Metadate

Ritalin is prescribed primarily to individuals who have attention deficit-hyperactivity disorder (ADHD) or attention deficit disorder (ADD). Ritalin has been found to be safe in the treatment of these conditions. As useful as Ritalin is for these conditions, it has great potentials for abuse. Counselors, teachers, and parents must know the facts regarding the safe use of Ritalin, as well as the unsafe use of Ritalin. The purpose of this article is to provide counselors, teachers, and parents with information regarding the therapeutic and non-therapeutic use of Ritalin.

Ritalin is the most frequently prescribed medication for the treatment of individuals who have attention deficit-hyperactivity disorder (ADHD) or attention deficit disorder (ADD) (NIDA, 2001). It is also prescribed for narcolepsy, a sleep disorder. Ritalin has been found to be safe in the treatment of these conditions. The child must take the medication as ordered by his/her medical provider and be carefully monitored by the medical provider. As useful as Ritalin is for these conditions, it has great potentials for abuse. Counselors, teachers, and parents must know the facts regarding the safe use of Ritalin, as well as the unsafe use of Ritalin. Therefore, this article will provide counselors, teachers, and parents with information regarding the therapeutic and non-therapeutic use of Ritalin.

Brief Overview of Attention Deficit Hyperactivity Disorder (ADHD)

Attention deficit hyperactivity disorder (ADHD), once called hyperkinesis or minimal brain dysfunction, is one of the most common mental disorders among children (U.S.-National Institutes of Health. National Institute of Mental Health [U.S.-NIH.NIMH], 1994). It is characterized by inattention, distractibility, impulsivity, and restlessness. ADHD symptoms impair the child's ability to function at home, in school, and in the community (Valente, 2001).

Etiology

The exact etiology is unknown; but current research supports a neurobiological foundation (Buncher, 1996). Genetics plays a role. Yet, there are etiologic contributors who believe that adverse responses to food additives, intolerances to foods, sensitivities to environmental chemicals, molds, and fungi, and exposures to neurodevelopmental toxins such as heavy metals and organohalide pollutants (Kidd, 2000)may contribute to the disorder. Thyroid hypofunction also has been found to be a common denominator linking toxic insults with ADHD symptomatolgies (Kidd, 2000). Additionally, abnormalities in the frontostriatal brain circuitry and possible hypofunctioning of dopaminergic pathways are apparent in ADHD, and are consistent with the benefits obtained in some instances by the use of Ritalin and other potent psychostimulants (Kidd, 2000). Finally, nutrient deficiencies are common in ADHD; supplementation with minerals, the B vitamins (added in singly), omega-3 and omega-6 essential fatty acids, flavonoids, and the essential phospholipid phosphatidylserine (PS) can ameliorate ADHD symptoms (Kidd, 2000).

Another theory once believed was that refined sugar and food additives make children hyperactive and inattentive. As a result, parents were encouraged to stop serving children foods containing artificial flavorings, preservative, and sugars. In 1982, the National Institutes of Health (NIH), the Federal agency responsible for biomedical research, held a major scientific conference to discuss this issue. After studying the data, these scientists concluded that the restricted diet only seemed to help about 5 percent of children with ADHD, mostly either young children or children with allergies (U.S.-NIH.NIMH, 1994). It was also believed by these researchers that ADHD is not usually caused by: too much TV, food allergies, excess sugar, poor home life, and poor schools.

Incidence

ADHD affects three to five percent of all children, perhaps as many as two million American children (U.S.-NIH.NIMH, 1994). Other estimates suggest that at least five million "hyperactive" children in the United States, with three to ten percent of school-age children having some degree of learning disabilities (Warner, 1995). Data seem to support gender differences in prevalence of ADHD. Two to three times more boys than girls are affected (U.S.-NIH.NIMH, 1994). On the average, at least one child in every classroom in the United States needs help for the disorder (U.S.-NIH.NIMH, 1994). ADHD often continues into adolescence and adulthood (U.S.-NIH.NIMH, 1994).

Long Consequence of ADHD

It is estimated that only one-third to one-half of the children with ADHD outgrow their behavior (Warner, 1995). In many children, the symptoms of ADHD (particular hyperactivity) decrease with time (N. C. Frisch & L. E. Frisch, 2002). Impulsivity may persist into adulthood, and many children retain all of the symptoms throughout adolescence and into their adult years (N. C. Frisch & L. E. Frisch, 2002).

