A week ago, an op-ed appeared in the New York Times by L. Alan Sroufe, a professor emeritus of psychology at the University of Minnesota’s Institute of Child Development, questioning society’s reliance on medications to help children with attention deficit hyperactivity disorder (ADHD). He suggested that Ritalin has “gone wrong,” in that we simply rely too heavily on drugs to treat childhood disorders.
He starts off the op-ed, “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.”
Like most professionals who are trying to boil down decades worth of research into a layperson-friendly length, Dr. Sroufe unfortunately glosses over the psychological literature and what we know (and don’t know) about ADHD medications.
I will say this before we begin… most children would benefit not just from being prescribed an ADHD medication, but also getting specific psychological treatment as well. Few child psychologists and child specialists would be happy if their patients were only getting the benefits of one type of treatment, and many would agree that parents are too quick to medicate before trying non-medication options.
Which isn’t to say they would agree that ADHD medications have no place in the treatment regiment. Dr. Sroufe cites a 2009 study to prop up his anti-medication argument (oddly, the only modern research study he cites in the entire article):
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.
What Dr. Sroufe fails to mention is that this was an “uncontrolled naturalistic follow-up study” that, after 14 months of treatment in one of the four treatment groups, the subjects were welcomed to continue treatment, seek other treatment, or discontinue treatment as they saw fit. This hardly qualifies as a demonstration of treatment effects that “faded” over time.
What it does demonstrate, to me anyways, is someone who will cherry-pick the vast ADHD research literature to find something that supports his point of view, and then suggest this one study characterizes the vast majority of ADHD research. There are a dozen longitudinal studies measuring how ADHD progresses into early adulthood, and many other studies — some that are far more methodologically rigorous — that demonstrate just the opposite of Dr. Sroufe’s claims.
Alan Sroufe than carries into a tangential rant about brain imaging studies, suggesting they demonstrate little about causative factors. So if the brain isn’t to blame for ADHD behaviors, what is? Dr. Sroufe points to the child’s family environment:
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? […]
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.
The answer is, of course, that everything and anything could be to blame. We simply don’t know what the cause of most mental disorders are — including ADHD. Many ADHD researchers believe, for instance, that genetics contributes approximately three-quarters of the causative factors to attention deficit disorder, yet we have yet to identify how this expresses itself in any combination of specific genes. Perhaps genes are a necessary but not sufficient component — that something has to happen to trigger ADHD from one’s environment or development.
But rather than detail all the problems with Dr. Sroufe’s claims, I’ll point you instead to Dr. Harold Koplewicz’s rebuttal, that describes why the slam on ADHD medications is misleading at best.
In my reading of the research, it suggests to me that few children should be on ADHD medications alone. Adding a psychotherapy treatment to medications helps a child learn to augment and supplement the work of the medications, to prepare them for a time when medications can be reduced or discontinued altogether. And I firmly believe psychosocial interventions should be tried first, before ADHD medications, in most cases.
Finally, I wanted to point to an interesting blog post over at the Boston Globe from blogger Claudia M. Gold, M.D. that argues that prescribing medications to children with ADHD threatens to remove the motivation to work on its related problems:
The point of this story is that there are serious long-term consequences to prescribing stimulant medication to large numbers of children. In addition to the above dilemma, by controlling symptoms with medication, the motivation to provide more comprehensive treatment is lost. […]
Careful examination of the school setting and accommodations to decrease over-stimulation are similarly necessary. But if the drug makes the symptom go away, there is no motivation to devote effort and resources to make these kinds of changes.
I agree with her — right up to the point when she mentions a scare-mongering tidbit linking suicidal ideation and Focalin, a stimulant medication used for ADHD. Because the FDA has received 8 reports — only 4 of which they link to the medication — in the past 6 years. Odds ratios suggest these are not significant numbers compared to prescriptions, and probably do little to help inform the larger debate about how much we should be medicating children for ADHD.
Has Ritalin Really Gone Wrong?
So I end up wanting to provide some sort of answer to Alan Sroufe’s original question — why do we rely so heavily on drugs to treat mental health and behavioral health problems, especially in children? Has Ritalin “gone wrong?”
The short answer is that people have increasingly come to expect that there’s a quick fix for any problem, and that quick fix is often in the form of a pill and medical science. It is far easier for most parents to ensure their child is taking a daily medication than it is to take them to once or twice weekly psychotherapy sessions, sessions where they may also have to participate and help the child with learning new cognitive skills to help with their inattention and related problems.
This is the same reason antidepressants are far more popular among adults than psychotherapy. Psychotherapy requires not only that weekly time commitment, but also the commitment to change and willingness to try something different in your life. It requires actual work, effort and focus, week after week — something a lot of people just won’t commit to.
