The Inaccurate Diagnosis of ADD/ADHD and the Pros of Ritalin
Anthony Masi, Jr.
Attention Deficit Disorder/Attention Deficit Hyperactivity Disorder (ADD/ADHD) is a developmental disorder characterized primarily by difficulty controlling behavior and paying attention. According to the National Institute of Mental Health (NIMH), ADD and ADHD are characterized by the key behaviors of “inattention, hyperactivity, and impulsivity” (“Attention Deficit Hyperactivity Disorder”, n.d., para. 4). Methylphenidate, more commonly known by its brand name, Ritalin, has emerged as the primary treatment option for ADD/ADHD through its suppression of these key behaviors. Multiple studies corroborate this theory that Ritalin is in fact the best option for children diagnosed with either ADD or ADHD. However, there is evidence to suggest that even with such a well-researched pharmaceutical option at doctors’ disposal, ADD/ADHD is underdiagnosed and therefore under-prescribed worldwide amongst not only children, but adolescents and adults as well. Not only is Ritalin useful in treating the key behaviors of ADD/ADHD, it is the best option available for a disorder widely underdiagnosed among the general population.
ADD/ADHD’s key behaviors of inattention, hyperactivity, and impulsivity are represented by symptoms that manifest themselves most prominently in the classroom. Symptoms of inattention include difficulty listening, daydreaming, careless mistakes, difficulty staying focused, and disregard for detail (DeRuvo, 2009, p. 20). Symptoms of hyperactivity comprise of fidgeting, nonstop talking, and difficulty completing tasks or activities quietly (“Attention Deficit Hyperactivity Disorder”, n.d., para. 5). The key behavior of impulsivity is represented by a lack of regard for directions, taking shortcuts, and working carelessly (DeRuvo, 2009, p. 20). Together, all of these symptoms make it much more difficult for a teacher to keep control of a classroom if they are present during childhood as they impair a child’s ability to perform in an educational setting. This may result in subpar academic performance and also cause the student to serve as a distraction to his classmates. Left unchecked and untreated by a daily dosage of Ritalin, ADD/ADHD has potential to both complicate life at home and in the workplace in the future.
Ritalin has achieved such a high level of popularity among medical professionals due to its high level of effectiveness in treating those diagnosed with ADD/ADHD. One study conducted by psychologists William Pelham, Betsy Hoza, Elizabeth Gnagy, Heidi Kipp, Andrew Greiner, Daniel Waschbusch, and Sarah Trane (2002), testing the effects of Ritalin and its benefits in regard to behavior, academic performance, and attributions in a classroom setting found that Ritalin improved the percentage of 136 students following activity rules (80.7% vs. 69.4% placebo), reduced the percentage of students accused of noncompliance (1.0% vs. 3.1% placebo), interruption (2.9% vs. 8.6% placebo), complaining (1.5% vs. 4.9% placebo), and misconduct (0.3% vs. 1.4% placebo). The percentage of students reprimanded via negative verbalizations dropped from 14.3% when treated with a placebo to 2.9% when treated with Ritalin (Pelham et al., 2002). The percentage of students following classroom rules rose from 75.2% when treated with a placebo to a staggering 95.2% (Pelham et al., 2002). In addition to this, both the percentage of seatwork completion and accuracy rose from 67.5% when treated with a placebo to 84.8% when treated with Ritalin and 87.0% when treated with a placebo to 92.0% when treated with Ritalin, respectively (Pelham et al., 2002). This study consisted of a placebo-based design where after a 2 week medication-free time period, each child received either a placebo or 0.3mg Ritalin/kg of body weight dosage four days a week for six weeks. The students were told whether they received a real pill or a placebo at random, with four possible drug expectancy conditions of “received placebo, told real pill”, “received Ritalin, told fake pill”, “received Ritalin, told real pill”, and “received placebo, told fake pill”. Through this experiment, William Pelham and his associates found that Ritalin was the catalyst for improvement in almost every measurable category related to ADD/ADHD in the classroom.
