The Widespread Abuse of Ritalin

This article was originally published in 1987. It is no less pertinent today since Ritalin usage is now widespread and well entrenched as accepted management of learning disorders accompanied by short attention span and hyperactivity.

Unfortunately, this unquestioning acceptance fosters abuse, as we have learned in our experiences with many established treatment procedures for brain injury. It is vital that we guard against using such symptomatic treatment to the detriment of dealing directly with the basic pathological process itself.

Having spent over 25 years in close proximity with well and brain-injured children, I have become acutely aware of the difficult decisions that must be made by parents and physicians in regard to the use of medications. During these years, I have been concerned mainly with the gradual removal of anticonvulsants, sedatives, and other psychotropic drugs.

We have met with great success in this endeavor, as reported regularly in this journal under the title "Detoxification Victories." The successes we have won are due to scrupulous attention to the body's physiology in the areas of nutrition, respiration, and neurological development.

The actual removal of drugs has been accomplished gradually and with great care. Close contact with the parents and shared decisions have been essential elements. As a result, we have had the pleasure of seeing tremendous benefits gained for the children in alertness, learning ability, and general performance and health.

It is impossible to witness repeated improvements in the children's overall function, made possible by the elimination of such medications, without asking if it had really been necessary to begin giving the drugs in the first place.

The decision for or against any medication should be a shared responsibility of physician and family; obviously, it cannot be made fairly unless parents are provided with the information needed to make such a judgement. The willingness of a physician to discuss the use of any proposed treatment is essential and has existed for many years in a few doctors who appreciate input from the family. However, this healthy attitude is too often missing.

It is undeniable that some drugs are lifesaving -  many permit return to health and still others prevent serious illness. My own conviction is certainly not one of global condemnation of medications. To turn one's back on the achievements of modern medicine would indeed be detrimental to our children's well-being. However, every medication used for its desirable effects has equal potential for harmful effects.

It is important to make choices by weighing the harmful outcome of the illness against the potential problems arising from the use of the drug. In that way parents can make informed choices for their children's welfare.

Neurochemistry is the highly specialized chemistry of the nervous system. Its counterpart, neuropharmacy, is expanding with the development of more drugs that are designed to affect the functions of the central nervous system.

One of these drugs, Ritalin, is used mainly in school-age children and is the subject of much debate. Indication for the use of Ritalin (methylphenidate HCl) in children is spelled out in the Physician's Desk Reference (PDR) as part of a total program in the treatment of attention deficit disorders, also known as minimal brain dysfunction and hyperkinetic syndrome.

Ritalin is a mild central nervous system stimulant that activates the arousal system in the brain stem and cortex, in effect producing increased alertness. How it does this is unknown. It is of interest that the only other indication for the use of Ritalin is narcolepsy, a disorder of abnormal sleep.

Overdose of Ritalin produces overstimulation of the central nervous system. Contraindications for its use are signs of anxiety, tension, agitation, motor tics, Tourette's syndrome, and glaucoma.

The PDR also states that Ritalin should not be given to children under the age of six. Data for long-term use of the drug is not available, nor is information regarding its use during pregnancy.

Adverse effects in children are insomnia, nervousness, loss of appetite, weight loss, abdominal pain, and a rapid pulse. Warnings are issued to watch for growth suppression, high blood pressure, visual disturbances, and increased susceptibility to seizures (regardless of prior history of seizures).

When given to emotionally unstable persons it must be given cautiously, as chronic abuse can lead to psychic dependency. Periodic blood tests are recommended, and use of the drug should be interrupted periodically.

Attention deficit disorder is described as a behavioral syndrome characterized by distractibility, short attention span, hyperactivity, nonlocalizing (soft) neurological signs, and learning disability. An abnormal electroencephalogram (EEG) may or may not be present and a "diagnosis of central nervous system dysfunction may or may not be warranted." It is further stated that a complete history plus medical, psychological, educational, and social evaluations are essential before treatment is considered.

There are a number of issues raised by the above information and the current misuse of this and similar neuropharmaceutical drugs.

Certainly from our perspective here at The Institutes, the described problems most certainly warrant the diagnosis of "central nervous system dysfunction." What other possibility exists? Learning and behavior are nervous system functions. If the cerebral dysfunction is caused by an external agent such as environmental irritants and allergens, malnutrition, or chronic disease, these should be detected in the initial, thorough evaluation and treated appropriately.

Regardless of the origin, intrinsic or secondary to an outside agent, the end result is impaired brain function, which can be identified using the Developmental Profile as the principal evaluation tool. For whatever reason the neurological abnormality exists, rational and effective therapy is certainly indicated.

We question whether Ritalin answers that need. We deplore the careless manner in which its use is regarded by many educators, psychologists, and medical personnel. It is often prescribed hastily, without adequate evaluation, and by authority figures who may place unreasonable pressure on parents whose overwhelming wish is to do the best for their child. The beneficiary of the treatment is supposed to be the child - not a tired, overworked teacher or a classroom that lacks peace and quiet.

Rarely are all contraindications and warnings given the attention they deserve or shared with the parents who must make the final decision. Once prescribed, it is generally monitored poorly, and most importantly it encourages the delusion that it will bring about a healing process.

Ritalin has no healing or curative power - it is pure symptomatic management, and not very successful at that either.

by Roselise Wilkinson, M.D.
Medical Director Emeritus