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The run on Ritalin: attention deficit disorder and stimulant treatment in the 1990s.

Stimulants were first reported as a pharmacologic treatment for children's behavioral problems in 1937.[1] Methylphenidate, a derivative of piperidine, was synthesized in the 1940s and marketed as Ritalin in the 1960s.[2] It is structurally related to the older drug still used for the treatment of hyperactivity, d-amphetamine. Their pharmacological actions are essentially the same.

Stimulant treatment for children became more common in the 1960s when its short-term benefits for what was then called hyperactivity were documented in controlled trials. In 1970 it was estimated that 150,000 children were taking stimulant medication in the U.S.[3]

A furor over stimulants began in 1970. The reaction stemmed from an article in the popular press charging that 10 percent of the children in the Omaha school district in Nebraska were being medicated with Ritalin.[4] While ultimately shown to contain inaccuracies, the article spurred other reports of "mind control" over children and led to congressional hearings about stimulants that same year.[5] Numerous articles in newspapers and magazines and one book attacked Ritalin and the "myth" of the hyperactive child.[6] Subsequently it was found that some of the criticism appeared to be led by supporters of the Scientology movement, who have consistently challenged mainstream psychiatry's use of psychoactive medications.[7] Yet the negative publicity struck a nerve with the general public, which by the mid-1970s made it quite difficult to convince parents and teachers in many communities to attempt a trial of Ritalin.

The DEA began monitoring the amounts of medilyphenidate and amphetamine produced in this country in 1971. Both became Schedule II controlled drugs partly in -response to an epidemic of methylphenidate abuse occurring in Sweden and the illegal use of stimulants in this country. Estimates on the number of children using stimulants have varied widely. In 1980 it was estimated that from 270,000 to 541,000 elementary school children were receiving stimulants.[8] In 1987 a national estimate of 750,000 children was made.[9] Both estimates were guesses extrapolated from local surveys.

More precise than national estimates of children taking stimulants are the records of production quotas maintained by the DEA that show a steady output of approximately 1,700 kilograms of legal methylphenidate through the 1980s followed by a sharp increase in production in 1991.[10] From 1990 through May 1995, the annual U.S. production of methylphenidate has increased by 500 percent to 10,410 kilograms[11] (see figure), "an increase rarely seen for any other Schedule Il Controlled Substance," according to the DEA.[12] A national survey of physicians' diagnoses and practices based upon data collected in 1993 found that of the 1.8 million persons receiving medication for Attention Deficit-hyperactivity Disorder, 1.3 million were taking methylphenidate.[13] A comparison of 1993 Ritalin production with the latest figures available for 1995 suggests that 2.6 million people currently are taking Ritalin, the vast majority of whom are children ages five through twelve.

Who is taking all of this Ritalin, and why? To get at the answers to these questions, we need to look at changes in professional and lay attitudes regarding psychoactive drugs, the brain, and children's behavior. Six hypotheses are suggested to explain the sudden increase in the demand for this drug.

Changes in Diagnostic Criteria

As more children's behavior is viewed as abnormal, more treatment is offered. The American Psychiatric Association distinguishes deviancy from normalcy in its Diagnostic and Statistical Manual of Mental Disorder (DSM). With the introduction of the DSM HI in 1980, mainstream psychiatry officially changed its view from a diagnosis of hyperactivity, highlighting physical movement, to one where problems with attention, Attention Deficit Disorder, were of primary concern. This change reflected research that suggested the primary problem for children was one of focus and distractibility. Hyperactivity, as a reflection of motoric impulsivity, was still important but not critical to the diagnosis. Thus, one could meet the criteria for ADD without being overly motorically active at all. The name of the condition was changed again in DSM HI-R to Attention Deficit-hyperactivity Disorder, and in DSM-IV[14] separate subtypes of inattention and hyperactivity/impulsivity were restored.

There have been additional interpretative changes to the diagnosis. One need not demonstrate symptoms in every situation. Rather one need only display symptoms in at least two environments. Similarly one may concentrate satisfactorily at a number of tasks, perhaps even overfocus, yet still meet criteria for diagnosis if concentration and focus are problems for important tasks (for example, "selective inattention or attentional inconsistency").

