From Teaching Exceptional Children, Vol. 31, no. 4, March/April 1999
By Christina Pancheri and Mary Anne Prater
Olivia is a 15-year-old girl identified as having a learning disability and attention deficit hyperactivity disorder (ADHD). Her parents recently took her off Ritalin because they felt she no longer behaved hyperactively. Ritalin had been prescribed for Olivia to help her focus in school and to reduce her hyperactivity. Now, Olivia’s grades have slipped from As and Bs to Ds and Fs. Olivia’s parents do not understand why she is suddenly doing so poorly. Some of Olivia’s teachers think she is getting lazy because she does not turn in all of her assignments.
Mark, a 7-year-old boy with ADHD without hyperactivity, has recently started taking Ritalin to help him stay focused in school. His teacher feels that Mark is more attentive in academic and social situations, and she states that Mark’s grades are steadily climbing. Mark, however, seems to have lost his appetite for lunch, only picking at his food. Later in the afternoon he seems tired and irritable. His parents state that he argues with them when he gets home from school. Mark’s parents think they should discontinue Ritalin because it is making him irritable even though his teacher states it is helping him at school.Many teachers understand the plight of Mark and Olivia. Parents often look to the child’s teachers for opinions on what is best for the child. If you were Olivia or Mark’s teacher, what would you tell the parents? This article provides some introductory information about a stimulant medication, Ritalin, and examines both myths and facts about its use with students with ADHD.
The most prescribed stimulant medication is methylphenidate, patented in 1950 by the CIBA Pharmaceutical Company under the name Ritalin (Bosco, 1975). The U.S. Drug Enforcement Agency (DEA) regulates the manufacture and sale of Ritalin. Researchers have estimated that the number of people taking Ritalin since 1990 has grown from 2.5 to 5 times (Diller, 1996; Hancock, 1996).
Why Such a Demand?
In 1993 there was a nationwide shortage of Ritalin because manufacturers could not exceed the quota set by the DEA. Silver (1995a) expressed a belief that the growth in manufacturing and sales of Ritalin has resulted from a chain of effects: as physicians have gained a greater awareness of ADHD, the number of identified cases has increased, which has increased the demand for Ritalin.
Pros and Cons
Not all children with ADHD respond to stimulant medication. The percentages that do respond, however, are relatively high, as the following researchers noted:
- Neuwirth (1994) reported studies indicating that medication helps approximately 70% of those diagnosed with ADHD.
- Elliott and Worthington (1995) estimated that between 70% and 80% of children with ADHD respond positively to the medication.
- Hancock (1996) stated that 90% of those who need stimulant medication receive positive benefits from Ritalin.
The use of Ritalin, however, has not gone without criticism:
- Several groups have demonstrated against the use of Ritalin primarily on “ethical grounds” (Altman & Friedman, n.d.; Silver, 1995a).
- Other professionals have suggested that medications should not be used until instructional and behavior management interventions have been implemented correctly and long enough for improvement to occur (Howell, Evans, & Gardiner, 1997).
This article provides readers the opportunity to (a) assess their knowledge about the stimulant medication Ritalin, (b) compare their knowledge with other teachers and parents, and (c) to learn more about Ritalin.
The Ritalin Quiz
We used scientific information about the stimulant drug, Ritalin, to develop a quiz consisting of 17 true and false statements (see Table 1).
The Ritalin Quiz
After the following statements, circle T (true) if you agree or F (false) if you do not agree.
1. Children should stop taking Ritalin when they reach their teenage years. T F
2. Children build up a tolerance to Ritalin. T F
3. Taking Ritalin will lead to drug abuse later in the child’s life. T F
4. Children can become addicted to Ritalin. T F
5. Ritalin will stop children from growing. T F
6. When children reach their teenage years, Ritalin no longer controls aggression and impulsiveness but does cause the child to act out. T F
7. Ritalin causes children to lose their appetite. T F
8. Children taking Ritalin may have a hard time falling asleep. T F
9. Ritalin can cause some children to become more hyperactive. T F
10. Children taking Ritalin complain about their head hurting (headaches). T F
11. Children taking Ritalin complain about their belly hurting (stomachaches). T F
12. When children take Ritalin, it dulls their personality. T F
13. Ritalin builds up in the child’s bloodstream. T F
14. Ritalin can cause some children to tic (uncontrolled muscle movements). T F
15. Ritalin can cause children to have seizures. T F
16. Ritalin can cause a child’s heart to beat much faster. T F
17. Ritalin can cause depression in some children. T F
Who Took the Quiz?
