To find the optimal dose, the dosage is increased by increments of 2. Ritalins effects begin within 30 to 60 minutes of taking the medication, they peak within 1 to 3 hours, and they disappear after 3 to 5 hours. Within 12 to 24 hours, the drug has been totally metabolized by the body and is out of the system.
There are also sustained-release forms of methylphenidate. The effects of Ritalin SR sustained release last from 4 to 6 hours. A newer formulation called Concerta, which arrived on the market in , lasts up to 12 hours and needs to be taken only once daily. The short-term positive effects of Ritalin on childrens behavior have been reported by parents and teachers. According to Lawrence H. Diller in his book Running on Ritalin, Between 60 and 90 percent of children with attention,. Tired with hyperness. Andrews father was angry.
His son was perfectly behaved at home. He thought it was the teachers fault that Andrew misbehaved. Andrews mother, however, was not so sure. Andrew seemed to get into fights when playing with other children, and doing homework was a struggle for him. He completed his math homework quickly while standing by his chair and singing the numbers. However, he took a long time to write a list of words and color a picture. Many times, Andrew forgot to bring his homework to school. He never put it back in his backpack.
His mother had given up asking him to do it, and just packed it herself. But, the father insisted, except for homework, we have no problems with him. What about meals? The father shrugged. He likes to run around, so we dont make him sit with us. The loss of appetite some users experience does not necessarily translate into stunted growth. Usually, a growth rebound occurs after the first year of treatment and during periods when children are not taking the medication, such as weekends and holidays.
And shopping? Does he behave when you are at the mall? We never take him. He used to run away and get lost, his mother added. We dont take him anymore. It is not safe. By the end of the meeting, Andrews father reluctantly admitted that maybe Andrews problems were not only happening at school. When the teacher suggested that Andrew might benefit from Ritalin, his parents agreed to give it a try. While taking Ritalin, Andrews behavior improved. He did not fidget as much and listened to the teacher without interrupting.
However, he still needed extra attention from her. The parents asked for special arrangements, and an extra helper was assigned to help Andrew stay on task. Eventually, the medication was discontinued, but his workload was altered to include modified spelling lists and shorter writing assignments.
For Andrew, as for many hyperactive children, receiving one-on-one attention made a great difference. These symptoms are usually associated with dyskinesias abnormal muscle movements that stem from disrupted brain function , and also with Tourettes syndrome a condition in which the tics are accompanied by uncontrollable vocalization of one or more words or sounds, which are often offensive.
Although there was some preliminary evidence that Ritalin caused liver cancer in rats, further research did not substantiate this finding in humans. Ritalin may also have negative effects on behavior. Usually, if the child takes a smaller dose of Ritalin in the afternoon, the symptoms of the rebound effect will be reduced without any substantial change in the appetite or sleep patterns. Some experts have reported that children taking Ritalin experience a change in the cognitive and intellectual processes. Parents and teachers have noticed that some children answer questions in more compliant or narrow ways, which could suggest that their creative thinking is restricted.
The results of the studies on these effects are not consistent. In some cases, children on Ritalin become withdrawn, too focused, zombie-like, somber, and quiet, and spend increasing amounts of time alone. Ritalin can also cause toxic psychosis, a syndrome that includes symptoms of hallucinations, delirium, and sometimes violent behavior. Usually, this. The long-term effects of Ritalin are not clear. It is known that Ritalin does not cure ADHD, but merely reduces the symptoms of hyperactivity, poor attention, and impulsivity. When the patient stops taking Ritalin, no matter how long he or she has been taking it, the effects of the medication will disappear.
About 3. Despite these numbers, many people believe that ADHD does not exist. No one would contend that some children do have problems paying attention, lack self-control, and are hyperactive to such an extreme that they cannot perform well in an academic or social environment. Using this definition, ADHD clearly exists.
On the other hand, some professionals argue that to give these symptoms a name and list them in a book as a diagnosis is misleading, because ADHD is not a disease or a diagnosis, but only a list of symptoms with many possible causes. Sydney Walker III illustrates the difference between a symptom and a diagnosis in the following example from his book The Hyperactivity Hoax : Lets say you come down with a chronic cough. Should your doctor say, You have a coughing disorder, and prescribe cough drops without worrying about whether you have lung cancer, strep throat, or tuberculosis? Or if you develop a swollen leg, should you doctor diagnose it as a lump, and give you an aspirin, without determining whether that lump is a tumor, an insect bite, or gangrene?