The changes in diagnostic criteria and interpretation have greatly broadened the group of children and adults who might qualify for the diagnosis. The line between children with "normal" variations of temperament, lively or spontaneous children who are sensitive to stimuli, and those who have a "disorder" has become increasingly blurred. The sine qua non for the diagnosis of hyperactivity in the mid-1970s was a demonstration of motoric overactivity and/or distractibility in nearly all settings including the doctor's office. Some children who may have benefited from identification and treatment were undoubtedly missed under these criteria, but this is less likely today. Now children who sit quietly and perform well in social situations or in one-on-one psycho-metric testing can still be candidates for the diagnosis and treatment of ADHD if their parents or teachers report poor performance in completing tasks at school or at home.

Prior to DSM III, etiologic factors were important in the diagnosis of psychiatric disorders. Since 1980 diagnosis has been descriptive, based primarily on observed behavior and self-report. While the multiaxial codings of the DSM III presumably account for medical factors and social stressors on the patient, less emphasis is placed on psychosocial influences, such as family, school, or work environments. In addition, the ascendancy of biological psychiatry, with its emphasis on the genetic and neurochemical factors directing behavior, implicitly diminishes the significance of development, learning disabilities, emotional status, family interaction, classroom size, and other environmental factors that may be relevant. Meeting

ADHD criteria, which strictly speaking involves demonstrating a group of behaviors, has come to mean "having" ADHD, a neurological condition, such as Pervasive Developmental Disorder or Tourette Syndrome. Research purported to support a biological basis for ADHD, a brain scan of the cerebral cortex, or a survey of family epidemiology, cannot conclusively distinguish between biological or environmental etiologies.[15]

Environmental factors can be seen either as contributing to the etiology or maintaining the symptomatic behavior. Indeed, a strongly stated case for neurological factors has been useful to counterbalance beliefs that such behaviors were attributable to lazy children and disorganized adults. However, if the symptoms of ADHD are to be viewed within the biopsychosocial model, calling ADHD a neurological disorder can mislead some into discounting psychosocial factors as unimportant.

The "Lean and Mean" '90s

As professional viewpoints have changed, so too have societal pressures and public attitudes toward attention and behavior problems in children and adults. Over the past two decades the pressure on children to perform has increased while support needed to help maximize performance has declined. Twenty-five years ago three- and four-year-old children were not expected to know the alphabet and numbers. Community programs like Head Start and television shows such as Sesame Street, while benefiting millions, have also led to expectations that children can learn at an earlier age. Yet over the concurrent past twenty years poverty rates for children, as a measure of their general well-being, have increased from 15 percent to 20 percent nationwide and children comprise 40 percent of all those who live in poverty.[16]

More families are requiring two incomes to maintain their standard of living, and the increasing number of women in the workforce has led to large-scale preschool enrollment of children, requiring that younger children adhere to a more organized and less flexible social structure. Many children adapt easily to preschool and thrive in that group environment. Yet some children are not developmentally or socially ready for preacademic learning and a more demanding social structure. These children, had they stayed at home, would not be exposed to community scrutiny or come to the attention of teachers and physicians at an early age. At age three or four their behavior may qualify them for an ADHD diagnosis.

At the elementary school level, funding pressures on school systems have led to increased classroom sizes and higher student-to-teacher ratios. Also, more stringent criteria exist to qualify for special education services, which are often inadequately funded.

Similar conditions exist for high school and college students, especially in public education. The pressure to do well academically is immense. Inexorable pressures have developed to maintain a high grade point average in order to gain entry into a "good" college or graduate school. "Cs" have become unacceptable to many middle class families. This trend can be seen in the popularity of bolstering SAT scores through extracurricular preparatory classes. Increasing attention through the use of medication may be seen as just another method to improve performance and results.

A declining standard of living undergirds many of these conditions. With corporations "downsizing," there is greater competition for fewer choice positions. In the current climate of job insecurity, the perception is "Perform or else!" The human gene pool cannot change for cultural or economic reasons in twenty-five or thirty years. Thus relatively greater numbers of children and adults may be found wanting in their abilities to concentrate given the current pressures of their academic and work environments.

