In Talking Back to Ritalin: What Doctors Aren't Telling You about Stimulants for Children (Monroe, ME: Courage Press, 1998), psychiatrist Peter R. Breggin, M.D., warns us of the catastrophe now befalling children in the United States as a consequence of the clinical methods of organized psychiatry and psychology, the widespread use of professional diagnostic classifications for childhood mental disorders by these professions, and the prescribing of psychiatric medications for the treatment of those disorders. For more than 15 years, Breggin has written books that attack established psychiatry, psychology, and now pediatrics, for their approaches to the diagnosis and treatment of children and adults with mental and developmental disorders. In this book, the disorder known as ADHD, for attention deficit hyperactivity disorder, and the stimulant medication, Ritalin (methylphenidate) often used to treat it, come in for very heavy (and lopsided) criticism. Along the way, a number of leading clinical scientists in the field of ADHD, myself included, are criticized for misrepresenting the status of our science. National charities that advocate on behalf of those with the disorder, such as CHADD (Children and Adults with ADD), the pharmaceutical companies that produce the stimulant medications, such as Novartis (manufacturers of Ritalin), and even federal institutes that fund mental health research, such as the NIMH (National Institute of Mental Health), also receive the full brunt of Breggins' ire. Breggin claims that all are conspiring to "drug" America's school children for the management of their ADHD, among other behavior problems. Left unaddressed by the author is precisely how such a complex conspiracy could ever be organized and kept secret, if it actually existed. No persuasive evidence of such a conspiracy is ever provided in the book, just the repeated assertion that an ADHD/Ritalin conspiracy exists.
Breggin considers children with ADHD and other behavior problems actually to be among our most creative, sensitive, energetic, and intelligent. And so he fmds the use of medication for their management to be worthy of public concern and scorn. His assessment of ADHD children, however, ignores more than 30 years of longitudinal research on ADHD, including my own ongoing 20-year follow-up study, demonstrating the substantial and pervasive development risks that ADHD and its related disorders of oppositional and conduct disorder convey to a child. Such research clearly demonstrates that ADHD has a negative impact on intelligence (an average 7-10 points below normal), on academic achievement skills (an average of 10-15 points below normal), and academic progress (25-50% are retained in grade, 36% fail to graduate high school, and only 5% complete a college education). Children with ADHD, particularly those with childhood oppositional defiant disorder, are at much higher risk for later lying and stealing (45%), conduct disorder and delinquency (25-45%), early substance experimentation and substance dependence/abuse (15-25 %), and social rejection (50% or more). This is not to say that some children with ADHD fail to succeed in life; but it is to say that characterizing tl-iis group of children as our best, most creative, and brightest does a severe injustice to the facts of the matter and is woefully misleading to the public in general and to parents of these children in particular.
Literally from its opening pages, this book makes contorted attempts at the appearance of scholarship, replete with quotes, footnotes, and references to scientific papers and other sources. Throughout, any quote is mustered from scientific papers that can be taken out of context to support the author's biases along with every exaggerated fact and figure he can flnd to support his call to alarm, no matter the credibility (or lack of it) of his sources. However, the flaws of both his research methods and his arguments are evident to any scientist even slightly familiar with the scientific literature on the topics covered here. Lacking any sense of perspective and proportion, this book fails to place its facts and figures in their rightful context and history, and eschews any attempt at a balanced and thoughtfully reasoned approach to its major topics. We are left, their, with what appears to be a carefully and cleverly crafted piece of artful propaganda against the diagnosis of ADHD and its treatment with Ritalin. "We are left, then, with what appears to be a carefully and cleverly crafted piece of artful propaganda against the diagnosis of ADHD and its treatment with Ritalin."