Coughing or swollen legs are symptoms, not diseases in themselves. In this sense, ADHD is not a disease either. In the opinion of Walker and others, to say that a child has ADHD does not explain the underlying cause of the hyperactivity or lack of concentration. To them, giving a name to the condition may hide the fact that not much is known about what is wrong with the affected individual and may inhibit people from looking for the cause that would lead to a more permanent solution. On the contrary, the fact that the child seems to do better while taking Ritalin may give parents and physicians the false impression that the problem is solved and, as a consequence, prevent them from doing anything else to address the problem.
Although the term attention deficit disorder ADD , as ADHD was first called when the condition was named, had been in use since the s, the problem was not new. There have. Still described a group of 20 children as being aggressive, defiant, resistant to discipline, and excessively emotional or passionate. In a note that paralleled modern ideas of ADHD, he claimed that the children demonstrated little inhibitory volition. In other words, they showed a major defect in control that would make them prone to getting in trouble with the law later in life.
He considered this a chronic condition and hypothesized that the problem was either hereditary or the result of some birth-related brain injury. In the years , after an outbreak of encephalitis a viral infection of the brain , some of the children who survived the disease showed behavioral and cognitive impairment mainly hyperactivity, failure to control impulses, and impaired attentionthe same symptoms that define ADHD today.
Because many people thought the symptoms were a consequence of brain damage caused by the infection, they called the condition minimal brain damage. Later, as cases of children with these symptoms accumulated during many years of study, and no biological damage could be detected in their brains, the name was changed to minimal brain dysfunction. The name for these symptomsalways with an emphasis on the hyperactivity componentchanged over the following decades as researchers looked, without success, for a biological cause.
Then, in , a more pragmatic approach emerged. Researchers decided to describe the symptoms and, instead of looking for the cause, search for a way to improve them. During the s and s, stimulant medication, psychotherapy, and parental counseling were the tools used to alleviate these symptoms. Later, in the s, when.
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Figure 2. In a report before the Royal College of Medicine, Still described a group of children with behavioral problems he had studied. His theory was that the childrens hyperactivity and aggression was caused by an injury to the brain, a hypothesis that turned out to be incorrect. It was also during the s that hyperactivity was dropped as a requirement for the condition, and the emphasis was placed instead on impulsivity and lack of attention. To reflect this, the name of the condition was changed from. What is interesting about the inclusion of the symptoms of lack of attention and impulsivity in the ADHD diagnosis is that all of these symptoms respond to stimulants.
As Diller notes, it is as if The diagnosis has evolved and expanded. Even today, after decades of research, it is not easy to decide whether a person has ADHD. ADHD is not a clearly defined disease, like strep throat or chicken pox. There is no laboratory test to diagnose it. For a while, after the discovery of the impressive effects stimulants have on most ADHD symptoms, researchers thought stimulants themselves could be used as a test for ADHD. In other words, if the persons behavior improved while taking stimulants, then he or she had ADHD. If the persons behavior did not improve, then he or she did not have ADHD.
This belief has been proven inaccurate. As noted in Chapter 1, studies have shown that stimulants have the same effect on hyperactive and non-hyperactive children: Stimulants make all children calmer and better able to concentrate in the short term. Currently, the most common way to determine whether a person has ADHD is by comparing his or her symptoms.
The symptoms on this list are separated into three groups corresponding to the three principal characteristics of ADHD: inattention, hyperactivity, and impulsivity. For a positive diagnosis, the person must show at least six of nine symptoms of inattention or at least six of nine behaviors indicating hyperactivity-impulsivity.
Although some doctors take the list literally as a diagnostic tool for ADHD, checking the patients behavior against the list and counting the number of items for which he or she has tested positive, other physicians are more conservative. They believe diagnosis cannot be reduced to a mathematical, yes-orno formula. In addition, to give a yes or no answer to the questions in the list is not as straightforward as it would seem. How often is often anyway?
In fact, what may be often for one person may be rarely for another, depending on his or her personality. The expression of the behaviors, too, may depend on the number of children in a classroom, the teachers style of teaching, and many other factors that have nothing to do with the specific child. For example, it has been reported that teachers of smaller special education classes are less likely to consider a childs behavior disturbing than are teachers of larger, mainstream classes.
Other people wonder about the borderline cases. For example, does a child have ADHD if he or she is positive for five items in both categories? Some also worry about describing these symptoms as part of a disease state. All of the symptoms of ADHD exist in humans in a continuum; they are present, in some degree, in all of us. Also, symptoms such as fidgeting, not listening, losing things, getting distracted, and being noisy are seen in many children.
Some researchers suggest that we are treating childhood itself as a disease. As Diller, the author of Continued on page Table 2. Either 1 or 2 : 1. Six or more of the following symptoms of hyperactivityimpulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:. Some hyperactivity-impulsive or inattentive symptoms that caused impairment were present before age 7 years.
