Ritalin on Trial
Steven Keene is a man obsessed. He's also a man who says he can point to the source of his obsession with unusual clarity. It was a fall day in 1994, and the divorced graphic artist had driven to Katy to pick his son up from his ex-wife. At the time, the two parents had shared custody of their then eight-year-old child, and, Keene has said, he had little problem with how his son's mother was carrying out her part of the child-rearing. But on that day, when his son got into the car, the elder Keene noticed a change in his behavior. His tall, blond boy, who sometimes annoyed teachers with his frequent questions, didn't have his usual vitality. Normally, he would be bubbling about spending the long weekend with his dad in The Woodlands. But something was missing, Keene thought as he looked at the boy's face. The spark was gone from his son's green eyes.
The problem, he decided, was Ritalin. It was a drug he'd first heard about a couple of years earlier, when teachers at a private school had suggested that his son, who's also named Steven, might have Attention Deficit-Hyperactivity Disorder, or ADHD. Until 1987, the disorder didn't have that particular name; from 1980 to 1987, it had simply been known as Attention Deficit Disorder, and prior to 1980, it had gone under a variety of labels, including "minimal brain dysfunction" and "hyperkinetic disorder of childhood." But whatever the name, the symptoms were the same: children with the disorder typically can't sit still. They act on impulse, clown and cut up, get into fights, talk back to adults and, most important, can't seem to focus on school work.
Keene couldn't argue that his son didn't have some of the signs of ADHD. The younger Steven had never been an angel. Tall for his age, he'd always tested the limits of discipline. But despite his chronic behavior problems, all he really needed, his father thought, was firmness and discipline. And, he claims, the examinations carried out on his son at the behest of the private school confirmed his opinion -- though they also introduced him to the possibility of treatment with Ritalin. Since the late 1960s, millions of American parents have medicated their children with Ritalin, the brand name of the amphetamine methylphenidate. Though no one knows exactly why, Ritalin seems to calm down many children diagnosed as having ADHD. Some researchers believe that Ritalin might stimulate a portion of the brain that controls attention. And many parents with children so hyperactive that they can't function have come to view Ritalin as a godsend.
But Ritalin, according to others, has also become a drug that's prescribed too cavalierly, being given out not only to children who really need it, but also to children who can be better treated in other ways or, in the worst cases, to children whom adults want to quiet down not for the children's sake, but the adults'. Steven Keene felt his son fell into one of the latter categories. And even though the private school that had suggested his son be tested didn't end up recommending Ritalin, Keene had still taken him out of it, concerned that Ritalin was too popular a treatment there.
That's also why, he says, he sued for full custody of his child in July 1994. He'd just learned that his ex-wife would be putting his son into a public school, and in a Houston-area public school, Keene was convinced, Ritalin would be handed out immediately.
So when he picked his son up in September 1994 and saw that his fears had been realized, he knew, he says now, what he had to do. The first thing was to pick up the bag of Ritalin he'd been given to dose his child with and empty it out the car window, scattering a storm of yellow pills in his wake. The second was to push his custody battle even harder. It's a decision that's brought him considerable grief. He's been jailed twice, nearly lost his house and gone deeply into debt for legal fees. He's lost joint custody, getting instead every other weekend visitation. His ex-wife, Patricia Radloff, declined to be interviewed about the case, but in court her attorney has noted that she spends more time with their son and knows better what he needs, and one of the things he needs is Ritalin, which is, she says, helping him. Whatever problems the younger Steven has complained of, says her lawyer, are problems his father has coached him to report -- coached him in an effort to get full custody and, perhaps, child support.
Last September, after a year of legal maneuvering, Keene finally got a chance to argue his case in court. Presiding was family law judge Linda Motheral, and officially at issue was Keene's petition for full custody of his son. But to Steven Keene, the issue was even bigger. What he hoped to do was put Ritalin itself, the drug he says is his son's chemical straitjacket, on trial.
By the time Keene got his case into court, other parents around Houston had also begun to question what one calls the "flood" of Ritalin that's gone through area schools. And other parents have watched their children struggle with weight loss, headaches and depression induced when their children come down from the drug.
