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http://www.nytimes.com/2012/01/29/opinion/sunday/childrens-add-drug...
But are these drugs really helping children? Should we really keep expanding the number of prescriptions filled?
In 30 years there has been a twentyfold increase in the consumption of drugs for attention-deficit disorder.
As a psychologist who has been studying the development of troubled children for more than 40 years, I believe we should be asking why we rely so heavily on these drugs.
Attention-deficit drugs increase concentration in the short term, which is why they work so well for college students cramming for exams. But when given to children over long periods of time, they neither improve school achievement nor reduce behavior problems. The drugs can also have serious side effects, including stunting growth.
Sadly, few physicians and parents seem to be aware of what we have been learning about the lack of effectiveness of these drugs.
What gets publicized are short-term results and studies on brain differences among children. Indeed, there are a number of incontrovertible facts that seem at first glance to support medication. It is because of this partial foundation in reality that the problem with the current approach to treating children has been so difficult to see.
Back in the 1960s I, like most psychologists, believed that children with difficulty concentrating were suffering from a brain problem of genetic or otherwise inborn origin. Just as Type I diabetics need insulin to correct problems with their inborn biochemistry, these children were believed to require attention-deficit drugs to correct theirs. It turns out, however, that there is little to no evidence to support this theory.
In 1973, I reviewed the literature on drug treatment of children for The New England Journal of Medicine. Dozens of well-controlled studies showed that these drugs immediately improved children’s performance on repetitive tasks requiring concentration and diligence. I had conducted one of these studies myself. Teachers and parents also reported improved behavior in almost every short-term study. This spurred an increase in drug treatment and led many to conclude that the “brain deficit” hypothesis had been confirmed.
But questions continued to be raised, especially concerning the drugs’ mechanism of action and the durability of effects. Ritalin and Adderall, a combination of dextroamphetamine and amphetamine, are stimulants. So why do they appear to calm children down? Some experts argued that because the brains of children with attention problems were different, the drugs had a mysterious paradoxical effect on them.
However, there really was no paradox. Versions of these drugs had been given to World War II radar operators to help them stay awake and focus on boring, repetitive tasks. And when we reviewed the literature on attention-deficit drugs again in 1990 we found that all children, whether they had attention problems or not, responded to stimulant drugs the same way. Moreover, while the drugs helped children settle down in class, they actually increased activity in the playground. Stimulants generally have the same effects for all children and adults. They enhance the ability to concentrate, especially on tasks that are not inherently interesting or when one is fatigued or bored, but they don’t improve broader learning abilities.
And just as in the many dieters who have used and abandoned similar drugs to lose weight, the effects of stimulants on children with attention problems fade after prolonged use. Some experts have argued that children with A.D.D. wouldn’t develop such tolerance because their brains were somehow different. But in fact, the loss of appetite andsleeplessness in children first prescribed attention-deficit drugs do fade, and, as we now know, so do the effects on behavior. They apparently develop a tolerance to the drug, and thus its efficacy disappears. Many parents who take their children off the drugs find that behavior worsens, which most likely confirms their belief that the drugs work. But the behavior worsens because the children’s bodies have become adapted to the drug. Adults may have similar reactions if they suddenly cut back on coffee, or stop smoking.
TO date, no study has found any long-term benefit of attention-deficit medication on academic performance, peer relationships or behavior problems, the very things we would most want to improve. Until recently, most studies of these drugs had not been properly randomized, and some of them had other methodological flaws.
But in 2009, findings were published from a well-controlled study that had been going on for more than a decade, and the results were very clear. The study randomly assigned almost 600 children with attention problems to four treatment conditions. Some received medication alone, some cognitive-behavior therapy alone, some medication plus therapy, and some were in a community-care control group that received no systematic treatment. At first this study suggested that medication, or medication plus therapy, produced the best results. However, after three years, these effects had faded, and by eight years there was no evidence that medication produced any academic or behavioral benefits.
Indeed, all of the treatment successes faded over time, although the study is continuing. Clearly, these children need a broader base of support than was offered in this medication study, support that begins earlier and lasts longer.