Some impairment from the symptoms is present in two or more settings e. There must be clear evidence of clinically significant impairment in social, academic or occupational functioning. The symptoms do not occur exclusively during the course of a pervasive development disorder, schizophrenia, or another psychotic disorder and are not better accounted for by another mental disorder such as a mood, anxiety, dissociative, or personality disorder.
Source: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders , 4th ed. Washington, D. Running on Ritalin, testified in front of the U. Department of Justice in Washington, D. It depends on the combined efforts of parents, teachers, psychologists, doctors, and possibly other professionals to gather information on as many aspects of the childs life and history as possible. Although many pediatricians believe that depriving a hyperactive child of Ritalin is similar to, say, depriving a diabetic of insulin, others find this metaphor faulty.
Diabetes, they argue, is a physiological disease, whereas ADHD is a collection of behaviors without a known biological cause. Although diabetes is caused in part by the lack of insulin, the brains of children with ADHD cannot suffer from a lack of Ritalin. Unlike insulin, a hormone that naturally is produced in the body, Ritalin is an artificial drug.
Most were more influenced by other behaviors, such as acting out or learning problems. A modified version of their approach is as follows:. Step 1: Rule out medical problems as the cause of the observed symptoms. A physical examination of the child must be performed first to rule out many conditions whose symptoms could mimic ADHD. Among these conditions are vision and hearing problems, lead poisoning, thyroid problems, allergies, neurological problems, parasites, diabetes, and hypoglycemia. Taking some medications, such as those for asthma, could make a child fidgety or distracted.
Step 2: Rule out other emotional problems. Anxiety, depression, and thought disorders may interfere with attention and concentration or make the child so agitated that he or she may seem hyperactive. Only a skilled clinician can determine if the ADHD or the emotional problem came first, a necessary step in obtaining correct and effective treatment.
Step 3: Determine if the child has learning disabilities. Sometimes, teachers refer children to a doctor believing they have ADHD because they are having trouble staying on task and completing work at school. In some cases, the reason for this behavior is. A learning disability is defined first as a problem in learning that is not the result of low intelligence or poor teaching.
It also relates to the way a person perceives, processes, or expresses information. For example, a child may have difficulty remembering directions that are given orally, but no problem at all performing more difficult tasks that do not include oral communication. Alternatively, the child may easily work with numbers, solving difficult math problems, but have difficulties with easy reading or writing tasks. Obviously, this kind of disability can interfere with learning.
To complicate matters further, about one-third of children with ADHD also have learning disabilities.
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It is very important to determine if a child has a learning disability rather than jumping to the diagnosis of ADHD, because medication will not help a child with a learning disability. Step 4: Compare the diagnostic criteria of the DSM to the characteristics of the child. Step 5: Observe the child in as many settings as possible. It is important to gather information about the childs behavior before completing the DSM questionnaire. The DSM requires that at least two settings must be considered. Many professionals have pointed to the artificiality of the doctors office setting, where the childs behavior may not reflect his or her normal manner of behaving.
Step 6: Have a professional observe the child in the classroom. It may be worth the effort to have a trained observer collect the data in the school setting. Step 7: Have a professional conduct a psychoeducational evaluation. The professional must record learning potential and achievement levels in several areas, including math, language arts, spelling, written expression, and reading, and must record learning disabilities and gaps.
Based on the information that is gathered, a professional is better able to determine whether the child has ADHD. It is important to understand that a diagnosis of ADHD is not an end in itself, but a starting point. The goal is to gain a better understanding of the childs behavior that will help the doctor give a personalized treatment, one with a higher rate of success.
Several rating scales have been published to gather information on childrens behavior for both parents and teachers. The most frequently used scales are the Conners Rating Scales. The original scale, published for parents in , includes 93 questions that cover hyperactivity, immaturity, and emotional and behavioral factors. There are also several versions of the Conners Rating Scales for teachers. The original one includes 39 items covering hyperactivity, conduct problems, and emotional-overindulgent, anxious-passive, asocial, and daydreaming-inattentive behaviors.
An abbreviated form of the Conners Rating Scale can be used at periodic intervals by both parents and teachers to measure the effects of medication. Other rating scales for parents and teachers include the Child Behavior Checklist, which has two parts.
The first part of the parents version measures social activities; that of the teachers version measures how the child is adapting in the classroom. The second part, in both versions, measures. Alternative medications to Ritalin are Dexedrine or Cylert. Medication is not the only way to treat ADHD. Overall, studies show that Ritalin has an impressive shortterm effect on improving behavior. Ritalin improves attention span, gross motor coordination, impulsivity, aggressiveness, handwriting, and compliance. It also improves learning in the short term, but no long-term improvement in academic success has been shown.
