Hot Topic

Righting the Record on Ritalin

Why the slam on medications for ADHD is misleading 

Harold S. Koplewicz, MD

President
Child Mind Institute

Yesterday 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 opinion pages 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. Perhaps 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 produce 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 self-regulate, 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 the case Dr. Sroufe really wanted to make 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 of medications that really do work for kids who really do have ADHD.

To learn more, take a look at our guide to ADHD medications.

Published: January 30, 2012

Leave a Comment 11
View All Comments (11)

Please SIGN IN or REGISTER to post a comment.

yahweh · Oct 03 2012 Report

Before we get into an Us vs. Them debate, let's try to approach this with wisdom and understanding. Citing genetic or brain imaging is inherently flawed because an overall understanding of the brain related to behavior hasn't been achieved. Many say depression is incurable but that's absurd. Using meds to cure depression is likely flawed. So saying ADHD is incurable is absurd and shows a party mentality that psychiatrists line up on. People seem to be discounting that parents create the atmosphere for their children so if they have a problem their children will likely be casualties. Love is very powerful and along wih understanding can do a lot of good in some dysfunctional families. Can love heal people completely- probably not and these children may grow up hyperactive. Bu people should make exceptions for them and not force meds on them. Studies in hallucinogens show that normal people can end up with ptsd, depression, and even psychosis depending on if they panic or are taking too much. However recent studies show that they can reopen the mind and can heal most mental illnesses. Children will have to wait for adulthood before they can heal some of these problems but love can just about heal you.

yahweh · Oct 03 2012 Report

Before we get into an Us vs. Them debate, let's try to approach this with wisdom and understanding. Citing genetic or brain imaging is inherently flawed because an overall understanding of the brain related to behavior hasn't been achieved. Many say depression is incurable but that's absurd. Using meds to cure depression is likely flawed. So saying ADHD is incurable is absurd and shows a party mentality that psychiatrists line up on. People seem to be discounting that parents create the atmosphere for their children so if they have a problem their children will likely be casualties. Love is very powerful and along wih understanding can do a lot of good in some dysfunctional families. Can love heal people completely- probably not and these children may grow up hyperactive. Bu people should make exceptions for them and not force meds on them. Studies in hallucinogens show that normal people can end up with ptsd, depression, and even psychosis depending on if they panic or are taking too much. However recent studies show that they can reopen the mind and can heal most mental illnesses. Children will have to wait for adulthood before they can heal some of these problems but love can just about heal you.

· Feb 16 2012 Report

This is not what he was trying to communicate at all. This is a much more accurate description of his paper, with him explaining it http://www.abc.net.au/radionational/programs/lifematters/ritalin-and-adhd/3832426

· Feb 02 2012 Report

Thanks for your writing this. While I think the NYT's article has some reasonable points that idea that this medication doesn't have long term benefit is ridiculous. How would one measure that? With any medication, and particularly medication for a child who is learning and developing, the benefit received each individual day is crucial to the long term mental health and success of that child. It isn't magic but for many kids it is the magic that makes them able to function in the world they live in and gives them the ability and confidence to function like other children. That is huge and that is daily. I now have a child excited to go to school. Will he be excited in two years still? Time will tell, but I'd rather have had the two years than not have the two years.

rachel.ehmke · Feb 01 2012 Report

DCARLIN56687542: Here's the address of the original op-ed "Ritalin Gone Wrong" http://www.nytimes.com/2012/01/29/opinion/sunday/childrens-add-drugs-dont-work-long-term.html?pagewanted=1&_r=1&hp Hope that helps!

dcarlin56687542 · Jan 31 2012 Report

nancypeske: I couldn't find the article you were referring to. Do you have the web address for the page the article is on? Thanks.