Sandy Martin, a mother of three boys in Fort Bend County, was one who reluctantly put a son on Ritalin, but then took him off of it when, she says, he began showing signs of Tourette's syndrome, which is characterized by tics and loss of hand control. One day a couple of years ago, she compared notes with three fellow real-estate salespeople who were riding together to a sales conference. All of them, it turned out, had children taking Ritalin. What, Martin wondered, were the odds of that, when only 5 percent of the children in the entire U.S. are thought to have ADHD or ADD (the disorder minus the hyperactivity)?
No one knows exactly how many children are taking Ritalin and its generic equivalent, methylphenidate, but the Drug Enforcement Administration estimates it's somewhere in the range of 1.5 to 2.5 million kids. While the number of children taking methylphenidate is not known precisely, the amount manufactured is. Over the last five years, production of the drug has increased sixfold, from 1,700 kilograms in 1990 to 10,400 kilograms in 1995. Of the world's total supply of this amphetamine, American children consume by far the vast majority. Much of this increase in the use of Ritalin has been driven by a spate of self-help books and articles that created widespread public awareness of attention deficit disorders. And schoolteachers and counselors are increasingly urging parents to evaluate their children for the disorder.
Julie Williams, a mother of two boys in suburban Fort Bend County, was living in Europe when this upsurge of Ritalin use began. Williams says she must have been one of the few mothers at Austin Parkway School in suburban Sugar Land who hadn't heard of the "disorder of the '90s." But she soon learned a great deal when teachers suggested she have her son evaluated for ADD. The school gave her an inch-thick packet of articles on the disorder that explained how parents can better manage their children. On the top of the packet was a list of 11 physicians and several clinics and associations for referral.
Williams and her husband decided to use a local pediatrician, and on their visit, she and her son spent an hour and a half with a nurse-practitioner filling out questionnaires. When it was over, Williams was told her son had at least eight of the characteristics that qualified him for a diagnosis of ADD. The physician came in during the last ten minutes, looked over the nurse-practitioner's notes, and signed a recommendation for Ritalin, Williams says. Still, even though, as she says, "a lot of parents come in and beg for Ritalin," Williams hesitated.
"[The nurse-practitioner] knew I was resistant," says Williams. But the nurse countered her fears, telling Williams the drug wasn't addictive and suggesting she give it a 30-day trial. Then the nurse added a capper: "She said, 'If he had diabetes, you wouldn't withhold insulin, would you?' " Williams recalls. She put her son on it.
But Williams still had reservations. She began to be concerned that the Ritalin was masking her son's true problems, not helping him with them. She started to suspect that while her son was getting Ritalin, he wasn't getting the help he needed in school for his learning disabilities.
"In my heart I didn't think I had an ADD child," she says. "I couldn't forget my child had reading, writing and spelling problems. How was a pill going to affect that?"
Finally, a few weeks into the third grade and a year after he had been put on Ritalin, her son James came home with tears running down his face and a heartbreaking message: "I want someone to teach me to read."
Williams suspected dyslexia, and when she went to the Fort Bend Independent School District for help, the system that had given her an inch-thick file on attention deficit disorders reluctantly handed over to her its information on dyslexia. It amounted to only a few sheets. Ultimately, Williams successfully got her son's reading problems diagnosed.
Since her son's reading instruction has been changed, Williams reports, he's much happier in school. His morning stomachaches have gone away, for Williams has quit giving him his morning dose of Ritalin. She's kept quiet about that, though, out of fear that the school might suddenly report conduct problems if administrators there knew that his disciplinary medicine had disappeared, and that what has really calmed him down and focused his attention is learning to read.
In the course of her fight, Williams found that only a handful of Fort Bend students had been tested for dyslexia. So last March she filed a complaint with the federal Office for Civil Rights. That, Williams says, got the district's attention. Now the Fort Bend schools are starting to address the problem of dyslexia, and may be less quick to judge children who have it as being candidates for Ritalin. But, she adds, she has had to raise holy hell to get some action.
Fort Bend school officials have declined to talk about whether overuse of Ritalin is a problem in their school district, except to point out that it is physicians, not educators, who prescribe the medicine. As to how many children are actually taking Ritalin on a regular basis, Fort Bend officials say they don't know; they haven't any data on that. And legally, they're not required to keep such figures. So while some Fort Bend parents have been making sarcastic comments about a "river of Ritalin" flowing through the district, they can't be sure if their anecdotal evidence is true systemwide. And so far, school officials haven't made it any easier for them to know.