To study the long-term effects of medication, a long-term prospective study must be conducted. Prospective studies, which follow subjects over a period of many years, are difficult to perform. The results of the ones published to date have been disappointing. According to Diller: Studies beginning in the s showed that children who took stimulants for hyperactivity the name for ADD at the time over several years did just as poorly in. Compared to children without hyperactivity, both groups were less likely to have finished high school or to be employed, and more likely to have problems with the law or to have drug or alcohol problems.
A large percentage of the hyperactive group, medicated or not, did relatively well, but overall those in this category wound up struggling much more frequently than their normal peers. From this excerpt, it appears that taking Ritalin is not the key to a long-term improvement in the behavior of children with ADHD. When children on these treatments reached young adulthood, they were found to have fewer problems than those who only took medication.
Gaber and his colleagues, in the book Beyond Ritalin, suggest some simple educational and psychological changes that may improve the behavior and performance of a child with ADHD. A summary of their techniques follows: 1. Modify the environment. For example, at school, modifying the environment may include changing where the child sits in the classroom. Some children may need to sit in the front, where the teacher can give them closer attention, while others will do better sitting in the back of the room.
Sitting in a circle can offer the ADHD child too many excuses for socialization. Similarly, sitting by an open window or by the pencil sharpener does not seem to be the ideal place for a child with ADHD. On the other hand, although sitting alone will provide fewer distractions for some children, a child prone to daydreaming should not sit alone. Change the routine. Some children work better in the morning, and others in the afternoon. Scheduling the courses that require higher concentration accordingly can improve performance. Pair an ADHD child who has poor organizational skills with a buddy.
For older children, allow them to borrow notes from other students if they have problems writing. Consider carefully whether the teacher fits that particular student. Some children respond better to certain teaching styles than others. A class with a low student-to-teacher ratio is also advantageous. At home, find the right place and time to do homework. The child may need to unwind when coming home from school.
He or she may prefer to do homework after dinner or in the morning. Change the task to increase productivity. If the child has problems following directions, it may be better to give him or her one task at a time or to break the assignment into smaller tasks. It also may work best to alternate easier tasks with more difficult ones, to make eye contact with the child when giving the assignments, and, if fine motor skills are a problem, to minimize written assignments or let the child use a computer. Enhance positive responses. If the child has problems reacting to the consequences of his or her actions, or tends to act impulsively, behavioral interventions that enhance positive responses immediately may work best.
For example, give the child. In general, experience and research agree that, in the long run, an approach that combines the behavioral interventions described above with medication is more effective in treating ADHD symptoms than medication alone. Diller offers an interesting approach to reach an appropriate treatment. He suggests asking children, if they could take a pill that would fix all their problems, what would this pill do?
A childs answer to this question will provide the doctor with a clear idea of what the child wants to improve, and the treatment can be designed to reach these goals. Another factor that seems to make a great difference in the success of ADHD individuals in adulthood is the choice of job or career. Although this is important for everyone, individuals with ADHD must carefully choose a job or career that fits their special needs.
In general, jobs that require a high degree of concentration such as an air traffic controller or great attention to detail for example, accounting or editing are probably not appropriate for an individual with ADHD. People with ADHD tend do well in fast-changing, high-stress environments, such as the stock market or computer technology.
For long-term success, however, the behaviors associated with these symptoms can also addressed with different techniques, some of which have been described in Chapter 2. These two different types of treatments point to two different causes for ADHD. The improvement observed when taking a chemical substance seems to indicate that ADHD has a biological cause.
However, improvement by behavioral modification techniques suggests that ADHD may have an environmental cause. The prevalent theory among both health professionals and the general public today is that the symptoms of ADHD have a biological cause. The most generally cited causes are birth defects, an infant trauma, and the brains inability to produce enough of specific neurotransmitters, or brain chemical messengers.
The widespread use of expressions such as He has a chemical imbalance or Her brain is hard-wired this way when talking about children considered to have ADHD reinforces this belief. In , the British physician George Still attributed the aggressive and defiant behavior of the children he was studying to either a genetic cause or some birth-related injury. Brain damage was also thought to be the cause of the behavioral problems experienced by the children who had survived the encephalitis outbreak of As late as the s, symptoms similar to the ones now included in ADHD were grouped under the term minimal brain damage.
This physiological brain damage was never found, and eventually the term was abandoned. The search for a biological cause for ADHD, however, was not. Although there is evidence that ADHD is hereditary, it has proven difficult to separate the effects of genetic inheritance from those of family environment. The only data pointing to a genetic component for ADHD have been compiled when working with identical twins. These studies found that it was more likely for identical twins to meet ADHD criteria than it was for fraternal twins. Since, by definition, identical twins have the same genetic material, this indicated that at least part of the ADHD condition is genetic.
