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Ritalin / Ritalout

Recently I had discussion about Ritalin. This is not just about that discussion, but about the topic in general. I am not a doctor (but neither are most of the people making the objections), just some bloke with a computer science degree who tries to take a skeptical and science-based approach to everything. Oh, and I read a lot of sciencey stuff. And health stuff. Definitely a lot of sciencey health stuff. So take this for what it's worth.


There are a few objections to the use of Ritalin I hear/read about a lot, and I think they're all misguided. I think, in the right circumstances and for the right kids, Ritalin and similar drugs can be very beneficial.

Sedative. You keep using that word…

The first objection is based on the fact that many people have a completely inaccurate idea of what Ritalin and similar drugs are. I've often heard from the "alternative medicine" crowd that children on Ritalin are "sedated", "tranquilized", "numbed", or even "anesthetized" by Ritalin. None of these are even remotely accurate descriptions. Ritalin and similar drugs are actually powerful nervous system stimulants, not depressants or sedatives. When given in small(ish) doses, the stimulants act to help the person retain mental focus. From what I can tell, the exact way it does it this under a bit of debate (dopamine, serotonin, blah blah blah), but it in no way acts as a tranquilizer on the nervous systems of children.

So, no, it doesn't "sedate" children. No, it doesn't "numb" them. No, it doesn't "tranquilize" them. No, it doesn't turn them into zombies. No, it doesn't turn into mindless drones or drooling vegetables. And no, South Park, it doesn't make them like Phil Collins (shudder). Any "calming" observed is probably just the result of the enhanced focus: they now have the ability to pay attention for more than a few minutes so they don't act so fidgety.

In short: anyone saying these things is simply using scare words to make it seem a deplorable practice. Even if you disagree with its use, don't outright lie.

Not really a real problem. Really?

The second objection that pops up a lot is the idea that ADD and ADHD are not actual disorders, but just variations in personalities and learning styles. It's simply the way some kids' brains work. These kids' personalities and mental processes are not "deficient", but merely ill-suited for a classroom setting, and simply doing things differently would allow these kids to learn everything the other kids can do. Thought about in this way, using a medication to "treat" their non-existent "disorder" is horrible.

In a way, I agree: it is probably true that many kids are put on Ritalin unnecessarily. It is probably true for many children that some simple lifestyle changes (eg. better diet, no caffeine, less TV time, less video games, more discipline, more personal attention, etc) could reduce the child's "symptoms". It is probably true that Ritalin is over-prescribed and given to kids who don't really need it (but I don't know this for sure: that would be very hard to determine). Perhaps it's even true (though unlikely) that every single child on Ritalin now could function "normally" without Ritalin if they were taught differently or home-schooled.

While I do think those things could be true for many children, I do not think those are true for all children. I really think some kids simply cannot focus on almost anything for more than a short period of time. ( I have myself as an example, but I won't go into that personal anecdote at this time. ) I think there are a lot of kids who, no matter the learning style or environment or diet or whatever other variable, will simply have much more trouble focusing and learning than the majority of kids.

Is this a "disorder", or just a simple difference? I don't think it matters that much.

Variations, graphs, and extremes

People's "mental health variables" – such as intelligence, learning ability, emotional states, anxiety reactions, etc – fall on a range: a bell curve. The majority of people's variables fall within a certain percentage of the average. Some a bit higher, some a bit lower: there is a range, but we usually think of this as "being normal". But when people are too far away from the average, they might begin to experience negative effects, and have a hard time fitting in or dealing with certain situations or life in general.

If we put "the ability to focus mentally" on a graph (the units don't matter), you'll have many people in the middle and fewer people the farther you go to the left and right.

belldisorder

Most people are in the middle and can focus for some length of time, but will have a hard time concentrating if there are lots of distractions around. Some people are exceptionally gifted and can stay focused on a topic for hours and hours without being distracted by even major noise and events around them. And then there are those people who simply can't focus: every little thing can distract them. We don't have to call this a "disorder", but hopefully we can all say it negatively affects them relative to those in the middle. They'll have a much harder time learning in the environments available to them.

If you can't stand the heat, get a maid to cook your food or eat your food raw

This is where the second objection comes in: If the child's personality or "learning style" is not suited for the classroom, take them out and teach them differently, perhaps home-schooling! My objection is three-fold: 1) I disagree that it's always simply a "learning style" difference. 2) I disagree that home/special school is always the best option. 3) This is not always possible, even if it were the best option.

1) From what I've read, and my own personal experience, some children really, actually can't focus on anything for very long, and no matter what "learning style" is used, and they'll have an extremely difficult time learning because of it.

2) I do not believe home-schooling is always the best option: not all parents would make good teachers, for a variety of reasons which should be clear if you watch other parents for a while.

3) For financial and other pragmatic reasons, most people cannot afford to put their kids in a special school or home-school them.

