Why Ritalin is Wrong (Or… IS Ritalin Wrong?)

I recently read an article in The New York Times by L. Alan Sroufe, suggesting that ADHD/ADD (attention deficit and attention hyperactivity disorder/attention deficit disorder) may not really exist, that it is over diagnosed and that medications are not effective over time. I found it disturbing, potentially harmful, and counter to clinical experience. This may be yet another chapter in the media‘s current war on medications. Unfortunately, it makes it very difficult for people with diagnosable mental illnesses, who might be successfully treated with medication, to agree to even a trial of recommended psychopharm treatment. It makes it even harder for parents to allow their troubled children to be put on a trial of a medicine, even though the medication is likely to be effective.

When the doubts about treatment for ADD or ADHD with medication first hit the press, I turned to an expert for his opinion, Stephen Hinshaw. Hinshaw is a colleague of mine, former Chair of the Psych Department at UCB and an expert in childhood psychopathology with a specialty in ADHD. He was Director of the long-running ADHD summer camp for children with ADHD, and perhaps most important, he was one of 6 lead researchers in the long-term, multi-site study of ADD/ADHD in children, (known as the MTA study). Hinshaw and colleagues found that children treated with Ritalin AND behavioral/social skills training along with supportive therapies for parents (living with children with untreated ADD or ADHD is sometimes not easy) did significantly better on numerous indicators than those treated with either well-managed medications or behavioral/family treatments alone.

Then, a few years ago, it was reported that new studies indicated that over the long haul, when these children were revisited, the benefits didn’t hold. I called Hinshaw and asked him: “What’s this about?” He said that of course the improvements had ceased because these results were collected well after the randomly assigned phase—during which the children were monitored carefully. In fact, all children “reverted” to regular community care after 14 months of intensive, protocol-based treatment. So of course they didn’t show improvement. The treatment with medication (with Ritalin or other stimulants) had reverted to poorly-managed care, the social skills and behavioral therapy had stopped, and parental support had stopped. ADD/ADHD is a life-long problem or condition. While many children (and adults) routinely take Ritalin “vacations” (on weekends, on literal vacations etc.) which they can do because these medications have a very short half-life, when back at their school or work life, they continue to need or at least derive benefit from psychopharmaceutical treatment. Of course stimulants can become addictive in the wrong hands (though they aren’t for people with ADHD) so overuse can be a problem. But so can underuse for those who need them.

Other important pieces of information: When we (me and my close collaborator and statistician, Jack Berry) were first studying addicts with three months or more in recovery, abstinent from all mind-altering drugs, we wondered if these recovering addicts might have been given Ritalin (or some equivalent medicine) as children, and if this might be something that had set them up for addiction as adults. So we asked our subjects in recovery if they had been treated for ADD or ADHD with Ritalin when they were children. None of them had. When I discussed this with Hinshaw he told me that it was the UNTREATED children with ADHD who ended up vulnerable to drug use and addiction, because they are in a sense, “self-medicating,” and trying to deal with a life of failure.

Children with ADD/ADHD who are untreated, tend to be failures in school. Since school is the “job” children need to succeed in, failure in school amounts to, for a child, failure in life. The ramifications of failure in school are enormous —depression, anxiety, low self-esteem, poor social relationships— just for starters. To support this line of reasoning, Hinshaw’s research extended to examining what happens to girls with ADD or ADHD. Because girls tend to “act out” less obviously —they are not likely to be the kids that make a teacher’s life hell in the classroom. The girls aren’t running around wildly; they are far less likely to be a “problem” for their teachers. Therefore, girls are less likely to be appropriately diagnosed and treated. What happens to these untreated girls? They are at high risk for suicidal behavior and self-harm in late adolescence and early adulthood. Recent research from Hinshaw and his students suggests that when they revisited girls ten years later, the situation in some cases had become dire.

The Sroufe article suggests that there is no difference between children (or adults) with ADD/ADHD and children/adults without ADD/ADHD, in terms of reaction to Ritalin or other commonly used stimulant medications, (for example, Adderall). He makes the point that stimulants enhance attention in non-ADHD populations too. This is true, to a limited extent. A recent review of the literature (Smith & Farah, 2011) suggests that these medications may be linked with attention, motivation and general cognitive enhancement in normal healthy individuals. But they say nothing about negative reactions to stimulants in a normal population. From my clinical experience, anecdotal though it may be (and limited to adults since i don’t usually treat children) I have had patients who complained of difficulty concentrating, difficulty with attention and motivation. If it seems to be effecting their overall functioning, I send them to a physician for an evaluation for medication. If the physician deems it indicated, a trial of Ritalin is initiated.

