A LIBERAL 'HOAX' TURNS OUT TO BE TRUE.
Trick Question
by Michael Fumento
Post date: 01.27.03
Issue date: 02.03.03
It's both right-wing and vast, but it's not a conspiracy. Actually, it's more of an anti-conspiracy. The subject is Attention Deficit Disorder (ADD) and Attention Deficit Hyperactivity Disorder (ADHD), closely related ailments (henceforth referred to in this article simply as ADHD). Rush Limbaugh declares it "may all be a hoax." Francis Fukuyama devotes much of one chapter in his latest book, Our Posthuman Future, to attacking Ritalin, the top-selling drug used to treat ADHD. Columnist Thomas Sowell writes, "The motto used to be: 'Boys will be boys.' Today, the motto seems to be: 'Boys will be medicated.'" And Phyllis Schlafly explains, "The old excuse of 'my dog ate my homework' has been replaced by 'I got an ADHD diagnosis.'" A March 2002 article in The Weekly Standard summed up the conservative line on ADHD with this rhetorical question: "Are we really prepared to redefine childhood as an ailment, and medicate it until it goes away?"
Many conservative writers, myself included, have criticized the growing tendency to pathologize every undesirable behavior--especially where children are concerned. But, when it comes to ADHD, this skepticism is misplaced. As even a cursory examination of the existing literature or, for that matter, simply talking to the parents and teachers of children with ADHD reveals, the condition is real, and it is treatable. And, if you don't believe me, you can ask conservatives who've come face to face with it themselves.
MYTH: ADHD ISN'T A REAL DISORDER.
The most common argument against ADHD on the right is also the simplest: It doesn't exist. Conservative columnist Jonah Goldberg thus reduces ADHD to "ants in the pants." Sowell equates it with "being bored and restless." Fukuyama protests, "No one has been able to identify a cause of ADD/ADHD. It is a pathology recognized only by its symptoms." And a conservative columnist approvingly quotes Thomas Armstrong, Ritalin opponent and author, when he declares, "ADD is a disorder that cannot be authoritatively identified in the same way as polio, heart disease or other legitimate illnesses."
The Armstrong and Fukuyama observations are as correct as they are worthless. "Half of all medical disorders are diagnosed without benefit of a lab procedure," notes Dr. Russell Barkley, professor of psychology at the College of Health Professionals at the Medical University of South Carolina. "Where are the lab tests for headaches and multiple sclerosis and Alzheimer's?" he asks. "Such a standard would virtually eliminate all mental disorders."
Often the best diagnostic test for an ailment is how it responds to treatment. And, by that standard, it doesn't get much more real than ADHD. The beneficial effects of administering stimulants to treat the disorder were first reported in 1937. And today medication for the disorder is reported to be 75 to 90 percent successful. "In our trials it was close to ninety percent," says Dr. Judith Rapoport, director of the National Institute of Mental Health's Child Psychiatry Branch, who has published about 100 papers on ADHD. "This means there was a significant difference in the children's ability to function in the classroom or at home."
Additionally, epidemiological evidence indicates that ADHD has a powerful genetic component. University of Colorado researchers have found that a child whose identical twin has the disorder is between eleven and 18 times more likely to also have it than is a non-twin sibling. For these reasons, the American Psychiatric Association (APA), American Medical Association, American Academy of Pediatrics, American Academy of Child Adolescent Psychiatry, the surgeon general's office, and other major medical bodies all acknowledge ADHD as both real and treatable.
MYTH: ADHD IS PART OF A FEMINIST CONSPIRACY TO MAKE LITTLE BOYS MORE LIKE LITTLE GIRLS.
Many conservatives observe that boys receive ADHD diagnoses in much higher numbers than girls and find in this evidence of a feminist conspiracy. (This, despite the fact that genetic diseases are often heavily weighted more toward one gender or the other.) Sowell refers to "a growing tendency to treat boyhood as a pathological condition that requires a new three R's--repression, re-education and Ritalin." Fukuyama claims Prozac is being used to give women "more of the alpha-male feeling," while Ritalin is making boys act more like girls. "Together, the two sexes are gently nudged toward that androgynous median personality ... that is the current politically correct outcome in American society." George Will, while acknowledging that Ritalin can be helpful, nonetheless writes of the "androgyny agenda" of "drugging children because they are behaving like children, especially boy children." Anti-Ritalin conservatives frequently invoke Christina Hoff Sommers's best-selling 2000 book, The War Against Boys. You'd never know that the drug isn't mentioned in her book--or why.
