Debate Grows on Classroom's 'Magic Pill'
Glendale, Calif--Adelia Lorenzo considered her 7-year-old son, Michael, to be a "normal, healthy boy." She thought nothing of his racing his bicycle up and down the street or banging in and out of the screen door on their ground-floor apartment in this suburban Los Angeles community. Nor was she overly concerned about his occasional playground fistfights.
Michael's teacher and principal at Balboa Elementary School here thought differently.
In repeated phone calls to Ms. Lorenzo, in conferences, and in notes sent home almost daily, they insisted that Michael was not like the other children in his 1st-grade class. They said he needed "medicine" to help him learn, and urged Ms. Lorenzo to take him to a doctor who could prescribe it.
But Ritalin, the medication Ms. Lorenzo eventually obtained for her son, had disastrous consequences for Michael. He stopped eating and lost weight. He complained of stomachaches and was unable to sleep at night. And he told his mother of hallucinations in which he saw "somebody cutting up a baby."
The final straw for the young mother came when she visited Michael in his classroom. She found him, she said, in "a dazed stupor."
"My boy," said Michael's father, Eladio, sitting in a worn armchair in the family's tiny flat, "he is not the same anymore." The Lorenzos' is not an entirely isolated story. It is one piece of evidence in a growing debate over the use--and alleged misuse--of a powerful stimulant drug to treat hyperactive children.
As sales figures for the drug--called Ritalin--climb, and reports of alarming side effects continue to surface, a growing number of parents and physicians are asking critical questions: Is Ritalin being used to treat a specific childhood disorder? Or is it being used to sedate unruly students?
In the Lorenzos' case, a state judge may eventually decide whether the controversial drug was properly prescribed for Michael. Next week, the family plans to file a $5-million lawsuit against Glendale school officials, the principal of Michael's school, and the child psychiatrist who prescribed Ritalin.
In other communities across the country, the debate is expected to rage on.
The sharp increase in Ritalin sales in recent years has been one catalyst for the controversy surrounding its use. Growing demand for the drug recently prompted the U.S. Drug Enforcement Administration, which regulates the production of all controlled substances, to raise its proposed 1987 production ceiling to 2,682 kilograms--nearly twice what it was two years ago.
But at the same time, regulatory boards in at least three states where consumption of Ritalin is higher than average are reviewing the prescription practices of doctors in their states.
Ritalin is the trademark name for methylphenidate hydrochloride. When used properly, say many noted physicians and child psychiatrists, Ritalin can be "a miracle drug" for some children who suffer from a condition called Attention-deficit Hyperactivity Disorder, which is thought to stem from a chemical imbalance in the brain.
Only recently renamed, the disorder has been known variously as hyperkinesis, hyperactivity, and minimal brain dysfunction.
An estimated 3 to 10 percent of the nation's 45 million schoolchildren, mostly boys, are thought to suffer from the disorder, which is characterized by an inability to concentrate, and, in some cases, impulsivity and hyperactivity.
Pediatricians and psychiatrists say Ritalin is "the drug of choice" for treating these youngsters because it aids concentration by somehow stimulating the brain's system for filtering out unwanted stimuli. In a classroom setting, for example, the student is better able to ignore the janitor working in the hall or the birds flying outside the window.
"As medications go--when I think of some of the other medications I prescribe, like penicillin--stimulant medication is very, very safe," said Dr. Betsy Busch, a practicing pediatrician and assistant professor of pediatrics at Tufts University School of Medicine in Massachusetts. "Unfortunately, I think Ritalin is a drug that is both over-prescribed and under-prescribed."
Troubling Side Effects
Critics of Ritalin say they are concerned because the drug can produce disturbing side effects in a small4number of children--particularly if the dosage is too strong.
According to the Physicians' Desk Reference, a professional text on the effects of medications, Michael Lorenzo experienced some of the most common side effects of the drug--insomnia, loss of appetite, irritability, weight loss, and stomach aches.
Ritalin has also been known to inhibit the growth of some children while they are taking it. Such side effects may occur in 10 percent of the children treated with the drug, one child psychiatrist has estimated.
In much rarer instances, the drug is thought to have induced body tics in children whose families have a history of Tourette's syndrome, according to some experts.
While the mild appearance of such side effects may represent "the lesser of two evils" for the child who suffers from a genuine Attention-deficit Hyperactivity Disorder, some experts express concern about the countless other children who may be on the drug because of a misdiagnosis.
"The problem is that there are three symptoms of the disorder: hyperactivity, distractibility, and impulsivity," noted Dr. Larry Silver, a Washington, D.C. child psychiatrist and clinical professor of psychiatry at the Georgetown University School of Medicine. "And anxiety and depression can also cause the same symptoms."
