The Children of Israel – 2: Ritalin – Right or Wrong?

In the first blog, I noted that once Israel ratified the UN Convention on the Rights of Children, all children are entitled by law to be protected, to have their developmental needs provided for and to be allowed participation in decisions made on their behalf. Let me describe what I consider best practice regarding children who are inattentive at school and may benefit from Ritalin. I will place in parentheses the aspects of the child’s rights that are respected in such practice:

Allon is seen for an hour or two and establishes contact with a child psychiatrist and to consider carefully whether anxiety, depression or family tensions may be at the root of his inattention (provision). Allon’s parents are seen for an additional hour. Now Allon is told, “Would you like to try to find a way to be better focused in class? At home? If you would like to try this pill, you will know very quickly if it suites you. You will also know very quickly if it is not right for you(provision, participation). Now, this little white pill certainly cannot make attention. Only you can make attention. And at some point you will probably want to see if you can pay attention even without Ritalin. When you want to try this, tell me and we will make the try together. We can do it more than once (provision, participation).

“When medicine is like science, it knows the past, not the future. SO we are making an experiment, we agree it is worth a try. You are the director of this experiment; I and your parents are your advisors. At any time, you may say that you are not satisfied with the experiment and we will stop this particular pill (participation).

“You can start with ½ pill the first day. Every day increase by ½ pill until you feel you are getting the kind of help you want. Be in touch with me by phone to let me know every day or so how you are feeling and as partners we can decide on the next step. We will get to the right morning dose together. Then you will tell me if the kind of result that you like in the morning would be worth trying to get in the afternoon. I will help you to figure out the best way to get to this (provision, participation).

You and your parents may prefer to try alternative approaches before trying Ritalin, There are several natural approaches including Chinese herbs; dietary supplements and neurofeedback. Let us decide together what to try in what order (provision, participation).

“In addition to what you can do, we will have a careful look at what the school could be doing better to make how it teaches you be better suited to you.”

Just how far this practice deviates from the reality for many children in Israel can be seen by the following (composite) description of a family’s experience. Again in parentheses I note which of the child’s rights are being violated.

“We think Allon just doesn’t like his third grade teacher and she seems not to like him. He was fine until now. He bothered the class discipline a bit and suddenly she says she’s sure he needs Ritalin (failure of protection, provision and participation). We told her we differ but then we were invited to speak with the school psychologist who said that for sure he has ADD (failure of provision) and had better see a neurologist as soon as possible. The school suggested on particular neurologist who is an expert in this area. We understand that more than 9 out of 10 kids who go to this neurologist get Ritalin (failure of provision and participation). The neurologist read the teacher’s checklist, talked to Allon with us for 10 minutes and sat him at a computer (failure of provision and participation). The computer results were ADD, we were given a prescription for Ritalin 20 mg Long Acting and told to come back in 6 months (failure of provision and participation). Allon feels queasy with the Ritalin and says it slows him down (failure of protection). We talked with the family doctor who said we could try another Ritalin if we wished (failure of provision).”

Parents residing in the USA may recognize this last scenario as all too familiar, but then, as I pointed out in the last blog, the USA never ratified the UN Convention on the Rights of Children, but Israel did, and a full 25 years ago.

I became “board certified” in pediatrics in the USA a full 35 years ago, and in child psychiatry two years later. Let me be clear how I view this very unusual medical issue. On the one hand, I agree with those physicians who see very little reliable science in the “Attention Deficit” diagnosis. On the other hand, I have seen many children helped by Ritalin or other stimulants to achieve a more favorable developmental result in terms of intellectual function and emotional self-confidence and self-worth.  That is why I see the issue as mainly an “experiment” in each case. There is little to lose from a brief trial of Ritalin. There is a great deal to lose in making a “diagnosis” as if it is certain that Ritalin and only Ritalin could properly fix an inadequate brain (that is the way children often interpret their “diagnosis” if the issue is not mediated properly).

In the case of Ritalin, best medical practice and insistence upon the child’s rights go hand in hand. I would like to consider here what we may learn about the status of children in the State of Israel today from the widespread suboptimal practice that abrogates their legal rights.