Yet the probability for one identical twin to have ADHD if the other had it was less than one in three. Moreover, to date, no specific gene for ADHD behavior has been identified. Using different techniques of brain imaging, several groups of researchers have looked for differences between the brains of ADHD and non-ADHD individuals.
In one of the best-known studies, Alan Zametkin and his colleagues at the National Institute of Mental Health used positron emission tomography PET scanning to evaluate glucose metabolism in the brain. Because glucose is the only source of energy for the brain, the way the brain uses glucose can serve as a gross indicator of activity in its various parts. For the studies, patients were given radioactive glucose. Because of the high level of radiation associated with this. The results, published in the New England Journal of Medicine in , showed a 8.
Magazines and newspapers embraced this conclusion eagerly. After all, how can you argue with a brain scan? Despite the buzz, not everyone was convinced that the results proved that ADHD has a biological basis. First, efforts to replicate these findings have failed.
Second, the participants were adults, not children, which limits the applicability. Third, there is no evidence that an 8. In fact, this difference in metabolism did not correlate with performance on an attention task. When another group of researchers compared the metabolism of men and women in the control group of the Zametkin study, they found the statistical difference to be the same as the one they had found between the control and the hyperactive groups.
This means that the difference between the hyperactive and control group in Zametkins study could be the result of the hyperactive group having a larger percentage of males. Finally, even if the difference in brain metabolism between. In a later study, they looked at the glucose metabolism in the brain of ADHD individuals before and after taking Ritalin. The idea was that if ADHD symptoms are caused by a decrease on glucose metabolism and Ritalin improves ADHD symptoms their hypothesis , then taking Ritalin would increase glucose metabolism.
Again, their results failed to show any change.
Unfortunately, this is not currently possible because there is considerable overlap in our study between normal and ADHD brain metabolism. As an example, psychoanalyst Frederick Fisher, as recently as March 16, , stated in the Philadelphia Inquirer magazine that ADHD is a demonstrable organic condition that shows up on PET positron emission tomography scans involving glucose metabolism. This process, which uses less radiation.
These researchers claim there is a correlation between ADHD and decreased blood flow in the tissues of the prefrontal cortex Figure 3. Although other experts have criticized the lack of reproducibility of this study, Amen believes the scanning is evidence of the biological nature of ADHD and uses it to diagnose ADHD. In summary, no reliable scientific evidence for the biological cause of ADHD has been found to date. Zametkin, the researcher behind the PET scan studies on the brain, agrees: Could it be that a dysfunction of the central nervous system is the key to our understanding of the etiology of attention deficit disorder?
Individually, each finding is insufficient to prove that ADHD has a neurobiological basis. Indeed, it may still be a long time until the underlying cause of ADHD is established. In the book The Music of Dolphins, Karen Hesse tells the story of a girl raised by dolphins from the age of four.
Rescued as a teenager, she is taught how to talk and behave like a human. Although she progresses to a point where she is able to communicate, she cannot become fully integrated into a society she still perceives as alien. This story, which closely follows the modern theories about speech and behavior development, shows how much influence the environment has in shaping the self.
In other words, the story shows the importance of the nurture part in the old argument of nurture the influence of environment versus nature the influence of genetic makeup. Although the girl in the book had the genetic makeup to be human, without. Figure 3. This diagram of the brain shows the cerebral cortexthe area that some researchers posit may be connected to ADHD. As Daniel Goleman writes in his book Emotional Intelligence, there is increasing evidence that to develop in a healthy way, a childs brain needs real-life experiences.
The experiences after. Wiring refers here to the connection the neurons brain cells make with one another Figure 3. If we consider that the human brain is composed of about 10 to billion neurons, and that these neurons make thousands of connections with other neurons, we come up with a web of billions of connections. These connections, however, are not present in the newborn babys brain. In the newborns brain, about 4. Although the genome has a role in this complex process, it is the moment-to-moment experience of the child that determines which connections will remain and which will be cut.
Many examples suggest this plasticity. For example, if a child with a lazy eye covers the healthy eye, eventually the vision in the weaker eye improves because the neurons grow new connections to reinforce the path to the weaker eye. A child born in China learns to speak Chinese, while the same child raised in England would learn to speak English. Although every child growing up in Spain knows how to roll the r, it is difficult for an adult nonnative speaker to learn to do so. If environmental influences can actually alter brain functions and shape behavior, it is not surprising that many people believe a childs early experiences have an effect on whether he or she develops ADHD.
In other words, some experts contend that the environment can cause or change ADHD. Several studies support this theory. One of them, published in , observed children at 6-month intervals during early and middle childhood. The study found that variables operating at the level of the family mainly, quality of care giving, parents marital status at the time of the childs birth, emotional support given to the caregivers, and the caregiving style were good indicators of which children would or would not show ADHD-related problems.