"Originally I was going to have a chapter on it," Sommers tells me. "It seemed to fit the thesis." What stopped her was both her survey of the medical literature and her own empirical findings. Of one child she personally came to know she says, "He was utterly miserable, as was everybody around him. The drugs saved his life."
MYTH: ADHD IS PART OF THE PUBLIC SCHOOL SYSTEM'S EFFORTS TO WAREHOUSE KIDS RATHER THAN TO DISCIPLINE AND TEACH THEM.
"No doubt life is easier for teachers when everyone sits around quietly," writes Sowell. Use of ADHD drugs is "in the school's interest to deal with behavioral and discipline problems [because] it's so easy to use Ritalin to make kids compliant: to get them to sit down, shut up, and do what they're told," declares Schlafly. The word "zombies" to describe children under the effects of Ritalin is tossed around more than in a B-grade voodoo movie.
Kerri Houston, national field director for the American Conservative Union and the mother of two ADHD children on medication, agrees with much of the criticism of public schools. "But don't blame ADHD on crummy curricula and lazy teachers," she says. "If you've worked with these children, you know they have a serious neurological problem." In any case, Ritalin, when taken as prescribed, hardly stupefies children. To the extent the medicine works, it simply turns ADHD children into normal children. "ADHD is like having thirty televisions on at one time, and the medicine turns off twenty-nine so you can concentrate on the one," Houston describes. "This zombie stuff drives me nuts! My kids are both as lively and as fun as can be."
MYTH: PARENTS WHO GIVE THEIR KIDS ANTI-ADHD DRUGS ARE MERELY DOPING UP PROBLEM CHILDREN.
Limbaugh calls ADHD "the perfect way to explain the inattention, incompetence, and inability of adults to control their kids." Addressing parents directly, he lectures, "It helped you mask your own failings by doping up your children to calm them down."
Such charges blast the parents of ADHD kids into high orbit. That includes my Hudson Institute colleague (and fellow conservative) Mona Charen, the mother of an eleven-year-old with the disorder. "I have two non-ADHD children, so it's not a matter of parenting technique," says Charen. "People without such children have no idea what it's like. I can tell the difference between boyish high spirits and pathological hyperactivity. ... These kids bounce off the walls. Their lives are chaos; their rooms are chaos. And nothing replaces the drugs."
Barkley and Rapoport say research backs her up. Randomized, controlled studies in both the United States and Sweden have tried combining medication with behavioral interventions and then dropped either one or the other. For those trying to go on without medicine, "the behavioral interventions maintained nothing," Barkley says. Rapoport concurs: "Unfortunately, behavior modification doesn't seem to help with ADHD." (Both doctors are quick to add that ADHD is often accompanied by other disorders that are treatable through behavior modification in tandem with medicine.)
MYTH: RITALIN IS "KIDDIE COCAINE."
One of the paradoxes of conservative attacks on Ritalin is that the drug is alternately accused of turning children into brain-dead zombies and of making them Mach-speed cocaine junkies. Indeed, Ritalin is widely disparaged as "kiddie cocaine." Writers who have sought to lump the two drugs together include Schlafly, talk-show host and columnist Armstrong Williams, and others whom I hesitate to name because of my long-standing personal relationships with them.