Those with a childhood history indicative of possible ADHD —in general— seem to respond well to Ritalin; they calm down, they are better able to function at whatever it is they are doing. They feel better. Some have reported being able to sleep BETTER, when on a trial of Ritalin. Others however, while they may report improved concentration and overall cognitive enhancement, they also complain of increased “jitteriness” and insomnia. This latter group has been less likely to have a childhood history reflecting ADD/ADHD-type symptoms. Again, this is anecdotal data, from clinical experience. To summarize: While both groups of patients, one with ADD or ADHD, and one without, may report improvement in attention, concentration, motivation, and general cognitive enhancement, I have found that only the group with ADHD actually calms down with Ritalin.

Yet another point of contention —Sroufe (and many others) describe ADD/ADHD as representing a supposed brain “deficit.” A brain difference however, does not automatically mean deficit. Children (and adults) with ADD/ADHD are not plagued with a deficit. We have to look at brain differences from an evolutionary perspective. Something as common as ADD/ADHD, occurring frequently in the population, may exist because it serves a function for a group. It may be maladaptive for an individual in our contemporary life-style, it may be dysfunctional for children forced to learn by sitting all day in a classroom. This is not the way we were wired to learn, it is not the way people learn (or learned) in hunter-gatherer groups, in the “EEA” or what is known as the era of evolutionary adaptations. Children are wired to learn by imitating adults and older children; meaning; we all learn by imitation. In our contemporary world of knowledge workers, the most important skills to be learned may be particularly difficult for children with the attributes common in those with ADD/ADHD. That said, some of the characteristics common in ADHD/ADD —restless energy for example, a desire to explore or to try new things, to expand— may be crucial in a population in which the urge for exploration may be necessary for survival. A remarkable attribute of our species is our ability to adapt to changing conditions –this is how we managed to successfully spread out across our planet, and this is how we have been able to adapt to dramatic changes in the environment. The urge to explore, to create new tools as needed, to adapt to increased or decreased rainfall, may all depend upon having some members of a group having these same “brain differences” that are now problematic in the modern classroom, or contemporary corporations.

An interesting aside: Take a look at the demographics of use of Ritalin. Until quite recently, children of upper and middle class European American families were diagnosed and treated with Ritalin so that those with these brain differences, these characteristics that accompany the ADD/ADHD diagnosis, have a better chance to succeed in school as children, or in their jobs as adults. African American children, however, when beginning to fail in school, used to be written off as “stupid” or “impulsive” or “lazy” and there was no or little effort to treat them. I have been told that this has changed in recent years, African-American children have “caught up” with white children in terms of 1) the likelihood of being diagnosed with ADHD, and 2) the likelihood of receiving medication when diagnosed. But is this holding? Are all children with ADD or ADHD, from all socioeconomic groups being provided with “equal opportunity” to receive helpful medication?

Something is wrong with Sroufe’s analysis. I’m not inclined to look up all of his references, to see what is off in his data, but I can’t help but wonder what story led to his conclusions. In any case, his article certainly fits well with the current anti-psychiatric medication media frenzy. The assault on psychopharmaceutical medications is harmful to people who need them, and may even help to disguise whatever big pharma is really doing. We need to ask why there is a decrease in available Ritalin? I’m sure it’s about money. Ritalin is long past the time when it was lucrative for big Pharma. Psychopharmacologists that I respect have told me that generic Ritalin is not as effective as brand medication and I’m not sure if the reports of low supplies refer to both generic and brand medications. One recent report suggested that it is possible to purchase brand Ritalin, but at a high price, and in most cases, it’s not covered by insurance. Generic Ritalin, however, is scarce. So perhaps this is yet another way children from families with higher incomes are continuing to get treatment, while those from lower socioeconomic groups were going without. I’m sure it’s all about profits for someone. There are odd discrepancies in what is accepted as helpful and what is described as a drug company scam. The media is focused on trashing psychopharm treatments, presumably because they know that big Pharma is corrupt —but does that stop anyone from using prescribed antibiotics when they are diagnosed with bacterial pneumonia (for example)? I don’t think so.

To read the article by L. Alan Sroufe from The New York Times, go to:http://readersupportednews.org/opinion2/272-39/9791-why-ritalin-is-wrong