Nevertheless, findings in neuroscience are being used to prop up the argument for drugs to treat the hypothesized “inborn defect.” These studies show that children who receive an A.D.D. diagnosis have different patterns of neurotransmitters in their brains and other anomalies. While the technological sophistication of these studies may impress parents and nonprofessionals, they can be misleading. Of course the brains of children with behavior problems will show anomalies on brain scans. It could not be otherwise. Behavior and the brain are intertwined. Depression also waxes and wanes in many people, and as it does so, parallel changes in brain functioning occur, regardless of medication.
Many of the brain studies of children with A.D.D. involve examining participants while they are engaged in an attention task. If these children are not paying attention because of lack of motivation or an underdeveloped capacity to regulate their behavior, their brain scans are certain to be anomalous.
However brain functioning is measured, these studies tell us nothing about whether the observed anomalies were present at birth or whether they resulted from trauma, chronic stress or other early-childhood experiences. One of the most profound findings in behavioral neuroscience in recent years has been the clear evidence that the developing brain is shaped by experience.
It is certainly true that large numbers of children have problems with attention, self-regulation and behavior. But are these problems because of some aspect present at birth? Or are they caused by experiences in early childhood? These questions can be answered only by studying children and their surroundings from before birth through childhood and adolescence, as my colleagues at the University of Minnesota and I have been doing for decades.
Since 1975, we have followed 200 children who were born into poverty and were therefore more vulnerable to behavior problems. We enrolled their mothers during pregnancy, and over the course of their lives, we studied their relationships with their caregivers, teachers and peers. We followed their progress through school and their experiences in early adulthood. At regular intervals we measured their health, behavior, performance on intelligence tests and other characteristics.
By late adolescence, 50 percent of our sample qualified for some psychiatric diagnosis. Almost half displayed behavior problems at school on at least one occasion, and 24 percent dropped out by 12th grade; 14 percent met criteria for A.D.D. in either first or sixth grade.
Other large-scale epidemiological studies confirm such trends in the general population of disadvantaged children. Among all children, including all socioeconomic groups, the incidence of A.D.D. is estimated at 8 percent. What we found was that the environment of the child predicted development of A.D.D. problems. In stark contrast, measures of neurological anomalies at birth, I.Q. and infant temperament — including infant activity level — did not predict A.D.D.
Plenty of affluent children are also diagnosed with A.D.D. Behavior problems in children have many possible sources. Among them are family stresses like domestic violence, lack of social support from friends or relatives, chaotic living situations, including frequent moves, and, especially, patterns of parental intrusiveness that involve stimulation for which the baby is not prepared. For example, a 6-month-old baby is playing, and the parent picks it up quickly from behind and plunges it in the bath. Or a 3-year-old is becoming frustrated in solving a problem, and a parent taunts or ridicules. Such practices excessively stimulate and also compromise the child’s developing capacity for self-regulation.
Putting children on drugs does nothing to change the conditions that derail their development in the first place. Yet those conditions are receiving scant attention. Policy makers are so convinced that children with attention deficits have an organic disease that they have all but called off the search for a comprehensive understanding of the condition. The National Institute of Mental Health finances research aimed largely at physiological and brain components of A.D.D. While there is some research on other treatment approaches, very little is studied regarding the role of experience. Scientists, aware of this orientation, tend to submit only grants aimed at elucidating the biochemistry.
Thus, only one question is asked: are there aspects of brain functioning associated with childhood attention problems? The answer is always yes. Overlooked is the very real possibility that both the brain anomalies and the A.D.D. result from experience.
Our present course poses numerous risks. First, there will never be a single solution for all children with learning and behavior problems. While some smaller number may benefit from short-term drug treatment, large-scale, long-term treatment for millions of children is not the answer.
Second, the large-scale medication of children feeds into a societal view that all of life’s problems can be solved with a pill and gives millions of children the impression that there is something inherently defective in them.
Finally, the illusion that children’s behavior problems can be cured with drugs prevents us as a society from seeking the more complex solutions that will be necessary. Drugs get everyone — politicians, scientists, teachers and parents — off the hook. Everyone except the children, that is.
If drugs, which studies show work for four to eight weeks, are not the answer, what is? Many of these children have anxiety or depression; others are showing family stresses. We need to treat them as individuals.