Pressures on Physicians and Educators

Physicians are also under pressure. Even before the managed care era, the time and economic constraints on the primary care physician were great. When presented with a potentially complex child behavioral problem, the physician may be attracted to the option of prescribing a medication rather than addressing the thornier and more time-consuming issues of emotions, family relationships, or school environment. Even with genuine concern for a multimodal evaluation and treatment plan, often little else is done on the primary care level.[17]

Specialists, such as behavioral-developmental pediatricians and child psychiatrists, should be capable of spending more time and lending greater expertise to the resolution of the intricacies of the child, family, and school situation. These specialists are concerned, however, that the cost-containment measures of managed care will increasingly permit referrals only when medication is being considered for the child.

Increasing pupil-teacher ratios and diminishing special education services also have an effect. These conditions make it "easier" to medicate a child than to work with a dysfunctional family, decrease the size of the classroom, or augment funding for special education services. Because stimulants "work" more quickly, they are more attractive not only to families and physicians, but to managed care companies and financially strapped educational systems. It is unlikely that either would insist on medication in lieu of counseling or special education services, but neither would protest if medication allowed the child to function better without either service.

The Disability Issue

Society increasingly has interpreted performance problems as disease, which then become defined as a disability. People with defined disabilities cannot legally face discrimination and are entitled to the benefits of special services. The increasing numbers of children and adults who meet the broader ADHD criteria are beginning to have an impact in the classroom and workplace. Parents find the only way to get extra help for their children is to have them labeled with a disorder. The Individuals with Disabilities Education Act of 1990 and recent interpretations of Section 504 of the 1973 Rehabilitation Act have become broad and potent legal tools for families of children with ADHD seeking special services from their school districts.[18] Unfortunately, funding of die legislation has been fragmented and never fully appropriated by Congress. State educational systems have been left to provide funding for these entitlements. Court actions have forced one school district to scramble and allocate funds disproportionately to services for the disabled. In New York City, where nearly a quarter of the school budget is spent on 13 percent of the students categorized as disabled, the situation has reached crisis proportions. With nearly six times as much money spent on the special student, spending on regular students is among the lowest in the nation.[19] Whether this skimping on regular classrooms paradoxically will push more children struggling at the edge of "normalcy" to meet criteria for a "disorder" is speculative, but provocative and disturbing.

Categorizing ADHD as a disability has created other dilemmas. Typically someone with a disability is provided special circumstances or allowances for optimal performance, for example, more time provided in a college entrance examination. However, at least at one large university ADHD diagnosis has become so common that a doctor's diagnosis is no longer sufficient as the basis for special consideration.[20] Instead the school psychologists assess the student's performance in real life situations of test taking and studying to see how and why performance may be affected. In the workplace more and more employers are being asked to make changes for their workers who are affected with ADHD. It is only a matter of time until an employer balks and a suit is filed. The trend is being followed closely by the business community. Attention Deficit-Hyperactivity Disorder has also contributed to a crisis in the disability insurance industry. Claims have soared for a host of ill-defined conditions. Insurers have fled the business of providing disability insurance, making it prohibitively expensive or impossible to obtain.[21] As more people meet diagnostic criteria, many will attempt to gain services. It remains to be seen whether broadly defined disabilities ultimately trivialize suffering or make it more difficult for the more severely impaired person to obtain urgently needed recognition and services.

The Culture of Prozac

Prozac (fluoxetine), the first of the serotonin reuptake inhibitors, went on the market in 1988. With its low side-effect profile compared to the earlier generation of antidepressants, it widened the range of individuals who might tolerate a psychotropic drug for depression and led to widespread popul debate on the subject. Peter Kramer's best-selling book, Listening to Prozac, reflected and further encouraged popular interest in the use of psychiatric medication to enhance mood and performance. The overall prevalence of antidepressant use in certain communities has quadrupled in a ten-year period.[22] It has become much more acceptable to take a psychotropic medication. This new atmosphere has also increased acceptance of stimulant use for behavioral problems in children and attentional problems in adults.