Only in the past few years has ADHD been recognized as a long term, chronic condition that may persist throughout an individual's life (Warner, 1995). Many adults who today have been diagnosed as ADD may not been have diagnosed as children because they were not hyperactive (Warner, 1995). Diagnosis is usually difficult because ADD adults do not remember what they were like as children (Warner, 1995). Some adults are diagnosed with ADD after learning of their children's diagnosis (Warner, 1995).

Recent studies suggest that it may be useful to divide ADHD into two subsets based on predominant symptoms: inattentive ADHD and compulsive/hyperactive ADHD (APA cited in N. C. Frisch & L. E. Frisch, 2002). There is considerable evidence that the inattention subset (and also a combined type with both inattention and impulsivity/hyperactivity) has a worse academic outcome with more long-term learning difficulties (N. C. Frisch & L. E. Frisch, 2002). In contrast, children with primarily impulsive/hyperactive symptoms have reasonably good academic outcomes (N. C. Frisch & L. E. Frisch, 2002). These children, however, have more problems with interpersonal relationship (N. C. Frisch & L. E. Frisch, 2002). They also experience more physical injuries, presumably as a result of their impulsive behavior patterns (N. C. Frisch & L. E. Frisch, 2002). Valente (2001) stated that these children are at increased risk for school failure, substance abuse, and psychiatric disorders, when ADHD is untreated. Additionally, ADHD can cause problems in relationships, disruption in the person's daily life, and diminished self-esteem (U.S.-NIH.NIMH, 1994).

Diagnosis and Treatment

Many children are inappropriately diagnosed and treated (Nevada Nurses Association [NNA], 2000). The diagnosis is empirical, with no objective confirmation available to date from laboratory measures (Kidd, 2000). Therefore, an ADHD diagnosis should focus on the three main components of the disorder: impulsivity, hyperactivity, and inattention (Buncher, 1996). The diagnosis is primarily based on the child's and family's histories, interviews, physical examination, and developmental and psychological evaluations (Buncher, 1996).

There are other conditions that produce similar symptom of ADHD. Anything from chronic fear to mild seizures can make a child seem overactive, quarrelsome, impulsive, or inattentive (U.S.-NIH.NIMH, 1994). A chronic middle ear infection can make a child appear to be distracted and uncooperative (U.S.-NIH.NIMH, 1994). So, can living with family members who are physically abusive or addicted to drugs or alcohol make a child seem distracted and uncooperative (U.S.-NIH.NIMH, 1995). Finally, in other children, ADHD-like behaviors may be their response to a defeating classroom situation U.S.-NIH.NIMH, 1994). Because there are other conditions that have symptoms similar to ADHD, counselors, a through physical, educational, psychological, and family assessment must be done to avoid misdiagnosis.

Management should include a balanced treatment plan of pharmacologic methods combined with behavior-changing therapies, environmental manipulation, and educational options that may help individuals with ADHD to focus their attention, build their self-esteem, and to function in new ways (U.S.-NIH.NIMH, 1994; Buncher, 1996). A multidisciplinary approach is used in the treatment of ADHD. The child, family, and school personnel establish collaboratively the educational goals and activities needed to help the child. Medical treatment goals are established with the patient and the family; the health provider assist in the completion of these goals through teaching, monitoring, and referring to community services when appropriate (Buncher, 1996).

Current drug therapy supports the careful and closely monitored use of stimulants like methylphenidate (Ritalin, [Concerta, and Metadate]), dextroamphetamine (Dexedrine), and pemoline (Cylert), [and amphetamine (Adderall)] (Buncher, 1996). Additionally, patients and their families are encouraged to seek individual, group, family, and marital therapy (Buncher, 1996). Special adaptations for schools, homes, and workplaces are now also available (Buncher, 1996). The health provider's role in ADHD treatment should be that of evaluator, coordinator, and monitoring clinician (Buncher, 1996).

Issues of Concern

There are three major concerns related to ADHD and the use of Ritalin. First of all, research on ADHD has become a national priority, with so many American children diagnosed as having attention disorder (U.S.-NIH.NIMH, 1994). The number of diagnosed cases of ADHD in the United States has reached an all-time high. It continues to rise at what many assert is an alarming rate, making ADHD America's number-one childhood psychiatric disorder (Klatell, 1995-1996). Secondly, there a concern about how young children are being prescribed Ritalin. According to a recent study published by the Journal of the American Medical Association (JAMA), there has been a dramatic increase in the number of preschoolers taking psychotropic drugs (cited by NNA, 2000). The Journal revealed that the number of children aged two through four taking Ritalin has more than doubled (cited in NNA, 2000). Finally, there is a lack of understanding and agreement among parents, teachers and health professionals about the best diagnostic, pharmacological, and behavioral intervention that should be used in the diagnosing and treatment of ADHD involved child.