We administered the quiz to 78 parents and 20 teachers (11 general education teachers and 9 special education teachers), as follows:
- All the parents who participated had school-age children (5-18 years old). In addition, all of them had (a) considered or investigated placing one or more of their children on Ritalin, (b) children currently taking Ritalin, or (c) children who had taken Ritalin in the past.
- The teachers who answered the quiz taught kindergarten through Grade 12; these teachers worked with students who were taking Ritalin and who were identified with learning disabilities (LD), ADHD, or both.
How Did Parents and Teachers Respond?
Each quiz item, with the percentage of teachers’ and parents’ responses, appears in Table 2. Although not provided as an option, several participants wrote that they did not know the answer. Therefore, we also reported the number responding “don’t know.”
What Do You Think About Ritalin?
We encourage you to complete the quiz (Table 1) before looking at Table 2 or reading the next section. You can then compare your knowledge with the results of the study. It is important for teachers to recognize how much they know about a medication that is becoming more prevalent in schools and classrooms every day.
The Correct Answers
Here are the statements on the quiz, with the facts that explode the myths and misunderstandings. We also provide additional information and verification related to the “correct” responses.
Statement 1: Children should stop taking Ritalin when they reach their teenage years.
This statement is false. Some people believe that hyperactivity goes away during adolescence and, therefore, there is no reason to continue the medication. Clampit and Pirkle (1983) pointed out, however, that even if hyperactive behavior seems to be improving, maintaining attention is still very difficult. Teenage students have more requirements and more homework than in elementary school. This means they are required to stay focused for longer amounts of time in school and at home. Unless the child is experiencing severe side effects, there is no reason to discontinue Ritalin.
Statement 2: Children build up a tolerance to Ritalin.
This statement could be interpreted as true or false. Developing a tolerance to Ritalin is a controversial issue because no long-term studies have been conducted to discover if it occurs. It may seem as though a tolerance has developed because the child's needed dosage may increase. Elliott and Worthington (1995) offered several reasons why children's dosages increase. One reason might be that the child was recently changed from name-brand Ritalin to its generic form. The generic form of Ritalin is generally safe, but it may vary from Ritalin in strength by 15%. Therefore, a child may need a higher dosage to get the same results. A second reason a child may need an increase in medication is rapid growth or weight gain. Even though dosage is not calculated by weight, the child may need a different dosage because his or her body is changing. A third reason for dosage increase could be a change in the learning environment, with different demands.
Statements 3 and 4: Taking Ritalin will lead to drug abuse later in the child's life, and Children can become addicted to Ritalin.
These statements are both false. First, any medication can be abused. Children with ADHD who take Ritalin or other medications are no more or no less likely to try, abuse, or become addicted to drugs later in life than any other individual. There is no evidence that shows that taking stimulant medication to treat ADHD causes addiction or an increase in taking medication as an adult (Elliott & Worthington, 1995). Long (1995) reported that there is little chance of drug addiction, because children with ADHD do not feel euphoric when taking Ritalin. "They become dependent on stimulant drugs...in the same sense that a person with diabetes is dependent on insulin or a nearsighted person on eyeglasses" (p. 4). Ritalin is a safe medication when taken as directed and at normal prescription dosages. Ritalin can be a serious health risk, however, when crushed and snorted or injected into the body (Bailey, 1996). Adolescents taking Ritalin may be pressured by friends to share the medication for recreational use. Clampit and Pirkle (1983) suggested that parents and schools keep close control over students' access to medication. Students should not be carrying the medication with them. Parents should distribute the medication when students take it at home. Teachers should find out what their school's policy is on distribution of medication.
Statement 5: Ritalin will stop children from growing.
This statement is false. Research shows that growth is sometimes slow while the child is taking Ritalin, but does not support the claim that Ritalin stops growth. Copeland (1994) states that in 20 years of practice, only one child did not grow for over a year. Even though the child was diagnosed with constitutional slow-growth syndrome, he was switched from Ritalin to another medication; and he still did not grow. It is important to look at members of the child's family before deciding that Ritalin is keeping a child from growing. If members of the family are shorter than average, it is reasonable to speculate that the child's growth rate may be slow. Another important point is that children are individuals who grow and mature at their own speed.
Statement 6: When children reach their teenage years, Ritalin no longer controls aggression and impulsiveness but does cause the child to act out.
