinery, or performing other hazardous activities. Concerta may cause dizziness, drowsiness, blurred vision, or impair your ability to concentrate. If you experience dizziness, drowsiness,
blurred vision, or impaired concentration, avoid these activities.
What are the possible side effects of Concerta?
• If you experience any of the following serious side effects, stop taking Concerta and seek emergency medical attention or contact your doctor
immediately:
· an allergic reaction (difficulty breathing; closing of the throat; swelling of the lips, tongue, or face; or hives);
· an irregular or fast heartbeat;
· chest pains or very high blood pressure (blurred vision, severe headache, flushing);
· unusual behavior or confusion; or
· liver damage (yellowing of the skin or eyes, nausea, abdominal pain or discomfort, unusual bleeding or bruising, severe fatigue).
• Other, less serious side effects may be more likely to occur. Continue to take Concerta and talk to your doctor if you experience
· insomnia (difficulty sleeping);
· nervousness;
· drowsiness;
· dizziness;
· headache;
· blurred vision;
· tics (repetitive movements);
· abdominal pain, nausea, or vomiting;
· decreased appetite or weight loss; or
· slower weight gain and/or growth.
• Concerta may cause drug dependence.
• Side effects other than those listed here may also occur. Talk to your doctor about any side effect that seems unusual or that is especially bothersome.
What other drugs will affect Concerta?
• Do not take Concerta if you have taken a monoamine oxidase (MAO) inhibitor such as isocarboxazid (Marplan), phenelzine (Nardil), or
tranylcypromine (Parnate) in the last 14 days.
• Before taking Concerta, tell your doctor if you are taking any of the following medicines:
· warfarin (Coumadin);
· phenytoin (Dilantin);
· phenobarbital (Luminal, Solfoton);
· primidone (Mysoline);
· a tricyclic antidepressant such as nortriptyline (Pamelor), amitriptyline
(Elavil, Endep), doxepin (Sinequan), desipramine (Norpramin), clomipramine
(Anafranil), or imipramine (Tofranil);
· a selective serotonin reuptake inhibitor such as fluoxetine (Prozac), fluvoxamine (Luvox), paroxetine (Paxil), or sertraline (Zoloft);
· clonidine (Catapres); or
· guanethidine (Ismelin).
• You may require a dosage adjustment or special monitoring if you are taking any of the medicines listed above.
• Drugs other than those listed here may also interact with Concerta. Talk to your doctor and pharmacist before taking any prescription or over-the-counter medicines, including herbal products.
Where can I get more information?
• Your pharmacist has more information about Concerta written for health professionals that you may read.
PARENTS SHOULD ALWAYS CONSULT THEIR
PHYSICIAN ABOUT MEDICATION AND BEFORE
THEIR CHILD TAKES ANY MEDICATION.
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Ritalin
Methylphenidate Hydrochloride Tablets, USP
Methylphenidate Hydrochloride Extended-release Tablets, USP
Methylphenidate hydrochloride is a mild central nervous system (CNS) stimulant. Methylphenidate hydrochloride is available as 5, 10, and 20 mg tablets
for oral administration. A 20 mg extended-release tablet for oral administration is also available. Methylphenidate hydrochloride is methyl a-phenyl-2-piperi-dineeacetate hydrochloride.
Methylphenidate hydrochloride is a white, odorless, fine crystalline powder. Its solutions are acid to litmus. It is freely soluble in water and in methanol, soluble in alcohol, and sliglhtly soluble in chloroform and in acetone. Its
molecular weight is 269.77.
Inactive Ingredients: Methylphenidate hydrochloride tablets; lactose, magnesium stearate, microcrystalline cellulose, sodium starch glycolate; 5 mg
contains D&C Yellow #10; 10 mg contains FD&C Green #3, and 20 mg contains FD&C Yellow #6.
Methylphenidate hydrochloride extended-release tablets: cetyl alcohol, ethylcellulose, lactose and magnesium stearate.
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Brain Gym
Dr. Carla Hannaford, a professor of Biology for 20 years, offers dramatically different alternatives for such children. If learning disabilities are to be labeled,
the phrase 'Stressed Out Survival-Oriented Humans' (SOSOH) would encompass all. She suggests that, for these young people, brain function is
impaired and development hindered through chronic exposure to familial, social, and environmental stresses. Most significant of these is the stress
inherent in schooling based on an educational philosophy that encourages the use of certain areas of the brain (such as the visual system) before children are fully ready to use these areas.
Brain scans of people who have been identified as having ADHD show less neural activity in the prefrontal lobes of the brain leading to underdevelopment
of the forebrain, the area where concentration and rational behaviour originate (Hannford 1995). Dr. Hannford recommends Brain Gym activities. These simple movements improve co-ordination, and balance in gravity and sensory processing,
thus providing an increased sense of physical safety relaxation and self confidence.
Brain Gym, which is part of Educational Kinesiology (Edu-K) created by Paul Dennison Ph.D in the early seventies, has been shown to assist individuals in
learning to improve focus and concentration. Dr. Dennison developed a set of exercises that can be used to activate specific neurological pathways in the
brain which apparently stimulate motor activity in the frontal lobe and activate, develop and myelinate (a process for processing linkages between brain cells) these areas of the brain. The inability to concentrate and focus attention
is the identifying factor of ADD; thus, all children with ADD have a "learning problem" as well. In most cases such inabilities are due to lack of efficient communication between the left and right hemispheres of the brain, as in
dyslexia (literally, the inability to match a verbal name to a visual symbol or word). Dr. Dennison discovered a brilliant integration process that allows the left and right
hemispheres of the brain to communicate more effectively. Once this is achieved, the child can focus on new, more efficient strategies for decoding spelling, mental maths, etc., skills that previously could not be learned because the
area of the brain that processes them could not be accessed.
The results of the Edu-K programme were so exciting that Brain Gym has been put to use in the educational systems of more than thirty countries. In Holland, Edu-K is taught as a postgraduate course at the University of Groningen.