The results indicated that the childs early experiences do have an effect on the development of ADHD. The human brain is made up of billions of these neurons. Scientists who believe ADHD may have a biological cause are researching possible links between connections between neurons and the behavioral problems that are associated with the condition.
If the biological cause for the ADHD behavior is accepted, the use of medication as a cure easily follows. If, on the other hand, emotional or relational problems are considered the cause, medication is no longer the simple cure, and. The biological cause model remains popular because a solution in pill form is appealing and because accepting a biological cause removes blame from parents.
Yet to believe only in a genetic and neurological cause for the disorder would entail ignoring many environmental factors, such as learning disabilities, emotional problems, family dynamics, classroom size, and economic and cultural issues, which may also be of significance in the development of ADHD. Lawrence Diller believes that neither the genetic model nor the environment model alone provides the whole picture for ADHD.
Instead, he argues that a biopsychosocial model, in which several factorsincluding a persons biology, emotional status, and environment interactprovides a better solution. In this model, the path between the mind and the body is seen as a two-way street: The brain affects emotions and behavior and, in turn, the brain is affected by the persons experiences. After all, although everyone is born with a basic personality, it is the experiences an individual has while growing up that will shape him or her into the kind of person he or she will become. Ritalin also improves concentration, increases attention span, and lowers the activity level both in individuals with ADHD and without.
On the other hand, Ritalin may cause several adverse drug reactions, from growth inhibition to psychosis. How Ritalin accomplishes these changes is not completely understood. Nonetheless, several studies have shown that stimulants affect the structure, biochemistry, blood flow, and energy utilization of the brain. The areas of the brain affected. Table 3. Reticular Activating Impaired responsiveness, alertness, and System self-awareness Spinal Cord Temporal Lobe Impaired muscle tone and movement Impairment of memory and learning.
This reduction is believed to be caused by a constriction of the blood vessels, probably. Ritalin also has a significant effect on glucose metabolism in the brain. As noted previously, since glucose is the only source of energy in the brain, its metabolism is directly related to the brains overall energy consumption. At the lowest dosage, Ritalin increases energy consumption in many areas of the brain that are central to motor activity and mental function. Most of these areas are dopamine pathways.
Other studies suggest that in the long term, Ritalin may also cause cortical atrophy, which refers to the withering and shrinking of brain tissue. This finding poses great concern, since the cortex of the brain is critical to higher mental function, including intelligence. The brain is composed of cells called neurons. Unlike other cells in the body, neurons do not touch each other.
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The connection between any two neurons is made through neurotransmitters, chemicals that act as messengers. Neurotransmitters are very small molecules. They are released from the tip of the neuron extension, or axon, into the space called a synapse that separates individual neurons Figure 3. As a result, electrical impulses travel down the neuron membranes. Once neurotransmitters are released, they travel through the synapse until they are picked up by receptors in the neighboring cells.
Some neurotransmitters decrease inhibit activity, while others increase excite activity of the neuron to which they bind. Any particular neuron may be surrounded by thousands of others that are, at any given moment, releasing neurotransmitters. The neuron must weigh the relative strengths of the inhibitory and excitatory signals of these neurotransmitters to determine when a signal should be sent down its axon. Ritalin interferes with this complex neurotransmitter system both by increasing the number of neurotransmitters released.
Ritalin and other stimulants increase the number of neurotransmitters released into the synapses the spaces between individual neurons and help keep the neurotransmitters in the synapse longer than they would remain without the drugs. This diagram demonstrates the flow of neurotransmitters between neurons, across a synapse. Different neurons synthesize and release different neurotransmitters into the synapses.
Ritalin and other stimulants interact with the neurons that produce and respond to the neurotransmitters dopamine, norepinephrine, and serotonin. The activation of the dopamine pathways in the brain, researchers believe, produces the therapeutic effect of suppressing spontaneity as well as the most serious adverse effects of drug abuse and addiction. These effects occur because the neurons that release dopamine originate in two areas deep within the brain: the substantia nigra and the ventral tegmentum.
Dopamine neurons in the substantia nigra reach into the basal ganglia, which control motor activity and influence mental processes. These ganglia are connected to the reticular activating system that is the energizing core of the brain and the limbic system that regulates emotions. Dopamine neurons from the ventral tegmentum go directly to the centers of the brain that control thinking and feeling, including the frontal lobes and limbic system.
The dopamine system thus affects portions of the brain involved with the processes most essential to being human. Dopamine neurons also go to the hypothalamus and pituitary glands. There, they control the hormonal processes involved in growth and reproductive functioning. Ritalin also stimulates neurons that release norepinephrine into the synapse. This is believed to result in overactivity of the cardiovascular system and some symptoms of drug withdrawal. Most of the norepinephrine-generating neurons originate in the locus coeruleus of the brain.