This statement is false. Clampit and Pirkle (1983) stated:
When a hyperactive child suddenly increases in size and strength, the parents understandably are more fearful regarding the consequences of impulsive expression. Thus they are more likely to fall prey to the uninformed fear that medication will somehow release the monster inside the child, "stimulating" antisocial acts. Given the myth that medication, which had calmed their hyperactive child, might now stimulate their adolescent, well-intentioned parents often choose ironically to discontinue the very treatment which would give the adolescent more freedom to control impulses. (p. 817)
Statement 7: Ritalin causes children to lose their appetite.
This statement is true for most children. According to Elliott and Worthington (1995), this side effect usually diminishes after the first few weeks of taking Ritalin. If the side effect remains, the parent should schedule medication administration to fall after or at the same time the child eats. Scheduling the medication at mealtime should work because Ritalin has a 30- to 60-minute onset. For example, the child would take medication at 7:30 with breakfast, at 11:30 with lunch, and at 3:30 after school, which is long enough before a 5:30 or 6:00 dinner to not affect appetite. Many parents do not administer any medication after school unless the child has a lot of homework or there is a special function. Copeland (1994) states that not eating can cause the child to be irritable and tired, which is often mistaken as a rebound effect of Ritalin. Parents should work with the physician to adjust medication and food schedules before deciding to discontinue Ritalin.
Statements 8 and 9: Children taking Ritalin may have a hard time falling asleep, and Ritalin can cause some children to become more hyperactive.
These statements are both true. Once Ritalin has dissipated, or left the body, some parents have reported that their child is more hyperactive than before the medication and has trouble falling asleep (Elliott & Worthington, 1995). This is called the rebound effect, and it can be managed effectively without discontinuing medication. Either giving the child another dose of medication before bedtime to calm their overactivity or eliminating or cutting in half the child's last daily dose can eliminate insomnia. To help with the increased hyperactivity, Copeland (1994) suggested giving the child a third or fourth daily dose that is half of the morning or afternoon dose. The child's physician needs to be consulted before adjusting prescribed dosages.
Statements 10 and 11: Children taking Ritalin complain about their head hurting (headaches), and Children taking Ritalin complain about their belly hurting (stomachaches).
These statements are both true. To eliminate these side effects Copeland (1994) suggested that the physician should begin administering Ritalin at a low dose and increase the dosage as the side effects diminish. If the child is already on a high dose of Ritalin, the physician should try decreasing the dosage. In some instances, these side effects may actually be allergic reactions to dye in the Ritalin tablet. If these side effects persist, a different medication should be tried.
Statement 12: When children take Ritalin, it dulls their personality.
This statement is false. If children do seem to have a different, less spontaneous personality, the dosage could be too high and should be lowered. The dosage should also be lowered or the medication changed if the child appears lethargic or glassy-eyed (Copeland & Love, 1992; Silver, 1984).
Statement 13: Ritalin builds up in the child's bloodstream.
This statement is false. When a child takes medication that builds up in the bloodstream, the child will have blood tests close to every 6 months. Children who take Ritalin are not required to have blood tests very often because research indicates that Ritalin buildup is not a problem. Usually a physician, who wants to be thorough, will ask for blood tests once every 1-2 years (Silver, 1995b).
Statement 14: Ritalin can cause some children to tic.
This is a true statement. Children with a family history of tic disorder or Tourette's syndrome are more likely to develop tics when taking Ritalin. Elliott and Worthington (1995) reported that 1% of children with ADHD may develop a tic disorder. To alleviate this side effect, physicians can decrease the dosage of medication or change to a different medication.
Statement 15: Ritalin can cause children to have seizures.
This statement is false. Research suggests that Ritalin may lower the seizure threshold in children with a seizure disorder. Copeland (1994), however, states it is common practice for Ritalin to be used with seizure medication for these particular children. Ritalin does not cause a child to have seizures.
Statement 16: Ritalin can cause a child's heart to beat much faster.
This is a false statement. Ritalin may cause a slight increase in the child's heart rate and blood pressure. "When it does occur, it is often a minor increase and does not warrant discontinuation of medication" (Copeland, 1994, p. 170). If the child is already diagnosed with high blood pressure, an antihypertensive medication, Clonidine, can be prescribed. Clonidine has been found to be effective with some children with ADHD.
Statement 17: Ritalin can cause depression in some children.
This statement is false. Ritalin does not cause depression in children. If a child is suffering from depression, taking Ritalin can exacerbate the symptoms. If a child becomes sad, tearful, or "touchy" after starting treatment with Ritalin, Elliott and Worthington (1995) stated that this is a sign that the dosage is too high. Lowering the dose should diminish this side effect.