A disorder by any other name…

While it could be true that the affected person is simply not "well suited" for the situation and needs to look for a different way, that is not always possible. For example, I suffer from insomnia. Sometimes it is better and sometimes it is worse, but usually there are several nights a week where I wake up in the night and cannot get back to sleep for 2 hours or more. This can obviously leave me extremely sleepy during the day. Nothing besides a sleep aid has ever worked consistently: Not daily exercise (usually do that), not caffeine-avoidance (I don't drink it after early afternoon, besides, I fall asleep fine), not keeping to a rigid schedule, not waking naturally, not stress-reduction, not anything that I've tried.

Now, it could be that that is not a "disorder" or "condition" but simply how my body works "naturally". I could change my life to take my sleep "disorder" into account so my sleepiness wouldn't happen or matter. The reality of the situation, though, is that I have a full-time job, a house, a wife, and a young kid. These are things which I can't easily change. I can't simply say: "My body's natural rhythms dictate I should work really weird hours so the 'non-disorder' of insomnia doesn't affect me so badly." But I can't just quit my job without massive repercussions: my family needs money. I can't find a magical job that allows me to work 5 hours in the afternoon and then 3 more hours in the middle of the night, leaving my evenings free for interaction with my kid.

So, in this situation, I might consider my insomnia to be a "disorder" which negatively affects my life, and a medical solution - ie taking a sleep aid - is a viable option. In my case, it was, and it did improve my quality of life to some degree. I eventually stopped taking it because it didn't work well enough to compensate for the side effects, but that is beside the point. If my insomnia were slightly worse, I'd probably still be taking it. As it is now, I just deal with the resulting sleepiness as best I can, but others may not have that option.

So, even if you decide not to give it the "disorder" label, insomnia still negatively affects people in ways that are very difficult to counter without medication. It's the same with depression, anxiety, "social phobias", and, yes, ADD/ADHD. Even if they aren't "real disorders", sometimes the best available resolution is a medication.

Necessariness

You can say the medication is not strictly "necessary", but medications for any non-fatal condition aren't either. Sometimes when I do a certain kinds of activities, I end up with mild to moderate back pain. Sometimes when I am in a loud environment for too long, I get headaches. So when the carpet needs vacuumed, things need to be moved, kids need to be played with on the floor, or the office gets loud, I'll just take an aspirin. Technically, I could avoid those environments and activities in favor of environments and activities that "work with" my body, but those activities need to be done, so while taking a pain reliever is the "easy way out", it's also the best option available given the situation.

It is the same with allergies: most of the time a medication is not necessary: you could move to New Mexico and live in the desert, or just deal with the symptoms untreated. Chronic pain? Learn to meditate and suck it up! But medications are available, so we use them instead of completely and randomly changing our lives in the hopes that it resolves our issues.

In the case of a child with ADD, if his or her inability to focus is having large negative effects in relation to the median, and there's a medication that can improve the situation with few side effects, and the alternatives are either infeasible or impossible, why not take it?

"Over-prescribed"

I am not a doctor of any kind, and am not able to speak authoritatively on the matter of whether or not Ritalin is "over-prescribed", but, like most medications, I grant it probably is. However, this doesn't mean it is unnecessary in general.

God's divine plan for you, or the lack thereof

It is usually unspoken, but I think a big part of the objections comes from the idea that our brains are not purely physical: that the "mind" or "spirit" is somehow only loosely connected to the brain. Each person is created by God (or whatever) on purpose, and each person has a "role" or a "place" or some innate abilities that will lead them where they need to be. So surely each person can, using only their minds and bodies (and some religion's rules), live a happy and healthy life? No medications required!

So yeah, I disagree with every part of that. I surely do not understand how our brains work, but why assume there's an unseen spirit or disconnected mind floating around out there somewhere? I see no reason to believe gods exist. I see no reason to think each of us is "supposed" to do anything in particular: we all just seem to be making it up as we go along. For all the world it looks like some people are born smarter than others, some less. And some are born healthier than others, some less. And some are born with a better ability to live life with less depression, less anxiety, and yes, more ability to pay attention than others.

Honestly, I think this is the biggest objection people have: "God made it hard for my little boy to learn? Never!"… I'm mind-reading a bit, but that's my impression.

Conspiracies and scams

Finally, there's the matter of why doctors would prescribe Ritalin if ADD wasn't real or Ritalin didn't solve the problem / made things worse. If you think doctors are simply wrong, or that parents are just lazy and want easy solutions, that's fine. I don't think the doctors are wrong: see above or read some medical papers on the topic. But doctors and medical researchers can be wrong, and often are. And I admit: many parents are lazy, so that is a possibility for explaining any possible "over-prescribed-ness".

However, if you instead claim that ADD/ADHD is a scam put over by the pharmaceutical companies, and all those thousands of doctors are in on it, and the thousands of medical researchers are in on it, and the scientific review boards are in on it, the hospitals are in on it, and the FDA is in on it, and the regulatory agencies in other countries are in on it, and etc etc etc, you are far more cynical than I could ever hope to be, and far more confident than I in the ability of thousands of people, governments, and industries to keep a conspiracy going.

Epilogue

I am not completely satisfied with this article. It leaves many things unsaid and almost everything unreferenced, and it's a bit "unfocused". I may revisit this topic and/or edit this article in the future, so don't be surprised if it changes significantly.

2012-03-05

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