I became intrigued by an article that I read a few weeks ago in the NY Times and I keep finding myself coming back to it as I work with parents.  The topic?  Medication may not be as magical in treating ADHD as we had all hoped.

Now before I go any further, let me make clear that I am not a medical doctor and I am in no way trying to urge parents to discontinue their child’s ADHD medication.  I am, however, suggesting that parents continue to inform themselves of research findings in this area so they can discuss new information with their child’s treating physician and make informed choices as a result.

Dr. Sroufe, the author of the article and professor emeritus at the University of Minnesota’s Institute of Child Development, argues that the research world has a pattern of focusing on short-term effects of ADHD medication and fails to pay enough attention to long-term effects. 

It has been well-established that medications like Ritalin and Adderall can improve concentration and focus in individuals with ADHD.  These short-term effects can render a child once known for climbing the classroom walls able to sit and focus on reading.  Score one for medication!  (By the way, Dr. Sroufe states that these effects ring true for everyone and not just those with ADHD.) 

Dr. Sroufe goes on to look at the effects of long-term use of stimulant medication, and these don’t sound as fabulous.  He tells us that the positive effects lessen over time as people develop a tolerance to the drugs.  He also argues that the upsurge in behavior problems that parents report when they take their child off stimulant medication is actually due to withdrawal effects in a body that has become accustomed to the drug.  

Here’s the juicy part.  Dr. Sroufe reports that no studies have been able to support long-term benefits of using ADHD medication in the areas of behavior, academic performance, or relationships with peers.  “What?!” you may ask.  In fact, a long-term, well-conducted study that he cites from 2009 looked at a large group of children (almost 600) with attention problems that were placed into one of four groups: medication alone, medication + cognitive-behavioral therapy (CBT), CBT alone, or no treatment.  While initial results tooted medication’s horn, the results diminished over time to the extent that by eight years there were no detectable benefits to medication use in the areas of behavior and academics.  “Double what?!” you may now ask.

Argument is also made for a profound environmental component to the development of ADHD, effects that Dr. Sroufe says the research community has not addressed because the focus has been placed on brain and biological research.  And, Dr. Sroufe states, medication is no cure for environmental causes of ADHD symptoms.  For example, exposure to trauma can change the way our brains operate and the way we think, feel, and behave.  In fact, many trauma-related symptoms look a whole lot like what we see in ADHD.  A psychostimulant may help the traumatized child focus better at school, but does it address the trauma? 

In my own work with children with ADHD and their parents, I find that the most work gets done when there is a meaningful shift made at home and at school.  More structure, more predictability, more skills to help regulate emotions, plenty of fresh air and active play, changes meant to soothe and to ease anxiety and distress, improve adult-child communication and increase self-care in academic and social settings.  I could go on and on here.  My point is that there really are an astounding number of ways to change the experiences of children with ADHD.  Yes, medication may help and it sure is quick.  Over the long-term, we may need to be considering a whole lot more than that, though.

Thanks for reading.  –Anita

Source: Sroufe, L.A. (2012 January 28). Ritalin Gone Wrong. The New York Times.  Retrieved from www.nytimes.com

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4 Responses to Special Editorial: Shooting Holes in the Argument for Ritalin

  1. Dr. Sroufe’s argument about the lack of long-term evidence for ADHD medications is misleading. He makes it sound as though studies have failed to show any benefit of long-term use of stimulants. In fact – and I’ve combed the literature quite thoroughly in researching my book on young people who grew up taking psychiatric medications – there are next to no controlled, randomized, prospective studies that follow kids from childhood onward while they take medication and compare them to kids who don’t. This is true not just of ADHD medications, but of psychiatric medications in general. As I argue in my forthcoming book, Dosed: The Medication Generation Grows Up, medication use from a young age often does have unforeseen consequences, but these “psychosocial side effects” are not the kind Dr. Sroufe and the medication skeptics are talking about. Rather, they are much more subtle effects on personal identity, peer relations, ambition, etc. But these subtle effects tend to get lost in the heavy-handed rhetoric that generally characterizes the debate over medication for ADHD.

    • Anita M. Schimizzi, Ph.D. says:

      Thank you for your comment, Ms. Barnett. I absolutely agree that we are in need of more “gold standard” studies on the long-term effects not only of ADHD medication but of all types of medications used in children and adolescents to treat a variety of mental health disorders. In addition to looking at long-term outcomes of medication effectiveness, we also need to look carefully at long-term outcomes for other types of treatment (such as CBT) for managing disorders such as ADHD. Simply put, we need that information in order to best serve this young population that we aim to serve.

      Dr. Sroufe made a similar argument regarding the lack of longitudinal research on the use of ADHD medication. While he states that most long-term studies have been flawed, he points to the 2009 study known as the MTA Study (Multimodal Treatment Study of Children with ADHD) as a sound research project that has been going on for more than a decade and still continues. He also speaks, albeit briefly, to psychosocial side effects (e.g., children being led to believe “that there is something inherently defective in them”) in addition to physiological ones such as stunted growth.

      I did not go into each point made by Dr. Sroufe in his NY Times article for this blog post, but it is definitely worth a read by anybody curious about this debate.

  2. Karen DeBolt says:

    I am coming late to this conversation, but wanted to chime in. As a professional who works with children with ADHD, I can tell you that taking medication is vital for some children in order to have any chance at all of learning. I also firmly believe that it is only a small part of the answer and that as a child gets older coping skills to manage impulsivity, hyperactivity and attention challenges are the very best way to insure that they are healthy and happy. I also work with the parents of these children many of whom were not medicated or treated at all as children and instead were stigmatized in a different way as being “that kid who is always in trouble” or who was constantly having the phrase “not living up to his potential” on the reports cards. Those parents are struggling with many more serious psychosocial challenges today like substance abuse issues, low self esteem, and under employment.

    I honestly believe that through a combination of medication management, cognitive behavioral therapies (social skills training) and mental health counseling will children have the skills that they need to live successfully and happily. This is what the research bears out as well. Focusing on “Ritalin doesn’t work” is not helpful or productive.

    • Anita M. Schimizzi, Ph.D. says:

      Dear Ms. DeBolt,

      Thank you for your thoughtful response. I am in agreement with everything that you laid out here with the exception of the very end. I fear that Dr. Sroufe’s true arguments are being misrepresented, as he does not simply make the “Ritalin doesn’t work” case. Rather, he calls into question the long-term use of psychostimulants and the lack of gold standard longitudinal research. The MTA Study appears to be one of the only exceptions at this point and the outcomes from this study seriously call into question the long-term effectiveness of ADHD medication. Dr. Sroufe does clearly speak to the short-term effectiveness of psychostimulants, which may be the research that you referenced. The main takeaway for me is that we must continue to examine, to ask questions, and to call for more longitudinal research in this area. We cannot, in good faith, keep promoting the ongoing use of psychostimulants without better understanding their utility over the long-term.

      Thank you for speaking to the multi-modal treatment approach for ADHD. The combination of interventions are key for so many individuals that have ADHD.

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