Percentage of Responses by Parents and Teachers
|Statement||Parents (%)||Teachers (%)|
|1. Children should stop taking Ritalin when they reach their teenage years.||10||82||8||25||60||15|
|2. Children build up a tolerance to Ritalin.||26||63||12||55||35||10|
|3. Taking Ritalin will lead to drug abuse later in the child's life.||3||90||8||5||90||5|
|4. Children can become addicted to Ritalin.||15||76||9||35||65||0|
|5. Ritalin will stop children from growing.||21||73||6||20||70||10|
|6. When children reach their teenage years, Ritalin no longer controls aggression and impulsiveness but does cause the child to act out.||4||81||15||15||75||10|
|7. Ritalin causes children to lose their appetite.||74||23||3||80||10||10|
|8. Children taking Ritalin may have a hard time falling asleep.||50||47||3||65||10||25|
|9. Ritalin can cause some children to become more hyperactive.||24||65||10||55||30||15|
|10. Children taking Ritalin complain about their head hurting (headaches).||33||62||5||55||25||20|
|11. Children taking Ritalin complain about their belly hurting (stomachaches).||35||63||3||40||45||15|
|12. When children take Ritalin, it dulls their personality.||32||67||1||15||60||25|
|13. Ritalin builds up in the child's bloodstream.||9||79||12||40||40||20|
|14. Ritalin can cause some children to tic (uncontrolled muscle movements).||53||41||6||65||15||20|
|15. Ritalin can cause children to have seizures.||17||63||21||10||45||45|
|16. Ritalin can cause a child's heart to beat much faster.||45||44||12||20||40||40|
|17. Ritalin can cause depression in some children.||37||45||18||55||20||25|
|n = 78||n = 20|
Teachers' and Parents' Responses
After we reviewed teachers' and parents' responses on the Ritalin Quiz, we found common misunderstandings about Ritalin. Many parents wrote that they could only answer true or false to the statements based on what they observed in their own child, or that they did not know the answer. A few teachers felt that, because they were not qualified medical personnel, they could not answer the statements knowledgeably.
What About Side Effects?
In some children, side effects are not initially apparent, but develop later. It is important to know that some of these problems can be solved without switching the child to another medication or stopping medication. Sometimes side effects develop in the beginning; but if the child and parents can tolerate these for a few weeks, the side effects commonly go away. The child's physician should be consulted about the possibility of changing the dosage.
To properly regulate a child's medication, both the parents and teachers must be informed about the medication's positive and negative effects. Being informed allows one to monitor side effects and beneficial effects of the medication both at home and at school.
How Can Parents and Teachers Become Informed?
Parents should be in close contact with the child's teachers and physicians. "Parents need in-depth information regarding the use of stimulants, so that they can make well-informed decisions about this treatment for their child" (Elliott & Worthington, 1995, p. 17).
Teachers need to know what behaviors are truly considered side effects of Ritalin so as to monitor them properly. The physician will sometimes provide a questionnaire about side effects for the teacher to complete. Howell et al. (1997) pointed out that monitoring should focus not only on side effects (e.g., headaches), but also on academic behavior (e.g., skill acquisition), classroom behavior (e.g., participation), and social interactions (e.g., interpersonal skills). Monitoring all of these domains will help determine if Ritalin is benefiting the student.
Because of the amount of misunderstanding, the question of where a parent can turn to get correct information emerges. Many parents who are seeking answers turn to other parents who have children with the same difficulties. Although this type of support is helpful, it could be a problem if inaccurate information is passed from one parent to another. Parents should be careful to encourage each other to ask questions of many individuals (e.g., physicians, teachers, parents with positive and negative experiences).
Parents will often turn to their child's teacher(s) for answers to their questions. Teachers should base their answers on fact, not opinion. If teachers are unsure about their answers, they should refer the parent back to the child's physician or other experienced professionals.
Suggestions for Teachers
Parents rely on teachers to inform them of their child's progress and behavior in school. Many times teachers will be asked to monitor a student who is taking Ritalin on a trial basis. The information the teacher passes on to the parents of this child can affect their decision to continue with medication. Here are several suggestions:
- Inform yourself about the benefits and drawbacks of Ritalin. Information about Ritalin can be found in education journals, in medical journals, and on the Internet. Parent groups such as CH.A.D.D. (Children and Adults with Attention Deficit Disorder) and L.D.A. (Learning Disabilities Association) are excellent sources of information. Check local listings for area chapters (see box "Interested in Learning More?").
