As the school year opens, the benefits and possible overuse and abuse of methyphenidate and other prescription drugs for attention-deficit hyperactivity disorder are being discussed.
By JUDY SIEGEL-ITZKOVICHPills(photo credit: INGIMAGE / ASAP)‘The world is too much with us,” wrote William Wordsworth at the beginning of the 19th century, criticizing the world for the materialism of the first Industrial Revolution. What would the English Romantic poet have thought of today, with its infatuation with cellphones, Facebook and all things digital, that require constant multitasking? Such 21st-century demands on children and adults are apparently one explanation for the significant rise in diagnoses of attention-deficit hyperactivity disorder (ADHD) here and around the world. Other reasons include improved diagnosis and the availability in the basket of health services of (usually) safe prescription drugs to alleviate the problem. These join the genetic factor, as ADHD tends to run in families.ADHD is recognized by the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) as a neurodevelopmental psychiatric disorder in which the child or adult suffers from difficulty paying attention, is hyperactive or restless as well as impulsive. For the diagnosis to be made, the symptoms must begin between age six to 12 and persist for at least six months. It is up to three times more common in boys than girls.The condition affects between six percent and 10% of children in the lower grades of elementary school and decreases to about 4% in adults, according to Dr. Hadar Yardeni, a pediatrician and newly appointed head of the Health Ministry’s department for child development and rehabilitation. Teens and adults tend to develop skills for coping (or hire a good secretary to organize things for them) to compensate for their disability.The condition, whose causes are unproven but which are believed to involve interactions between genetic and environmental factors, is usually managed with cognitive and psychological counseling, prescription medications (especially methylphenidate, best known by one of its commercial names, Ritalin) and lifestyle medications.Parents of ADHD children are encouraged to undergo training to be integral parts of the professional treatment team. Counterintuitively, methylphenidate is a stimulant, but it nevertheless helps control overstimulation and hyperactivity.There are a variety of forms of the condition, some with hyperactivity and some without. Sufferers with attention deficits may be forgetful, easily distracted, have difficulty focusing on one task at a time, get bored easily, miss details, daydream, seem not to pay attention when addressed by others and struggle to follow instructions.Those who also are hyperactive may speak incessantly, constantly be in motion, squirm in their seats and have trouble doing things quietly; these symptoms tend to ease up, turn into restlessness or disappear. Most ADHD suffers also have problems interacting in social settings and forging friendships, thus children tend to be rejected socially by their peers.As if this were not enough, various other problems such as learning disabilities – dyslexia (difficulty learning to read), dyscalculia (problems with math) and various developmental speech and language disorders and academic skills disorders – frequently go together with ADHD, even though this phenomenon does not occur in many cases. As learning disabilities occur in about 15% of children, they are much more common than attention- deficit problems.ADHD TREATMENT, which received an impetus in the 1970s, remains controversial.Some claim the disorder is highly overdiagnosed and overtreated, while others say this is a “myth” caused partly by increased awareness and greater numbers of medical experts trained in the field.
Yardeni is among those who believes there is over-medication.“In 2012, over 700 kg of Ritalin [the most commonly sold methylphenidate drug] were sold in Israel, compared with around 400 kg in 2011,” she said, citing figures provided by the Anti-Drug Authority.In addition, an anonymous survey conducted of 1,156 university and college students around the country found that 75% admitted to using Ritalin to improve their academic achievements. Fourteen percent obtained legal prescriptions from their doctors, 51% got the drug from a friend who had his own prescription and 24% received pills from another person on campus.Yardeni continued that the active ingredient in Ritalin can be injected and even ingested nasally to create a “high” in people who don’t suffer from ADHD.“Our department conducted a check of pregnant women who contacted experts to find out if they could safely take Ritalin in the form of Concerta, which is a slow-delivery form of methylpheidate, and the requests increased tenfold since 1994. This is much more than the increase in pregnant women since then,” said Yardeni.The ministry professional believes that the best way of overcoming what she sees as overdiagnosis and overuse of the ADHD drug is teaching more doctors – pediatricians and general practitioners as well as neurologists and psychiatrists – about the condition.“We have 262 graduates of our six-session course at Sheba Medical Center, and now we have done three such courses,” said Yardeni. “They have to undergo an exam at the end.We will open three more such courses, and it will greatly increase knowledge of ADHD.”In some schools, there is a program for teachers to identify children at risk of ADHD and refer them for help.Although methylphenidate in its various forms and most other – but not all – ADHD drugs are included in the basket of health services supplied by the health funds, the costs of diagnosis is not. In children, the disorder is diagnosed only by a developmental pediatrician, psychiatrists or pediatric neurologists, but the prescription is renewed (often for years) by pediatricians or general practitioners. In adults, prescriptions may initially be given by general practitioners. The four public health funds are responsible for supervision, Yardeni said.“We do not reject Ritalin,” she continued.“There are some children and adults who have been saved by the drug. But there are others who use it out of social pressure or because they think it will improve their test performance.”Dr. Eyal Schwartzberg, the ministry’s chief pharmacist, said that though it isn’t really dangerous, methylphenidate is considered a “dangerous drug” so that the health authorities can better control its use.