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Book Forum: Somatic Therapies   |    
Ritalin: Theory and Practice, 2nd ed.
RACHEL KLEIN, PH.D.
Am J Psychiatry 2001;158:668-668. doi:10.1176/appi.ajp.158.4.668
View Author and Article Information
New York, N.Y.

Edited by Laurence L. Greenhill, M.D., and Betty B. Osman, Ph.D. Larchmont, N.Y., Mary Ann Liebert, 2000, 443 pp., $90.00.

I approached this book with some misgivings because its title connotes a promotional text about a brand drug. Since Ritalin is one of five marketed stimulants with few clinical distinctions, why focus exclusively on one? Perhaps because Ritalin, and its generic methylphenidate, are commonly prescribed in attention deficit hyperactivity disorder (ADHD) and have borne the greatest public outcry concerning alleged misuse and abuse. Therefore, a summary of current knowledge serves a useful purpose.

The book is scholarly and interesting. It does an excellent job of reviewing important, timely topics. The chapter on pharmacoepidemiology by Safer and Zito is especially informative in describing secular patterns of use. Staff from the Drug Enforcement Administration report a fivefold increase in methylphenidate "emergency room mentions" and conclude that its abuse is similar to that observed with other psychostimulants, including cocaine. This thought-provoking review would be more informative if it explained the meaning of the "mentions" in emergency room records. Could these reflect the increased use of stimulants in accident-prone children with ADHD rather than medical emergencies linked to the medication? Although cocaine and methylphenidate are mentioned with equivalent frequency in emergency room records, these figures are not interpretable because the rate of exposure for each compound is not given.

It is often assumed that adjusting methylphenidate dose to body weight equates drug exposure across individuals of differing sizes. Rapport and Denney describe empirical strategies that refute the idea that body weight is a guide to dose. Such studies are important to clinicians and parents as well as researchers who often struggle to standardize doses across individuals. This goal may well be an elusive one.

Other clinically relevant topics include the effect of anxiety disorders on methylphenidate response in children with ADHD. The jury is still out, but it seems possible that children with ADHD and anxiety disorders may differ in pharmacological sensitivity. The book serves clinicians well by also including thoughtful discussions of the effects of methylphenidate on learning and cognition, aggression, and tics as well as side effects and long-term treatment.

There is limited attention to other treatments for ADHD, except for parent training in a chapter by Schachar and Sugarman, who note a dilemma in interpreting seemingly contradictory findings. Thus, parent training alone is reported to be effective, but it offers no incremental advantage when added to methylphenidate. This conclusion is not trivial because it should guide practice. The reader would have been better served by being informed that efficacy for parent training is found on parent reports exclusively. Since parents are active treatment participants, they are likely to report improvement. Due to its timing, the text does not include the large National Institute of Mental Health study of intense psychosocial treatment and medication used alone and in combination (1), which failed to reveal superiority for combination treatment over solo medication.

The stated mission of the text is to set the record straight—a worthwhile goal given public controversies that have plagued patients and professionals. However, the examination of Ritalin focuses exclusively on ADHD, but methylphenidate has wider clinical applications. Since these are omitted, a full appreciation of methylphenidate is not part of the package. It may be time to rethink the title.

The Multimodal Treatment Study of Children With ADHD Cooperative Group: A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder. Arch Gen Psychiatry 1999; 56:1073–  1086
 
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References

The Multimodal Treatment Study of Children With ADHD Cooperative Group: A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder. Arch Gen Psychiatry 1999; 56:1073–  1086
 
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