The controversy over using Ritalin and other stimulants to treat ADHD surfaces repeatedly, often with emotional rhetoric which can lead those in need to avoid ever using such medications or allowing their children to, thereby giving up on a class of medications with enormous potential benefits. Examples of this genre of coverage include the Jan 28, 2012 article in the NYTimes "Ritalin Gone Wrong" (Alan Sroufe, PhD) and a response to that article in Psychology Today blogs, "Debunking Ritalin" (Jefferson Fish, Ph.D.)
What follows is an interview with Edward Hallowell, M.D., which offers a different perspective. Dr. Hallowell is a child and adult psychiatrist who has been treating ADHD for over 30 years, taught at Harvard Medical School for over 20, and who has both ADHD and dyslexia himself. (More about him is at the end of this article for those who are interested.)
Will there ever be a single solution, or one pill, for all children (or even adults)?
No enlightened clinician offers medication as the single solution for ADHD. We offer it as one tool that can and often does help, but always as part of a comprehensive treatment plan.
When these medications work, they do not solve the problem, any more than eyeglasses solve the problem of myopia. But they sure do help!
What is a comprehensive treatment plan?
In addition to medication other key elements such as education of parent, child, and teacher; lifestyle modification, including sleep, diet, exercise, and meditation; coaching on how to better organize life; and ongoing follow up to monitor progress and offer encouragement and various specific tips on managing life with ADHD.
Are we becoming a pill-solves-all society?
It has become a cliché cited endlessly that we live in a society that believes all of life's problems can be solved with a pill. But have you ever met anyone who actually does believe that? I haven't. Furthermore, 19 out of 20 people who come to me for help for themselves or their child adamantly oppose the use of medication. Only when they fully understand the medical facts do some of them change their minds. Far being predisposed to the use of medication, the people who come to see me are predisposed in precisely the opposite direction.
Enlightened clinicians do not simply prescribe the medication and leave it at that, allowing the parent and child to imagine they have "something inherently defective in them."
So how do we help a child understand ADHD?
I tell the child that he is lucky in that he has a race car for a brain, a Ferrari engine. I tell him he has the potential to grow into a champion. I tell him (assuming it is a he, but he could just as easily be a she) that with work he can achieve greatness in his life, and then I tell him about the billionaires, CEO's, Pulitzer Prize winners and professional athletes with ADHD I've treated over the years. But I also tell him he does face one problem. While he has a race car for a brain, he also has bicycle brakes. I tell him I am a brake specialist, and one of the many tools I can use to strengthen brakes is medication. I remind him he will have to do much more than take the medication to strengthen his brakes, but, if we're lucky, the medication will help him in that effort.
The child and parents leave my office full of hope. Far from feeling defective, the child feels like a champion in the making. Which he most certainly can be!
What is the real problem with focusing on drugs as a cure?
The illusion that children's behavior problems can be cured with drugs prevents us as a society from seeking the more complex solutions that will be necessary. Drugs get everyone—politicians, scientists, teachers and parents—off the hook. Everyone except the children, that is.
I take exception to Dr. Sroufe's assumes that we have all bought into the notion that "children's behavior problems can be cured with drugs," and that such a belief gets us "off the hook." It gives the impression, my perspective, that politicians, scientists, teachers, parents, and heaven knows who all else were so sweetly deluded and so uncaring that we welcome any excuse to get us off the hook of doing the deep probing into the "complex solution."
No clinician worth his or her salt believes that all problems can be cured with drugs. But neither does a responsible clinician deny the good that medications can do.
Don't people ask you if you believe in Ritalin?
When people ask me, "Do you believe in Ritalin?" I reply that it is not a religious principle. Ritalin, like all medications, can be useful when used properly and dangerous when used improperly. Why is it so difficult for so many people to hold to that middle ground?
And yet difficult it is. Ritalin continues to be a political football, a hot-button issue almost on a par with abortion or capital punishment. One is pushed to be for it or against it, while the right and good position is to be an advocate for whatever will help a child lead a better life, as long as it is safe and it is legal.
Used properly, Ritalin is safe, safer than aspirin. And it is legal, albeit highly regulated.
How do we handle 'pseudo-ADHD' children?
We need to address the complex issues that contribute to behavioral, emotional, and learning problems in children. I've written extensively about what I call "pseudo-ADHD," children who look as if they had ADHD but in fact have an environmentally-induced syndrome caused by too much time spent on electronic connections and not enough time spend on human connections, i.e., family dinner, bedtime stories, walks in the park, playing outdoors with friends or relatives, time with pets, buddies, extended family, and other forms of non-electronic connection.
Pseudo-ADHD is a real problem, and the last thing a child with pseudo-ADHD needs is Ritalin.
What do children need if they have ADHD?
All children need a loving, safe, and richly connected childhood. And medication can help and as physicians and psychiatrists we have an obligation to help our patients and families.
The long-term study that Dr. Sroufe cited in his opinion piece does indeed show that over time, medication becomes a less important force in a child's improvement and that human connections become ever more powerful. It is good and heartening to know that human connection—i.e., love—works wonders over time. Love is our most powerful and under-prescribed "medication." It's free and infinite in supply, and we most definitely ought to prescribe it more!
Do I believe that "Ritalin has gone wrong" as a drug?
We may go wrong in how we use it, when we over-prescribe it, or when we use it as a substitute for love, guidance, and the human connection.
As long as we use it properly, it remains one of our most proven and valuable of all medications. Going all the way back to the first use of stimulants to treat what we now call ADHD in 1937, stimulants have served us well as a tool—not the tool—for helping children and adults learn how to strengthen the brakes of their race car brains and become the champions they can be.
Edward M. Hallowell, M.D. is a child and adult psychiatrist, and the founder of The Hallowell Centers for Cognitive and Emotional Health (NY and Boston). He is the co-author with Dr. John Ratey of the best-selling book on ADHD, Driven to Distraction: Recognizing and Coping with Attention Deficit Disorder from Childhood Through Adulthood and has also authored 17 other books on mental health. He is a graduate of Harvard University and Tulane Medical School. His website is at www.drhallowell.com.