As for shortages, they will continue to wax and wane. Because these drugs are habit forming, Congress decides how much can be produced. The number approved doesn’t keep pace with the tidal wave of prescriptions. By the end of this year, there will in all likelihood be another shortage, as we continue to rely on drugs that are not doing what so many well-meaning parents, therapists and teachers believe they are doing.
Permalink Reply by Kelley Woods on "One of the most profound findings in behavioral neuroscience in recent years has been the clear evidence that the developing brain is shaped by experience." - Eureka! It's so important that parents begin to consider the possibility that their child's problems may be sourced elsewhere. (Clean up that diet, along with the environment!)
"Behavior problems in children have many possible sources. Among them are family stresses like domestic violence, lack of social support from friends or relatives, chaotic living situations, including frequent moves, and, especially, patterns of parental intrusiveness that involve stimulation for which the baby is not prepared. For example, a 6-month-old baby is playing, and the parent picks it up quickly from behind and plunges it in the bath. Or a 3-year-old is becoming frustrated in solving a problem, and a parent taunts or ridicules. Such practices excessively stimulate and also compromise the child’s developing capacity for self-regulation." - Like disappointing a child with a crummy Christmas gift from Santa?!
Excellent article, Michael. Thank you so much. You, I and many other enlightened souls believe in treating children not only as individuals but as equal humans deserving all the rights, freedom and protection we can provide. Keep spreading the word...
PS ~ When public school "experts" tried to convince me my first grader had ADHD and suggested he be treated with Ritalin I just said, "No" and started homeschooling him. Their complaint was that he talked too much, he refused to clean out his desk of papers and that he couldn't read (he was reading "The Adventures of Tom Sawyer" at home with his cat every night...) Today, he's a sharp 18 yr old who just designed an Artificial Intelligence computer program for his Vo-Tech course at the local community college. Oh...and he's drug free!
Permalink Reply by Bill Kennedy on This is an opinion piece, not an overview of ADHD research. A balanced view of the need for research, which raises many of the issues in this opinion piece can be found in the Centers for Disease Control and Prevention site here: http://www.cdc.gov/ncbddd/adhd/research.html For example, Sroufe says, "To date, no study has found any long-term benefit of attention-deficit medication on academic performance, peer relationships or behavior problems." The problem with this statement is that for a long time, the research was focused on school aged boys and rarely went for more than 15 months. Sroufe should be pointing to the lack of research rather than the efficacy of the medication. The CDC is looking to rectify this lack of research.
In the talk with ADHD specialist, Dr. Umesh Jain of the Sick Children's Hospital in Toronto, which I summarized here: http://www.hypnothoughts.com/group/kidsworks/forum/topics/coping-wi...
there is a list of 5 attentional issues that look like ADHD in a school setting. I also included his list of interventions. You will note that medication comes last in the list. Dr. Jain said that the statistics are clear: an alarming number of prescriptions for ADHD medication are written by doctors with no training in this area. Yes, children are being underdiagnosed and overmedicated. Just don't throw the baby out with the bathwater.
Attentional issues are real. It is damaging for a child to be told that (s)he should just get on with it or quit complaining, when what they need is help rather than yet another blow to their self-esteem.
I am a little surprised that Sroufe does not talk about other interventions for ADHD. He mentions only medication and cognitive behavioral therapy. He does not discuss the other strategies used by Dr. Jain and other ADHD specialists, which I summarized. Where are sleep, exercise and nutrition? What about coaching and goal setting strategies? In addition, the idea that medication can be used as a short-term bridge to a long-term medication-free solution should be explored as well.
I too have had a teacher tell me that my son was behind for his age. Once we informed the teacher that our son was left handed (something she initially denied), his performance increased dramatically. Teachers are only human and ours had 29 other children to contend with at the same time.
We don't need more rants and conspiracy theories. We need to get the word out that there are excellent strategies for attentional issues, in both children and adults. And yes, medication is one of them.
Permalink Reply by Bill Kennedy on Response from the Canadian ADHD Resource Alliance:
RE: NATIONAL POST [New York Times] ARTICLE JANUARY 31ST, 2012 – RITALIN GONE WRONG
Few physicians and parents are aware of the “lack of effectiveness of ADHD drugs”, claims Dr. L Alan Sroufe in his misleading article: “Ritalin Goes Wrong”. In fact, it is Dr Sroufe who shows blatant disregard for years of peer-reviewed medical studies documenting the efficacy of ADHD medication.
