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April 20, 2000     Beverly Hills Weekly
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April 20, 2000
 

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opinionn comn-00entary E RING The public opinion forum where Beverly Hills dukes out the issues IS RITALIN OVERPRESCRIBED TO OUR CHILDREN? PRO Walter E. Jacobson, M.D. "Is Ritalin overprescribed?" Perhaps we should be asking: "Is the brain illness for which Ritalin is being prescribed -- Attention Deficit/Hyperactivity Disorder (ADHD) -- overdiagnosed?" I believe it is. I believe that more children are diagnosed as having ADHD (and treatment is begun, often with Ritalin) than actually have it. The fact that a child is disruptive, can't sit still, is impulsive, can't pay attention, can't complete tasks (common symptoms of ADHD), does not mean that the child has ADHD. These same symptoms can be seen in a number of other disorders in which the treat- ment is not a stimulant medication such as Ritalin. The child might actually be exhibiting age appropriate behaviors in active children. The child might be "acting out" in an attempt to get attention. The child might have a learning disability, Oppositionai Defiant Disorder, Conduct Disorder, Pervasive Developmental Disorder, depression, anxiety, a bipolar dis- order (Manic-Depression), or a psychotic disorder, among others. Tim point is, physicians making the diagnosis of ADHD need to be aware of all the other possibilities described above. I don't believe this is presently the case. I believe ADHD is misdiagnosed not infrequently, and therefore Ritalin, which is one of the more prevalent treatments for ADHD, is overprescribed. Assuming we've got a child who has been correctly diagnosed as having ADHD, "Is Ritalin overprescribed?" Again, I believe it is. Although Ritalin is an appropriate and effective treatment of ADHD, it is not the only treatment and it is not without side effects. Before a physician decides to use medication as a treatment, he/she should first consider if non-medication treatments could be utilized instead. In many cases, because the behavioral dyscontrol of the ADHD child is so intense and disruptive to caregivers, teachers and other children, Ritalin is start- ed immediately and the non-medication modalities are not (or are insufficient- ly) utilized. I suspect there are also a number of cases where the behavioral dyscontrol is not all that severe, but it is annoying and disruptive enough that frustrated caregivers, teachers, and relatives "diagnose" ADHD and then vigor- ously lobby for Ritalin, putting pressure on physicians to prescribe it. One could make a case that Ritalin is overprescribed because there are non- stimulant medications, which have been shown to be effective in some cases, that do not share the side effect potentials of the stimulants like Ritalin. This is a judgment call that the caretakers need to make after being adequately informed by their physician of the risks, benefits, side effects and alternatives of Ritalin. Because Ritalin is so well-known, if the caregivers aren't adequately informed of all options in the treatment of ADHD (which I suspect is often the case), then the overprescription of Ritalin is a likely scenario. Dr Jacobson is a psychiatrist who practices in Beverly Hills. If you 00ave an idea for "The Ring", call 310,688,6761 CON Alireza Pakkar, M.D. There is no doubt that we live in the era of sophisti- cated technology, high-speed, and stressful social inter- personal, spatial and time constrictions. A lot of us wake up in the morning and drive to work in the traffic as fast as we can. There is a rush to work through the tasks, meet the dead-lines in almost all fields, and more stress- ful of all, to keep everyone satired. The day goes by and in the evening, we go home exhausted. Suppose that we, as parents, care takers or teachers are faced with another stressful situation on top of all that: having kids who seem unable to listen, fol- low directions, recognize and follow through on instructions and tasks. Kids who have a 'motor' inside and are constantly on the go, and knowingly or unknow- ingly do not fit in social, interpersonal or physical boundaries. Often we do not have to be rocket scientists to figure out that our child is hav- ing a problem with hyperactivity, inattention, impulsivity, or all of the above. We wonder "is it normal for my kid to behave this way and if not, what is really wrong with him or with his environment and what can be done about it". Then we get a call from the school, the psychologist, the social worker, the primary careqhysician, or others that "your kid has a short attention span, is acting up, etc. and may be suffering from ADD (Attention Deficit Hyperactivity Disorder or ADHD to be more specific)". Then ampsychological test or a very short and limited psychiatric assessment establishes the so-called 'diagnosis' of ADHD and most of the time such 'diagnosed' patients are recommended to take medications. However, parents and specialists alike, oftendo not realize that current psy- chiatric diagnostic criteria and psychological tests are only descriptive tools that ascertain the presence of certain signs and symptoms, and usually do not provide us with 'etiology' or 'cause' of the problem. In other words, many different envi- ronmental (social, interpersonal, physical, biological, etc.) as well as many dif- ferent internal (mainly biological) processes may solely or together (as usually is the case) lead to affirmative result on descriptive assessment tools, each which must be determined and treated accordingly, a fact that is so often ignored. To make a long story short, each entry mentioned above (and the ones not mentions in this article) must be determined individually as well as in combina- tion with other factors to have a clear picture of the problem an individual, his family and the society at large, is facing and treatment should  directed at each of those elements accordingly. At the time of writing this article, millions of children in the U.S. are diag- nosed with ADHD and are given stimulant, medications (e.g. Ritalin). But because only individuals with specific structural and functional alterations in the brain, either internally, or as a result of interaction with external factors may truly benefit from ADHD medications and because the side-effect profile of such pharmacological agents such as stimulants (that precludes their liberal use), there may have been a trend toward over-prescription of such agents. Large-scale sci- entific studies are needed to explore this possibility, I believe any individual who seems to be suffering from ADHD should be referred to a physician who is able and willing to perform an in-depth evaluation and to see the child, adult, or family in therapy at least for a while and to offer other treatments including medications in the context of such a comprehensive evaluation and therapy only. Dr. Pakkar is a phys&ian specializing in psychiatry and psychotherapy. April 20-26, 2000 ,, 5