In October 1993, when Williams took her son's prescription to a local Randall's to be filled, she found that the pharmacy was out of the drug. There was a national shortage, one that some people have blamed on a bureaucratic foul-up in Washington by the DEA, and one that some have charged was manipulated by Ritalin's manufacturer, New Jersey-based Ciba-Geigy, to stir up public concern and help increase the drug's "quota" -- the amount the manufacturer is legally allowed to produce by the DEA.
In a report on methylphenidate released last October, the DEA contended that Ciba-Geigy "issued a press release and sent over 400,000 letters to health-care professionals accusing the DEA of creating an impending shortage of their product." Ciba-Geigy also alerted the membership of Children and Adults with Attention Deficit Disorders, or CHADD, that a shortage was imminent, the DEA reported. CHADD members protested to Congress and, according to the DEA, "many parents rushed to their physicians to get multiple prescriptions for methylphenidate in order to ensure they had several months' supply on hand. In short, Ciba-Geigy was contributing to a situation which promoted the increased sale of product through panic buying."
The DEA also reported another interesting fact about CHADD, a 30,000 member association that distributes expertly printed brochures on ADD. Over the last five years, while Ritalin usage soared, Ciba-Geigy had given nearly $750,000 to CHADD.
CHADD has also lobbied to have Ritalin taken off Schedule II, the DEA's list of nationally monitored drugs that includes amphetamines, cocaine and morphine-based drugs. Prescriptions for Schedule II drugs are not renewable with a phone call; they must be rewritten in triplicate and signed by a physician on a monthly basis. CHADD's national president says that CHADD's membership wants relief from this burden.
Mary Richard, a counselor of college students with learning disabilities at the University of Iowa who serves as the volunteer president of CHADD, says the organization exists to provide information, not to promote a medication. In any event, Ciba-Geigy's contributions never amounted to more than 11 percent of the organization's budget, she says.
CHADD probably deserves some credit -- or responsibility -- for the increased use of Ritalin, Richard says, because it has lobbied so hard to get information out to schools and the public about ADD. But she's not concerned about overdiagnosis of the syndrome or overuse of Ritalin. If anything, she says, ADD is underdiagnosed. There are principals who don't believe in ADD and school systems that don't recognize it as a learning disability, she claims. And as for the dangers of Ritalin, Richard insists, "When it is properly prescribed and properly used, it is safe."
CHADD's literature heavily emphasizes the need to use multiple therapies to deal with ADD. The problem is, many insurance companies will pay for drugs to treat ADD, but are less likely to pay for the long-term, and expensive, educational and talking therapies that some ADD experts say their patients need.
Jay Tarnower, a Houston child psychiatrist with a team practice devoted to helping people with ADD, says that while Ritalin and other medications are enormously helpful, "the pill doesn't teach skills. What it can do is create the biological environment to learn skills."
Because 30 to 60 percent of children with ADD have learning disabilities, Tarnower says, they need to have their individual learning styles identified. They can then be taught study, organizational and time-management skills and learn strategies to deal with their emotions. Tarnower says he has ADD himself, but manages it without taking drugs. Instead, he constantly writes lists and spends a lot of time organizing his daily and weekly goals.
According to Tarnower, an effective diagnosis of ADHD requires several hours of observation and work. He believes that only board-certified child psychiatrists should prescribe Ritalin, and that pediatricians and other non-specialized physicians should get out of the business of doing so. Besides learning disabilities, he says, afflictions such as epilepsy and depression should be eliminated as a possible source of behavioral problems before a child is diagnosed as needing Ritalin. But while the literature on ADHD stresses that successful treatment of the syndrome requires a complex web of therapies, time management training and other teaching techniques, what most ADHD children get, according to the DEA, is a pill.
Connie Hall is the mother of two boys who underwent Ritalin therapy during the last few years, and she was dismayed by the side effects. Hall lives in the suburban town of Stafford, and her sons, Nick and Tony, attended public schools in the Stafford Municipal School District.
Nick, the older boy, started Ritalin in the third grade. He was calmer under Ritalin, but the tics that are sometimes a side effect of the drug were horrible, Hall says. "He began to have head tics, eye tics, rolling of the head, jerking," she remembers. "His eyes would roll up in his head and he was constantly blinking.