For more information, contact the Edu-K Foundation, 12 Golders Rise, Hendon, London W4 2HR. Tel: 020 8202 3141, fax: 020 8202 3890.
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Why Ritalin Rules
By MARY EBERSTADT
There are stories that are mere signs of the times, and then there are stories so emblematic of a particular time and place that they demand to be designated cultural landmarks. Such a story was the New York Times’ front-page report on
January 18 appearing under the tame, even soporific headline, "For School Nurses, More Than Tending the Sick."
"Ritalin, Ritalin, seizure drugs, Ritalin," in the words of its sing-song opening. "So goes the rhythm of noontime" for a typical school nurse in East Boston "as
she trots her tray of brown plastic vials and paper water cups from class to class, dispensing pills into outstretched young palms." For this nurse, as for her counterparts in middle- and upper-middle class schools across the country,
the day’s routine is now driven by what the Times dubs "a ticklish question," to wit: "With the number of children across the country taking Ritalin estimated at well over three million, more than double the 1990 figure, who should be
giving out the pills?"
"With nurses often serving more than one school at a time," the story goes on to explain, "the whole middle of the day can be taken up in a school-to-school
scurry to dole out drugs." Massachusetts, for its part, has taken to having the nurse deputize "anyone from a principal to a secretary" to share the burden. In
Florida, where the ratio of school nurses to students is particularly low, "many schools have clerical workers hand out the pills." So many pills, and so few
professionals to go around. What else are the authorities to do?
Behold the uniquely American psychotropic universe, pediatrics zone — a place where "psychiatric medications in general have become more common in
schools" and where, in particular, "Ritalin dominates." There are by now millions of stories in orbit here, and the particular one chosen by the Times — of
how the drug has induced a professional labor shortage — is no doubt an estimable entry. But for the reader struck by some of the facts the Times
mentions only in passing — for example, that Ritalin use more than doubled in the first half of the decade alone, that production has increased 700 percent
since 1990, or that the number of schoolchildren taking the drug may now, by some estimates, be approaching the 4 million mark — mere anecdote will only
explain so much.
Fortunately, at least for the curious reader, there is a great deal of other material now on offer, for the explosion in Ritalin consumption has been very nearly
matched by a publishing boom dedicated to that same phenomenon. Its harbingers include, for example, Barbara Ingersoll’s now-classic 1988 Your
Hyperactive Child, among the first works to popularize a drug regimen for what we now call Attention Deficit Disorder (ADD, called ADHD when it includes
hyperactivity). Five years later, with add diagnoses and Ritalin prescriptions already rising steeply in the better-off neighborhoods and schools, Peter D.
Kramer helped fuel the boom with his bestselling Listening to Prozac — a book that put the phrase "cosmetic pharmacology" into the vernacular and thereby inadvertently broke new conceptual ground for the advocates of Ritalin. In 1994,
most important, psychiatrists Edward M. Hallowell and John J. Ratey published their own bestselling Driven to Distraction: Recognizing and Coping with Attention Deficit Disorder from Childhood to Adulthood, a book that was perhaps the
single most powerful force in the subsequent proliferation of add diagnoses; as its opening sentence accurately prophesied, "Once you catch on to what this syndrome is all about, you’ll see it everywhere."
Not everyone received these soundings from the psychotropic beyond with the same enthusiasm. One noteworthy dissent came in 1995 with Thomas
Armstrong’s The Myth of the add Child, which attacked both the scientific claims made on behalf of ADD and what Armstrong decried as the "pathologizing" of normal children. Dissent also took the form of wary public pronouncements by
the National Education Association (NEA), one of several groups to harbor the fear that add would be used to stigmatize minority children. Meanwhile, scare stories on the abuse and side effects of Ritalin popped out here and there in
the mass media, and a national controversy was born. From the middle to the late 1990s, other interested parties from all over — the Drug Enforcement
Administration (DEA), the Food and Drug Administration (FDA), the medical journals, the National Institutes of Health (NIH), and especially the extremely
active advocacy group chadd (Children and Adults with Attention Deficit Disorder) — further stoked the debate through countless reports, conferences,
pamphlets, and exchanges on the Internet.
To this outpouring of information and opinion two new books, both on the critical side of the ledger, have just been added: Richard DeGrandpre’s
iconoclastic Ritalin Nation: Rapid-Fire Culture and the Transformation of Human Consciousness (Simon and Schuster, 1999), and physician Lawrence H. Diller’s superbly analytical Running on Ritalin: A Physician Reflects on Children,
Society and Performance in a Pill (Bantam Books, 1998). Their appearance
marks an unusually opportune moment in which to sift through some ten years’ worth of information on Ritalin and add and to ask what, if anything, we have
learned from the national experiment that has made both terms into household
words.
Let’s put the question bluntly: How has it come to pass that in fin-de-siècle America, where every child from preschool onward can recite the "anti-drug" catechism by heart, millions of middle- and upper-middle class children are being
legally drugged with a substance so similar to cocaine that, as one
journalist accurately summarized the science, "it takes a chemist to tell the difference"?
What is methylphenidate?
The first thing that has made the Ritalin explosion possible is that methylphenidate, to use the generic term, is perhaps the most widely
misunderstood drug in America today. Despite the fact that it is, as Lawrence Diller observes in Running on Ritalin, "the most intensively studied drug in
pediatrics," most laymen remain under a misimpression both about the nature of the drug itself and about its pharmacological effects on children.
What most people believe about this drug is the same erroneous characterization that appeared elsewhere in the Times piece quoted earlier —
that it is "a mild stimulant of the central nervous system that, for reasons not fully understood, often helps children who are chronically distractible, impulsive
and hyperactive settle down and concentrate." The word "stimulant" here is at least medically accurate. "Mild," a more ambiguous judgment, depends partly on the dosage, and partly on whether the reader can imagine describing as "mild"
any dosage of the drugs to which methylphenidate is closely related. These include dextroamphetamine (street name: "dexies"), methamphetamine (street name: "crystal meth"), and, of course, cocaine. But the chief substance of the Times’
formulation here — that the reasons why Ritalin does what it does to children remain a medical mystery — is, as informed writers from all over the debate have long acknowledged, an enduring public myth.