The Drug

Ritalin is the trademark name for methylphenidate hydrochloride, or MPH. It was introduced in the 1940s. It is manufactured by Ciba-Geigy from a white, odorless, fine crystalline powder into tablets. Ritalin is classified as a mild central nervous system stimulant or psychostimulant and as a Schedule II drug. It stimulates the central nervous system, with effects similar to but less potent than amphetamines and more potent than caffeine (U.S.-NIH.National Institute of Drug Abuse [NIDA], 2003). It has a high abuse potential with severe psychic or physical dependence liability. Because of its abuse potential, the United States Drug Enforcement Agency (DEA) has implemented strict guidelines for its manufacture, distribution, and prescription. Additionally, DEA requires special licenses for these activities. Under the Controlled Substances Act of 1970, refillable prescriptions are illegal.

The Legal Use of Ritalin

There are two legal indications or medically approved uses of Ritalin. Ritalin may be prescribed for narcolepsy and attention deficit-hyperactivity disorder (ADHD). Ritalin is prescribed primarily to individuals who have ADHD. Recent statistics report that nearly 4.3 million children in the United States use Ritalin to control this disorder (Ruenzel, 1996).

Research has found Ritalin to be safe and effective (Ludwikowski & DeValk, 1998). Ritalin has a short half-life (3 to 6 hours), which means it will not accumulate in the body. With this short-life, frequent dosing of two to four times a day is required. There is a sustained-released form of the medication available that can be used alone or in combination with the faster-acting form to eliminate frequent administration of the drug. Careful monitoring of the child's response may reveal a need for changes in frequency of administration of the drug.

Ritalin can be addictive to teenagers and adults if misused. It has not been found to be addictive in children with ADHD. Although we do not understand fully how it works, Ritalin has a notably calming effect on hyperactive children and a "focusing" effect on those with ADHD (U.S.NIH.NIDA, 2003). It seldom makes these children "high" or jittery. Nor do they become sedated. In fact, Ritalin has a paradoxical effect on ADHD/ADD children (U.S.-NIH.NIDA, 2003). In other words, Ritalin has the opposite affect on children with ADHD. It helps these children to control their hyperactivity, inattention, and other behaviors (U.S.-NIH.NIDA, 2003). It does this by increasing the amount of particular neurotransmitters in the brain, such as dopamine, to reduce hyperactivity and improve ability to focus, work, and consequently learn (U.S.-NIH.NIDA, 2003).

As useful as Ritalin is to children who have ADHD, it has potential side effects that the child, the parents, and the medical provider must weigh against the benefits before prescribing or continuing the therapy. While on Ritalin, some children have experienced weight loss, decrease or loss of appetite, a temporary decrease in bone growth, sleep disturbance, increase in blood pressure, occasional tics, nausea, hypersensitivity, anxiety, tension, or nervousness (Lilley & Aucker, 1999). However, recent research has shown that there is little evidence that stimulant use affects either weight or normal grown (Spencer, Biederman & Wilens cited in N. C. Frisch & L. E. Frisch, 2002). Also, N. C. Frisch and L. E. Frisch identified one study that reported that childhood use of stimulant drugs reduced by 85% the likelihood of later substance abuse (Biederman, Wilens, Mick, Spencer & Faraone cited in N. C. Frisch & L. E. Frisch, 2002). With careful monitoring of the child's height, weight, and overall development, the medical provider can address these problems by monitoring dosage.

The Illegal Use of Ritalin

The most highly abused stimulants are illicit drugs, including cocaine and methamphetamines (Meadows, 2001). In April 2001, NIDA launched a new initiative on prescription drug abuse, misuse, and addiction that was announced at a press conference in Washington, D.C. There was a scientific program that followed the press conference that provided an overview of current research into the major issues associated with prescription opioid drugs used in pain relief, central nervous system depressants prescribed for anxiety and sleep disorders, and stimulants used to treat ADHD and obesity. Wilens (cited in Zickler, 2001), one of the researchers presenting at the conference, discussed prospective studies designed to determine whether children treated for ADHD with the stimulant methyphenidate (Ritalin) are at risk for abuse of other stimulant drugs. Wilens reported that those who were treated with methyphenidate were less likely to abuse drugs, including prescribed or unprescribed stimulants, during treatment and throughout youth and adolescence.