The Role of Mass Media

The effects of mass media on the practice of medicine and concerns of patients are well documented. As TV news, talk shows, and print journalism have highlighted the use of psychotropic medication to cope with one's problems, a corresponding public interest in Ritalin and ADHD has developed. Personal and affecting testimonies of dramatic improvements after using Ritalin have been reported on national television broadcasts and many syndicated talk shows. A book on ADHD in adults and children has edged toward the best-seller list for over a year.[23] Prominent local and national news weeklies have made ADHD their cover stories.[24]

In both the professional and lay media ADHD is routinely referred to as a neurological disorder. While most experts agree that genetic-biochemical factors influence behavior to some degree, the general public tends to transform this view into a biological determinism in which only heredity and brain chemistry determine behavior rather than in interactions with the environment. This interpretation may be comforting to some perplexed and worried parents who feel responsible for their children's difficulties and help overburdened teachers gain assistance in teaching children with this "disability." Psychotherapeutic strategies can help "externalize" the disease as separate from the child. Yet when behavior is regarded as stemming from biological pathology, interventions like stimulant medication become more easily justified and emphasized, while others become less valued. Indeed, ADHD has become the somewhat dubious leading self-diagnosis as the "biological cause ... for job failure, divorce, poor motivation, lack of success, and chronic mild depression."[25]

Cosmetic Ritalin

"Cosmetic psychopharmacology," as Kramer puts it, is the elective use of medically prescribed drugs to enhance mood or improve behavior. Currently, it is considered medically and ethically justifiable to prescribe stimulants only when behavior meets criteria for a medical or psychiatric disorder. It is not known how much Ritalin currently is being prescribed for those on the indistinct line between disease" and the general struggle for success. It is known, however, that Ritalin improves the focus and themselves. However, important questions remain unanswered and a pending request to decrease DEA controls on methylphenidate production and physician prescription practice[28] makes them all the more urgent. Ritalin's reemergence as a popular fix" overlooks adverse side effects, a performance of those who do not meet ADHD criteria (normal, nonreferred children(26)) and that the drug is prescribed for such use. There remains no definitive "test" for ADHD. The ambiguities of the ADHD diagnosis were highlighted in a study on stimulant medication and primary care.[27] Over one quarter of children diagnosed with ADHD by their physician failed to meet criteria for the diagnosis when the cases were compared to structured psychiatric interviews with the parents. The number of children who failed to meet criteria increased to half when compared to structured interviews with the children's teachers. While the overall number of children medicated was not seen as high by the investigators, they noted the nonspecificity of the behavioral symptoms in the children that responded to stimulants. Thus, the ADHD diagnosis was seen as a diagnostic cover, albeit inaccurate, for the use of stimulants in a range of behavioral and performance problems in children.

Questioning Ritalin

Stimulants can be used in an effective and sensible way, especially when other modalities of treatment for attentional problems are addressed concurrently. Undoubtedly many parents of children with ADHD and adults with ADHD feel Ritalin has been of immense benefit to their children or dearth of long-term studies, and a host of other ethical questions concerning unwitting coercion, fairness, informed consent, and potentially inadequate treatment of patients. Larger societal questions also should be asked: Should society use a biological fix to address problems that have roots in social and environmental factors? If it consistently does, how might society be affected?

If elective treatments are to warrant consideration, their side effects must be minimal. The short- and long-term physical side effects of Ritalin are generally considered minor on the basis of fifteen- to twenty-year follow-up studies[29] involving children who took stimulants for several years up until early adolescence. The effects of continuous Ritalin use through adolescence and into adulthood have not, as yet, been studied. The drug's immediate side effects, brief appetite suppression and possible insomnia, are generally well tolerated by children. Some reports suggest Ritalin unmasks the ties of Tourette Syndrome, but this remains controversial.[30] Long-term growth suppression. has been attributed to Ritalin, but this effect can be minimized through the scheduling of drug "holidays."[31]

Although one reason for the much greater use of Ritalin compared to amphetamine for ADHD has been the erroneous belief that it has less abuse potential, there exists a possibility of abusing Ritalin. The Swedish experience of the late 1960s and very recent examples of Ritalin abuse by teenagers in this country belie this myth of safety.[32] However, there is little evidence of physical addiction to or abuse of Ritalin when used appropriately for ADHD. Despite the possibilities of abuse, Ritalin appears relatively safe from a strictly physical standpoint.