gg94@columbia.edu · Jan 31 2012 Report

In defense of Dr. Sroufe, it should be noted here that Dr. Sroufe is a brilliant researcher, having made an indelible mark on the attachment research literature. While I appreciate Dr. Koplewicz's level-headed reply (in contrast to Caroline Miller's shrill judgment ("This piece is so bad it hurts me to link to it"), I do think it's important to linger on the knee-jerk use of psychostimulant medication for ADHD symptoms. What Dr. Sroufe curiously omitted from his piece is the enormous weight that the pharmaceutical industry brings to bear on the psychiatry establishment's use of these medications--perhaps at the expense of examining other factors. What is sorely needed is more research, particularly research that could document 1) the potential addictive qualities of psychostimulant medication such as tolerance (which Dr. Sroufe suggests by acknowledging that loss of appetite and sleepnessness fade over time), 2) the potential long-term benefits of psychostimulant medication, and 3) the potential benefits of #2 accounting for the potential liabilities of #1. These are still open questions, which both Dr. Sroufe and Dr. Koplewicz seem to write about as if they were settled issues. Personally, I believe that psychostimulant medication is helpful in the short-term to facilitate the child's use of the therapy setting. Parent/child therapy can be enormously helpful in helping the child feel heard in an environment that might not be listening. Geoff Goodman, Ph.D.

c.psych. · Jan 31 2012 Report

It would seem to me that Dr. Sroufe is clearly behind the times, with respect to the overwhelming evidence (thanks to neuroscience) that ADHD is a highly genetic brain-based disorder. Of course, before making such a diagnosis, one must always consider other clinical disorders or medical conditions that might mimic ADHD, or co-exist with ADHD. It would also stand to reason that one take a comprehensive psychosocial and developmental history from the patient (if old enough) and from other informants/historians. It would also seem that Dr. Sroufe misses the boat, in that ALL psychotropic medications target symptoms, they don't treat the whole disorder, and of course, like ALL clinical disorders, ADHD is treatable not curable. In addition, Dr. Sroufe is clearly out of date that Ritalin is but one of several stimulants available to patients, and that the current thinking is that long-acting, once daily dosing is often the preference to the shorter acting stimulants. Of course, while medication is considered the mainstay of ADHD treatment, psychosocial treatments such as CBT can also play a role for such patients. Some may also derive good benefit from ADHD coaching. In closing, I wonder what the outcry and reaction would be if Dr. Sroufe was writing about other well-known and well-documented clinical disorders (be it depression, anxiety or psychotic disorders). For those old enough to remember, psychiatry blamed many clinical entities on "the mother".

ginapera · Jan 31 2012 Report

Thank you, Dr. Koplewicz, for your ready response to the NYTimes cynical pattern of posting hooey about ADHD to generate traffic. (What other reason could there be? Could it be that the Times editors and writers aren't educated in the sciences? Come to think of it, that's an excellent possibility, too.) I'm afraid you are too generous with this point, though: "The sad thing here is that I think the case Dr. Sroufe really wanted to make in this piece is that knee-jerk use medication isn't the right response to behavioral problems—or the only necessary response." When I wrote to a highly cited psychiatric researcher asking if he'd seen the op-ed, he responded: "I've known him for years, he's an attachment researcher, has long denied any underlying psychobiological reality to ADHD, etc." And that is the cold, hard truth. We don't want to believe that people with this kind of bully pulpit can be as myopic, ego-filled and old-dogma-wed as they are. But if we don't believe it, we allow these issues to to become muddled in the public's mind -- and many professionals', too.

nkonigsberg@milestonemom · Jan 31 2012 Report

Thank you for this very necessary rebuttal. NOt only am I an occupational therapist, but I am the mom of an extremely hyperactive 7 year old. Without the stimulant medication, he does not function well in structured situations. I have even started medicating him so that he can be a member of a freestyle ski team. As an interesting aside, he tried out for the group the same day as another boy who was also ADHD (confirmed and with an IEP). The other boys mom does not medicate. Both boys had about equal skiing ability. I decided to give my son the best chance to make the group by medicating. At the end of the day, my son was invited to join, and the other boy was not. The coach told the mom that her son was too distracted and non-compliant with the group. this weekend, my son entered 3 freestyle competitions and won medals in all three events. Yay for medication! As a final comment I would like to add that I am getting certified as a behavior analyst. I note this because I implement a lot of behavior strategies and my son still needs that medication.

nancypeske · Jan 30 2012 Report

A marvelous rebuttal to a terribly muddled Op-Ed piece! http://www.sensorysmartparent.com

Please help us improve the Symptom Checker!

Click here to share your thoughts about using the tool.