His article ignores decades of genetic research that indicates ADHD is highly inheritable. It dismisses modern brain scan technology showing considerable difference in the brains of children, adolescents and adults with ADHD compared to the brains of individuals without ADHD. Like autism, bipolar disorder and schizophrenia, ADHD is a disorder of the brain. It is not caused, as suggested by Dr Sroufe, a University of Minnesota psychologist, by “experiences in early childhood”.
We, the Board of the Canadian ADHD Resource Alliance, agree that not everyone who is forgetful or very active has ADHD. There are comprehensive guidelines that assist healthcare professionals identify and treat individuals with the disorder. Medication is part of a multi modal treatment approach (along with psychosocial treatment and individual and family interventions).
Contrary to claims in “Ritalin Gone Wrong”, the stimulant medications used for treating ADHD are considered among the most effective medications in all of medicine. They have been in more or less continuous use since 1937. As clinicians practicing in the ADHD field for more than 25 years, we have seen firsthand that these medications are safe and effective over the long-term, with few side effects.
The decision to use medication must be an informed decision involving both parents and physicians. This article will unnecessarily worry parents who have made the decision to place their child on medication, add to the stigma erroneously associated with ADHD medication, and may make them feel like bad parents.
Dr Sroufe refers to the exhaustive study of the use of stimulant medication for ADHD, the Multimodal Treatment Study of Children with ADHD (MTA), funded by the National Institutes of Health in the United States. This is the largest and most comprehensive treatment study of ADHD that has ever been conducted and one of the seven international study sites was in Montreal. The study proved conclusively that stimulant medication, given on a regular basis and in a supervised setting, is very effective for treating the symptoms of ADHD.
The article choses to focus on follow-ups to this study that were inconclusive but fails to explain this is largely due to poor compliance once children and adolescents left a vigorous study protocol. What is not said is that long-term randomized studies on the effects of ADHD medication are incredibly expensive and difficult to conduct; they are also unethical as they would involve children given a placebo for years for the purpose of a study.
When participants leave the controlled research environment created within a study, community follow-up is often poor. There are infrequent medication visits (one or two per year) with usually no input from the school to guide medication adjustment. This poor follow-up often results in patients discontinuing their medication either because of a lack of effect or side effects. Regular, standardized follow-up in the community is essential in order to improve the long-term outcome in patients with ADHD and to maintain the kind of treatment gains seen in the short-term with carefully monitored interventions.
In his article, Dr. Sroufe appears to be trying to make the point that inappropriate use of medication to deal with children’s behavioural problems or disadvantaged environments is wrong. CADDRA is in total agreement with him on this point but his scatter-gun approach, raising concerns about the diagnosis of ADHD and its appropriate treatment with stimulant medication as well as other modalities of treatment, is doing a great disservice to Canadians who suffer from this condition and the doctors, psychologists and mental health workers who struggle to assist them.
Yours respectfully,
Lily Hechtman MD, FRCPC, Professor, Psychiatry & Paediatrics, McGill University, Montreal, QC
CADDRA Board
Canadian ADHD Resource Alliance
CADDRA is a Canadian, national, not-for-profit association. We are the voice of doctors who support patients with Attention Deficit Hyperactivity Disorder (ADHD) and their families.
Permalink Reply by Michael Ellner on Response from Michael E.
Bill Kennedy said:
Response from the Canadian ADHD Resource Alliance:
RE: NATIONAL POST [New York Times] ARTICLE JANUARY 31ST, 2012 – RITALIN GONE WRONG
Few physicians and parents are aware of the “lack of effectiveness of ADHD drugs”, claims Dr. L Alan Sroufe in his misleading article: “Ritalin Goes Wrong”. In fact, it is Dr Sroufe who shows blatant disregard for years of peer-reviewed medical studies documenting the efficacy of ADHD medication.His article ignores decades of genetic research that indicates ADHD is highly inheritable. It dismisses modern brain scan technology showing considerable difference in the brains of children, adolescents and adults with ADHD compared to the brains of individuals without ADHD. Like autism, bipolar disorder and schizophrenia, ADHD is a disorder of the brain. It is not caused, as suggested by Dr Sroufe, a University of Minnesota psychologist, by “experiences in early childhood”.
