On Sunday, Jan. 29th, the New York Times fired a shot across the bow of every parent of a child who's taking stimulant medications for ADHD. A piece in the Times' Sunday Review section claimed that there is no evidence that medication helps kids with ADHD after an initial couple of years, and, worse, that ADHD is the result of abusive or even garden-variety bad parenting.
The piece, by L. Alan Sroufe, a psychology professor emeritus at the University of Minnesota, was such a broad assault on what we know about ADHD, and how it is affected by medications like Ritalin and Adderall, that it deserves point-by-point response.
1. Dr. Sroufe claims that studies show that stimulant meds are not effective after the first two years. He refers specifically to a long-term study published in 2009 of 600 children who were treated with medication, or intensive psycho-social interventions, or both. After 14 months the children showed a positive response to medication, and those who had the combined treatment did a somewhat better still. But following up with the kids 8 years later, researches found the benefit had eroded. What he doesn't explain is that after the first 14 months the children were no longer being treated as part of the study. The authors of the study itself call it an "uncontrolled naturalistic follow-up study." In the latter 6 years the children got what the authors call "routine community care. " No surprise that, as they note, "the differential effects of the ADHD treatments, evident when the interventions were delivered, attenuated when the intensity of treatment was relaxed."
The point here is that when we prescribe Ritalin or Adderall for ADHD we don't claim to be curing it. There is no cure for ADHD. We claim that it helps kids while they are taking it by reducing excessive inattention, impulsivity and hyperactivity so they are able to function better in every part of their lives -- at school, with friends, and within their families. There is abundant evidence that it does that, and that kids with ADHD who are treated with medication do have fewer symptoms and function better. As my colleague Dr. Rachel Klein, who has led seminal research on ADHD, explains, "The medications work as long as you give them. That's true of all psychiatric treatments and most medical treatments. Arthritis, diabetes, congestive heart failure. We don't have cures for many chronic illnesses. So, yes, it's too bad, but it doesn't follow that we should not use the treatment."
By the end of adolescence many children no longer need medication, as they have outgrown their ADHD. Others (figures range from 35% to 40%) will continue to experience some symptoms -- and may continue to use medication -- all their lives.
2. Dr. Sroufe suggests that because we don't have randomized studies of the effectiveness of the drug for more than two years, we should conclude that those benefits don't continue. There is no reason to draw this conclusion, especially given overwhelming clinical evidence that it continues to work, in adulthood as well as childhood. There are no randomized long-terms studies that show continued effectiveness of insulin for diabetes either. These kind of studies are extremely difficult and extremely expensive and often unethical: you can't put a child on a placebo for his entire adolescence for the purpose of a study.
3. At the heart of Dr. Sroufe's attack on medication is his observation that many "behavior problems" appear to be generated by a child's environment, including disadvantaged, stressed, chaotic home situations. This is certainly true; the mistake here is to assume that all children who have problems with behavior -- impulsivity, inattention, trouble self-regulating -- have ADHD.
"Yes, there could be some children who show inattention and hyperactivity because their environment hasn't given them the opportunities for appropriate development," notes Dr. Klein. "There are different causes to different presentations. It doesn't mean that one invalidates the other. They can co-occur. And the challenge to the clinician is to distinguish them."
One of Dr. Sroufe's studies, done in the 1970s, was on treating what the authors called "problem children" with stimulant drugs. This vagueness may have been acceptable in the '70s, but it's not now. Many kids with behavior problems don't have ADHD -- or don't only have ADHD. For many kids, stimulant medications are not the right (or the only) needed intervention. But that doesn't mean they don't work for kids who have been accurately diagnosed with ADHD.
4. Dr. Sroufe suggests that since we don't know how these medications work, we should be reluctant to use them. If this standard was applied to all medications, a great many wouldn't pass the test. We didn't understand the mechanism of action of aspirin until the 1970s -- some 70 years after it became widely used. "There are lots of things we do that help people, but we're not sure how they work," says Dr. Klein. "But if they work, we use them. Understanding the mechanism is a goal for science, but it's not a requirement for therapeutic action."
5. Dr. Sroufe notes accurately that these medications have side effects, notably problems with sleep and appetite, which can lead to what he calls "stunted growth." What he doesn't note is that sleep and appetite problems tend to go away after the first month or two, and if they don't we try changing the dose or the kind of medication until we solve the problem. No one said these medications should be used without careful monitoring. The charge of "stunted growth" is an exaggeration; the reality is that kids do fall slightly behind their peers in growth in the first year they take medication, but they also, according to a 2010 study, catch up by the fourth year.
The reality is that the side effects of Ritalin or Adderall are much less problematic than those of many medications considered invaluable. "There are side effects to almost all drugs," Dr. Klein notes. "Aspirin can be lethal. You can have lethal bleeding from aspirin. Does it mean it should never be used? That would be absurd." The fact is that the rate of response (the percentage of cases in which it is effective) is one of the highest in medicine--higher, for instance, than most antibiotics.
6. Dr. Sroufe paints a scary picture of stimulant medications changing a child's brain, that they "develop a tolerance for the drug," and "become adapted to the drug" so that if they stop taking it their symptoms become worse. In fact, there is no evidence at all that kids develop habituation or tolerance to stimulant medications, that they need escalating amounts to get the same effect. And while it is true that there's something called "rebound" that can cause irritation and exacerbated symptoms when the drug wears off, this is a temporary effect, not unlike, as Dr. Sroufe himself points out, if you suddenly cut back on caffeine.
7. In a way the most distressing comment Dr. Sroufe makes in this piece is that ordinary parents who make ordinary mistakes during a child's early development could result in the kind of brain changes we see in children with ADHD. He includes among these potential sources not only "family stresses like domestic violence, lack of social support from friends or relatives, chaotic living situations, including frequent moves," but also, bizarrely, "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."
It's certainly true that parental patterns influence the development of a child's ability to regulate his behavior, and that changing those patterns can help a child learn to rein in his own disruptive behavior -- we see it work spectacularly in parent-child interaction therapy (PCIT). But PCIT doesn't cure the core symptoms of ADHD; in fact kids with severe ADHD usually have to be on medication to be able to focus enough on the training sessions to learn effectively from them.
The sad thing here is that I think what Dr. Sroufe really wanted to argue for in this piece is that knee-jerk use medication isn't the right response to behavioral problems -- or the only necessary response. Kids may get prescribed drugs because it's cheaper and easier than figuring out what's causing the behavior. Many kids who show some of the symptoms of ADHD may have other psychiatric problems that need attention -- they may have anxiety disorders or be on the autism spectrum. Or they may need relief from a chaotic or abusive home situation, consistent support and discipline from their parents, positive role models, and many other things that are harder to muster than a prescription.
We agree with Dr. Sroufe that that is unfortunate. It's too bad that to make that case, he attacked the well-established effectiveness for medications that really do work for kids who have ADHD.
Harold S. Koplewicz, M.D., is a leading child and adolescent psychiatrist and the president of the Child Mind Institute. For more about ADHD, go to childmind.org, which also offers a wealth of information on childhood psychiatric and learning disorders.