In addition to behavioral improvements, Ritalin has been proven to increase mathematical performance in children. This study, conducted in 2013 by Natalie Grizenko, Emmy Cai, Claude Jolicoeur, Mariam Ter-Stepanian, and Ridha Joober tested the effects of Ritalin on 198 school aged children between the ages of six and twelve years old. Tests showed that children with ADD/ADHD displayed improvement in their mathematical performance when treated with methylphenidate/Ritalin compared to when the children were treated with a placebo. When treated with Ritalin, children not only answered 16.5 more mathematical problems than with a placebo, but answered 15.6 more problems correctly as well (see Appendix for a table showing the full results of this study) (Grizenko et al., 2013). Children were also tested on the Restricted Academic Situation Scale (RASS), which is an observational tool used to assess motor activity and orientation to assigned tasks in children. This test consists of an evaluator sitting in an observation room and marking off any inappropriate behavior such as fidgeting, playing with objects, and speaking out of turn (Grizenko et al., 2013). Children diagnosed with ADD/ADHD received either one week of 0.5mg Ritalin/kg body weight in a twice-daily dose followed by a week of placebo treatment or vice versa. These capsules were prepared in identical capsules and the children were not notified of what pill they were receiving. Students then were evaluated using the RASS before their morning dosage and reevaluated one hour after it while being asked to complete math problems during both of these examinations. Natalie Grizenko notes in her study that she found a strong correlation between higher RASS scores and math improvement on methylphenidate/Ritalin and that patients are more likely to improve their mathematics scores if there is a great improvement on the total RASS score. According to the study, these findings are of considerable importance because the RASS is a short, concise 15-minute observational exam that is strongly correlated with mathematical improvement (Grizenko et al., 2013). This indicates to psychologists that behavioral improvement during the RASS is likely to anticipate noteworthy mathematical development in children diagnosed with ADD/ADHD. Not only does Ritalin significantly suppress the behavioral symptoms of ADD/ADHD in children, it improves their academic performance in the classroom as well.
With Ritalin looking to treat hyperactivity in children, you would assume that one of its side effects would include sedation. However, Ritalin has also been proven to improve reaction time in children, in addition to its other benefits. In a study conducted by J.J. van der Meere, R.S. Shalev, N. Borger, and J.R. Wiersema (2009), children diagnosed with ADHD were introduced to Ritalin over a two week schedule. After four weeks on Ritalin, children were given a reaction test twice, once after the administration of Ritalin and once after the administration of a placebo. The children were placed in front of a screen and required to press either “Go” or “No-Go” in response to a stimulus as quickly as possible. After a practice period, the children’s results were recorded. The results indicated that children responded faster and more accurately on a long interstimulus interval (ISI) of eight seconds (540ms response time/35% inaccuracy) than when administered a placebo (680ms response time/45% inaccuracy) (van der Meere et al., 2009). Children also responded faster on an ISI of four seconds as well (460ms) compared to their response time when administered a placebo (500ms) (van der Meere et al., 2009).
Not only is Ritalin extremely effective in treating the symptoms of ADD/ADHD, it is the best option available for treatment. Jaswinder K. Ghuman is quoted in the Brown University Child & Adolescent Behavior Letter (2009) as stating that after an “exhaustive review of four decades’ worth of research (1967-2007)”, Ritalin is more effective than any other medication, professional psychological intervention, social intervention, or alternative remedy in treating young children. Among 20 out of 24 published studies on the use of medication in treating ADHD, they all found that Ritalin was the only form of treatment deemed “Level A” evidence. Level A evidence implies that a form of treatment has denoted a significant difference on an ADHD outcome variable in at least two randomized controlled trials or in two designed experiments comparing the evidence to alternatives or a placebo (“Pharmacological and behavioral treatments for ADHD in preschoolers”, 2009). Two psychological/social interventions and one alternative treatment were rated as “Level B” evidence, implying that the treatments trigger a noticeable difference on an ADHD outcome variable in preschoolers in either one randomized controlled trial, two or more of these trials with mixed results, or one series of designed experiments comparing the evidence to alternatives or a placebo. These three “Level B” alternative treatments were parent behavior training, child training, and an additive-free elimination diet (“Pharmacological and behavioral treatments for ADHD in preschoolers”, 2009). Ritalin being designed “Level A” evidence in the treatment of ADD/ADHD signifies that alternative remedies are best used in conjunction with Ritalin as a treatment for the disorder and not as direct alternatives for Ritalin.