"Methylphenidate," in the words of a 1995 dea background paper on the drug, "is a central nervous system (CNS) stimulant and shares many of the
pharmacological effects of amphetamine, methamphetamine, and cocaine." Further, it "produces behavioral, psychological, subjective, and reinforcing
effects similar to those of d-amphetamine including increases in rating of euphoria, drug liking and activity, and decreases in sedation." For comparative
purposes, that same dea report includes a table listing the potential adverse physiological effects of both methylphenidate and dextroamphetamine; they
are, as the table shows, nearly identical (see below). To put the point conversely, as Richard DeGrandpre does in Ritalin Nation by quoting a 1995 report in the Archives of General Psychiatry, "Cocaine, which is one of the most
reinforcing and addicting of the abused drugs, has pharmacological actions that are very similar to those of methylphenidate, which is now the most commonly prescribed psychotropic medicine for children in the U.S."
Such pharmacological similarities have been explored over the years in numerous studies. DeGrandpre reports that "lab animals given the choice to self-administer comparative doses of cocaine and Ritalin do not favor one over another" and that "a similar study showed monkeys would work in the same
fashion for Ritalin as they would for cocaine." The dea reports another finding — that methylphenidate is actually "chosen over cocaine in preference studies" of non-human primates (emphasis added). In Driven to Distraction,
pro-Ritalin psychiatrists Hallowell and Ratey underline the interchangeable nature of methylphenidate and cocaine when they observe that "people with add feel focused when they take cocaine, just as they do when they take Ritalin
[emphasis added]." Moreover, methylphenidate (like other stimulants) appears to increase tolerance for related drugs. Recent evidence indicates, for example, that when people accustomed to prescribed Ritalin turn to cocaine, they seek
higher doses of it than do others. To summarize, again from the dea report, "it is clear that methylphenidate substitutes for cocaine and d-amphetamine in a number of behavioral paradigms."
All of which is to say that Ritalin "works" on children in the same way that related stimulants work on adults — sharpening the short-term attention span
when the drug kicks in and producing equally predictable valleys ("coming down," in the old street parlance; "rebounding," in Ritalinese) when the effect
wears off. Just as predictably, children are subject to the same adverse effects as adults imbibing such drugs, with the two most common — appetite
suppression and insomnia — being of particular concern. That is why, for example, handbooks on add will counsel parents to see their doctor if they feel
their child is losing too much weight, and why some children who take methylphenidate are also prescribed sedatives to help them sleep. It is also why one of the more Orwellian phrases in the psychotropic universe, "drug holidays" —
meaning scheduled times, typically on weekends or school vacations, when the dosage of methylphenidate is lowered or the drug temporarily withdrawn in order to keep its adverse effects in check — is now so common in the literature that
it no longer even appears in quotations.
Just as, contrary to folklore, the adult and child physiologies respond in the same way to such drugs, so too do the physiologies of all people, regardless of
whether they are diagnosed with add or hyperactivity. As Diller puts it, in a point echoed by many other sources, methylphenidate "potentially improves the performance of anyone — child or not, add-diagnosed or not." Writing in the
Public Interest last year, psychologist Ken Livingston provided a similar summary of the research, citing "studies conducted during the mid seventies to early eighties by Judith Rapaport of the National Institute of Mental Health"
which "clearly showed that stimulant drugs improve the performance of most people, regardless of whether they have a diagnosisof adhd, on tasks requiring
good attention." ("Indeed," he comments further in an obvious comparison, "this probably explains the high levels of ‘self-medicating’ around the world" in the form of "stimulants like caffeine and nicotine.")
A third myth about methylphenidate is that it, alone among drugs of its kind, is immune to being abused. To the contrary: Abuse statistics have flourished
alongside the boom in Ritalin prescription-writing. Though it is quite true that elementary schoolchildren are unlikely to ingest extra doses of the drug, which
is presumably kept away from little hands, a very different pattern has emerged among teenagers and adults who have the manual dexterity to open
prescription bottles and the wherewithal to chop up and snort their contents (a method that puts the drug into the bloodstream far faster than oral ingestion).
For this group, statistics on the proliferating abuse of methylphenidate in schoolyards and on the street are dramatic.
According to the DEA, for example, as early as 1994 Ritalin was the fastest-growing amphetamine being used "non-medically" by high school seniors in
Texas. In 1991, reports DeGrandpre in Ritalin Nation, "children between the ages of 10 and 14 years old were involved in only about 25 emergency room visits connected with Ritalin abuse. In 1995, just four years later, that number had
climbed to more than 400 visits, which for this group was about the same
number of visits as for cocaine." Not surprisingly, given these and other measures of methylphenidate’s recreational appeal, criminal entrepreneurs have responded with interest to the drug’s increased circulation. From 1990 to 1995,
the DEA reports, there were about 2,000 thefts of methylphenidate, most of them night break-ins at pharmacies — meaning that the drug "ranks in the top 10 most frequently reported pharmaceutical drugs diverted from licensed
handlers."
Because so many teenagers and college students have access to it, methylphenidate is particularly likely to be abused on school grounds. "The
prescription drug Ritalin," reported Newsweek in 1995, "is now a popular high on campus — with some serious side effects." DeGrandpre notes that at his
own college in Vermont, Ritalin was cited as the third-favorite drug to snort in a campus survey. He also runs, without comment, scores of individual abuse
stories from newspapers across the country over several pages of his book. In Running on Ritalin, Diller cites several undercover narcotics agents who
confirm that "Ritalin is cheaper and easier to purchase at playgrounds than on the street." He further reports one particularly hazardous fact about Ritalin
abuse, namely that teenagers, especially, do not consider the drug to be anywhere near as dangerous as heroin or cocaine. To the contrary: "they think
that since their younger brother takes it under a doctor’s prescription, it must be safe."
