As mentioned above, Dr. Stein is concerned about the side effects of Ritalin. He states that the action on the body of Ritalin is virtually identical to that of cocaine and amphetamines, drugs that are banned illegal substances. Concerta is another drug used for ADD/ADHD, which had an identical effect on the body as cocaine. In the Federal Government Control Act of 1988, Ritalin is classified in the same category as cocaine and morphine. Figures were presented during the workshop showing that Ritalin leads to depression in 8.7% of cases, whereas with amphetamines the figure drops to less than 1%. Also, Ritalin holds higher risks for the development of tics, lethargy and drowsiness, loss of appetite, nausea, and an increase in blood pressure than amphetamines do. Another alarming side effect of Ritalin is cognitive toxicity, occurring in 40% of cases. Research into the long-term side effects of Ritalin is limited, but some studies have found that it can interfere with normal growth in children, as it reduces the action of the pituitary gland.
Dr. Stein mentions some other drugs that are, or have been used to treat ADD/ADHD, and the information he gives is just as alarming as that regarding Ritalin. Cylert was given to children, and was rated as a Schedule 4 drug, as it was seen as a less addictive drug group. However, it was later implicated in liver damage and is now prescribed less and less. One of Dr. Stein’s sons was prescribed Cylert. Some of the other drugs are Adderall, which contains Benzedrine and Dexedrine, one of which has been banned for adults in the USA, but is still being given to children. Desoxyn and Gradumet are both methamphetamines (known on the street as Speed) prescribed for ADD/ADHD, and Focalin is another prescribed drug that is similar to Ritalin but stronger. Atomoxetine is an antidepressant that was used, but was taken off the market, as it was ineffective.
In the presentation, and also in the book, it is pointed out that there are no psychological or medical tests available to identify children who may be predisposed to addiction to alcohol or drugs. Amphetamines are one of the most addictive groups of drugs available. They have a record of abuse throughout history since they were first introduced, but this is the first time that they have actually been prescribed to children. It is worth noting that when treating addictions there is only a 20% success rate, so once a child becomes addicted, it is extremely difficult to reverse this. In his book, ‘Ritalin is not the answer’, Dr. Stein tells of a child who was started on Ritalin when he was eight years old because his teacher believed he did not pay attention in class. Even though the child was found to be extremely intelligent, and spent hours at home concentrating on a rock collection he had, studying it and organising it, he was placed on Ritalin. He came to believe that he could not function well in school without the drug, and did not want to come off it. A few years later, he started to experiment with other drugs, such as cannabis, and when he was fifteen he tried heroin for the first time. He is now in jail serving a five-year sentence for possession and supplying of drugs.
Ritalin is already being sold as a street drug for recreational use, and some children are even selling their medication to others who use it to ‘get high’. Dr. Stein indicates the paradox in American society, where on the one hand they are trying to fight against children being involved with drugs, and on the other hand giving them exactly the same drugs as medication to make them feel better. There seems no sense in this at all.
So what do we do with children who suffer from the symptoms of ADD/ADHD if the medication is so unsafe? Dr. Stein has developed a behavioural programme, which he calls the Caregivers Skills Programme. It is designed to help ADD/ADHD children think and solve problems without the use of medication, behave correctly, function independently and to pay attention. The child’s carers are trained thoroughly in all the skills they need to put the programme into action. The main aims of the Caregivers Skills Programme are to stop the use of drugs to treat the child, which also allows certain behaviours to develop again, as drugs tend to mask the main behaviours that need to be identified; to treat the child as normal and capable; to change the way they think as well as the way they behave; to change the parenting techniques already used, and to change all misbehaviours, not just impulsivity and not paying attention.