Mary Eberstadt wrote the "authoritative" Ritalin-cocaine piece for the April 1999 issue of Policy Review, then owned by the Heritage Foundation. The article, "Why Ritalin Rules," employs the word "cocaine" no fewer than twelve times. Eberstadt quotes from a 1995 Drug Enforcement Agency (DEA) background paper declaring methylphenidate, the active ingredient in Ritalin, "a central nervous system (CNS) stimulant [that] shares many of the pharmacological effects of amphetamine, methamphetamine, and cocaine." Further, it "produces behavioral, psychological, subjective, and reinforcing effects similar to those of d-amphetamine including increases in rating of euphoria, drug liking and activity, and decreases in sedation." Add to this the fact that the Controlled Substances Act lists it as a Schedule II drug, imposing on it the same tight prescription controls as morphine, and Ritalin starts to sound spooky indeed.
What Eberstadt fails to tell readers is that the DEA description concerns methylphenidate abuse. It's tautological to say abuse is harmful. According to the DEA, the drugs in question are comparable when "administered the same way at comparable doses." But ADHD stimulants, when taken as prescribed, are neither administered in the same way as cocaine nor at comparable doses. "What really counts," says Barkley, "is the speed with which the drugs enter and clear the brain. With cocaine, because it's snorted, this happens tremendously quickly, giving users the characteristic addictive high." (Ever seen anyone pop a cocaine tablet?) Further, he says, "There's no evidence anywhere in literature of [Ritalin's] addictiveness when taken as prescribed." As to the Schedule II listing, again this is because of the potential for it to fall into the hands of abusers, not because of its effects on persons for whom it is prescribed. Ritalin and the other anti-ADHD drugs, says Barkley, "are the safest drugs in all of psychiatry." (And they may be getting even safer: A new medicine just released called Strattera represents the first true non-stimulant ADHD treatment.)
Indeed, a study just released in the journal Pediatrics found that children who take Ritalin or other stimulants to control ADHD cut their risk of future substance abuse by 50 percent compared with untreated ADHD children. The lead author speculated that "by treating ADHD you're reducing the demoralization that accompanies this disorder, and you're improving the academic functioning and well-being of adolescents and young adults during the critical times when substance abuse starts."
MYTH: RITALIN IS OVERPRESCRIBED ACROSS THE COUNTRY.
Some call it "the Ritalin craze." In The Weekly Standard, Melana Zyla Vickers informs us that "Ritalin use has exploded," while Eberstadt writes that "Ritalin use more than doubled in the first half of the decade alone, [and] the number of schoolchildren taking the drug may now, by some estimates, be approaching the 4 million mark."
A report in the January 2003 issue of Archives of Pediatrics and Adolescent Medicine did find a large increase in the use of ADHD medicines from 1987 to 1996, an increase that doesn't appear to be slowing. Yet nobody thinks it's a problem that routine screening for high blood pressure has produced a big increase in the use of hypertension medicine. "Today, children suffering from ADHD are simply less likely to slip through the cracks," says Dr. Sally Satel, a psychiatrist, AEI fellow, and author of PC, M.D.: How Political Correctness Is Corrupting Medicine.
Satel agrees that some community studies, by the standards laid down in the APA's Diagnostic and Statistical Manual of Mental Disorders (DSM), indicate that ADHD may often be over-diagnosed. On the other hand, she says, additional evidence shows that in some communities ADHD is under-diagnosed and under-treated. "I'm quite concerned with children who need the medication and aren't getting it," she says.
There are tremendous disparities in the percentage of children taking ADHD drugs when comparing small geographical areas. Psychologist Gretchen LeFever, for example, has compared the number of prescriptions in mostly white Virginia Beach, Virginia, with other, more heavily African American areas in the southeastern part of the state. Conservatives have latched onto her higher numbers--20 percent of white fifth-grade boys in Virginia Beach are being treated for ADHD--as evidence that something is horribly wrong. But others, such as Barkley, worry about the lower numbers. According to LeFever's study, black children are only half as likely to get medication as white children. "Black people don't get the care of white people; children of well-off parents get far better care than those of poorer parents," says Barkley.
MYTH: STATES SHOULD PASS LAWS THAT RESTRICT SCHOOLS FROM RECOMMENDING RITALIN.
Conservative writers have expressed delight that several states, led by Connecticut, have passed or are considering laws ostensibly protecting students from schools that allegedly pass out Ritalin like candy. Representative Lenny Winkler, lead sponsor of the Connecticut measure, told Reuters Health, "If the diagnosis is made, and it's an appropriate diagnosis that Ritalin be used, that's fine. But I have also heard of many families approached by the school system [who are told] that their child cannot attend school if they're not put on Ritalin."
