The Age Of Ritalin

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But it is not the severe cases so much as the borderline ones--the children who occupy that gray area between clear dysfunction and normal unruliness--who raise the tough ethical issues, both public and private. The pace at which Ritalin use has been growing has alarmed critics for a while now. Some doctors find themselves battling anxious parents who, worried that their child will daydream his future away, demand the drug, and if refused, go off to find a more cooperative physician. Some parents feel pressured to medicate their child just so that his behavior will conform a bit more to other children's, even if they are quite content with their child's conduct--quirks, tantrums and all.

Many doctors won't discuss the matter publicly because the issues are so hot. Production of Ritalin has increased more than sevenfold in the past eight years, and 90% of it is consumed in the U.S. Such figures invite the charge that school districts, insurance companies and overstressed families are turning to medication as a quick fix for complicated problems that might be better addressed by smaller classes, psychotherapy or family counseling, or basic changes in the hectic environment that so many American children face every day. And the growing availability of the drug raises the fear of abuse: more teenagers try Ritalin by grinding it up and snorting it for $5 a pill than get it by prescription.

"Let's not deny Ritalin works," says J. Zink, Ph.D., a Manhattan Beach, Calif., family therapist who has written several books on raising children and who lectures extensively around the country. "But why does it work, and what are the consequences of overprescribing? The reality is we don't know."

For parents, even harder than the abstract social questions are the very personal ones they confront when they see or hear that their child is struggling. Will Ritalin help? Will it change her personality? Is it fair for me to make this choice for him? Does it send the signal that she is not responsible for her behavior? Is the teacher suggesting it just to make her own day easier? Will he have to take it forever? What if all children would be a little happier, perform a little better if they took their pills like vitamins every morning? Do we have a problem with that?

Given all the debate about how to diagnose ADHD and how to treat it (and the same for its related condition, attention-deficit disorder, or ADD), experts in the field believed it was time to convene a kind of science court to sort through the evidence and arguments on all sides. So last week in Bethesda, Md., several hundred doctors, experts and educators gathered for a long-awaited consensus conference held by the National Institutes of Health to examine the data on how well Ritalin works. Conclusion: very well--better than researchers imagined--but in ways and for reasons that are still not entirely clear (see box).

And yet the real consensus that emerged was how much we still need to learn. The experts warned that not enough is known about the risks and benefits of long-term Ritalin use; that there is too little communication between doctors, teachers and parents; and that a pill alone is no magic bullet. Some combination of behavioral therapy and medication seems to be most helpful for children with the severest problems, but there is no data to determine what combinations work best.