In short, methylphenidate looks like an amphetamine, acts like an amphetamine, and is abused like an amphetamine. Perhaps not surprisingly, those who value its medicinal effects tend to explain the drug differently. To some, Ritalin is
to children what Prozac and other psychotropic "mood brightening" drugs are to adults — a short-term fix for enhancing personality and performance. But the analogy is misleading. Prozac and its sisters are not stimulants with stimulant
side effects; there is, ipso facto, no black market for drugs like these. Even more peculiar is the analogy favored by the advocates in chadd: that "Just as a pair of glasses help the nearsighted person focus," as Hallowell and Ratey
explain, "so can medication help the person with add see the world more clearly." But there is no black market for eyeglasses, either — nor loss of appetite, insomnia, "dysphoria" (an unexplained feeling of sadness that sometimes
accompanies pediatric Ritalin-taking), nor even the faintest risk of toxic psychosis, to cite one of Ritalin’s rare but dramatically chilling possible effects.
What is methylphenidate "really" like? Thomas Armstrong, writing in The Myth of the ADD Child four years ago, probably summarized the drug’s appeal best.
"Many middle and upper-middle class parents," he observed then, "see Ritalin and related drugs almost as ‘cognitive steroids’ that can be used to help their
kids focus on their schoolwork better than the next kid." Put this way, the attraction to Ritalin makes considerable sense. In some ways, one can argue,
that after-lunch hit of low-dose methylphenidate is much like the big cup from Starbucks that millions of adults swig to get them through the day — but only in
some ways. There is no dramatic upswing in hospital emergency room visits and pharmacy break-ins due to caffeine abuse; the brain being jolted awake in
one case is that of an adult, and in the other that of a developing child; and, of course, the substance doing the jolting on all those children is not legally
available and ubiquitous caffeine, but a substance that the dea insists on calling a Schedule II drug, meaning that it is subject to the same controls, and for the same reasons of abuse potential, as related stimulants and other
powerful drugs like morphine.
What is CHADD?
This mention of Schedule II drugs brings us to a second reason for the Ritalin explosion in this decade. That is the extraordinary political and medical clout of CHADD, by far the largest of the add support groups and a lobbying
organization of demonstrated prowess. Founded in 1987, chadd had, according
to Diller, grown by 1993 to include 35,000 families and 600 chapters nationally. Its professional advisory board, he notes, "includes most of the most prominent academicians in the add world, a veritable who’s who in research."
Like most support groups in self-help America, CHADD functions partly as clearing-house and information center for its burgeoning membership —
organizing speaking events, issuing a monthly newsletter (Chadderbox), putting out a glossy magazine (named, naturally enough, Attention!), and operating an exceedingly active website stocked with on-line fact sheets and items for
sale. Particular scrutiny is given to every legal and political development offering new benefits for those diagnosed with add. On these and other fronts of interest, CHADD leads the add world. "No matter how many sources of
information are out there," as a slogan on its website promises, "chadd is the one you can trust."
One of CHADD’s particular strengths is that it is exquisitely media-sensitive, and has a track record of delivering speedy responses to any reports on Ritalin or add that the group deems inaccurate. Diller quotes as representative one
fundraising letter from 1997, where the organization listed its chief goals and
objectives as "conduct[ing] a proactive media campaign" and "challeng[ing] negative, inaccurate reports that demean or undermine people with add." Citing "savage attacks" in the Wall Street Journal and Forbes, the letter also went on
to exhort readers into "fighting these battles of misinformation, innuendo, ignorance and outright hostility toward CHADD and adults who have a neurobiological disorder." The circle-the-wagons rhetoric here appears to be typical of the
group, as is the zeal.
Certainly it was with missionary fervor that chadd, in 1995, mounted an extraordinary campaign to make Ritalin easier to obtain. Methylphenidate, as
mentioned, is a Schedule II drug. That means, among other things, that the dea must approve an annual production quota for the substance — a fact that
irritates those who rely on it, since it raises the specter, if only in theory, of a Ritalin "shortage." It also means that some states require that prescriptions for
Ritalin be written in triplicate for the purpose of monitoring its use, and that refills cannot simply be called into the pharmacy as they can for Schedule III
drugs (for example, low-dosage opiates like Tylenol with codeine, and various compounds used to treat migraine). Doctors, particularly those who prescribe
Ritalin in quantity, are inconvenienced by this requirement. So too are many parents, who dislike having to stop by the doctor’s office every time the Ritalin
runs out. Moreover, many parents and doctors alike object to methylphenidate’s Schedule II classification in principle, on the grounds that it makes children feel stigmatized; the authors of Driven to Distraction, for example, claim
that one of the most common problems in treating add is that "some pharmacists, in their attempt to comply with federal regulations, make consumers [of Ritalin] feel as though they are obtaining illicit drugs."
For all of these reasons, CHADD petitioned the dea to reclassify Ritalin as a Schedule III drug. This petition was co-signed by the American Academy of
Neurology, and it was also supported by other distinguished medical bodies, including the American Academy of Pediatrics, the American Psychological
Association, and the American Academy of Child and Adolescent Psychiatry. Diller’s account of this episode in Running on Ritalin is particularly credible, for he is a doctor who has himself written many prescriptions for Ritalin
in cases where he has judged it to be indicated. Nevertheless, he found himself
dissenting strongly from the effort to decontrol it — an effort that, as he writes, was "unprecedented in the history of Schedule II substances" and "could have
had a profound impact on the availability of the drug."
What happened next, while CHADD awaited the dea’s verdict, was in Diller’s words "a bombshell." For before the DEA had officially responded, a television
documentary revealed that Ciba-Geigy (now called Novartis), the pharmaceuticals giant that manufactures Ritalin, had contributed nearly $900,000 to CHADD over five years, and that chadd had failed to disclose the contributions to all
but a few selected members.