The book's biases and unbalanced scholarsl-lip are evident from the very first page of Chapter 1. Here the author quotes that 'The U.S. Drug Enforcement Administration ... has warned about a record six-fold increase in Ritalin production between 1990 and 1995.' And that "The International Narcotics Control Board. . . deplores that 'l 0 to 12 percent' of all boys between ages 6 and 14 in the United States have been diagnosed as having ADD and are being treated with methylphenidate [Ritalin]." Withheld from the reader are the following facts that would have helped to put these statements in their proper perspective:
In the next sentence we are told that"While estimates vary widely, the total number of children on Ritalin has probably increased to 4-5 million or more per year." Checking out the footnote that appears in this sentence, one finds that Breggin is well aware of the most recent, largest study, and best study to date on this issue conducted by Daniel Safer and his colleagues (Pediatrics 98:1084-1088, 1996) in which the investigators attempted to determine the prevalence of Ritalin use in the United States. Their study found Ritalin use to be less than half the figure Breggin claims it to be. But Breggin dismisses this study as just a "hodgepodge of mostly local sources." He prefers instead to rely on his own firsthand conversations with physicians and teachers around the country that medication use is much higher than this study indicates it to be. In essence, we are asked to take Breggin's subjective and biased impressions over the available scientific research on the matter, no doubt because that research would not support his call to alarm about the issue. In reality, out of over 40 million school children in the U.S., only 1.5 million of them are taking medication for the treatment of ADHD. This extent of Ritalin use is well below the 5 to 7 percent of children estimated to have this disorder and so the figure for medication use hardly seems out of proportion or scandalous when viewed in its rightful context. Such distortions of fact, dismissives of the scientific literature (tucked away in footnotes), and citations of exaggerated statistics await the reader on every page thereafter.
This book further accuses leading scientists, physicians, the Food and Drug Administration, NIMH, and established psychiatry and psychology of withholding negative or critical information about stimulant medication and ADHD from the public. Meanwhile, the author does precisely this very same sort of thing himself. Breggin draws upon quotes, facts, figures, and the personal musings of laypeople from many sources in the popular media, all of which are critical of ADHD or stimulant medications like Ritalin. Never is their accuracy or credibility challenged. Yet this book almost ceaselessly criticizes scientific research that supports the validity of ADHD as neurodevelopmental disorder and on the use of stimulant medications as safe and effective treatments for it. This nit-picking at the petty faults of the clinical studies and the investigators quickly grows tiresome when there is no equally balanced critical treatment of the sources Breggin wishes to cite in support of his own prejudices. It is a lack of balance so lopsided as to invite disbelief.
Not until the last fifth of this book are we finally told what Breggin believes is the cause of children's developmental disorders, such as ADHD and autism, and behavioral/emotional problems such as oppositional defiant disorder and depression. The causes are said to be: (1) lack of parental love, (2) lack of parental attention, (3) lack of parental discipline, (4) family stress, (5) poor educational methods, and (6) a mental health profession that is prejudiced toward neurobiological explanations for behavior over psychosocial ones. The recommendations proposed for parents to follow are, of course, the inverse of these causes; love more, pay more attention, use more discipline, reduce family stress, work to reform your child's educational system, and avoid getting help from organized psychiatry and psychology. While there may be nothing inherently wrong with some of these admonitions, there is nothing inherently right about them either. Some may even ring with the sound of common sense about them, but common sense is often just that, common and often misinformed. Witness the widely held belief among the lay public that sugar is a major cause of ADHD and learning disabilities when the weight of credible scientific evidence unquestionably shows that it is not so. Science has shown that ADHD and the other disorders Breggin discusses, including autism, are not the consequence of the causes he cites in his book. And so addressing them is not likely to remedy the child's problems. Neither is avoiding the established scientific and clinical pediatric and mental health professions as Breggin recommends. Breggin's view must be seen for what it actually is -- a not-so-subtle form of parent-bashing that lays the blame for ADHD and other complex developmental and mental disorders at the feet of the child's parents, family, and school. This is outdated psychoanalytic thinking, discarded decades ago by the scientific community for its explanatory uselessness not to mention its cruelty toward parents seeking help for their children.
The propaganda Breggin offers here will be easily dismissed by the scientific and clinical professional communities as having nothing to add to the important issues related to understanding and managing ADHD. But to the lay reader, such misguidance as Breggin provides in Talking Back to Ritalin can do real harm. Breggin literally encourages parents of ADHD and developmentally disordered children to turn away from the established fields of pediatrics, psychiatry, and psychology and the professionals who practice within them. Instead, Breggin instructs parents to seek outdated, unscientific, and ineffective pop-psychological views of disorders and their treatment. What was so dismaying to me as a professional by the end of the book was the knowledge that Dr. Breggin took an oath as a physician to "first, do no harm." In my opinion, his book has violated that sacred oath.
Dr. Barkley has been a clinician, scientist, and educator specializing in ADHD and related disorders for more than 20 years. He is the author of more than 150 scientific papers and book chapters on ADHD and related topics and the author or editor of 13 books, including Attention Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment (1990, 1998) and Taking Charge of ADHD: The Complete Authoritative Guide for Parents (1995). At the time this was written, Dr. Barkley was Director of Psychology and Professor of Psychiatry and Neurology at the University of Massachusetts Medical Center, Worcester, MA. In 2002, he relocated to the University of South Carolina.