The programme begins by identifying target behaviours. These are specific and observable behaviours that occur frequently, are inappropriate, and are habitual. Once these have been identified, they can start to be changed. This is done by the use of reinforcers. Dr. Stein states that social reinforcers are most effective and long standing, such as paying attention, spending time with the child, looking at them, talking to them, praising, touching, listening, and just responding to them. He argues against the use of material reinforcers such as watching TV, playing outside, riding a bike, playing games, having their favourite food, or receiving money or toys. He says these are less effective as the improvements in the child’s behaviour fade quite quickly once they tire of the reinforcer. This does not happen with social reinforcers. They also promote payment expectancy, where the child will not behave unless they are going to receive a material reward. Social reinforcement is also very important for children, as it helps them develop a more positive self-image and increases their self-esteem.
The Caregivers Skills Programme regards punishment as ineffective, as it can actually perpetuate the child’s misbehaviour and have negative and defeating effects. More effective forms of discipline are taught, such as ignoring, time out and reinforcement removal. Reinforcement removal is only used when behaviours, commonly lying and aggression, are resistant to other methods. The programme also includes improving school performance. However, this must not be attempted until all target behaviours are under control at home. Once the child starts to behave better, they generally start to feel better about themselves. People are responding to them more positively, and this can lead to the child becoming even better behaved and respondent.
The Caregivers Skills Programme starts to work within one to two weeks of beginning treatment, and has worked for all the children who have seen it through so far. Why then, is there a need to risk children’s health and safety by placing them on drugs? Well, as mentioned earlier, not everyone shares the same views and opinions as Dr. Stein. There are some that do, for example, David Pentecost, who has also written a book about ADD entitled, ‘Parenting the ADD child – Can’t Do? Won’t Do?’ (2000). There are many others that do not though, and much research into ADD/ADHD contradicts Dr. Steins views.
Cantwell (1996) carried out a literature review of articles, books, and chapters published in the last ten years to do with ADD. He cites several studies that link ADD with physiological make up. For example, Zametkin et al. (1990) carried out a PET study of adults with ADD who also had a child with ADD. The results showed that compared with normal adults, the adults with ADD had lower cerebral glucose metabolism in certain areas of the brain. The results were not as strong in adolescents however. Several other studies have shown possible links, although Cantwell (1996) does state, ‘there is a general agreement that psychophysiological studies have not revealed global autonomic underactivity in children with ADD.’ (p.978). Tannock (1998) has emphasised biological factors as being related to an increased risk of ADD/ADHD, and points out the rapidly growing literature on genetics and neuroimaging in relation to the cause of ADD/ADHD. ADHD has been found to run in families, suggesting a genetic link (Hechtman, 1994). No specific genetic abnormalities have been found, however. Faraone, Biederman and Millberger (1996) found that 35% of the immediate and extended family members of children with ADHD are also likely to have the disorder. Recent twin and adoption studies have also indicated a link (Tannock, 1998; Stevenson, 1992; Sherman, Iacono & McGue, 1997).
Contrary to Dr. Stein’s belief, Cantwell (1996) states that psychosocial factors are not thought to play a role in the aetiology of ADD. Woolfe and Mash (1999) support this by giving a list of possible causes of ADHD that have been discarded due to lack of consistent support. Included in these are bad parenting, poor school environment and living in an urban environment. This contradicts Dr. Stein’s suggestion that ADD/ADHD could be caused by symptoms of modern day society, such as both parents working, children not playing outside so much, loss of extended families, the education system and other social factors that he indicated. This is not to say that these factors do not have an influence on the manifestation of the disorder.
Another contradiction between Dr. Stein and Cantwell is that ADD/ADHD can be diagnosed. In his book, ‘Ritalin is not the Answer’, Dr. Stein comments that there are no psychological tests that can indicate the presence of an ADD/ADHD disease. He believes that the most accurate diagnosis can only be made by a mother who observes her child, and that the tests given by doctors are just checklists of certain behaviours, and he also emphasises that the psychologists and doctors cannot diagnose a disease, only give the behaviour a label. Cantwell, although acknowledging that there are pitfalls in the diagnostic process, believes they can be overcome if a proper diagnostic approach is followed.