The response from the dea, which appeared in the background report cited earlier, was harsh and uncompromising. Backed by scores of footnotes and well
over a 100 sources in the medical literature, this report amounted to a public excoriation of CHADD’s efforts and a meticulous description, alarming for those
who have read it, of the realities of Ritalin use and abuse. "Most of the adhd literature prepared for public consumption and available to parents," the DEA
charged, "does not address the abuse liability or actual abuse of methylphenidate. Instead, methylphenidate is routinely portrayed as a benign,
mild stimulant that is not associated with abuse or serious effects. In reality, however, there is an abundance of scientific literature which indicates that methylphenidate shares the same abuse potential as other Schedule II
stimulants."
The dea went on to note its "concerns" over "the depth of the financial relationship between CHADD and Ciba-Geigy." Ciba-Geigy, the dea observed,
"stands to benefit from a change in scheduling of methylphenidate." It further observed that the United Nations International Narcotics Control Board (INCB) had "expressed concern about non-governmental organizations and parentalassociations in the United States that are actively lobbying for the medical use
of methylphenidate for children with add." (The rest of the world, it should be noted, has yet to acquire the American taste for Ritalin. Sweden, for example,
had methylphenidate withdrawn from the market in 1968 following a spate of abuse cases. Today, 90 percent of Ritalin production is consumed in the United
States.) The report concluded with the documented observations that "abuse data indicate a growing problem among school-age children," that "adhd adults
have a high incidence of substance disorders," and that "with three to five percent of today’s youth being administered methylphenidate on a chronic basis, these issues are of great concern."
Yet whatever public embarrassment chadd and its supporters may have suffered on account of this setback turned out to be short-lived. Though it failed
in the attempt to decontrol Ritalin (in the end, the group withdrew its petition), on other legislative fronts CHADD was garnering one victory after another. By the end of the 1990s, thanks largely to chadd and its allies, an add
diagnosis could lead to an impressive array of educational, financial, and social service benefits.
In elementary and high school classrooms, a turning point came in 1991 with a letter from the U.S. Department of Education to state school superintendents
outlining "three ways in which children labeled add could qualify for special education services in public school under existing laws," as Diller puts it. This
directive was based on the landmark 1990 Individuals with Disabilities Education Act (idea), which "mandates that eligible children receive access to
special education and/or related services, and that this education be designed to meet each child’s unique educational needs" through an individualized
program. As a result, add-diagnosed children are now entitled by law to a long list of services, including separate special-education classrooms, learning specialists, special equipment, tailored homework assignments, and more. The
idea also means that public school districts unable to accommodate such
children may be forced to pick up the tab for private education.
In the field of higher education, where the first wave of Ritalin-taking students has recently landed, an add diagnosis can be parlayed into other sorts of
special treatment. Diller reports that add-based requests for extra time on sats, lsats, and mcats have risen sharply in the course of the 1990s. Yet the example of such high-profile tests is only one particularly measurable way of
assessing add’s impact on education; in many classrooms, including college classrooms, similar "accommodations" are made informally at a student’s demand. A professor in the Ivy League tells me that students with an add diagnosis now
come to him "waving doctor’s letters and pills" and requesting extra time for routine assignments. To refuse "accommodation" is to risk a hornet’s nest of
liabilities, as a growing caseload shows. A 1996 article in Forbes cites the example of Whittier Law School, which was sued by an add-diagnosed student for giving only 20 extra minutes per hour long exam instead of a full hour. The
school,fearing an expensive legal battle, settled the suit. It further undertook a
preventive measure: banning pop quizzes "because add students need separate rooms and extra time."
Concessions have also been won by advocates in the area of college athletics. The National College Athletic Association (NCAA) once prohibited Ritalin usage (as do the U.S. and International Olympic Committees today) because of what
Diller calls its "possible acute performance-enhancing benefits." In 1993, citing legal jeopardy as a reason for changing course, the ncaa capitulated. Today a letter from the team physician will suffice to allow an athlete to ingest
Ritalin, even though that same athlete would be disqualified from participating in the Olympics if he were to test positive for stimulants.
Nor are children and college students the only ones to claim benefits in the name of add. With adults now accounting for the fastest-growing subset of add diagnoses, services and accommodations are also proliferating in the workplace.
The enabling regulations here are 1997 guidelines from the Equal
Employment Opportunity Commission (EEOC) which linked traits like chronic lateness, poor judgment, and hostility to coworkers — in other words, the sorts
of traits people get fired for — to "psychiatric impairments," meaning traits that are protected under the law. As one management analyst for the Wall Street
Journal recently observed (and as CHADD regularly reminds its readers), these eeoc guidelines have already generated a list of accommodations for add-diagnosed employees, including special office furniture, special equipment such as tape recorders and laptops, and byzantine organizational schemes (color
coding, buddy systems, alarm clocks, and other "reminders") designed to keep such employees on track. "Employers," this writer warned, "could find
themselves facing civil suits and forced to restore the discharged people to their old positions, or even give them promotions as well as back pay or reasonable accommodation."
An add diagnosis can also be helpful in acquiring Supplemental Security Income (SSI) benefits. ssi takes income into account in providing benefits to the
add diagnosed; in that, it is an exception to the trend. Most of the benefits now available, as even this brief review indicates, have come to be provided in
principle, on account of the diagnosis per se. Seen this way, and taking the class composition of the add-diagnosed into account, it is no wonder that more
and more people, as Diller and many other doctors report, are now marching into medical offices demanding a letter, a diagnosis, and a prescription. The
pharmacological charms of Ritalin quite apart, add can operate, in effect, as affirmative action for affluent white people.
What is Attention Deficit Disorder?
Another factor that has put Ritalin into millions of medicine cabinets has to do with the protean nature of the disorder for which it is prescribed — a disorder
that was officially so designated by the American Psychiatric Association in 1980, and one that, to cite Thomas Armstrong, "has gone through at least 25
different name changes in the past century."