We, the Board of the Canadian ADHD Resource Alliance, agree that not everyone who is forgetful or very active has ADHD. There are comprehensive guidelines that assist healthcare professionals identify and treat individuals with the disorder. Medication is part of a multi modal treatment approach (along with psychosocial treatment and individual and family interventions).
Contrary to claims in “Ritalin Gone Wrong”, the stimulant medications used for treating ADHD are considered among the most effective medications in all of medicine. They have been in more or less continuous use since 1937. As clinicians practicing in the ADHD field for more than 25 years, we have seen firsthand that these medications are safe and effective over the long-term, with few side effects.
The decision to use medication must be an informed decision involving both parents and physicians. This article will unnecessarily worry parents who have made the decision to place their child on medication, add to the stigma erroneously associated with ADHD medication, and may make them feel like bad parents.
Dr Sroufe refers to the exhaustive study of the use of stimulant medication for ADHD, the Multimodal Treatment Study of Children with ADHD (MTA), funded by the National Institutes of Health in the United States. This is the largest and most comprehensive treatment study of ADHD that has ever been conducted and one of the seven international study sites was in Montreal. The study proved conclusively that stimulant medication, given on a regular basis and in a supervised setting, is very effective for treating the symptoms of ADHD.
The article choses to focus on follow-ups to this study that were inconclusive but fails to explain this is largely due to poor compliance once children and adolescents left a vigorous study protocol. What is not said is that long-term randomized studies on the effects of ADHD medication are incredibly expensive and difficult to conduct; they are also unethical as they would involve children given a placebo for years for the purpose of a study.
When participants leave the controlled research environment created within a study, community follow-up is often poor. There are infrequent medication visits (one or two per year) with usually no input from the school to guide medication adjustment. This poor follow-up often results in patients discontinuing their medication either because of a lack of effect or side effects. Regular, standardized follow-up in the community is essential in order to improve the long-term outcome in patients with ADHD and to maintain the kind of treatment gains seen in the short-term with carefully monitored interventions.
In his article, Dr. Sroufe appears to be trying to make the point that inappropriate use of medication to deal with children’s behavioural problems or disadvantaged environments is wrong. CADDRA is in total agreement with him on this point but his scatter-gun approach, raising concerns about the diagnosis of ADHD and its appropriate treatment with stimulant medication as well as other modalities of treatment, is doing a great disservice to Canadians who suffer from this condition and the doctors, psychologists and mental health workers who struggle to assist them.
Yours respectfully,
Lily Hechtman MD, FRCPC, Professor, Psychiatry & Paediatrics, McGill University, Montreal, QC
CADDRA BoardCanadian ADHD Resource Alliance
CADDRA is a Canadian, national, not-for-profit association. We are the voice of doctors who support patients with Attention Deficit Hyperactivity Disorder (ADHD) and their families.
Permalink Reply by Bill Kennedy on Hi Michael,
You could well be right, however, if they are a front for big-pharma, they are being subtle about it. For example, this is their discussion of the treatment of young children. They use medication as a last resort:
The new American Academy of Pediatrics (AAP) Guidelines on diagnosing and managing ADHD in children, which recommend that doctors evaluate children between the ages of four and 18 years that show symptoms, have generated significant media coverage across Canada since their release. Their previous Guidelines put the span at six to 12 years of age.
The concern expressed in many of news reports is that the lowering of the diagnosis and treatment age may lead to both over-diagnosis and to children prescribed medications at a very young age that they may not need.
The main points of the new AAP Guidelines are:
The CADDRA Board would like to reiterate that, in the comprehensive evaluation, a health professional needs to rule out other causes for inattention, hyperactivity and impulsivity. These other causes can include medical causes such as hearing and vision problems, hyper or hypothyroidism, hypoglycaemia, petit mal epilepsy or mild retardation.
Practitioners should also exclude psychiatric causes such as anxiety, depression, etc.
With young children, parent training is critical to assist parents in helping their children deal adaptively with their symptoms. This is the first approach. Medication is added in small dosages only in extreme situations where parent training and behavioural management have proven inadequate.
The CADDRA Guidelines include specific information on the diagnosis and treatment of children in Chapter 3and information and guidance on psychosocial interventions and treatment in Chapter 6.
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