When it comes to the section on management of ADD in Cantwell’s review, it seems that a combination of psychosocial and medical interventions is regarded as the most effective way of dealing with ADD. Psychosocial interventions are described as educating parents and teachers about what ADD is and what it is not, and support groups such as CHADD are mentioned. This is the very group that Dr. Stein refers to in his book, who are funded by the drug company that manufacture Ritalin. Behavioural programmes are talked about as being important, and so are school-focused interventions, although it does mention placing children in special classes, which Dr. Stein is very against. It seems that psychosocial factors are taken seriously, and behavioural schemes are also recommended in this review.
When referring to the use of medication to treat ADD, Cantwell paints quite a rosy picture. He states that when a child is given medication, ‘Interactions between the child and peers, family, siblings, teachers and significant others (such as scout masters and coaches) also improve. In addition, participation in leisure time activity, such as playing baseball, improves’ (1994). A study by Swanson, McBurnett, Christian and Wigal (1995) also showed that in 80% of cases, Ritalin shows a dramatic increase in sustained attention, impulse control, and persistence of work effort, and decreases in task-irrelevant activity and noisy and disruptive behaviour. So it seems that Ritalin is extremely effective. He does list some of the side effects of taking medication, but says that most of the side effects will disappear with time and many can be managed. Cantwell believes growth suppression is dose-related, if it occurs at all. This does not quite match with Dr. Stein’s fact. When Cantwell mentions the development of tics as a side effect, he points out that these normally dissipate after a time, and if they do continue they can be controlled by more medication. No mention is made, however, of the side effects related to the drugs that treat the tics. Cognitive toxicity is also mentioned, but Cantwell states that this only occurs when the maximum dosage is given, and in this case the dosage can be lowered. Cantwell also states that abuse of the substances does not seem to be a major problem, another contradiction to Dr. Stein’s concerns. Woolfe and Mash (1999) also share this opinion, stating, ‘Although stimulant medications can be addictive (one recreational name for Ritalin is Vitamin R!), they are not addictive for most children who take them. Medications seldom make children “high”, nervous, or jumpy, or turn them into non-feeling zombies’ (p.175).
Cantwell (1996) goes on to list some other drugs that have been used to treat ADD, and true to Dr. Stein’s statement, there are a great deal of psychological drugs that have been tried. The list of drugs is quite alarming, and it seems that everything has been given a try at some point. The side effects of most of these drugs are not mentioned, although it is shown that when serotonin reuptake blockers were used, 80% of the children presented with major depressive disorder. It really starts to seem like children with ADD have been used as guinea pigs for a whole list of psychological medications. In his conclusion, Cantwell states that the staple treatment of ADD remains psychostimulants. He does also state, however, that psychotherapeutic and psychosocial interventions play an important role in treatment, as do school-based interventions, and comments that more long term research needs to be carried out on the effect of childhood treatment of this disorder. This is one point that Dr. Stein would actually agree with.
The great debate over whether children should be given stimulant medication to treat ADD/ADHD has been taking place for years, and will probably continue for years to come. Clearly, there is much controversy surrounding this debate, and much supporting evidence on each side of the argument. At present it would seem that medication is the most popular form of treatment for this disorder (if in fact it is an actual disorder) despite some strong opposition to this by certain members of the field. However, the view that a combination of both medication and behavioural programmes is most effective is beginning to become more popular. If indeed children can be quickly and effectively treated with behavioural programmes alone, then this does beg the question ‘Why use medication at all?’ Most studies find the effects of stimulants to be as strong or stronger than those for behavioural programmes (Barkley, 1998). However, the source or the funding of this research is not mentioned. It may be that more research needs to be carried out by neutral organisations in order to gain an accurate insight into both the benefits and risks of treating children with symptoms of ADD/ADHD with medication.