- Ask parents for permission to talk to their child's physician. Talking directly to the physician can alleviate miscommunications that may occur when communicating through the parents. Also, the physician can answer questions the teacher may have about the medication.
- Know the child's dosage and what the medication looks like. Short-acting Ritalin comes in three sizes: 5-mg, 10-mg, and 20-mg. It is also available in a long-acting, sustained-release 20-mg tablet, called Ritalin-SR. This tablet lasts 7-10 hours, but it has not been as successful as the short-acting tablets (Copeland, 1994).
- Know and understand your school's policy for administering medication. In fact, as Howell et al. (1997) suggested, you should (a) learn what is required of you in terms of the medication regime, (b) be certain that you will not be held liable for someone else's mistake, (c) not administer the medications yourself, (d) provide a written report of any violations of policy regarding administration of medications, and (e) never allow medications to be stored in your classroom or to be carried about the school campus by students.
- Do not assume that once a child starts taking medication, there will be an automatic improvement in academic and social skills. These skills still need to be taught directly and cannot be ignored (Howell et al., 1997).
Although stimulant medications continue to have many critics, Wallis (1994) stated that they are the best known therapy for ADHD. We have not attempted to address the controversy about stimulant medication as an intervention. Our intent is to inform teachers and parents about Ritalin. The increased use of prescribed medications by children in the schools requires teachers and parents to be knowledgeable about those drugs, and in particular, about Ritalin, the most commonly prescribed medication.
Interested in Learning More About ADHD and Ritalin?
- The ADHD Report, published six times a year, provides up-to-date information on the evaluation, diagnosis, and management of children with ADHD. For information or to subscribe write: The ADHD Report, Guilford Press, 72 Spring Street, New York, NY 10012.
- For general information about learning disabilities, contact the Learning Disabilities Association (L.D.A.) at 4156 Library Road, Pittsburgh, PA 15234 (e-mail: firstname.lastname@example.org), or call (412) 341-1515.
- The National Information Center for Children and Youth with Disabilities (NICHCY) can provide information about ADHD. Information can be requested by writing: NICHCY, P.O. Box 1492, Washington, DC 20013-1492. The National Institute of Mental Health also provides information about ADHD in online publications. Available: http://www.nichcy.org/faqs.htm#2
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Copeland, E. D., & Love, V. L. (1992). Attention without tension: A teacher's handbook on attention disorders (ADHD and ADD). Atlanta, GA: Resurgens.
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Hancock, L. (1996, March 18). "Mother's little helper." Newsweek, pp. 51-56.
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Neuwirth, S. (1994). "Attention deficit hyperactivity disorder. National Institute of Mental Health" (NIH Publication No. 94-3572) [On-line]. Available: http://www.nimh.nih.gov/publicat/helpchild.cfm Silver, L. B. (1984). The misunderstood child: A guide for parents of learning disabled children. New York: McGraw-Hill. Silver, L. B. (1995a, February). "The confusion relating to Ritalin." Paper presented at the annual meeting of the Learning Disabilities Association, Honolulu, Hawaii. Silver, L. B. (1995b, February). "The role of medication." Paper presented at the annual meeting of the Learning Disabilities Association, Honolulu, Hawaii. Wallis, C. (1994, July 18). "Life in overdrive." Time, pp. 43-50. Christina Pancheri (CEC Chapter #823), Special Educator, Variety School of Hawaii, Honolulu. Mary Anne Prater (CEC Chapter #412), Associate Dean for Graduate Studies and Instructional Research, College of Education, University of Hawaii at Manoa. Address correspondence to Christina Pancheri, 3100L Preamble Lane, Grafton, VA 23692. Teaching Exceptional Children, Vol. 31, No. 4, pp. 20-26.
Copyright 1999 CEC. All rights reserved.
Silver, L. B. (1984). The misunderstood child: A guide for parents of learning disabled children. New York: McGraw-Hill.
Silver, L. B. (1995a, February). "The confusion relating to Ritalin." Paper presented at the annual meeting of the Learning Disabilities Association, Honolulu, Hawaii.
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Wallis, C. (1994, July 18). "Life in overdrive." Time, pp. 43-50.
Christina Pancheri (CEC Chapter #823), Special Educator, Variety School of Hawaii, Honolulu. Mary Anne Prater (CEC Chapter #412), Associate Dean for Graduate Studies and Instructional Research, College of Education, University of Hawaii at Manoa.
Address correspondence to Christina Pancheri, 3100L Preamble Lane, Grafton, VA 23692.
Teaching Exceptional Children, Vol. 31, No. 4, pp. 20-26.