Ritalin for ADHD - a curse or a blessing?

The phenomenon of the restless child is not new. The history of the terms used to describe the phenomenon is a reminder of this: it runs from the well-known «fidget spinner» from the late 19th century to POS (psycho-organic syndrome) from the 1960s/70s to today's term ADHD.

The same phenomenon is always described, but explained and treated differently in each case. What is new is the widespread use of medication, so-called methylphenidates (MPH, e.g. Ritalin) to treat fidgetiness. But even this development has become outdated: Medication-based treatment of ADHD experienced its first boom in the 1980s in the USA and reached Europe a little later.

Diagnosis and treatment of ADHD

The abbreviation ADHD stands for attention deficit hyperactivity disorder and originates from psychiatric diagnostics. The term ADHD has its origins in English, in German-speaking countries it is often referred to as hyperkinetic disorder.

Both definitions describe a disorder of attention and activity in the affected person. It is important to note that the principle of multimodal treatment of ADHD applies in child and adolescent psychiatry today, i.e. ADHD children should always receive a combination of different measures and treatments. In addition to psychotherapy, this also includes counselling and educational training programmes for parents. Drug treatment is only recommended in cases of severe ADHD.

Drug treatment of ADHD with Ritalin is only recommended for severe cases and not as the sole therapy.

Against this background, the question arises as to how a sharp increase in Ritalin treatments has nevertheless occurred in recent years. Ritalin, a popular drug? There are indeed reports of a worrying increase in Ritalin treatments in Switzerland.

But what figures can we actually rely on? Only studies that are limited in time and geography are available. For example, a study from the canton of Zurich shows that MPH prescriptions for school-age children increased from 1.5 per cent in 2006 to 2.6 per cent in 2012 [1]. The following reasons are theoretically conceivable:

A) More children are stressed:
The incidence of stressed children overall has increased in Switzerland.

B) More children are being diagnosed:
The frequency of recognised or diagnosed cases has increased.

C) More children are receiving medication:
The frequency of children being prescribed MPH has increased.

Explanation A (more children are «ill») seems unlikely, as a doubling of affected children within four years is hardly to be expected based on data from other countries. Explanations B and C are more plausible: more schoolchildren have been diagnosed with ADHD in recent years, e.g. due to more frequent assessments, and/or an increasing proportion of diagnosed children have been treated with medication.

Variant C2 seems less likely because the medication is prescribed by a specialist in the majority of cases. It is important to note that the increase in MPH treatments does not necessarily have to be due to a change in treatment preferences towards «more medication»; it can also be explained solely by increased clarifications or more diagnosed cases.

ADHD and medicalisation

The results of this brief excursus indicate that the growing significance of ADHD among schoolchildren is not solely due to the greater stress placed on the children. Rather, it seems that the children's environment, i.e. parents and teachers, are reacting differently to a phenomenon that has always existed. Nowadays, there is often a «therapeutic» or «medical» response to behaviour that is no longer considered acceptable in its manifestation.

This is where the sociological theory of «medicalisation» comes in. This term stands for the theory that conspicuous behaviour and experiences are explained as an expression of a health disorder and treated medically. The historical perspective plays an important role here: it is about behaviours that were previously not regarded as a health problem or illness, but as a disciplinary, educational problem or even as a life fate.

Parents and teachers are reacting very differently today to a phenomenon that has always existed.

These phenomena are now being made accessible to medicine and categorised by a specific diagnosis. The Swiss Academy of Medical Sciences aptly described medicalisation as follows: «We speak of medicalisation when, for example, stress at work or excessive demands from childcare lead to symptoms that are treated medically; in other words, when, instead of tackling the social causes, problem-solving is outsourced to the responsibility of doctors» [2].

The thesis of medicalisation was developed by the American sociologist Peter Conrad. He described the following drivers of medicalisation: firstly, the development of psychiatric diagnostics. This can be seen, for example, in the American diagnostic manual for psychiatry, where the number of diagnoses almost tripled between 1952 and 1994 from 102 to 297.

Secondly, from the 1950s onwards, the first psychotropic drugs appeared on the market that could be used to treat mental illness. Thirdly and finally, the behaviour of potential patients also changed: Today, they are also consumers on the healthcare market, they are informed and want to make decisions as autonomously as possible.

Against this backdrop, experts report that the diagnosis of ADHD is not always sound, due to pressure from parents who expect quick help for their child's problems.

Consequences

Medicalisation is not something negative per se. Particularly in the area of mental illness, the quasi-reverse phenomenon is also known, whereby mental problems remain untreated for a long time - sometimes with serious consequences for the people affected. Nevertheless, medicalisation entails risks that should not be underestimated:

• The pathologisation of conditions that were previously regarded as serious but ultimately commonplace. The danger here is that we are less and less able to cope with difficult situations without the help of experts.

• The individualisation of behavioural problems. The focus of attention is on behaviour and less on the circumstances that contribute to the problems. With regard to ADHD, for example, it is noticeable that there is comparatively little discussion about the extent to which the school's demands on children's attention contribute to the ADHD diagnosis.

• The change in the social norm of what is considered «normal» or «healthy» behaviour. The WHO has defined health as a state of complete physical, mental and social well-being, which encompasses more than the mere absence of disease or infirmity. Based on this yardstick, we are not always in a state of maximum well-being, but this does not mean that we are considered ill.

It is wrong to demonise the drug treatment of AHDs and thus contribute to the further stigmatisation of parents.

From this perspective, the process of medicalisation can also be described as a shift in the boundary of a problem's need for medical treatment towards health. As a result of this shift, the spectrum of conditions and behaviours that are still considered healthy is generally becoming narrower. However, the narrower this spectrum is, the more people need treatment and the more measures are required.

Conclusion

The development of ADHD diagnoses and the treatment of affected children should continue to be monitored critically. The often great suffering of parents and children must be taken into account: it would be wrong to demonise the drug treatment of ADHD in principle and thus contribute to the further stigmatisation of parents.

However, more attention needs to be paid to problem-solving skills on the ground, beyond resorting to medical or other therapeutic interventions. In particular, the interplay between home and school should be considered. Both areas are so interdependent that interventions that only address one area are likely to have limited success.

The question arises as to how both parents and teachers can be better supported in successfully guiding children with attention problems in everyday life - without resorting to medication. It is also necessary to examine how the requirements of the school curriculum can be made more tolerant and flexible to the learning pace and learning needs of these children.

Diagnosis of ADHD

According to the DSM-5, at least six symptoms from the focal phenomena of inattention or hyperactivity/impulsivity must be identified for the diagnosis of ADHD (Criterion I). The symptoms should have occurred in the last six months and to an extent that is incompatible with the child's stage of development.

In addition, four further main criteria must be met when diagnosing ADHD. Adverse symptoms must have occurred before the age of twelve (criterion II) and at least two areas of life must be disrupted by the symptoms (criterion III): In addition, there must be clear evidence of impairment in school, social or occupational areas (criterion IV).

In addition, the symptoms cannot be explained by a developmental disorder, schizophrenia or other psychotic disorder or are not triggered by another mental illness (criterion V). The ICD-10 defines hyperkinetic disorder «by an early onset (usually in the first five years of life), a lack of persistence in activities that require cognitive effort, and a tendency to switch from one activity to another without completing anything; in addition, there is a disorganised, poorly regulated and final activity».