In addition to Ritalin being the best option for the treatment of ADD/ADHD in children, it is also the best form of treatment for the disorder in adults (Peterson & McDonagh, 2008). In a comparison of twenty-two placebo-controlled trials, the benefit of immediate release methylphenidate was also found to be 3.26 times greater than for those taking longer-acting stimulants, and 2.24 times larger than for patients taking long-acting forms of bupropion (Peterson & McDonagh, 2008). Immediate release methylphenidate was found to be the only drug able to reduce ADD/ADHD symptoms in adults facing substance abuse problems (Peterson & McDonagh, 2008). 59% of the overall patient population of these studies was male, with a mean age of 38 years old and treatment was double-blinded in all of the trials. The results of these twenty-two trials further support the hypothesis that Ritalin is the best form of treatment for ADD/ADHD, young and old alike.
With ADD/ADHD being so underdiagnosed, it is hard for children and adults to get the Ritalin they need. If a diagnosis is missed while the patient is a child, there’s a great chance that it may go undiagnosed for the rest of the patient’s life. Some medical professionals continue to “express fear about treating a ‘non-existent disease’ or causing drug addiction with stimulant medication” due to the stigma of ADD/ADHD being exclusively tied to children when attempting diagnosis in adults (Kooij et al., 2010). Kooij further goes on to describe stimulants such as Ritalin as the most thoroughly studied and effective treatment for ADD/ADHD across the patient’s lifespan. Studies of families, twins, and adoptions have demonstrated that ADHD is a familial disorder with a strong risk of being passed down, which implies an inevitable growth in diagnosis of the disorder (Kooij et al, 2010). According to Kooij, ADD/ADHD is commonly ignored in favor of diagnosis of other disorders such as anxiety, bipolar disorder, major depression, and personality disorder due to very similar symptoms. Comorbid substance use disorder (SUD) is considered a disease with a major population of patients that remain undiagnosed with ADD/ADHD, due to similar symptoms between the two. Twenty five published studies that screen for substance abuse in ADHD samples estimate that substance abuse was prevalent in 45% to 55% of cases, some in cases of self-medication (Kooij et al, 2010). On the other hand, ten studies that screen for undiagnosed ADD/ADHD in those diagnosed with SUD found that 11% to 54% of this population showed signs of the undiagnosed disorder (Kooij et al, 2010). As you can see, the lines are very easily blurred between ADD/ADHD and other disorders, which profoundly impacts the course of treatment taken.
When not mistaken for another disease or illness, it’s been found that ADD/ADHD is still underdiagnosed in children due to irregular treatment caused by poverty and insurance issues. According to Dr. Tanya E. Froehlich, a developmental-behavioral pediatrician at Cincinnati Children’s Medical Center, nearly 9% of children in the U.S. have ADD/ADHD but only 32% of them are receiving the treatment necessary to suppress the disorder (Reinberg, 2007). According to Froehlich and her colleagues, 2.4 million children between the ages of 8 and 15 meet the medical standards of an ADHD diagnosis but 1.2 million of them have not been officially diagnosed or administered any kind of treatment (Reinberg, 2007). Poverty is a factor in this case, as children from poor families are less likely to have any kind of consistent treatment due to money and insurance issues. After collecting data on 3,082 children who participated in their National Health and Nutrition Examination survey, conducting interviews, and collecting data from doctors the researchers found that of the 8.7% of children meeting the clinical definition of ADD/ADHD, only 47.9% were diagnosed with the disorder and only 32% were treating consistently with any form of medication (Reinberg, 2007). With such a low rate of diagnosis in eligible children and common misdiagnosis among adults, ADD/ADHD is clearly underdiagnosed amongst the general population.
ADD/ADHD is a disorder affecting many more people than are receiving treatment for it. Even among the men, women, and children diagnosed with ADD/ADHD, only a fraction of them are receiving the best form of treatment available, methylphenidate, also known by its brand name Ritalin. With so many of the symptoms of ADD/ADHD suppressed through the administration of Ritalin, along with the academic benefits it reaps in both children and adults, both parents and doctors should be prescribing it as the primary treatment for the disorder, using alternative treatments only in conjunction with it or not at all. Through a more thorough screening process of the disorder and the proper administration of Ritalin following diagnosis, the negative symptoms of ADD/ADHD can be suppressed in far more people in dire need of treatment worldwide.
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