Despite the successful efforts to have add construed as a disability like blindness, the question of what add is remains passionately disputed. To
CHADD, of course, it is a "neurobiological disorder," and not only to CHADD; "the belief that add is a neurological disease," as Diller writes, also "prevails
today among medical researchers and university teaching faculty" and "is reflected in the leading journals of psychiatry." What the critics observe is something else — that "despite highly successful efforts to define add as a
well-established disorder of the brain," as DeGrandpre puts it in a formulation
echoed by many, "three decades of medical science have yet to produce any substantive evidence to support such a claim."
Nonetheless, the effort to produce such evidence has been prodigious. Research on the neurological side of add has come to resemble a Holy Grail-like
quest for something, anything, that can be said to set the add brain apart — genes, imbalances of brain chemicals like dopamine and serotonin, neurological
damage, lead poisoning, thyroid problems, and more. The most famous of these studies, and the chief grounds on which add has come to be categorized as a neurobiological disability, was reported in The New England Journal of Medicine in
1990 by Alan Zametkin and colleagues at the National Institute of Mental Health (NIMH). These researchers used then-new positron emission tomography (PET) scanning to measure differences in glucose metabolizing between hyperactive
adults and a control group. According to the study’s results, what emerged was a statistically significant difference in the rates of glucose metabolism — a difference hailed by many observers as the first medical "proof" of a
biological basis for add.
Diller and DeGrandpre are only the latest to argue, at length, that the Zametkin study established no such thing. For starters — and from the scientific point of view, most important — a series of follow-up studies, as Diller
documents, "failed to confirm" the original result. DeGrandpre, for his part, details the
methodological problems with the study itself — that the participants were adults rather than children, meaning that the implications for the majority of the
Ritalin-taking population were unclear at best; that there was "no evidence" that the reported difference in metabolism bore any relationship to behavioral
activity; that the study was further plagued by "a confounding variable that had nothing to do with ADD," namely that the control group included far fewer male subjects than the add group; and that, even if there had been a valid
difference in metabolism between the two groups, "this study tells us nothing about the cause of these differences."
Numerous other attempts to locate the missing link between add and brain activity are likewise dissected by Diller and DeGrandpre in their books. So too is
the causal fallacy prevalent in add literature — that if a child responds positively to Ritalin, that response "proves" that he has an underlying biological disorder. This piece of illogic is easily dismissed. As these and other
authors emphasize, drugs like Ritalin have the same effect on just about everybody. Give it to almost any child, and the child will become more focused and less aggressive — one might say, easier to manage — whether or not there were
"symptoms" of ADD in the first place.
In sum, and as Thomas Armstrong noted four years ago in The Myth of the ADD Child, ADD remains an elusive disorder that "cannot be authoritatively identified in the same way as polio, heart disease, or other legitimate illnesses."
Instead, doctors depend on a series of tests designed to measure the panoply of add symptoms. To cite Armstrong again: "there is no prime mover in this chain of tests; no First Test for add that has been declared self-referential and
infallible." Some researchers, for example, use "continuous performance tasks" (cpts) that require the person being tested to pay attention throughout a series of repetitive actions. A popular CPT is the Gordon Diagnostic System, a box
that flashes numbers, whose lever is supposed to be pressed every time a particular combination appears. Yet as numerous critics have suggested, although the score that results is supposed to tell us about a given child’s ability to
attend, its actual significance is rather ambiguous; perhaps, as Armstrong analyzes, "it only tells how a child will perform when attending to a repetitive series of meaningless numbers on a soulless task."
In the absence of any positive medical or scientific test, the diagnosis of add in both children and adults depends, today as a decade ago, almost exclusively on behavioral criteria. The diagnostic criteria for children, according to
the latest Diagnostic and Statistics Manual (DSM-IV), include six or more months’ worth of some 14 activities such as fidgeting, squirming, distraction by extraneous stimuli, difficulty waiting turns, blurting out answers, losing
things, interrupting, ignoring adults, and so on. (To read the list is to understand why boys are diagnosed with add three to five times as often as girls.) The diagnostic latitude offered by this list is obvious; as Diller understates
the point, "what often strikes those encountering dsm criteria for the first time is how common these symptoms are among children" generally.
The dsm criteria for adults are if anything even more expansive, and include such ambiguous phenomena as a sense of underachievement, difficulty getting
organized, chronic procrastination, a search for high stimulation, impatience, impulsivity, and mood swings. Hallowell and Ratey’s 100-question test for add in Driven to Distraction, an elaborately extrapolated version of the dsm
checklist, illustrates this profound elasticity. Their questions range from the
straightforward ("Are you impulsive?" "Are you easily distracted?" "Do you fidget a lot?") to more elusive ways of eliciting the disorder ("Do you change the radio station in your car frequently?" "Are you always on the go, even when
you don’t really want to be?" "Do you have a hard time reading a book all the way through?"). Throughout, the distinction between what is pathological and what is not remains unclear — because, in the authors’ words, "There is no clear
line of demarcation between add and normal behavior."
Thus the business of diagnosing add remains, as Diller puts it, "very much in the eye of the beholder." In 1998, partly for that reason, the National Institutes of Health convened a conference on add with hundreds of participants and a
panel of 13 doctors and educators. This conference, as newspapers reported at the time, broke no new ground, and indeed could not reach agreement on several important points — for instance, how long children should take drugs for add,
or whether and when drug treatment might become risky. Even more interesting, conference members could not agree on what is arguably the rather fundamental question of how to diagnose the disorder in the first place. As one panelist, a
pediatrician, put it succinctly, "The diagnosis is a mess."
Who has ADD?
To test this hypothesis, I gave copies of Hallowell and Ratey’s questionnaire to 20 people (let’s call them subjects) and asked them to complete it and total up the number of times they checked "yes." The full questionnaire appears at
the conclusion of this piece so that interested readers can take it themselves.