"Every time there was a problem, the teacher would suggest that maybe he needed to go up in his [dosage]. He was up to 25 milligrams twice a day [60 milligrams is the maximum daily amount a prepubescent child is supposed to take], but he couldn't sleep, couldn't calm down, and when he did go to sleep, he would have a terrible time."
Nick's younger brother, Tony, started at five milligrams, Halls says, "and they jacked him up every four weeks. Every time he had a problem, they would recommend an increase. He was up to 20 milligrams three times a day."
Unlike his older brother, Tony had no problem sleeping at night. "He slept all the time," his mother says. "He constantly looked drugged. His eyes had that blank stare." Both of her sons also lost weight on the medication, she says.
"They say this will help the neurotransmitters," says Hall. "They make you feel that this is going to help to perhaps correct the situation from now on. But it was just masking some of the problems without doing anything about them."
After three years of Ritalin, Tony Hall was falling further and further behind in school. He was in the fifth grade, but was working at second- and third-grade levels. Connie Hall, decided to do something about his problem. And as a Scientologist, she turned to one particular option: a private school called Tanglewood Academy.
Tanglewood Academy is a 60-student school for grades pre-K to high school housed in a former daycare center in southwest Houston. Tanglewood subscribes to the educational principles of Scientology, a movement headquartered in Los Angeles whose beliefs are based on the work and life of the late science fiction writer L. Ron Hubbard. Scientology, to be charitable, has a rocky reputation; quite a few people consider it little more than a cult. Scientologists have long waged war on psychiatry, which they consider one of the century's greatest evils, and that war has included long-standing opposition to psychiatric drugs, among them Ritalin. Indeed, some observers credit an anti-Ritalin campaign carried out by Scientologists in the late '80s for producing one of the few declines in the drug's use since it was first introduced in the 1960s. Scientology members distributed pamphlets, threatened lawsuits, went on talk shows and, according to one report out of Minneapolis, even rented an elephant to carry a banner proclaiming "Psychs, stop drugging our children" near where a pyschiatrists convention was being held.
One apparent result of all this was a dip in Ritalin production in 1989. Since then, though, Ritalin production and usage has increased dramatically.
But at Tanglewood Academy, Ritalin and other such drugs are still seen as something to be avoided. Instead, the school uses a self-paced curriculum and a special study technique to cope with the problems of children with attention deficit disorders. The school asks that students not watch TV during the school week, and prefers that parents store their televisions until their children leave for college. It also forbids sweetened drinks and cereals at school, and asks that parents sign an agreement to keep their children off sugar. (Some physicians have claimed a correlation between ADD and sugar and food allergies, though the majority of the medical community says that no such link exists.)
After stopping Tony's medication, Hall enrolled him at Tanglewood, where he's completing second- and third-grade work. She also put him and his brother on a low-sugar diet based on natural, rather than processed, foods, and that seems to have helped, she says. Tony's older brother is also off Ritalin, and seems to be doing better without having to cope with the drug's side effects, Hall says.
Hall's frustration with her children's education has now led her back to college, where she's working on a degree in elementary education. She says she recently completed a textbook on human growth and development. "Of course," she notes wryly, "they had Ritalin written down as perfectly safe."
Shortly after Steven Keene's son started taking Ritalin, he began complaining to his father of stomachaches. That was simply the beginning of what Keene insists were numerous negative side effects of the drug, so he notified the administration of Nottingham Country School and the Katy school district that, during the periods his son was in his custody, he didn't want the school to administer the drug to the child. One day, Keene showed up at the school to underline his intention. He also sent a letter to the child psychiatrist who had prescribed the medication, letting him know that he did not approve of the drug or his son's diagnosis. The psychiatrist immediately sent a letter to the boy's mother recommending cessation of the drug and dropping the boy from his care. But Patricia Radloff didn't share her ex-husband's opinion of Ritalin use; she took her son to a pediatrician at an HMO, who continued the medication.
The fight over the Ritalin use was one of the factors that, in November 1994, led a court to end Steven Keene and Patricia Radloff's joint custody arrangement. The court ruled that Keene's refusal to administer Ritalin to his son constituted a threat to the boy's health and safety, and gave sole custody to the child's mother.
