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Article Excerpt
When I was young, a turbulent social movement centring on the possibilities of human flourishing open to women was in full swing. One of the issues feminism raised was the treatment of `suburban neurosis'--the depression that isolated and frustrated housewives experienced--by the routine popping of analgesics and tranquillisers. So commonplace was the taking of such medications that they gained a popular name: `mother's little helper'. The women's movement, rather than accept the `normality' of such medication, framed the whole question of women's dependence on tranquillisers very differently.
Such behaviour, they argued, had meaning. Women's stories--their unheard cries--needed to be told. Doubtless the causes of depression among women were more complex than those early feminist critiques allowed. Yet they caught something important. Psychological distress in those times was telling us something profoundly important about a fundamental problem in women's roles; the way marriage forever foreclosed the world of achievement. In modern parlance, one might say these women were not suffering from a biochemical imbalance in the brain, but a living imbalance.
That approach, of treating the underlying causes, not just medicating the symptoms, left me with a powerful sense of the need to be attentive to the social and economic frame in which psychological distress is occurring. Like another social movement of that time concerned with the institutionalisation and treatment of those with a mental illness, it raised for me the moral dilemmas of patients' autonomy, their control over, or at least input into, the medication they received, and the broader pursuit of social and economic circumstances which might help them to flourish. The fundamental importance of asking the question why there were so many cases of female distress was clear.
Hence, when I first heard of the exponential increase in American children being diagnosed and medicated for Attention Deficit and Hyperactivity Disorder (ADHD), as well as the rising incidence of childhood depression, I felt a sense of unease. On a daily basis American children line up in ordinary primary schools for their dose of Ritalin or other medication for ADHD. The little bottles are neatly labelled with the child's photo and name to ensure that they get the right dose. Sometimes, so many children are on medication they must present in shifts. From 1990 to 1998 the number of American children and adults diagnosed with ADHD, who are now, as the paediatrician Lawrence Diller put it, `running on Ritalin', jumped from about 900,000 to almost 5 million. This resulted in a 700-fold increase in Ritalin production. The numbers of children prescribed Prozac for depression quadrupled in the same period.
Australia has no cause for complacency. There was a similar dramatic rise in prescriptions of antidepressants dispensed through pharmacies over the period 1990-1998; from nearly 5,000 to over 3.5 million for all age groups--a 700-fold increase. Prescriptions for Ritalin jumped from 24,335 to 345,868 while another medication, dexamphetamine, has seen a 24-fold increase. Australian schools also regularly dispense Ritalin to young ADHD children. According to the Sydney Morning Herald one in forty Australian school children is being medicated for an emotional or behavioural problem.
Even more worrying, younger and younger children are being treated with drugs. An Australian survey, reported in May 2002, revealed that 8 per cent of psychiatrists and paediatricians had prescribed the hypertension drug Clonidine (for sleep problems and aggression), while 10 per cent had prescribed Ritalin (for ADHD) to children under three years of age. `Little is known', confessed Royal Children's Hospital paediatrician, Daryl Ephron, `about the long-term effects of some of these medications'. Dr Ephron also said that some parents had given overdoses of Clonidine to their children, with one child being admitted to the intensive care unit. In America, child deaths due to heart failure have been linked to long term use of Ritalin or Dexedrine.
While many doctors accept the existence of some kind of ADHD type condition which may respond to drugs like Ritalin, a wide range of specialists have expressed their concern over the sudden increase in apparent sufferers, the long-term consequences of drug use, the possibility of a manufactured epidemic, the grey area of possible misdiagnosis, the confusion over causation, and the nebulous nature of the symptoms. One of the world's most eminent child psychiatrists, Sir Michael Rutter, has said that for a diagnosis to be useful it must be distinctive from other disorders in its causation, natural progression and treatment. His view is that ADHD, as currently defined, does not satisfy these requirements. One behavioural checklist for self assessment for ADHD, drawn from the best-selling Driven to Distraction for example, was full of questions which ranged from the vague to the ridiculous. `Are you left handed or ambidextrous? Do you drum your fingers a lot, tap your feet, or pace? Do you tune out a lot? Do you love to travel', and even `Are you hyper-sexual?'
Diagnosis also varies sharply from community to community. In the United States it is a largely white and middle to upper middle-class phenomenon. It is often diagnosed among children who are in institutional settings--like schools and daycare centres--where there are strong performance demands. Very few African-American children take Ritalin. In Canada the increase in Ritalin prescriptions seemed to flow closely on the heels of a reduction in spending on special education teachers, psychologists and social workers in the education system, leading some to wonder whether we were now treating behavioural problems with drugs rather than through specialised support staff! In Australia there are wide regional disparities in the rates of children diagnosed with ADHD; a mere 2 per cent in NSW compared with 6 per cent in Western Australia. Unlike the United States experience, diagnosis is more common in low income groups. Prepubescent boys are eight times more likely than girls to be diagnosed as having ADHD. There is no coherent theoretical explanation for such variations based on region, age, gender and social class.
Disturbing too, is the growing schoolyard blackmarket trafficking in Ritalin and other amphetamines. A NSW parliamentary inquiry heard troubling accounts of an Australian playground market for stimulants. Tellingly, in other countries where social and legal restraints have inhibited their use, the booming market in stimulants has not occurred. Also pertinent to ADHD diagnosis is the problem Peter Kramer, author of Listening to Prozac, called `diagnostic bracket creep'--the phenomenon whereby fewer and fewer behavioural problems are required for someone to receive a psychiatric diagnosis and to qualify for medication. In 2002, a national study of behaviour modifying drugs on Australian school children found that twenty five per cent of drugs such as Ritalin and Dexedrine, intended for the treatment of ADHD, were being taken for other conditions that would not be helped by such stimulants.
Most importantly, why have so many children in America, Canada and Australia suddenly been discovered,...
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