Ritalin & ADHD Basics
I. Attention Deficit Hyperactivity
What is ADHD?
Attention Deficit Hyperactivity Disorder is a behavioral disorder marked
by severe inattentiveness, impulsivity, and hyperactivity, which usually
emerge in early childhood. A great deal of controversy surrounds the
disorder because there is no known biological marker for it and critics say
the diagnostic criteria are very subjective. While such symptoms have
historically been observed and treated in children for many decades, the
condition was only added to the Diagnostic and Statistic Manual of Mental
Disorders in 1980.
How many children have ADHD?
It is estimated that between four and ten percent of all school age
children currently suffer from Attention Deficit-Hyperactivity Disorder,
commonly referred to as hyperactivity. (American Psychiatric Association,
Diagnostic and Statistical Manual of Mental Disorders 50 (3d ed. rev. 1987))
II. Psycho-stimulant Medications
What are psycho-stimulants?
Psycho-stimulants are a class of
drugs that stimulate the central nervous system. They include drugs such
as: Adderall®, Adipex-P®,
amphetamine, amphetamine / dextroamphetamine, Banobese, Benzadrine,
benzphetamine, Biphetamine®, chlorphentermine, cocaine, Cylert, Delcobese,
Desoxyn®, Dexedrine, dexmethylphenidate, dextroamphetamine, DextroStat,
Didrex, diethylpropion, Fastin®, fenfluramine, Focalin™, Ionamin, mazindol,
Mediatric, methamphetamine, Methylin™, methylphenidate, Obenix, Oby-Cap, Oby-Trim,
paramethoxyamphetamine, pemoline, phendimetrazine, phenmetrazine,
phentermine, PMA, Pondimin®, Ritalin®, Tenuate, Tepanil, Zantryl.
What psycho-stimulants are used
to treat ADHD?
Methylphenidate (sold under the
brand name Ritalin®, among others) and amphetamine (sold under the brand
name Adderall, among others) are two of the primary central nervous system
stimulants used to treat Attention Deficit Hyperactivity Disorder.
How are these drugs taken?
Ritalin, a brand of methylphenidate approved for use in patients aged six
years and older, is taken orally. Tablets are available in 5, 10, and 20
mgs. A 20 mg extended-release tablet (Ritalin-SR), is also available.
In addition, methylphenidate is also the active ingredient of the new
medication Concerta. Concerta uses osmotic pressure to provide even release
of the medication over a 12-hour period.
III. ADHD Diagnosis
How is ADHD diagnosed?
Current physician guidelines recommend that diagnosis should begin with
thorough input from a child’s parents. The goal is to establish, in detail,
under what circumstances the presenting symptoms occur and to take a
complete developmental, medical, and family history. Following these
interviews, the clinician should ideally interview the child in order to
elicit his or her input.
thorough medical examination is then used to rule out neurological or
sensory problems (poor hearing or eyesight, for example) as the cause of
symptoms. Intelligence and achievement tests are then given, and the
clinician will also evaluate questionnaires filled out by both parents and
teachers. These questionnaires ask the respondent to indicate the degree to
which the child displays the patterns of behavior that are considered
markers for ADHD. Further tests may be required to rule out possible
problems that emerge during this lengthy examination. (See, Dennis P.
Cantwell, M.D., in a recent review of the last decade of research on ADHD
for the August 1996 issue of the Journal of the American Academy of Child
and Adolescent Psychiatry)
What are the Diagnostic Criteria
for Attention-Deficit/Hyperactivity Disorder?
According to the American Psychiatric
Association (Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition, Washington, D.C.: American Psychiatric Association,
2000, pp. 92-93), a diagnosis of ADHD is appropriate if a patient exhibits
the following diagnostic symptoms:
(A) Either (1) or (2):
(1) six (or more) of the following symptoms of
inattention have persisted for at least 6 months to a degree that is
maladaptive and inconsistent with developmental level;
- often fails to give close attention to details or makes careless
mistakes in schoolwork, work, or other activities
- often has difficulty sustaining attention in tasks or play activities
- often does not seem to listen when spoken to directly
- often does not follow through on instructions and fails to finish
schoolwork, chores, or duties in the workplace (not due to oppositional
behavior or failure to understand instructions)
- often has difficulty organizing tasks and activities
- often avoids, dislikes, or is reluctant to engage in tasks that
require sustained mental effort (such as schoolwork or homework)
- often loses things necessary for tasks or activities (e.g., toys,
school assignments, pencils, books, or tools)
- is often easily distracted by extraneous stimuli
- is often forgetful in daily activities
(2) six (or more) of the following symptoms of
hyperactivity-impulsivity have persisted for at least 6 months to a
degree that is maladaptive and inconsistent with developmental level:
- often fidgets with hands or feet or squirms in seat
- often leaves seat in classroom or in other situations in which
remaining seated is expected
- often runs about or climbs excessively in situations in which it is
inappropriate (in adolescents or adults, may be limited to subjective
feelings of restlessness)
- often has difficulty playing or engaging in leisure activities quietly
- is often "on the go" or often acts as if "driven by a motor"
- often talks excessively
- often blurts out answers before questions have been completed
- often has difficulty awaiting turn
- often interrupts or intrudes on others (e.g., butts into conversations
(B) Some hyperactive-impulsive or inattentive
symptoms that caused impairment were present before age 7 years.
