GROSSE POINTE TOPS IN RITALIN DISPENSING?

Victor Bloom MD

The Grosse Pointes seem to have gained a new distinction--- either we have the most kids with attention-deficit-hyperactivity disorder (ADHD), or this condition is over-diagnosed, (or in other places under-diagnosed), or we have a situation conducive to the diagnosis and drug treatment of that condition.

Many years ago this condition was called "minimal brain damage" (MBD), and it was considered to be due to birth injury, such as the compression of the newborn's brain in a long and difficult labor, or due to brain damage by forceps delivery. The brain damage was not demonstrable by x-ray or clear neurological signs, but the infants had a history of having been irritable and highly distractible; that is, overly reactive to minimal stimuli, such as noise or movement. I remember my first case as I was a second year resident and interviewing an eight year old boy who was brought in for evaluation of learning and behavior difficulties. Sure enough, he showed the classic signs: he was fidgety in the chair, in constant motion, and could not maintain attention to the interview. What was really startling was that the boy literally jumped when he heard what I thought was a slight sound--- the wind outside the window blew a branch from a bush against the windowpane, making a slight noise. The boy jumped as if he had heard a gunshot.

We were told that the minimal brain damage was due to an interference with the reticular activating system, that part of the brain that enabled us to distinguish between minor and major stimuli, and which dictated our ability to attend to important stimuli, such as words (meanings, symbols) in an interpersonal relationship. Imagine being a child bombarded by stimuli as if he were in a war zone, while a teacher is teaching in school, or at a dinner table at home. These children are often mistaken for being deliberately inattentive or unruly, and are usually the object of derision and punishment. In a context which is ignorant of the child's mental state, psychological damage escalates and behavioral problems can increase exponentially to a crisis point.

In those days the treatment was amphetamine, usually Dexedrine, which is otherwise a habit-forming stimulant, a street drug called "speed," otherwise known as an "upper." At first it would seem to make no sense that a stimulant would be given to a child who seemed already to be overstimulated. But in practice, the child often demonstrated a dramatic slowing down of hyperactive behavior, and an ability to be attentive, and thereby better behaved and able to learn in school. In fact, often these hyperactive kids were really quite bright, and when not distractible or hyperactive they became star pupils. So in many cases Dexedrine, and then a closely related Ritalin offered dramatic relief. Perhaps the mechanism of action was that the heretofore inactive reticular activating system, preventing the normal screening of stimuli, was activated by the medication.

Since the medication actually slowed the physical activity of these hyperactive children, and significantly increased their attention span, the common misconception was that the child was 'drugged' with 'downers' (sedatives, tranquilizers). Nothing could be further from the truth. If a child were actually slowed by the stimulant, it was further demonstration that the medicine was truly affecting the particular defective brain mechanism, the one that caused hyperactivity and inattention. If you give a stimulant to a child who does not have this diagnosis, he gets more hyper, not less. Experienced teachers see a dramatic change in the students who have forgotten to take their medicine in the morning, and so arrangements are made for the morning dose to be given in school in that event.

We don't call the condition 'brain damage' anymore, and the diagnosis is not necessarily related to difficult labor and delivery. Sometimes it just happens, we don't always know why. The condition is said to run in families. Many families have become used to the fact that multiple members may be on Ritalin and do quite well in school or work, as long as they are on the medication (we shouldn't say 'drug'). As the children grow up there is adult attention-deficit-disorder, and adults as well continue to get benefit from daily doses of what would be a stimulant to anyone else. Support groups have evolved over the years for people with this known disorder.

As for the prevalence of the use of Ritalin in the Pointes, that is a curious finding. The researcher has an interesting perspective:

"The things to think about is the relative level of health care in Grosse Pointe as opposed to other communities," said Wennberg. "Also the treatment of ADHD is an interesting triad. There are the physicians, the schools and then there are the families. I don't know the dynamics that drive that triad, but if I were going to start investigating why the Grosse Pointes are where they are, you'd have to start to understand the differences in that triad in the Grosse Pointes versus other communities."

I have heard that there are Grosse Pointe specialists in the diagnosis and treatment of ADHD to which teachers and school social workers quickly refer their behavior problems. Since impulsive and hyperactive behavior, as well as learning disability can have environmental (psychologic) roots as well as neurological ones, it is hoped that in the haste for a quick fix, an adequate neuropsychiatric evaluation is not bypassed.

Some parents seek social security disability status for diagnosed ADHD pupils, which brings in a significant monthly check, and is based simply on diagnosis, not necessarily financial need. It is clear that some kids are diagnosed ADHD largely on the basis of behavioral problems and learning difficulties, even though it is well known that in most cases, these behavior and learning problems are psychological, not neurological.

The Grosse Pointes may be blessed with the best specialists and a high incidence of the correct diagnosis and treatment, but it is possible that there is over-diagnosis and undue 'treatment'.

Therefore, I would suggest that whenever a diagnosis of ADHD is made, and there is any doubt, the family should get a second opinion, especially one outside the 'triad'.

Dr Bloom is Clinical Associate Professor of Psychiatry, Wayne State University School of Medicine. He is a member of the American Academy of Psychoanalysis and on the editorial board of the Wayne County Medical Society. He welcomes comments at his email address--- vbloom@comcast.net.