"These questions," as Hallowell and Ratey note, "reflect those an experienced diagnostician would ask." Although, as they observe, "this quiz cannot confirm
the diagnosis" (as we have seen already, nothing can), it does "offer a rough assessment as to whether professional help should be sought." In short, "the
more questions that are answered ‘yes,’ the more likely it is that add may be present."
In a stab at methodological soundness, I had equal numbers of males and females take the test. All would be dubbed middle- or upper-middle class, all but
one are or have been professionals of one sort or another, all are white, and the group was politically diverse — which is to say, the sample accurately reflects the socioeconomic pool from which most of the current Ritalin-taking
population is drawn. As to the matter of observer interference, although some
subjects may have guessed what the questionnaire was looking for, all of them (myself excepted, of course) took the test "blind," that is, without any
accompanying material to prejudice their responses.
We begin with results at the lower end of the scale. Of the 18 subjects who completed the test, two delivered "yes" scores of 8 and 10 (a professor of
English and his wife, an at-home mother active in philanthropy). These "yes" results, as it turned out, were at least threefold lower than anyone else’s. In "real" social science, according to some expert sources, we would simply call
these low scores "outliers" and throw them out for the same reason. We, however, shall include them, if only on the amateur grounds of scrupulousness.
The next lowest "yes" tallies — 29 in each case — were achieved by an editorial assistant and a school nurse. That is to say, even these "low scorers" managed to answer yes almost a third of the time (remember, "the more questions that
are answered ‘yes,’ the more likely it is that add may be present"). After them, we find a single "yes" score of 33 (an assistant editor). Following that, fully six subjects, or a third of the test-finishers, produced scores in the
40s. These include this magazine’s editor, two at-home mothers (one a graphic designer, the other a poet), a writer for Time and other distinguished publications, Policy Review’s business manager, and — scoring an estimable 49 — the
headmaster of a private school in Washington.
Proceeding into the upper echelons, a novelist who is also an at-home mother reported her score as 55, and a renowned demographic expert with ties to
Harvard and Washington think tanks scored a 57. A male British journalist and at-home father achieved a 60, and a female American journalist and at-home
mother (me) got a 62. Still another at-home mother, this one with a former career in public relations, garnered a 65.
In the lead, at least of the test-finishers, was a bestselling satirist whom we shall call, for purposes of anonymity, Patrick O’Rourke; he produced an estimable score of 75. "Mr. O’Rourke" further advanced the cause of science by
answering the questions on behalf of his 16-month-old daughter; according to his proud report, 65 was the result. Then there were the two subjects who, for whatever reason, were unable to complete the test in the first place. One of
these subjects called to say that he’d failed to finish the test because he’d "gotten bored checking off so many yes answers." When I pressed him for some, any, final tally for me to include, he got irritated and refused, saying he was
"too lazy" to count them up. Finally he said "50 would be about right," take it or leave it. He is a Wall Street investment banker specializing in the creation of derivative securities. Our last subject, perhaps the most pathological
of all, failed to deliver any score despite repeated reminding phone calls from the research team. He is the professor mentioned earlier, the one who reported that ADD is now being used as a blanket for procrastination and shirking on
campus.
Now on to interpreting the results. Apart from the exceedingly anomalous two scores of ten and under, all the rest of the subjects reported answering "yes" to at least a quarter of the questions — surely enough to trigger the
possibility of an add diagnosis, at least in those medical offices Diller dubs "Ritalin mills." (As for the one subject who reported no result whatsoever, he is obviously entitled to untold ADD bonus points for that reason alone.)
Fully 15 of the finishers, or 80-plus percent, answered yes to one-third of the questions or more. Eight of the finishers, or 40-plus percent of the sample, answered yes more than half of the time, with a number of scores in the high
40s right behind them. In other words, roughly half of the sample answered yes roughly half of the time.
My favorite comment on the exercise came from the school nurse (who scored, one recalls, a relatively low 29). She has a background in psychiatry, and
therefore realized what kind of diagnosis the questionnaire was designed to elicit. When she called to report her result, she said that taking the test had made her think hard about the whole add issue. "My goodness," she concluded,
"it looks like the kind of thing almost anybody could have." This brings us to the fourth reason for the explosion of add and its prescribed corollary, Ritalin: The nurse is right.
What is childhood?
The fourth and most obvious reason millions of Americans, most of them children, are now taking Ritalin can be summarized in a single word that crops
up everywhere in the dry-bones literature on add and its drug of choice: compliance. One day at a time, the drug continues to make children do what
their parents and teachers either will not or cannot get them to do without it: Sit down, shut up, keep still, pay attention. That some children are born with or
develop behavioral problems so severe that drugs like Ritalin are a godsend is true and sad. It is also irrelevant to the explosion in psychostimulant
prescriptions. For most, the drug is serving a more nuanced purpose — that of "help[ing] your child to be more agreeable and less argumentative," as Barbara Ingersoll put it over a decade ago in Your Hyperactive Child.
There are, as was mentioned, millions of stories in the Ritalin universe, and the literature of advocates and critics alike all illustrates this point. There is no
denying that millions of people benefit from having children take Ritalin — the many, many parents who will attest that the drug has improved their child’s
school performance, their home lives, often even their own marriages; the teachers who have been relieved by its effects in their classrooms, and have
gone on to proselytize other parents of other unruly children (frequently, it is teachers who first suggest that a child be checked for the disorder); and the
doctors who, when faced with all these grateful parents and teachers, find, as Diller finds, that "at times the pressure for me to medicate a child is intense."
Some other stories seep through the literature too, but only if one goes looking for them. These are the stories standing behind the clinical accounts of
teenagers who lie and say they’ve taken the day’s dose when they haven’t, or of the children who cry in doctor’s offices and "cheek" the pill (hide it rather than swallow, another linguistic innovation of Ritalinese) at home. These are
the stories standing behind such statements as the following, culled from case
studies throughout the literature: "It takes over of me [sic]; it takes control." "It numbed me." "Taking it meant I was dumb." "I feel rotten about taking pills; why
me?" "It makes me feel like a baby." And, perhaps most evocative of all, "I don’t know how to explain. I just don’t want to take it any more."