A series of court appearances, charges and countercharges followed, but last September Steven Keene finally got his chance to put Ritalin on trial. Getting there had not been easy; Keene estimates he had spent close to $60,000 on his custody battle over the previous year and a half. His printing and graphic arts business had entered bankruptcy proceedings for an unpaid sales tax bill. His ex-wife had sued him for failure to pay child support, and he had been jailed twice for contempt of court.
Early on, Keene, an articulate and persistent man, tried to cut costs by acting as his own attorney, but by the time he entered Judge Linda Motheral's courtroom, he had hired attorney Shawn Casey to represent him.
Proponents of the ADHD diagnosis believe that the disorder is hereditary. If it is, and if his son actually has ADHD, then Keene doesn't seem to be the source. He is one focused individual. The 36-year-old grew up on Long Island and attended both public and private schools, finally dropping out of high school from boredom, he says. It was only when he got into college that he felt academically challenged. He thinks something similar may be happening to his son. The child's misbehavior may stem from his intelligence, Keene believes, not from a mental disorder. He points out that the diagnostic manual for mental disorders reminds physicians that "inattention in the classroom may also occur when children with high intelligence are placed in academically understimulated environments."
In private school, says Keene, where his son got a lot of individual attention, the child made all A's but had N's in conduct, for "needs improvement." In public school under Ritalin, Keene adds, his son's conduct has become satisfactory, but his grades are high C's and low B's.
And that points to Keene's central accusation: that Ritalin is a drug prescribed to make life easier for the teachers and parents, not for the child. Not for his child, anyway.
Shortly after his son started taking Ritalin, Keene remembered that a couple of months earlier he had tuned in to a Rush Limbaugh program that featured a psychiatrist who criticized the use of Ritalin for treating children. Keene called Limbaugh's producers, and within an hour he had a fax with the psychiatrist's name, Peter R. Breggin. A Harvard-trained doctor and consultant to the National Institute of Mental Health, Breggin was widely critical of his profession in a book titled Toxic Psychiatry. Breggin has called for the abandonment of the diagnoses of ADD and hyperactivity and the end to what he considers the mass medication of children.
Breggin put Keene in touch with San Diego physician Fred Baughman, who would become Keene's expert witness in his attempt to debunk ADHD and Ritalin. Baughman spent a day on the stand in Judge Linda Motheral's family law court. Baughman, who recently retired after 35 years as a child neurologist, has been relentless in his questioning of the ADHD diagnosis. He disputes that there is any organic symptom of the disease, and has challenged the medical establishment to show one. On that issue, he knows himself to be on safe ground, for although the popular literature and many scientists theorize that some sort of chemical imbalance in the brain causes ADHD, no one has pinpointed a specific cause of the disorder. Baughman contends that ADHD is not a disease or even a disorder. Instead, he says, it's a list of symptoms that are subjectively evaluated by doctors, teachers and parents.
Patricia Radloff's attorney didn't bother to put on an expert witness to rebut Baughman. That may have been a good tactic. After all, giving a child Ritalin therapy isn't exactly exotic these days, and Baughman's views are known to be in the medical minority.
At the end of the custody hearing, Motheral told the parties that while she could make a ruling quickly, she thought it might be better if young Steven were evaluated by an independent team of medical and psychological experts. Both sides agreed to the judge's request for a medical evaluation, but the process of picking a team of physicians has been slow. Keene wants to make certain that someone on the panel has a healthy skepticism about diagnosing ADHD. Still, he believes -- or perhaps hopes -- that Motheral asked for the evaluation because she takes his son's complaints about Ritalin's side effects seriously.
But Keene wonders how objective such an evaluation will be if his son is still on Ritalin while he's being evaluated. And he doesn't understand why other adults can't discipline his son the way he does: with a pointed finger and a sharp voice. Keene says that during weekend visits, once his son has come down from the drug, he manages himself well. Keene still can't shake what seems to him an essential unfairness in forcing his son to take a drug for something that is not life-threatening.
"Steven wishes we could trade heads," Keene says, "so I could see what it's like." And since he can't do that, Keene is determined to keep fighting, and will appeal if he loses the present battle. "All the child has to save him from being drugged," Keene says, "is his parents.
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