A great deal of concern has been raised by the DEA and others related to the potentials of abuse of Ritalin. Ritalin is considered by the DEA to have a significant potential for abuse and misuse. As a result, it has been classed as such and can be obtained legally by prescription only. Additionally, the DEA lists Ritalin as a "drug of concern" (Meadows, 2001). Basically, the trigger for this concern is centered around the increased use of Ritalin. It has been estimated that the number of people taking Ritalin since 1990 has grown from 2.5 to 5 times (Diller, 1996; Hancock, 1996). Reed (1995) estimated that nearly three million children are prescribed Ritalin to cope with ADHD and the number is rising.

The abuse of methylphenidate is occurring on college campuses. For example, Quinton and Byrne (2000) stated the methylphenidate has become readily accessible in the college environment. These researchers conducted a survey study in which questionnaires were distributed to the student body at a public, liberal arts college. They found that more than 16% of the students reported they had tried methylphenidate recreationally, and 12.7% reported that they had taken the drug intranasally. Quinton and Byrne also found that use of the drug was more common among traditional students than among nontraditional students. Among traditional-age students, reports of methylphenidate use were roughly equivalent to reports of cocaine and amphetamine use.

Younger children have also been found to abuse Ritalin. There have been recent reports of Ritalin abuse among middle and high school students (Meadow, 2001). These individuals use Ritalin to suppress their appetite or to stay awake while studying (Meadows, 2001).

Almost all reports of abuse of Ritalin have been of poly substance-abusing adults who have tried to solubilize the tablets and inject them (Greenhill, 1995). It may also be snorted. It may be recognized by any of the following street names: "Vitamin R," "R-Ball," "Skippy," "Jiff," and the "Smart Drug." This abuse problem associated with Ritalin led Sweden to withdraw methylphenidate from the market in that country entirely in 1968 (Perman, 1970). The drug produces a cocaine-like stimulant effect.

Long-term Benefits of Ritalin

Researchers have obtained conflicting results when investigating the effects of Ritalin on cognition, achievement, and behavior. Barkley (1977) and Abikoff and Gittelman (1985) reported that stimulant drug medication did not produce significant changes in basic intellectual or cognitive abilities. Conversely, Kupietz, Winsberg, Richardson, Maitinsky, and Mendall (1988) found improvements in cognitive functioning in remedial reading performance. However, they concluded that remedial instruction was more important then the medication in reducing the reading disability deficits. A review of the literature conducted by Barkley and Cunningham (1978) revealed little support for the idea that stimulant mediation had consistent positive effects on academic achievement test scores. However, other researchers have found short-term benefits of Ritalin on academic performance (Pelhan. Carlson, Sams, Vallano, Dixon, & Hoza, 1993). Finally, Barkley (1976) estimated that 75% of hyperactive children benefit from stimulant medication in controlling behavior. The researchers for all of these studies coneluded directly or indirectly that the positive benefits of Ritalin were observed when combined with other treatments.

Helping Parents Coping with ADHD

Frequently, neither the parents nor society are prepared to deal with ADHD children (Warner, 1995). Thy are often labeled as troublemakers, resulting in excessive discipline or child abuse (Warner, 1995). Parents are also judged as failure for letting the child run wild (Warner, 1995). Given the disruptive behavior of some children with ADD/ADHD, it is quite understandable that parents may have the child evaluated by the family care provider and to have Ritalin considered for treatment of the child's behavior. Also, family dynamics can be severely affected by ADD/ADHD. Sometimes, parents feel forced to look for a quick "fix." However, parents should be assisted in understanding the complexity of this condition. It is important that parents must not view Ritalin as the first and only intervention for controlling ADD/ADHD (Reed, 1998). The use of any type of medication to control or change behavior must be accompanied by school and home behavior intervention plans. The approach to helping students with ADHD should be ecological; that is, the intervention should be designed to increase self-management skills (through cognitive/behavior modification), provide environmental supports (reinforcement and consequences for behavior), and be consistently applied across all environments. As a part of a total behavior management plan, Ritalin (or any other medication) is only one part. Ritalin alone to control ADHD would be inappropriate.

Conclusions

Ritalin can play an important role in the management of ADD/ADHD. Counselors, teachers, and parents must remember that ADD/ADHD is a complex condition requiring an ecological treatment plan approach. Ritalin coupled with appropriate behavioral support and classroom/instruction accommodations can help these children find meaning and fulfillment in everyday activities (Reed, 1998). Also, Ritalin is a safe drug when taken as prescribed and carefully monitored by a medical provider. However, it is easily abused. Counselors, teachers, and parents have a responsibility to teach all students about drug abuse, which includes Ritalin abuse.

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HAZEL L. WHITE

Southern University and A. & M. College

BATON ROUGE, LA

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