Scarcity of resources would be the first “explanation.” Israeli medical personnel cannot cope with the flood of referrals and have to cut corners. To my mind this explanation comes up short. How shall we explain this “flood” of referrals since about 1995? Do we not have a circle here, the overly quick diagnoses themselves opening the flood gates?

I believe a more complete explanation is rooted in the educational system, with the “medical” practice mainly a by-product. Over the last two decades Israel has become an OECD outlier in its investment in education. The unbelievably low salaries and high work load (including overcrowded classrooms) produce a negative motivation for capable young people to pursue a career in education. The “economy” of Israel is popularized as one of “hi-tech” and that is where young people feel some hope of success and recognition. Some journalists began to suspect that the government’s management of the last teacher’s strike suggested an interest in actually increasing the gap between the public education sector and the private, another expression of the peculiar logic of the last several governments’ policies that make the gap between rich and poor in Israel another OECD outlier.

According to the possible “logic” behind these recent trends, the public educational system does not serve its supposed classical function of providing educational opportunity to all children. Rather, this system widens the gap of resources already in childhood. The schools serve to concentrate “wealth” in the sense of educational resources. The “result” that richer kids “do better” would look like a justification for the concentration of “success” among the better endowed sector.

Suboptimal treatment with Ritalin then serves as a discriminator, not as an equalizer. This is a description of how things are operate in fact, a ”dispotif” in the terminology of social critic Michel Foucault, with whom I engaged in a book-length virtual “discussion” of my experiences in mental health in my recent Losing It (Hadassa Word Press, 2015). Optimal practice with Ritalin would be an equalizer, a tool worth trying if the results would be equalizing, i.e. a happier more successful camper. But suboptimal Ritalin practice works in just the opposite direction. The teacher needs something to quiet down the less attentive kids in an overcrowded classroom. The “diagnosis” effectively “blames the victim” – the class, teacher, Minister of Education are all fine, but your brain is not, Sonny.  The school can virtually force you to take this pill, without any feedback regarding its result or even its precise dosing. It really does not matter if it makes you learn or not, as long as it makes the classroom more tolerable.

These unfortunate (or perhaps highly desirable to someone) results are of course familiar to Americans of my generation. The year 1978 signified a complete shutdown of the suboptimal practice of Ritalin for about five years. Dinosaurs like me recall it well. The first 20 year studies of the results of Ritalin for MBD (that it what it was called then –Minimal Brain Damage) showed that the treated kids were more quiet but did not learn and many of them were on the street or disturbed. In addition, studies suggested that taking Ritalin cut your height a bit. Finally, the “paradoxical effect” that justified the use of Ritalin, (on the logic that if a stimulant could quiet you down “paradoxically” that very fact proved the diagnosis) was shown to be the scientific and methodological equivalent of bullshit.

But there was more. MBD was at the time supposedly a disorder especially of premature babies who were presumable hypoxic early on. And where were the bulk of preemies in the big cities? –In the minority ghettoes where adolescent pregnancy was rife and prenatal care sorely lacking. And of course, where the schools were overcrowded and barely functioning. The proportion of kids in these schools who were getting Ritalin was approaching 20%!  So “we doctors” found out that the ghetto felt that we were “pushing speed” on all their kids to shut up the protest about terribly unequal medical and educational services – and turning them into “shrimps” at that!. The result was “politically unsustainable” and Ritalin was barely prescribed for half a decade.

Ritalin is not the issue. Even “Big Pharma” profits are not the issue. Used properly, in optimal provision and participation with the child and his family, it can produce favorable results and serve as an equalizer and even organize people to insist on a change in priorities in educational investment. What is of interest here is that the very fact that the suboptimal use of Ritalin tramples the rights of children serves as well as a warning regarding the social and economic policies that many have claimed inform the budgets of the governments of the last two decades. Attention to the rights of children then becomes a marker, and a possible instrument of social protest and change.

About the Author
Alan Flashman was born in Foxborough, MA, and gained his BA from Columbia, MD from NYU, Pediatrics, Adult and Child Psychiatry at Albert Einstein. He has practiced in Beer Sheba since 1983, and taught mental health at Hebrew University, Tel Aviv University and Ben Gurion University. Alan has also edited readers on Therapeutic Communication with Children (2002) and Adolescents (2005).