But these quotes, as any reader will recognize, appeal only to sentiment; science, for its part, has long since declared its loyalties. In the end, what has
made the Ritalin outbreak not only possible but inevitable is the ongoing blessing of the American medical establishment — and not only that
establishment. In a particularly enthusiastic account of the drug in a recent issue of the New Yorker, writer Malcolm Gladwell exults in the idea that "we are now extending to the young cognitive aids of a kind that used to be reserved
exclusively for the old." He further suggests that, given expert estimates of the
prevalence of add (up to 10 percent of the population, depending on the expert), if anything "too few" children are taking the drug. Surely all these experts have a point. Surely this country can do more, much more, to reduce
fidgeting, squirming, talking excessively, interrupting, losing things, ignoring adults, and
all those other pathologies of what used to be called childhood.
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Depakote
Depakote (valproate) is being prescribed with increasing frequency for children who have ADHD. Depakote (also known as Valproate or Valproic Acid) was once only prescribed for epileptics. But this anticonvulsant medication is now being
prescribed to treat several disorders, including ADHD.The use of anticonvulsants to treat psychiatric conditions is not a new concept. N. Frank Feiner, Ph.D., M.D., writes that the original 'first-generation' antiepileptic drug which appeared in 1857 was also known for its tranquilizing
properties. After phenobarbital came into use for epilepsy in 1912 there soon followed reports of its sychopharmacologic application. It is now common practice to treat Bipolar Disorder with Depakote. Depakote has been approved as an
anticonvulsant for ages 2 and older, which means it can be used to treat younger patients.
Why is Depakote prescribed to people who have ADHD?Aside from being an effective anticonvulsant for patients who have epilepsy, Depakote has demonstrated abilities as a mood stablizer. It is this property that leads doctors to
prescribe this medication for ADHD.
Most children who have ADHD are given either Ritalin (methylphenidate), Adderall or some other stimulant medication. These medications control most
symptoms of ADHD. However, they may or may not be effective in controlling mood swings or other behavioral problems. Depakote has been shown to be
effective in treating severe disruptive behavior disorders, including explosive behavior in children, allowing these patients to have fairly normal lives.
New research on Depakote and Ritalin shows that Depakote prevents sensitization to Ritalin (methylphenidate) in rats. While rats are not perfect
models for human responses to medications, the study does have implications for patients who may develop sensitization to Ritalin.
But Depakote is not without its problems. Side effects include weight gain, loss of appetite, trembling hands and other problems. The drug has been known to affect the liver, and regular blood tests are required.
Some patients have reported valproate-induced tinnitus that may be misinterpreted as psychotic symptoms. A study released in January, 2001
shows that Depakote has been associated with thrombocytopenia , or a low platelet count in the blood and can result in excessive bruising or bleeding.
While this condition is more common among elderly patients, it is a potential risk for children who are using Depakote. Precautions for patients with this
condition should be observed.
There have been reports of adverse reactions to the combination of Ritlain and Depakote, including dental problems resulting from bruxism, or tooth grinding. Other adverse reactions have included dyskinesia, which looks like writhing
or wiggling movements similar to those seen in patients who have Parkinson's.
Research published in the January 15th issue of the American Journal of Medical Genetics describes the cases of two siblings with fetal valproate
syndrome and their long-term follow-up. It also reviews cases of children born to epileptic women who took Depakote while pregnant. In all, the report cites 69 cases could be attributed solely to valproic acid exposure to the baby
during the mother's pregnancy. Musculoskeletal abnormalities were found in 62% of cases, minor skin defects in 30%, cardiovascular abnormalities in 26%, genital abnormalities in 22%, and pulmonary abnormalities in 16% of cases.
Fifteen percent of the cases had growth retardation and 9% had an overgrowth pattern. Defects of the brain, eye, kidney, and hearing were less common.
Always Check With Your Doctor
Depakote has been shown to be helpful in treating some of the problems associated with ADHD, particularly in controlling mood swings and behavior.
However, like all medications, it has side effects that will vary from patient to patient.
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Inositol
Inositol, a nutrient found in organ meats such as liver, may be effective in the treatment of patients with depression, panic disorder and obsessive compulsive disorder (OCD) . This research supports previous findings that inositol
reduces depressive-like behaviors in animals.
Hannibal Lechter would no doubt have some serving suggestions, but you don't have to eat liver. Wheat and wheat bran, cantaloupe, and oranges are also
excellent sources of inositol.
Depression, panic disorder (or anxiety disorders) and OCD are all more common among people who have ADHD than among the general population. Although there had been some claims that inositol supplements could help ADHD, researchers
found that the nutrient,part of the b-vitamin complex, was probably not an effective treatment for attention deficits or hyperactivity.
According to an extract of the study published in the January 2001 Journal of Affective Disorders, inositol treatment was not observed to have any effect on
amphetamine-induced hyperactivity or on the performance of memory tasks by monkeys.
Inositol As An Option for treatment
Controlled trials using inositol on humans have shown that inositol appears to have therapeutic effects in the spectrum of illness responsive to serotonin
selective re-uptake inhibitors (SSRI), a class of medications that includes Prozac, Paxil and Zoloft. While these medications are commonly prescribed to
people who have ADHD, they are not considered to be first-line treatments for the disorder. Typically, SSRI medications are used to treat depression or some other diagnosis that is also present along with ADHD.
Reseachers warn that it is too early to tell if inositol can be used as a replacement for these medications.
Those in favor of nutritional treatments in lieu of medications cite an extensive list of disorders treatable with inositol, claiming that the nutrient can cure everything from aging to vertigo.
So, enjoy some liver... along with some fava beans and a nice Chianti!
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PARENTS SHOULD ALWAYS CONSULT THEIR PHYSICIAN ABOUT MEDICATION AND BEFORE THEIR CHILD TAKES ANY MEDICATION.