(C) Some impairment from the symptoms is
present in two or more settings (e.g., at school [or work] and at home).
(D) There must be clear evidence of clinically
significant impairment in social, academic, or occupational functioning.
(E) The symptoms do not occur exclusively during the course of a
Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder
and are not better accounted for by another mental disorder (e.g., Mood
Disorder, Anxiety Disorder, Dissociative Disorder, or Personality Disorder).
Why is the rate of ADHD diagnosis in the United States controversial?
Doctors do not always follow the recommended guidelines for diagnosing
the disorder. In a recent survey of pediatricians, published in the
Archives of Pediatric and Adolescent Medicine, nearly 50 percent of
doctors confess to spending an hour or less with a child before making a
diagnosis and prescribing medication (usually Methylphenidate).
Current diagnostic criteria may be over-inclusive. Dr. Mark
Wolraich and his colleagues at the Vanderbilt University Child Development
Center applied the criteria for ADHD from both DSM-III-R and DSM-IV to the
same sample of 8,258 children and found that 7.3 percent of them have ADHD
according to DSM-III-R, while almost half again as many, 11.4 percent,
qualify using DSM-IV criteria.
IV Treating ADHD
What causes ADHD?
Advocates of ADHD as a diagnosis, and of stimulant drugs as a treatment
for ADHD, have claimed that ADHD is associated with changes in the brain.
However, both the NIH Consensus Development Conference (1998) and the
American Academy of Pediatrics (2000) report on ADHD state that no
biological marker for ADHD has been found.
Proposed by James McCracken, professor of psychiatry at UCLA, and Steven
Plisz and James Maas, professors of psychiatry at the University of Texas
Health Science Center in San Antonio, the catecholamine hypothesis posits
that persons with ADHD have a catecholamine, or neurotransmitter, imbalance
in the part of the brain that controls attention. They believe that
stimulant drugs such as Ritalin increase the amount of time that certain
catecholamine molecules remain active in certain synapses. (March 1996
issue of the Journal of the American Academy of Child and Adolescent
How does methylphenidate work?
Doctors are still uncertain exactly how methylphenidate works in the
body. Recent research indicates that it affects the balance of Serotonin
working with Dopamine in the brain. (Nora Volkow, et al., Therapeutic Doses
of Oral Methylphenidate Significantly Increase Extra-cellular Dopamine in
the Human Brain, The Journal of Neuroscience,
What side effects are associated with methylphenidate?
The most common side effects are loss of appetite and difficulty sleeping.
Is psycho-stimulant therapy
Seventy percent of ADHD-diagnosed children
respond to psycho-stimulant drugs, most of them to methylphenidate. Another
15% show improvement when given anti-depressant drugs known to affect
catecholamine neurotransmitters. Some children do not respond to any of
these drug therapies. (Ken Livinston, “Ritalin: Miracle Drug or Cop-Out?”
The Public Interest, No. 127 (Spring 1997), pp. 3-18 ©1997 by National
Do I have to put my ADHD-diagnosed child on psycho-stimulants?
No. As a parent or legal guardian, you have the right to make medical
decisions for your child, and your doctor, school personnel, and others must
respect your decision.
How can I decide if psycho-stimulants are right for my child?
The first step is to get an accurate diagnosis by a health care
professional. Discuss your questions about the disorder and all possible
treatments with this professional and come to a decision that is in the best
health interest of your child.
V. Drug Use Rates
The United States uses approximately 90% of the world's
methylphenidate. (Peter R. Breggin M.D. Testimony September 29, 2000
Before the Subcommittee on Oversight and Investigations Committee on
Education and the Workforce U.S. House of Representatives)
A recent report in the Journal of the American Medical Association by
Zito et al. has demonstrated a three-fold increase in the prescription of
stimulants to 2-4 year old toddlers. (Zito, J.M., Safer, D .J., dosReis,
S., Gardner, J.F., Boles, J., and Lynch, F. (2000). Trends in the
prescribing of psychotropic medications to preschoolers. Journal of the
American Medical Association , 283, 1025-1030.)
In 1999, 9.9 million methylphenidate prescriptions were written in the
United States. (Do It Now Foundation, Ritalin: Fast Facts, # 526,
April, 2000. On the web at
8.5 tons of Methylphenidate are produced each year globally.
(United Nations, INCB Report, 1999).