Suffer the Children

The case against labeling and medicating children, and effective alternatives for treating them

Bias in ADHD Research

Facts are stubborn things but statistics are more pliable.

Scientific research studies, with their graphs, tables, and numbers, give us a solid kind of feeling. Scientific research somehow feels hard and weighty, while fiction feels soft and fluffy. Lately, however, I've come to think that research studies are not all that different from the more explicitly fictional sort of narratives. Like other stories, research papers have a beginning, a middle, and an end. The author or authors of a research paper construct a story about what the data says. It is widely accepted that many different stories can be constructed from the same data, depending on the author's point of view or what he is predisposed to discover. Bias is inevitable in research, and shapes the way researchers spin the data. As Mark Twain famously remarked, "facts are stubborn things, but statistics are more pliable."


      Like fiction, research papers can have a rhetorical impact. They can persuade the reader to take one course of action or another by stirring up our emotions--in particular by stirring up our fears. This is especially true when we read new research about something that affects our children.


      Recently, a group of researchers at UCLA and the University of South Carolina, Columbia, set out to analyze 27 older studies on the topic of whether children diagnosed with ADHD are more likely than non-ADHD kids to use drugs later on in adolescence and young adulthood. The researchers call their study, which was published in the Clinical Psychology Review, a "meta-analysis." In layman's terms, this means that the authors construct a new story by mining and rearranging the data in the older stories. The older studies followed 4100 children who had been diagnosed with ADHD and a control group of 6800 children without the diagnosis. The meta-analysis found that the ADHD kids had much higher rates of using or abusing nicotine, cocaine and marijuana later in life than the non-ADHD kids.

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     However, the meta-analysts omit a piece of the story that seems fairly critical to me. The authors tell us that they "did not control for treatment status." This means that we don't know how many of the children diagnosed with ADHD were taking medication at the time of the studies. This would seem to be a vital piece of information because amphetamines (like Adderall) and methylphenidates (like Concerta), which are the drug treatments of choice for ADHD, are both deemed to be habit forming by the National Institutes of Mental Health. If most or all of the ADHD kids were being treated with medication, then the data suggests that it is early reliance on drugs, rather than the fact of being hyper or inattentive, that makes these kids more prone to use and abuse drugs later on in their lives. At least one of the research papers cited in the meta-analysis (by Dr. Nadine Lambert of the University of California at Berkeley) suggests exactly that: that stimulant drugs taken by the ADHD kids may be a contributing factor to their using illicit drugs as a crutch in adolescence and adulthood. This alternate story certainly jibes with ordinary common sense.


     The singular contribution to the treatment of ADHD offered by the authors is the inclusion in their story of the idea of "parent and family-based" interventions for at-risk kids in early adolescence when they are most at risk for substance abuse. The authors dismiss family interventions earlier on to prevent childhood mental disorders like ADHD as not "cost-effective." To my mind, not only is this to close the barn door six to eight years after the horse has departed, it is also to rule out the most efficient and effective way to prevent childhood mental disorders: early intervention. In my experience as a family therapist, parenting and behavioral intervention at the very first sign that the child is having trouble is the safest and most efficient way to help a child overcome inattentiveness, hyperactivity and a host of other behavioral problems. Why wait until the child is about to reach adolescence?


     The place of cost effectiveness in the authors' story is also perplexing. It begs the question: for whom are early interventions not cost effective? Could it be the drug companies who would miss out on selling all those amphetamines and methylphenidates? Surely a few visits to a family therapist early on is less expensive than years of visiting the doctor's office and filling prescriptions.


     Simplified summaries of the new meta-analysis have been widely carried by print and online media, including USA Today and The Wall Street Journal. The headlines are enough to compel parents to run for the Ritalin bottle in hopes of curing their child's ADHD. On the other hand, if parents believe the story that later drug abuse may be just one more side effect of ADHD medication (along with personality changes, insomnia, appetite disturbance and hallucinations), they might be moved to seek out alternative interventions.

 

Copyright Marilyn Wedge 2011

Marilyn Wedge, Ph.D., is a family therapist and the author of Suffer the Children: The Case Against Labeling and Medicating and an Effective Alternative.

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