Evaluation of the emotional and psychological consequences of Ritalin use is more complex. There is still a strong cultural belief that it is better to cope by using one's inherent resources and interacting with people than by resorting to medication. This `pharmacological Calvinism' may lead to feelings of inadequacy in the child who takes the drug,[33] despite the physician's and family's view that Ritalin is necessary or benign. Teenagers, particularly sensitive about their identity, are especially vulnerable to issues of competence and biologic integrity. These beliefs can be overcome, but remain a potential downside.

While physical addiction doesn't occur when Ritalin is used as prescribed for ADHD, psychological dependence is possible for the child, the family, the adolescent or adult. When queried, children attributed most of their success in a "vigilance" assignment to their own efforts rather than medication.[34] It is family members and teachers who more often notice the child performing suboptimally and ask, "Did you take your pill today?" The question expresses an underlying message to the child about the drug's important contribution to performance and behavior, and, ultimately, this message may undermine the child's confidence. This sense of dependency is highlighted when the medication is used "as necessary," in event-driven dosing, for example, when studying for an exam or attending a weekend family gathering. It is even possible that event-driven dosing may promote or exacerbate the often disorganized ADHD lifestyle by allowing the procrastinating individual to "catch up" at the last minute. The teenager and adult may also be tempted to stretch the normal wake-sleep cycle in order to achieve even greater performance, which could ultimately lead to an abuse pattern. The long-term consequences of self-administered stimulants by teenagers and adults for ADHD have not been studied to determine the likelihood of such a pattern developing. Thus, while achievements made under the influence of stimulants can enhance a sense of competence, self-esteem, and independence, the specter of psychological dependence, altered self-image, and potential abuse remains, especially in a society that paradoxically continues to be somewhat critical of psychotropic drugs while demanding greater performance.

Ritalin should be questioned further because no long-term studies prove its efficacy. Numerous reports show the stimulants to be of value in short-term memory and performance. In long-term studies benefits to children formally classified under the hyperactivity diagnosis have not been demonstrated.[35] For children with ADHD without hyper-activity or for teenagers and adults there are no long-term studies of Ritalin's efficacy. Long-term controlled studies are difficult to run and fund, and one can question the ethics of withholding a potentially effective treatment until there is more definitive proof of benefit. However, a single study in which children received Ritalin along with child-family counseling and special education services is the only research demonstrating long-term improvements.[36] Most child behavior experts advocate a multimodal approach to treatment despite the lack of definitive evidence of improvement. In actual practice, though, the follow through for behavioral recommendations is poor.[37] The multimodal model of treatment is also suggested for adults.[38] Yet, here too, the emphasis in professional and lay articles is on the pharmacological interventions. The increasing availability and use of Ritalin to enhance performance also raise questions of subtle coercion and fairness. As more children and adults use Ritalin to work more efficiently at school or in the office, will those who are also struggling to perform feel pressured to consider medication? Will there be an impetus to keep up with others, to compete for the good grade, bonus, or job promotion by whatever means necessary, medication or otherwise? Moreover, is it fair to use the same performance criteria for those who use Ritalin as for those who do not? In athletic competition, stimulants remain banned precisely because of fairness issues. Yet, recently, the case has been made that athletes with ADHD be allowed to compete while taking Ritalin because of their "handicap." Somehow viewing behavior as neurologically based makes it more acceptable to use medication.

Because many Ritalin users are children, issues concerning informed consent also arise. Although the treatment of undesired nonpathological conditions in adult medicine is not uncommon (for example, plastic surgery, topical minoxidil for baldness, estrogens for menopause, treatment for infertility, and contraceptives), elective therapies for children have been more controversial because it is the parents, not the children, who decide upon treatment. For example, growth hormone for constitutional short stature has been hotly debated.[40] Who decides for whom in these cases? And how high should the standard be?

