Ritalin Gone Right: Children, Medications and ADHDA 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?