“A prescription is given for one month at a time, not three months.There is a daily maximum dose. We monitor side effects. The ministry’s unit against pharmaceutical crime is always on the lookout for counterfeit supplies,” he noted. “But it could be there is abuse.”PROF. AVINOAM Reches, the head of the Israel Medical Association’s ethics bureau and himself a senior neurologist (for adults) at Hadassah University Medical Center in Jerusalem’s Ein Kerem, told The Jerusalem Post the bureau held a special discussion two years ago on the philosophical and medical use of drugs for ADHD.“Some people believe that all kinds of drugs are acceptable for cognitive enhancement, but that one is not allowed to give amphetamines to sportsmen to succeed in the Tour de France bicycle race. There are anti-fatigue agents to help people cope with emergencies, or in flight simulators, and nobody objects to this. But one is not allowed to give drugs to those in competitive bicycle races,” said Reches.Although some pediatric neurologists the Post spoke to maintained that the ethics bureau made it possible for any adult to ask for Ritalin for himself, the Hadassah neurologist said this was “a misunderstanding, caused partly by the media. Our discussion made a big splash for a few days, and then it was forgotten. In fact, we didn’t even mention Ritalin by name in our discussion. We set down numerous checks and balances, and not every adult could get it just by asking his doctor. There has to be a clear medical indication for it. He has to weigh the benefits against the risks.”He recalls that after the media hype, he received a lot of nasty emails and letters.Although he does not treat children, Reches believes there is overuse.“When I went to school, overactive kids were called shovavim [disruptive]. Today, their parents and teachers want them to take Ritalin.”But Dr. Lidia Gabis, a senior pediatric neurologist and director of the Weinberg Child Development Center at Sheba Medical Center in Tel Hashomer, disagrees.“I don’t think there is abuse or misuse. It may be a myth coming from the US, but even there I don’t think there is a lot of it.”Gabis was also under the impression, denied by Reches, that any adult could walk into his general practitioner’s office and demand Ritalin.“I have dealt with ADHD in Israel for 12 years and for 17 years in New York,” said Gabis, who studied pediatrics here.“There are some differences between Ritalin use here and in the US. In the US, parents give their children the drug daily, including on weekends and vacations. But here, many parents decide not to do this, but only when they are in school. They worry about appetite problems.”She thinks the increased number of people diagnosed with ADHD results from “our technological world. Children and adults have to do things they never had to face decades ago, so it’s harder for those who can’t manage.In addition, there are crowded schoolrooms and a much larger amount of information to absorb.”Studies have shown that toddlers exposed to TV and computers before the age of two are more likely to develop ADHD. But she is even more worried about the increase in prevalence of autism, which she also studies. She encourages parents and teachers to teach children simple things and not to give several tasks at once. Assignments must be clearly assigned, predictable and repeated.Tel Aviv University, Sheba and University of Haifa researchers recently claimed that they had developed a “foolproof” tool for diagnosis of ADHD by performing tests involving involuntary eye movements. They maintained that until their discovery, there were no reliable physiological markers to diagnose ADHD. Instead, doctors generally diagnosed the disorder by recording a medical and social history of the patient and the family, discussing possible symptoms and observing the patient’s behavior.But the researchers said their eye-tracking, reported in the journal Vision Research, both objectively picked out ADHD patients and determined whether ADHD medication really worked. Gabis, who was familiar with the study, said it was “only a marker but not a foolproof way of diagnosing ADHD.”It was unfortunate, Gabis said, that both diagnosis of ADHD and cognitive and psychological treatments – even occupational therapy – have to be paid for by parents or are covered by well-off municipalities. Naturally, higher socioeconomic groups get care, while the poor are much less likely to get it.“It is not available to all, yet more accessible in special-education schools. But most who have ADHD are in regular schools. Learning disorders can be mistaken for ADHD. If children are not properly diagnosed, they may get unsuitable treatment.”Dr. Adi Aran, an ADHD expert and pediatric neurologist at Jerusalem’s Shaare Zedek Medical Center, said that while ADHD occurs at similar rates around the world, he thought that medication was somewhat more in demand in ultra-Orthodox (haredi) sector.“There, small boys aged as young as three years learn to read and study Torah. Maybe some of them are not ripe for it, and excelling in this is [considered] very, very important. So if any child doesn’t keep up, parents may think he needs Ritalin. Use is acceptable among [this community]. Ritalin is usually not given under the age of six, but a qualified professional can if there is a good reason.”“Neurofeedback, which is somewhat similar to biofeedback and very expensive, can help. Various natural remedies, except perhaps omega 3, have not been proven,” added Aran.Aran believes that some environmental chemicals, such as organophosphates, may contribute to the development of ADHD, along with food coloring and additives.The SZMC specialist agrees with Gabis that alleged overuse and abuse “are mostly rumors, at least in Israel. Multitasking and other complex demands on children today are involved, as well as genetics. Not everyone with ADHD needs treatment.”While he says today there is better awareness among parents and better treatment by professionals, he thinks that there is underdiagnosis among the Arab sector because of low awareness and generally lower socioeconomic status.“There may even be a genetic cause,” he adds, “because of inbreeding among first cousins.”If Aran were in charge in the Health Ministry, he would see to it that ADHD diagnosis was covered by the health funds – or at least there could be subsidization for lower socioeconomic groups.