We can lament the popularity of psychiatric medications all we want, but ease-of-use and lower costs are two powerful factors that make the decision easy for many, many people.
Cited Articles:
Read the original New York Times op ed: Ritalin Gone Wrong
Read Harold S. Koplewicz, MD, President of the Child Mind Institute’s response: Righting the Record on Ritalin
Meds for ADHD: They Work, But Is That the Right Question?
13 comments
John Grohol quotes Claudia M. Gold, MD, who writes, “…there are serious long-term consequences to prescribing stimulant medication to large numbers of children”. Gold’s concern is indeed justified, but I think that the situation is perhaps worse than either Grohol or Gold imagine it to be.
The best recent review of the long-term harm caused by Ritalin (and related drugs) can be found in Robert Whitaker’s excellent book, Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America.
Chapter 11 (“The Epidemic Spreads to Children”) contains a lot of useful — and disturbing — information about the long-term effects that occur when childen take Ritalin and other psychotropic drugs. Google Books will allow you to read parts of the chapter for free, but you’ll have to consult the book to read all of it.
I think I can see both sides. I have epilepsy and know what such strong medications can do. I spent 2 years trying to help my son without medication. It was only until I couldn’t handle it emotionally anymore that I gave in. However, even ater 2 year of different medications, 2 family therapists and 1 psychiatrist, my son’s grades still leave alot to be desired and his lack of respect either bring me to tears or have me packing for a weekend alone every six months.
“This is the same reason antidepressants are far more popular among adults than psychotherapy. Psychotherapy requires not only that weekly time commitment, but also the commitment to change and willingness to try something different in your life. It requires actual work, effort and focus, week after week — something a lot of people just won’t commit to.
We can lament the popularity of psychiatric medications all we want, but ease-of-use and lower costs are two powerful factors that make the decision easy for many, many people.”
Amen to this comment! And people come in and are perplexed and annoyed WHEN the medications do not “fix” the problem. Gee, marital discord, unemployment, financial struggles, family dynamics of perpetual dysfunction, and whatever other major psychosocial stressors aren’t impacted by chemicals. Isn’t that in the package insert for all psychotropics?!
What a wonderful message managed care, big pharma, academic psychiatry, and too many colleagues have perpetuated on society.
Just because patients are reluctant to follow through with psychotherapy interventions that require additional time and work doesn’t mean that this is still not the best combination of treatment modalities. Perhaps we need to focus more on engaging the patient in the recommended treatment, rather than accepting their reluctance as proof of ineffectiveness.
I believe we are often ignoring the very import environmental factor of “learned behaviors” in treatment efficacy studies. Especially for those who are identified with ADHD in later childhood, adolescence or adulthood, even though stimulant medication provide symptom relief, there are still years of practiced approach and response behaviors with which the patient must contend. They are habituated to certain behaviors in certain settings, and that needs to be addressed in treatment. This is similar to the “habit strength” that is the vast majority of difficulty in achieving successful smoking cessation for cigarette smokers. Nicotine only takes about 72 hours to leave the system, and what is left is learned behavior.
Additionally, we all tend to suffer from the desire to identify over-simplistic causative factors in disorders and diseases. Human behavior seems to involve extremely complex mixtures of genetic, nutritional, familial, cultural, and environmental factors, yet we want studies to successfully target one or two causative factors before we consider them significant. The latest trend to site results from individual studies has also been a major diservice to the general public, who place disproportionate meaning on “a recent research study has shown that….”. One of my personal guidelines is, “Everything is more complicated than is convenient; and everything matters.”
The reason we treat mental illness with drugs is, well simply put, it is a natural instinct. We have had alchemist, wizards, shamen, and medicine men in every culture. It is why we as a society have issues with alcoholism, drug addiction, and prescription abuse. Because we know very little about how to control our unwanted thoughts and behaviors AND drugs aid in the repression process. But just like leaching, bleeding, or sweating doesn’t lead to long lasting physical health, neither does using drugs to treat the psyche lead to long lasting mental health.
Scratch all the manipulated and biased data, what I never understood is why a psychologist doesn’t see the damage in telling a child, “Here take these drugs, it will make you feel better.” doesn’t increase the chances that the child will grow up to accept that using other kinds of drugs to make them feel better. How does one not see the irony in the conversation, “I don’t ever want to catch you kids doing drugs again!! Where did you learn that using them is alright I will never know. Now go to your room, mommy is going to have to take another pill for her anxiety because of you!!” I don’t understand how somebody who has studied the human psyche can’t see the dysfunction in promoting drugs to small children.
Another thing I don’t understand. We can repeat experiments such as the classics that test external elements time and time again and get the same results from the likes of Zimbardo. Yet we can not say the same about any experiments where internal elements are tested. (Abu Grhaib will prove the Stanford experiments every time. Yet the introduction of AD’s into the military has not resulted in less depression, but in fact more suicides and homicides.) As an engineer, if we troubleshot planes the same why the mental health community did people, every now and then planes would just fall out of the sky, and most of the engineers would agree that the sky was to blame and we would just accept that.