This locus is connected to the cerebral cortex and the reticular activating system. By increasing the activity of the neurotransmitter serotonin, Ritalin affects both higher human activities and basic physiological functions. In fact, increasing serotonin levels affects every brain function described in Table 3. Some researchers believe that Ritalin produces more extreme mental. The relationship between Ritalin and the overall mental function of the brain is far from being well understood. Dopamine, norepinephrine, and serotoninthe neurotransmitters known to be affected by Ritalinare only three of the hundreds of substances that control brain functioning.
The brain does not welcome external molecules. It sees them as intruders and tries to compensate for their effect. In the case of stimulant drugs, the brain reacts to the excess of neurotransmitters in the synapse in two ways: 1. The neuron releasing the neurotransmitter receives feedback signals that cause it to shut down, causing less neurotransmitter to be released into the synaptic space. The neuron receiving the neurotransmitter tries to reduce the amount of stimuli by destroying the receptors that bind to that particular neurotransmitter.
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The disappearance of the receptors has actually been measured in experiments with animals. Sometimes, these compensatory changes in the brain become permanent, causing irreversible malfunction. In summary, although its advocates claim that Ritalin corrects an imbalance in the brain or enhances brain function, the reality is not so simple. The only thing certain is that Ritalin, like any external substance that reaches the brain, has a high probability of disrupting the normal mental process in unexpected ways.
At the same time, the number of prescriptions for Ritalin has increased from 3 million in to 11 million in In addition, the age and the type of individuals diagnosed as having ADHD has also changed. As late as the s, ADHD was considered a childhood problem. The majority of children diagnosed with the disorder had very severe symptoms, of which hyperactivity was obligatory. According to Diller in his book Running on Ritalin , the typical profile of an ADHD sufferer in the s consisted of boys from six to 12 years old, extremely hyperactive and impulsive, functioning poorly if at all in a normal school situation.
Many were quite out of control, and Ritalin was often needed to give other treatments a chance to work. In most cases, they had not heard of ADHD. Some parents, especially fathers, refused to believe there could be something wrong with their childs brain and blamed the mothers parenting style for. Often, parents refused to give their child a stimulant drug and had to be coerced into doing so.
The situation is quite different now. Today, everybody seems to know about ADHD, and Ritalin is widely accepted as a miracle pill that makes children behave. This belief is so widespread that some parents cannot wait for their children to turn six, the recommended age for a child to start receiving Ritalin. In fact, some do not wait, and, although it is against the American Psychiatric Associations recommendations, the number of children under the age of six taking Ritalin is increasing.
Nowadays, when parents call the doctor to make an appointment, they may already have decided that their child. When, after years of struggling with their childs behavior, parents ask a doctor whether their child has ADHD, what they are really asking is whether there is a physiological reason for their child to behave the way he or she does.
What they are asking is whether the child cannot behave or whether he or she will not behave. Tired of blaming themselves for what they see as their own failure, parents are often eager to embrace the idea that there is some malfunction in the childs brain that puts the desired behavior outside of his or her control. If the cause of the behavior is biological, the child is physically unable to behave differently and the parents are not at fault.
If the cause is psychological, on the other hand, this implies an emotional or relational problem, one for which parents might be considered partly responsible. In the first case, taking a pill is readily justified. In the second, there is no easy cure. This accounts for the allure of a biological cause for ADHD.
Many ask directly whether the doctor will perform ADHD tests. If the doctor tells them that an ADHD test does not exist, they will take their child to another doctor. If this particular doctor does not give their child a prescription for Ritalin, they will take the child elsewhere until they find a doctor who does. It is not surprising, then, that the number of children diagnosed with ADHD and taking Ritalin has increased. Between 2 and 3. These numbers make some people uneasy. But others, such as Joseph Biederman, believe this increase is a positive development because it means child psychiatry is finally recognizing the need for medication.
If all these children were prescribed Ritalin, the current treatment rates would double. Parents are not the only ones responsible for the increase in Ritalin use. In some cases, schools will not allow children diagnosed with ADHD into the classroom if they are not on Ritalin. In the case of divorced parents, one court reportedly took custody away from a father because he would not agree to give Ritalin to his child.
The profile of the children described as ADHD sufferers has changed, too. Although some of the children have problems at home or school, more often, children who are not hyperactive and who may function normally at school are diagnosed with ADHD. These children are identified for their inability to pay attention and get their work done, or because they have problems with daydreaming, concentration, or getting organized. Today, parents embrace the ADHD diagnosis with relief because, following the prevailing theory, they accept that the.