One last question concerns the tendency for genetic contributions and neurochemical influences on behavior to be understood deterministically by society, such as the media and the courts. Such an interpretation can have the effect of eclipsing other treatment options. Even "good" psychopharmacology decreases the need to scrutinize the child's social environment and may permit a poor situation to continue or grow worse. Should dysfunctional family patterns and overcrowded classrooms be tolerated just because Ritalin improves the child's behavior? An effort is underway to determine which combination of treatments is most effective. The National Institutes of Mental Health has funded a multisite ADHD study involving several thousand children, with the goal of comparing treatment efficacies with a variety of approaches and combinations.[41] Yet in the absence of confirmed, effective long-term treatment for ADHD and the general recommendations for a multimodal approach, will medication-only treatment produce persistent problems later in a child's life?

Furthermore, this bioreductionistic interpretation of the neurobiological components of ADHD behavior attributes less power to free will and individual choice. Thus, the popular viewpoint of maladaptive behavior as disease conflicts with another historically strong cultural perspective: accountability and responsibility. This clash of "views is likely to be resolved ultimately in the civil and criminal court systems and by the economic imperatives of the workplace. It is worth noting how recent court decisions on recovered memory of child sexual abuse are influencing psychiatric technique and practice and the frequency of diagnosis of multiple personality disorder.[42] Similar court guidelines are likely to emerge for those on the borderline of an ADHD diagnosis.

Responses to the Epidemic

The main response to date over the epidemic of ADHD and the use of stimulants in America has been further efforts at informing professionals and the public about the "new" ADHD (without hyperactivity).[43] For many physicians, psychologists, and educators, the identification of potential ADHD and consequent stimulant treatment are meeting an important need of the community. Further education about the benefits of diagnosis and stimulants is the present goal. Academic medicine remains primarily focused on substantiating a biological substrate for ADHD. A notable exception is a recent study on the effects of family stressors in the development of ADHD.[44]

However, another view of ADHD diagnosis and the rise in stimulant use is far more sobering. As suggested earlier, the ADHD/stimulant phenomenon may reflect how the demands on children and families have increased as the social network supporting them has declined. The rise in the use of stimulants is alarming and signals an urgent need for American society to reevaluate its priorities.

On a clinical level, physicians treating children and adults may be locked into a "social trap."[45] Though it may make sense to medicate individuals so they can function more effectively and competently within a certain environment, do doctors unwittingly permit and support a long-term collective negative outcome for the society. Are they unintentionally promoting an antihumanistic, competitive environment that demands performance at any cost? Should they more aggressively promote a general redistribution of society's resources to children and families? Some say there is no choice but to offer medication; it is not up to physicians to address society's ills. Peter Kramer in Listening to Prozac seems rather sanguine about a society that copes with newer, safer, improved psychopharmacologic agents. Whether individually beneficial or societally dangerous it behooves the physician to at least raise these questions about ADHD and stimulants with parents, teachers, and colleagues.

Acknowledgments

I gratefully thank John Jacobs, Lane Tanner, Denise Bostrom, Glenn Elliott, and Tom Boyce, for their review and comments on the manuscript, Fred Gardner for editorial assistance and Helen Reyes, librarian, John Muir Medical Center, for research support.

RELATED ARTICLE: Henry Knowles Beecher Award

To Sissela Bok

The Board of Directors of The Hastings Center has awarded Sissela Bok the Henry Knowles Beecher Award. The Beecher Award is given periodically to recognize lifetime contributions to ethics and the life sciences. Sissela Bok's contributions are remarkable in that they have had an important influence on the thinking of the general public as well as on that of scholars in the field of ethics. In particular, her books Lying and Secrets are written in a language that is easily accessible to the educated lay person. This account for their influence with the general public. At the same time, they are characterized by an intellectual rigor that makes them valuable resources for scholars in the field of ethics.

Her influence in the public policy arena has been felt for over two decades. Her paper "Fetal Research and the Value of Life," for example, had a major effect on the decisions reached in 1975 by the National Commission for the Production of Human Subjects of Biomedical and Behavioral Research. Her doctoral dissertation in the department of philosophy at Harvard in 1970 was one of the first dissertations in the field of applied ethics in that department for many decades.

