April 13, 2000
MEDICATING CHILDREN WITH RITALIN
By: Benjamin H. Hardy, Research Analyst
You asked several questions about the effects of Ritalin on children:
1. Are accounts accurate that recent school shooting incidents all involved children taking Ritalin or a similar drug?
2. How many schoolchildren take Ritalin?
3. Are there any studies of the long-term effects of taking Ritalin?
4. If a student is diagnosed with attention-deficit disorder and a member of the school staff recommends he be given Ritalin, what are the parents' rights?
Despite much press and Internet speculation, there is no reliable information about whether the shooters in several well-known incidents of school violence were taking Ritalin, primarily because in most cases a person's medical history remains privileged even after he is accused of a crime. Although no organization tracks the number of schoolchildren taking Ritalin, estimates of manufacturing volumes and numbers of prescriptions written suggest the number has grown rapidly and may exceed 10 million. There are no long-term studies of Ritalin's effects, but the federal government recently announced plans for a major program to produce them; there are already numerous studies of the short-term effects. If a school official were to suggest that parents obtain a Ritalin prescription for their child, they would have the right to decline to do so.
RITALIN AND ATTENTION-DEFICIT HYPERACTIVITY DISORDER
In recent decades researchers have developed many psychotropic medications to treat mental disorders. Ritalin is the trade name for methylphenidate (often referred to as MPH), one of several varieties of amphetamine used in medicine as stimulants. The most common others are Dexedrine (dextroamphetamine) and Cylert (pemoline).
Ritalin and other stimulants are unusual among psychotropic medications in that they are most often prescribed for children, usually to treat attention-deficit hyperactivity disorder (ADHD). We enclose an excerpt from Mental Health: A Report of the Surgeon General, produced by the federal government's National Institute of Mental Health (NIMH), which describes ADHD and lists the clinical symptoms necessary to establish a diagnosis. In ADHD patients, Ritalin often heightens mental alertness and concentration and calms excessive or impulsive physical activity.
Although the use of stimulants to treat ADHD has been known since 1937, it became controversial in the 1990s. A NIMH information sheet advises parents:
Psychotropic medications may be prescribed for young children with mental, behavioral, or emotional symptoms when the potential benefits of treatment outweigh the risks. Some problems are so severe and persistent that they would have serious negative consequences for the child if untreated, and psychosocial interventions may not always be effective by themselves. The safety and efficacy of most psychotropic medications have not yet been studied in young children.” (“Treatment of Children with Mental Disorders―Questions and Answers,” enclosed.)
For school-age children there is ample information about the short-term effects of Ritalin, but NIMH cautions that its long-term effects remain unstudied.
The risk of addiction from amphetamine use is well known and the Physicians' Desk Reference entry for Ritalin emphasizes the possibility of dependence. The increasing use of Ritalin and other medications to treat children has prompted a considerable public debate, recently intensified in the aftermath of several school shootings by youths who, some have alleged, received treatment with such medications. These concerns appear to have given new impetus to research into the physical, mental, emotional, and social effects of Ritalin and similar drugs on children ranging in age from preschool to late adolescence.
SCHOOL SHOOTINGS AND RITALIN
There is no reliable, documented information on whether the youths who shot classmates and teachers at schools in Jonesboro, Arkansas; Springfield, Oregon; Littleton, Colorado; Conyers, Georgia; and other communities were taking psychotropic medications. A person's medical records normally remain privileged information even when he is accused of a crime. A NIMH official, citing absence of such information, declined comment on the numerous reports circulating via the Internet. Some Internet reports allege that shooters used medications other than stimulants, such as Prozac, which treats depression, or Luvox, which treats obsessive-compulsive disorder. Others, however, speculate that long-term use of stimulants such as Ritalin might induce psychotic reactions, and manic psychosis might manifest itself through violence.
NUMBER OF SCHOOLCHILDREN TAKING RITALIN
There are no specific data on Ritalin consumption by schoolchildren. However, a NIMH booklet, “Medications” (excerpts enclosed) states that “about 15% of the U.S. population below age 18, or over 9 million children, suffer from a psychiatric disorder that compromises their ability to function.” It does not give a figure for stimulants, but adds that “a child with ADHD should take a stimulant medication only on the advice and under the careful supervision of a physician.”
