On January 29, 2012, the New York Times Sunday Review of the Week featured a piece entitled "Ritalin Gone Wrong," written by L. Alan Sroufe, Ph.D., a retired psychology professor. The article is poorly focused: its central claim that Ritalin (methylphenidate), a stimulant medication for attention deficit hyperactivity disorder (ADHD), does not work for children over the long term. It is filled with inaccuracies and misleading claims. The article does a great disservice to the public and to the millions of parents whose children are helped by the medication.
Dr. Sroufe's central thesis, that Ritalin does not work over the long term, is not supported by the study he incorrectly cites. Dr. Sroufe provides only scanty information about the study, does not name the study, draws the wrong conclusions from the study, and quickly moves on to a number of issues only weakly related to his central claim.
Here is a list of some of the tangential topics mentioned in the article that are at best only weakly related to the long term effectiveness of Ritalin:
- The number of children on stimulant medication
- The shortage of stimulant medications.
- The increase in the use of stimulant medications.
- Brain scan studies of children on stimulant medications.
- The causes of ADHD.
- A longitudinal study of children reared in the ghetto compared to children reared by the affluent.
- Overstimulation as a cause of ADHD.
- Moralistic concerns, for example, creation of an expectation that relief of all ills might come from medication use.
Here is a list of some of the misleading statements found in the article, along with a brief response:
- Ritalin causes the "serious" side effect of stunted growth.
This term "serious" is misleading. Serious side effects, when applied to medications, imply potentially life threatening complications. Dr. Sroufe does not mention that growth reduction, when it occurs, is by less than one inch over the course of several years. Most parents, children, and physicians do not consider this a serious side effect. For many children, the growth loss may be attenuated by not taking the medication on weekends and over the summer.
- Ritalin leads to "tolerance" to its behavioral effects.
Tolerance is a technical pharmacological term referring to a patient's need to have more and more of a medication to achieve the same effect. As children age they may require higher doses of stimulant medication, but this is most likely because of their increase in body size.
- Ritalin causes "withdrawal."
Resumption of symptoms after the medication wears off each day is not a sign that the patient is going through medication "withdrawal." Withdrawal is a technical pharmacological term referring to physiological or psychological symptoms that occur upon cessation of a drug. There is little evidence that this occurs for stimulant drugs used to treat ADHD. Patienta have no drug cravings, pain or other symptoms associated with withdrawal. The return of symptoms after the drug wears off each day is a measure of the drug's effectiveness and not a measure of withdrawal. Ritalin leaves the body after four hours. When the drug leaves the body, the symptoms return; this is an expectable phenomenon that has nothing to do with the development of withdrawal.
The crux of Dr. Sroufe's argument is that Ritalin and other stimulant medications do not work; his attention might have been better focused on the most important scientific study of the topic to date. The study is known as the Multimodal Treatment of ADHD study (MTA). Dr. Sroufe alludes to the study but does not name it. He incorrectly suggests that it supports his position, and incorrectly describe its conclusions.
The MTA study alluded to by Dr. Sroufe was conducted with the support of NIMH in the mid 1990s. To oversimplify this complex study, 545 children with an average age of 8.5 years were assigned to one of four treatment groups. Two of the treatment groups received adequate doses of Ritalin prescribed by study doctors; one group received what turned out to be inadequate doses by their community physicians, and one group received behavior therapy alone (no medication). After fourteen months it was clear that the children in the two groups that received adequate doses of Ritalin fared much better with respect to their ADHD symptoms than those who did not. The experimental phase of the study ended after fourteen months. (Dr. Sourfe repeatedly and incorrectly complains that studies of stimulant medications only last two to four weeks.)
After the controlled fourteen months study ended, all of the patients were followed for twelve years. The researchers wanted to learn what treatments, if any, the patients would receive and how the patients would do over time. One-third of the children were found to have received Ritalin from their family doctors at some point during the twelve years. Most took it sporadically, making it difficult to draw conclusions about the long term effects of Ritalin; with respect to side effects, expected height was slightly lower and pulse rate was slightly higher for the Ritalin recipients.
The MTA is correctly understood, based on the 14 month experimental study, as demonstrating that children with ADHD who are treated with stimulants do better than children with ADHD who are not treated with stimulants. It is irresponsible to suggest otherwise; evidence of a more effective or safer treatment for ADHD is absent. Until such a time as a better treatment is developed, parents are well advised to stay focused on the advice of their children's stimulant prescribing providers.
Copyright: Stuart L. Kaplan, M.D.
Stuart L. Kaplan, M.D., is the author of Your Child Does Not Have Bipolar Disorder: How Bad Science and Good Public Relations Created The Diagnosis