Finally, the committee wishes to recognize her important contributions to the institutions if bioethics as exemplified by her service on the Board of Directors and other working committees of The Hasting Center.

References

[1.] C. Bradley, "The Behavior of Children Receiving Benzedrine," American Journal of Psychiatry 94 (1937): 577-85. [2.] L. L. Greenhill, "Pharmacologic Treatment of Attention Deficit Disorder," Psychiatric Clinics of North America 15 (1992): 1-27. [3.] K. D. Gadow, "Prevalence of Drug Treatment for Hyperactivity and Other Childhood Behavior Disorders," in Psychosocial Aspects of Drug Treatment for Hyperactivity, ed. K D. Gadow and J. Loney (Boulder, Colo.: Westview Press, 1981). [4.] R. Maynard, "Omaha Pupils Given `Behavior Drugs,'" Washington Post, 29 June 1970. [5.] C. E. Gallagher, "Federal Involvement in the Use of Behavior Modification Drugs on Grammar School Children of the Right to Privacy Inquiry," Committee on Governmental Operations. House of Representatives 91st Congress, 2nd session. no. 52-268 (Washington, D.C.: U.S. Government Printing Office, 1970). [6.] J. M. Rogers, "Drug Abuse--Just What the Doctor Ordered," Psychology Today (September 1971): 16-24; P. Schrag and D. Divoky, The Myth of the Hyperactive Child and Other Means of Child Control (New York: Pantheon Books, 1975). [7.] J. Sappell and R. Welkos, "Suits, Protests Fuel a Campaign against Psychiatry," Los Angeles Times, 6 June 1990. [8.] Gadow, "Prevalence of Drug Treatment for Hyperactivity." [9.] D. J. Safer and J. M. Krager, "A Survey of Medical Treatment for Hyperactive/Inattentive Students," JAMA 260 (1988): 2256-58. [10.] Office of Public Affairs, Drug Enforcement Administration, Department of Justice, Methylphenidate Yearly Production Quota (1975-1995), (Washington, D.C.: U.S. Government Printing Office, 1995). [11.] Federal Register, 9 May 1995, p. 24649. [12.] Background Information on Methylphenidate Ritalin)," Office of Public Affairs. Drug Enforcement Administration, Department of Justice (Washington, D.C.: U.S. Government Printing Office, 1993). [13.] J. M. Swanson, M. Lerner, and L. Williams, "More Frequent Diagnosis of Attention Deficit-Hyperactivity Disorder' (letter), NEJM 333 (1995): 944. [14.] Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (Washington, D.C.: American Psychiatric Association, 1994). [15.] C. A. Ross and A. Pam, Pseudoscience in Biological Psychiatry: Blaming the Body (New York: Wiley, 1995). [16.] S. Roberts, Who Are We? A Portrait of America Today Based on the Latest United States Census (New York: Times Books, 1994), p. 199. [17.] M. L. Wolraich et al., "Stimulant Medication use by Primary Care Physicians in the Treatment of Attention Deficit Hyperactivity Disorder," Pediatrics 86 (1990): 95-101. [18.] R. Reid and A. Katsiyannis, "Attention-Deficit/Hyperactivity Disorder and Section 504," Remedial and Special Education 16 (1995): 44-52. [19.] S. Dillon, "Special Education Absorbs School Resources," New York Times, 4 April 1994. [20.] H. Beck, Disabled Students' Program, University of California, Berkeley, personal communication. [21.] M. Quint, "New Ailments: Bane of Insurers," New York Times, 28 November 1994. [22.] A. Hume et al., "Is Antidepressant Use Changing? Prevalence and Clinical Correlates in Two New England Communities," Pharmacotherapy 15 (1995): 78-84. [23.] E. M. Hallowell and J. J. Ratey, Driven to Distraction (New York: Pantheon Books, 1994). [24.] For example, C. Wallis, "Life in Overdrive," Time, 18 July 1994, pp. 42-50. [25.] D. Shaffer, "Attention Deficit Hyperactivity Disorder in Adults," American