In May 1999, three specialists in pediatric psychopharmacology reported:
Data from diverse sources suggest a steeply rising rate of stimulant-prescribing in the United States over the past decade. Outpatient visits devoted to ADHD have increased from 1.6 to 4.2 million per year during the years 1990 to 1993. During those visits, 90% of the children were given prescriptions, 71% of which were for the stimulant MPH. During the same period, MPH production in the United States increased from 1,784 kg to 5,110 kg. More than 10 million prescriptions for MPH were written in 1996, and epidemiological surveys have estimated that U.S. school-age children's 12-month stimulant prescription prevalence ranges from 6% (urban) to 7% (rural). (“Stimulant Medications,” Journal of the American Academy of Child and Adolescent Psychiatry, v. 38:5, pp. 503-11, enclosed.)
The authors note a substantial increase in the number of studies focusing on use of stimulants to treat ADHD. These report overprescription in some patient populations and underprescription in others. The authors also cite a study finding that many schoolchildren receiving stimulants did not fit the criteria used for diagnosing ADHD.
The use of stimulants to treat increasingly younger children has also become an issue in the medical community. A recent study, “Trends in the Prescribing of Psychotropic Medications to Preschoolers,” published in the February 23, 2000 Journal of the American Medical Association (enclosed), examines psychotropic drug prescription rates for two-to-four-year-old children in three geographically diverse Medicaid programs. The authors found that between 1991 and 1995 the prevalence of Ritalin tripled in two regions and increased by 170% in a third.
STUDIES OF RITALIN'S LONG-TERM EFFECTS
In the context of the growing public controversy over using stimulants to treat ADHD, the authors of “Stimulant Medications” point out that the federal National Institutes of Health (NIH) and the American Medical Association (AMA) disagree on whether there is enough evidence to conclude that the benefits of stimulants in therapy outweigh the risks. (The NIH reserves judgment, while the AMA says individual cases must be monitored closely but the overall results are “highly favorable.”) As the authors note, numerous studies conclude that stimulants do provide short-term relief to many ADHD sufferers. Problems arise because (1) physicians prescribe them “off label,” that is, for conditions other than those for which they have been approved; (2) they prescribe them for very young children even though studies to establish their efficacy and safety for that population are lacking; and (3) the long-term effects of use have not been established through studies.
Efforts to obtain the studies are under way in Connecticut and elsewhere. The General Assembly is currently considering a bill, sSB 5797, that requires the Mental Health and Addiction Services commissioner to study and report to the Public Health committee by December 31, 2000 on the prescribing of psychotropic medications to children. The bill does not mention studying stimulants, but it appears to be worded broadly enough to include them. It also does not mention long-term effects.
At the federal level, NIMH recently extended its Multimodal Treatment Study of Children with ADHD, a multisite, cooperative agreement treatment study of children with ADHD (description enclosed). The study has examined 600 children across the U.S. for 14 months, and will track them into adolescence to document and evaluate long-term outcomes with respect to safety and efficacy of treatments, which include prescription of Ritalin.
On March 20, 2000 the White House announced that NIMH would conduct a new long-term study of Ritalin, Prozac, and other drugs used to medicate children under age six (New York Times, March 20, 2000, copy enclosed). In an interview accompanying the announcement, NIMH Director Steven E. Hyman explained that under the study hundreds of children across the country would receive Ritalin, behavior therapy, or some combination of the two. The White House said the Food and Drug Administration would soon tell drug companies to begin developing dosage information that can be included on labels of Ritalin and other drugs used to treat ADHD and similar disorders in young children.
Guardianship, defined as the authority of a parent or guardian to make major decisions affecting a minor's welfare, including consent regarding major medical, psychiatric, or surgical treatment (CGS § 45a-604(5)), is limited only by the best interests of the child (CGS § 45a-605). According to Mark Stapleton of the State Department of Education, it would be unusual for a school official to suggest that parents consider the use of Ritalin for their child, and they would have the right to decline to do so.