Instead of having to be coerced to give Ritalin to their children, many parents are eager to do so. A very telling example of this change in the popular trend is exemplified by the fact that parents, teachers, and children refer to the condition as having ADHD or being ADHD. By doing this, they reinforce the validity of the condition as a medical disorder and ignore the slippery nature of the diagnosis; they ignore the fact that ADHD is not a disease itself but a metaphorical construct that refers to a wide array of symptoms.
Even the phrase having ADHD as in having asthma or diabetes implies the condition is a disease state, and therefore biologically based, discounting the possible effects of the environment. This overlooks the possibility that the childs behavior may be a result of how the child has been or is being treated. Because ADHD is often viewed as a disease state, the affected children are prescribed Ritalin, but nothing is done to change the environment that may also be influencing their behavior.
The fact is that there may be nothing inherently wrong with the child. It is possible that all that is needed is a change in parenting style, teaching, or the childs social environment. Another important distinction between diseases such as diabetes and asthma as opposed to ADHD is that the two former conditions are malfunctions of the body. As such, they do not define the personality of the individual who suffers from them the way ADHD, a malfunction of the brain, does.
Perhaps that is why most children under the age of 10 do not like to take Ritalin. These children do not like the way it makes them feel and are worried about being teased by their peers or perceived as crazy. The fact that they have to go to the nurses office to receive a second dose. Not only can taking Ritalin be damaging to childrens selfesteem, but being labeled with ADHD cause problems, too. A Ritalin prescription implies that ADHD has a biological origin, that there is a chemical imbalance in the childs brain, and that an external drug is needed to fix it.
If this is true, then what children are being told is that there is something wrong with them at a very basic level. Because Ritalin does not cure ADHD, but only helps control the symptoms, the implication is that what is wrong with the childrens brains will never change and that they will have to take medication forever. It is not surprising that children often have low self-esteem under these circumstances.
Low self-esteem may be the reason why many children refuse to continue taking medication by the time they reach the age of 12 or The fact that children with more severe symptoms are the ones who are most eager to reject Ritalin seems to support this theory, because these children are probably the ones with lower self-esteem.
Interestingly enough, when it comes to teenagers and adults with ADHD, the situation is quite different. Many teenagers and adults view the fact that they have ADHD as a positive trait. Books like Driven to Distraction by Hallowell and Ratey may be partly responsible for this change in attitude toward taking Ritalin. By introducing into the public mainstream the concept that along with the negative traits, ADHD individuals possess many positive characteristics, Hallowell and Ratey are attempting to remove the stigma associated with ADHD.
In fact, Hallowell, who claims to have ADHD, defines the disorder as having an indefinable, zany sense of life. Talking about one of his patients, he says, Like many ADDers, he was intuitive, warm, and empathic. In fact, I would much rather have ADD than not have it, since I love the positive qualities that go along with itcreativity, energy, and unpredictability. These people believe themselves to be distinctively different from the non-ADHD population in terms of learning abilities, outlook on life, and creativity.
They view their ADHD qualities, once thought to be only a negative burden, as assets. This does beg the question that if being ADHD bestows positive traits, why would individuals with the disorder want to take medication for it? During the s, children diagnosed with ADHD were expected to outgrow their symptoms, and generally stopped taking Ritalin by the time they reached puberty.
The fact that children do not always outgrow their ADHD symptoms after reaching puberty is one of the factors that have contributed to the increase in the incidence of ADHD and, consequently, of Ritalin use among the adult population. Without hyperactivity as a requirement, many adults began to recognize aspects of ADHD in themselves when their own child was diagnosed with the disorder and started to take medication.
Although the authors insist that their list is not intended to be a self-test, people began to use the list to diagnose themselves. The traits are so general that nearly everyone can relate to them. For example, the first 10 items on the list from their book are: 21 1. Are you left-handed or ambidextrous? Do you have a family history of drug or alcohol abuse, depression, or manic-depressive illness?
Are you moody? Were you considered an underachiever in school? Do you have trouble getting started on things? Do you drum your fingers a lot, tap your feet, fidget, or pace? When you read, do you find that you often have to reread an entire paragraph or an entire page because you were daydreaming? Do you tune out or space out a lot? Do you have a hard time relaxing? Are you excessively impatient? Upon reading the book and taking the test, many adults recognized a pattern in the problems with which they had.
Still, Ritalin use in adults is low compared to that in children. According to Diller, author of Running on Ritalin, The families [who bring their children to his practice thinking ADHD is behind their problematic behavior] are mostly white, middleand upper-middle class. In nearly all cases, at least one parent has a job; in most families, both parents are working. Overall, the Ritalin boom appears to be primarily a North American, white, middle- to upper-middle-class, suburban phenomenon.
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