Two attorneys I interviewed who specialize in child-disability issues, including one from the liberal Bazelon Center for Mental Health Law in Washington, D.C., acknowledge that school personnel have in some cases stepped over the line. But legislation can go too far in the other direction by declaring, as Connecticut's law does, that "any school personnel [shall be prohibited] from recommending the use of psychotropic drugs for any child." The law appears to offer an exemption by declaring, "The provisions of this section shall not prohibit school medical staff from recommending that a child be evaluated by an appropriate medical practitioner, or prohibit school personnel from consulting with such practitioner, with the consent of the parent or guardian of such child." [Emphasis added.] But of course many, if not most, schools have perhaps one nurse on regular "staff." That nurse will have limited contact with children in the classroom situations where ADHD is likely to be most evident. And, given the wording of the statute, a teacher who believed a student was suffering from ADHD would arguably be prohibited from referring that student to the nurse. Such ambiguity is sure to have a chilling effect on any form of intervention or recommendation by school personnel. Moreover, 20-year special-education veteran Sandra Rief said in an interview with the National Education Association that "recommending medical intervention for a student's behavior could lead to personal liability issues." Teachers, in other words, could be forced to choose between what they think is best for the health of their students and the possible risk of losing not only their jobs but their personal assets as well.
"Certainly it's not within the purview of a school to say kids can't attend if they don't take drugs," says Houston. "On the other hand, certainly teachers should be able to advise parents as to problems and potential solutions. ... [T]hey may see things parents don't. My own son is an angel at home but was a demon at school."
If the real worry is "take the medicine or take a hike" ultimatums, legislation can be narrowly tailored to prevent them; broad-based gag orders, such as Connecticut's, are a solution that's worse than the problem.
THE CONSERVATIVE CASE FOR ADHD DRUGS.
There are kernels of truth to every conservative suspicion about ADHD. Who among us has not had lapses of attention? And isn't hyperactivity a normal condition of childhood when compared with deskbound adults? Certainly there are lazy teachers, warehousing schools, androgyny-pushing feminists, and far too many parents unwilling or unable to expend the time and effort to raise their children properly, even by their own standards. Where conservatives go wrong is in making ADHD a scapegoat for frustration over what we perceive as a breakdown in the order of society and family. In a column in The Boston Herald, Boston University Chancellor John Silber rails that Ritalin is "a classic example of a cheap fix: low-cost, simple and purely superficial."
Exactly. Like most headaches, ADHD is a neurological problem that can usually be successfully treated with a chemical. Those who recommend or prescribe ADHD medicines do not, as The Weekly Standard put it, see them as "discipline in pill-form." They see them as pills.
In fact, it can be argued that the use of those pills, far from being liable for or symptomatic of the Decline of the West, reflects and reinforces conservative values. For one thing, they increase personal responsibility by removing an excuse that children (and their parents) can fall back on to explain misbehavior and poor performance. "Too many psychologists and psychiatrists focus on allowing patients to justify to themselves their troubling behavior," says Satel. "But something like Ritalin actually encourages greater autonomy because you're treating a compulsion to behave in a certain way. Also, by treating ADHD, you remove an opportunity to explain away bad behavior."
Moreover, unlike liberals, who tend to downplay differences between the sexes, conservatives are inclined to believe that there are substantial physiological differences-- differences such as boys' greater tendency to suffer ADHD. "Conservatives celebrate the physiological differences between boys and girls and eschew the radical-feminist notion that gender differences are created by societal pressures," says Houston regarding the fuss over the boy-girl disparity among ADHD diagnoses. "ADHD is no exception."
But, however compatible conservatism may be with taking ADHD seriously, the truth is that most conservatives remain skeptics. "I'm sure I would have been one of those smug conservatives saying it's a made-up disease," admits Charen, "if I hadn't found out the hard way." Here's hoping other conservatives find an easier route to accepting the truth.
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