In such cases, the medical experts say, Ritalin may only serve to mask for years the child's true problems.
An estimated 90 percent of adhd children also suffer from learning disabilities--a problem that can only be remedied with special education and not with drugs.
"It's not something any Tom, Dick, or Harry can diagnose," said Dr. Busch of the attention-deficit syndrome.
Parents also complain that the symptoms of the disorder are ambiguous at best. They point to the American Psychiatric Association's newly revised diagnostic criteria, which state, for example, that the adhd child often fidgets or squirms in his seat, has difficulty waiting his turn in games, often blurts out answers to questions before they are completed, and "loses things necessary for tasks"--behaviors that could describe any normal child.
In all, the apa lists 13 such characteristics. To be diagnosed with the disorder, a child must persistently display eight of those behaviors.
'Magic Pill' for Teachers?
"The key is all those things in one child," Dr. Levine said.
To gauge the prevalence of such behaviors, medical experts say they rely heavily on the observations of the child's classroom teacher. But, as teachers become increasingly familiar with the dramatic behavioral improvements that Ritalin can bring about in some children, the fear is that they will begin to see the drug as a "magic pill" or a "cure all."
"It's a quick fix," said Andy Watry, executive director of the Georgia Composite Board of Medical Examiners, which regulates prescription-drug use in Georgia, a state that ranks fourth nationally in Ritalin consumption. "And there are some educators who are rather quick to suggest to parents that they try the drug."
In Georgia, concern over the higher-than-average Ritalin sales has drawn the attention not only of Mr. Watry's agency, but of a special legislative committee and a study group formed by Superintendent of Schools Werner Rogers.
The driving force behind that concern was LaVarne Parker, a suburban Atlanta mother whose son's experience with the drug was similar to Michael Lorenzo's. She said that her son, Melvin, who was then 10 years old, was also hallucinating and attempted suicide after taking Ritalin.
"The doctor said, 'I'll take you to court before I let you take that kid off the drug,"' Ms. Parker recalled. "And the teacher said, 'Oh, no, I think he needs it."'
No longer on Ritalin, Melvin is currently earning B's in school, Ms. Parker said.
She took her story to the local news media, and the publicity prompted more than 200 phone calls from other concerned parents--roughly half of whom said schools had also pressured them to obtain the drug for their children.
"I've seen school districts that have a list of preferred physicians who are best described as having the fastest prescription blanks in the West," said Dr. Michael Levine, a child psychiatrist in San Antonio.
In Michael Lorenzo's case, which is typical of parents' stories elsewhere, school officials are vigorously denying that they "coerced" Ms. Lorenzo into putting Michael on the drug.
"Educators can't prescribe," noted Vic Pallos, a spokesman for the Glendale school district. "What the principal and other staff members did do was counsel the parents to have the boy evaluated by an outside professional."
The debate over the use of the drug--and educators' role in promoting it--is not new. In the 1970's, several lawsuits similar to the Lorenzos' were filed, charging school officials and doctors with conspiring to push the drug on problem students.
The attention given Ritalin then was followed by a general decline in nationwide sales, which lasted until approximately 1986, according to the dea
In the drug's current resurgence, instances of suspected overuse may be less a national phenomenon than a problem for particular geographic areas.
"I am more concerned that in some parts of the country, the amount of Ritalin sold per capita is much higher than in other states," said Dr. Levine of Washington.
He noted that the handful of states that have consistently ranked at the top in Ritalin consumption--Georgia, Utah, and Maryland--report sales of the drug that are five times higher than most other states. And Georgia's Composite Board of Medical Examiners found that 45 percent of the Ritalin prescriptions there were being filled by pharmacies located in affluent Atlanta suburbs, where the medication, in Mr. Watry's words, had become "almost trendy."
Regulatory boards in all three states are currently investigating sales of the drug. Both federal and state officials said there had been no evidence that the drug was being illegally diverted for street use.
"I think this is an educational issue," said Dr. Levine of San Antonio. "I don't think anyone's going to regulate it."
In most cases, he and other experts said, Ritalin should be used as part of a "multimodal" treatment program that might also include behavior modification, special education, counseling, and parent-training. Doctors also recommended frequent "vacations" from the drug, because children often outgrow the disorder as their brain's filtering system matures.
But the experts agreed that Ritalin remains a drug whose use in children is an effective solution only for the specific medical conditions it is designed to treat.
"It's like any other medication," Dr. Levine said. "You've got to have the right disease."