Obviously you have never had to deal with children with ADHD. Spend a weekend with two children with ADHA, I promise you, within the first six hours you’ll be praying for a doctor to knock on your door with his prescription pad.
And as for your rebuking of giving children “feel-good” medicine, you do it every time you give a child an ice cream cone, candy, or a happy meal. Just because it comes in a pill all the sanctimonious wagon-jumpers want to come out of the woodworks.
Thank you for a well-reasoned response to the Times piece. I have posted it to my FaceBook page, along with Dr. Ned Hallowell’s, who sums up nicely with this: “”Ritalin, like all medications, can be useful when used properly and dangerous when used improperly. Why is it so difficult for so many people to hold to that middle ground?”
I am a [life] coaching pioneer, founder of the ADD Coaching field, and The ADD Poster Girl. Side effects preclude methylphenidate [generic Ritalin] in my case, but I have taken dex-based ADD stimulant medication for over 20 years now. With an IQ in the gifted range, my life simply did not BEGIN until I was properly medicated at 38. And, like the patients in the movie Awakenings, if you take away my medication, I go back to that time when I could not function well enough to have any sort of a life worth living.
I struggle still, remnants of decisions made during the almost four decades prior to diagnosis and medication. My life will never be what it might have been, had I been diagnosed and medicated since childhood. It breaks my heart that many parents will take the recent Times article as gospel, dooming their children to a life of needless struggle and under-performance similar to my own, simply because they will be afraid to pursue medication.
I am now an ADD expert – globally well-informed on anything and everything impacting Executive Functioning Dysregulations right down to neurochemistry. Believe me, I KNOW what to do to work with and around ADD. I teach it. I coach it. I train others to coach it. Without my medication, however, I can’t DO what I know, any more than I can focus on the words I am typing without my glasses. But I still have to know how to read!
I guess someone needs to write a Glasses Gone Wrong article. I’ll bet we could do a study where we gave 6,000 illiterates glasses and VERY few would be able to read without further interventions and supports. And if we weren’t careful to make sure the prescriptions were correct, I’ll bet many of them would suddenly develop headache side-effects, broken bones from accidents due to visual misperceptions, and who knows what else. Then we could go after the optometrists and all of the businesses that create frames and lenses – those capitalist pigs who are pushing glasses on well-intended parents.
Ridiculous, yes? So is the New York Times article. And sad. And harmful.
Madelyn Griffith-Haynie, SCAC, MCC – (blogging at ADDandSoMuchMore and on ADDerWorld – dot com!)
“It takes a village to educate a world!”
Was it Ritalin Gone Wrong or NY Times Op Ed Gone Wrong – many parents and experts are outraged. Last night I sat down with Dr Charles Parker author of New ADHD Medication Rules discussing the article and the pros and cons of medications from a professional and parental view. http://t.co/PREEJnSh
Nicely said and appreciated. I took Ritalin for the first time (at age 35) after ADHD was diagnosed by a perceptive psychologist. Contrary to what the omnipresent moron chorus everywhere keeps saying, I most certainly did not get “high.” I sat on the floor and sobbed, realizing how different my life could have been.
However, after the relief and wonder wears off, one realizes that the medicine can’t do all the work of making needed changes, and a difficult journey begins. A psychologist/”coach” is an immense help at this point, especially given that a lifetime of failure to reach potential, feeling “lost,” and hating oneself for the latest bit of impulsivity can lead to serious depression.
OMG, Thank you for saying what actually does help. Please tell me it gets better. My thoughts are like a ball of draining spaghetti and before I can get them out and untangle them, the next batch is on it’s way! I never catch up to what I meant to say, or even remember it if I do. It’s where I’m afraid to go anywhere anymore, like I make a fool of myself every time I try. I think this is the reason I like going into big cities because bouncing off the walls can seem “normal” or not as noticeable in an environment more active (“crazy-looking”) than me. Anyway, my doctor mentioned Ritalin to me last visit and I think I am ready. I am missing out on so much of my life, and every one else’s also. Thanks for listening.
Stephen
I see the need for balance but I am interested in whether the proponents have their own children on these drugs. And why aren’t diet and fitness and lifestyle change part of the treatments? Sitting still for 6 or more hours a day should not be considered normal.
As an adult with a child who has ADHD, I can easily tell you that the greatest barrier to therapy (in addition to medication) is the cost of therapy. Unless you have amazing benefits, they don’t cover this type of therapy (at most, basic therapy benefits cover very brief therapeutic interventions for a personal/family crisis and they do everything to end them within 1-3 visits due to heavy pressure from insurance problems).