Journal of Psychiatry 151 (1994): 633-38. [26.] J. L. Rapoport et al., "Dextroamphetamine: Cognitive and Behavioral Effects in Normal Prepubertal Boys," Science 199 (1978): 560-62. [27.] Wolraich, "Stimulant Medication Use by Primary Care Physicians." [28.] "Methylphenidate" (a background paper), Drug and Chemical Evaluation Section, Office of Diversion Control, U.S. Department of Justice, Drug Enforcement Administration (Washington, D.C.: U.S. Government Printing Office, 1995). [29.] D. Jacobvitz et al., "Treatment of Attentional and Hyperactivity Problems in Children with Sympathomimetic Drugs: A Comprehensive Review," Journal of the American Academy of Child and Adolescent Psychiatry 29 (1990): 677-88. [30.] K D. Gadow et al., "School Observations of Children with Attention Deficit Hyperactivity Disorder and Comorbid Tic Disorder: Effects of Methylphenidate Treatment," Journal of Developmental and Behavioral Pediatrics 16 (1995): 167-76. [31.] R. Klein et al., "Methylphenidate and Growth in Hyperactive Children," Archives of General Psychiatry 45 (1988): 1127-30. [32.] S. L. Jaffe, "Intranasal Abuse of Prescribed Methylphenidate by an Alcohol and Drug Abusing Adolescent with ADHD," Journal of the American Academy of Child and Adolescent Psychiatry 30 (1991): 773-75. [33.] E. K Sleator, R. K Ullman, and A. von Neumann, "How Do Hyperactive Children Feel about Taking Stimulants and Will They Tell the Doctor?" Clinical Pediatrics 21 (1982): 474-79. [34.] Milich et al., 'Attention Deficit Hyperactivity Disordered Boys' Evaluation of and Attributions for Task Performance on Medication versus Placebo," Journal of Abnormal Psychology 98 (1989): 280-84. [35.] J. M. Swanson et al., "Effect of Stimulant Medication on Children with Attention Deficit Disorder: A 'Review of Reviews,'" Exceptional Children 60 (1993): 154-62. [36.] B. T Satterfield and A. M. Schell, "Therapeutic Interventions to Prevent Delinquency in Hyperactive Boys," Journal of the American Academy of Child and Adolescent Psychiatry 26 (1987): 56-64. [37.] Wolraich, "Stimulant Medication Use by Primary Care Physicians." [38.] K. G. Nadeau ed., A Comprehensive Guide to Attention Deficit Disorder in Adults: Research, Diagnostic, and Treatment (New York. Brunner/Mazel, 1995). [39.] P. G. Dyment, "Hyperactivity, Stimulants, and Sports," The Physician and Sportsmedicine 18 (1990): 22. [40.] See for example J. Lantos, M. Siegler, and M. Cuttler, "Ethical Issues in Growth Hormone Therapy," JAMA 261 (1989): 1020-24. [41.] J. E. Richters et al., "NIMH Collaborative Multisite Multimodal Treatment Study of Children with ADHD: Background and Rational," Journal of the American Child and Adolescent Psychiatry 34 (1995): 987-1000. [42.] E. R. Saks, 'Does Multiple Personality Disorder Exist? The Beliefs, die Data, and the Law," International Journal of Law and Psychiatry 17 (1994): 43-78. [43.] For example, E. M. Hallowell and J.J. Ratey, Answers to Distractions (New York: Pantheon Books, 1994). [44.] J. Biederman et al., "Family-Environment Risk Factors for Attention Deficit Hyperactivity Disorder," Archives of General Psychiatry 52 (1995): 464-70. [45.] C. K. Whalen and B. Henker, "The Social Ecology of Psychostimulant Treatment: A Model for Conceptual and Empirical Analysis," in Hyperactive Children: The Social Ecology of Identification and Treatment, ed. C. K. Whalen and B. Henker (New York: Academic Press, 1980).
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Author:Diller, Lawrence H.
Publication:The Hastings Center Report
Date:Mar 1, 1996
Words:5836
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