Ritalin Results Gone Wrong
Do ADHD drugs stop working over time?
Posted Feb 15, 2012
Ritalin and other drugs for Attention Deficit Disorder don't produce long-term improvements in behavior and worse may harm children who suffer not from a complex neurological disorder but from bad parenting, poverty and stress and thus cannot be cured with a simple pill.
So claimed L. Alan Sroufe, Professor Emeritus University of Minnesota's Institute of Child Development in a recent New York Times op-ed that whipped up anger and no doubt confusion in many a household familiar with inattentiveness and poor impulse control. A lot has changed since the 1970's when Sroufe reviewed the drug literature for The New England Journal of Medicine. For one the old nature versus nurture dichotomy has been thrown out the window of the burgeoning epigenetics lab churning out finding after finding of the ridiculously complicated interplay between genes and environment.
Nonetheless the claims merit a second look, especially the argument of interest to many parents wavering in the pharmacy aisle:
Attention-deficit drugs increase concentration in the short term, which is why they work so well for college students cramming for exams. But when given to children over long periods of time, they neither improve school achievement nor reduce behavior problems. Ritalin Gone Wrong, New York Times, Jan, 29
To date there isn't any scientific evidence about long-term effectiveness because there are no studies that can answer whether Ritalin, Adderall or similar drugs work long-term. The data simply do not exist. It would be highly unethical if not impossible to force kids into these treatments for a decade.
What does exist is a large 2009 study interpreted as evidence of the drugs' short-term effectiveness, ahem, their long-term effectiveness, long-term inefficacy, the benefits of behavioral therapy, the benefits of a combination of drug and behavioral treatment and probably the sham of modern psychiatry. Yes, mental health professionals have argued about the study for over 10 years since the first set of results were published back in 1999. The MultiModal Treatment of Attention Deficit Hyperactivity Disorder Study.
Here's the sordid affair.
In the early 1990s almost 600 children aged 7-9 diagnosed with ADHD were randomly assigned to either get drug therapy (from a select doctor), behavioral therapy, both or a control group (i.e. their regular doctor visits). After 14 months the interventions stopped, the data analyzed and published in 1999. At that point all groups appeared to improve but the medication and combined medication/behavioral treatment groups showed significantly more improvements in ADHD symptoms than either children receiving the behavior treatment alone or the control group (that also included some drug treatment though far less time/attention to moderating meds). The combo therapy was superior in some outcomes like family relations and school performance.
It's starting to get complicated, no? The drugs appeared to improve many ADHD symptoms, the combo for more psycho-social ones. But the study didn't end there.
The kids were observed for another 6 years in an "uncontrolled naturalistic follow-up study." Meaning parents could do whatever they wanted and over half of the kids in the drug treatment group discontinued the meds. Six years later there were no longer any significant differences between the original treatment groups. Of special interest here, there were no differences between the kids who originally got the meds and the rest of the lot.
It's tempting to think the drugs lost their effectiveness. Due to the time lag and thus the fact that the families were no longer observing the original treatments conditions we can't make any such conclusion or really any conclusion about treatment effects. From a methodological standpoint it's impossible to make any conclusions about the treatment effects some 8 years later - a limitation that hasn't stopped some from making said conclusions. Even the National Institute of Mental Health almost blew it with this headline: Short-term Intensive Treatment Not Likely to Improve Long-term Outcomes for Children with ADHD despite their own warning "it is not possible to draw accurate conclusions about the effectiveness of interventions beyond 14 months, or determine if treatment improves long-term functioning."
Further complicating an already fraught set of findings we have this from the NIMH website potentially cheap-shotting Ritalin:
Children who were no longer taking medication at the eight-year follow-up were generally functioning as well as children who were still medicated, raising questions about whether medication treatment beyond two years continues to be beneficial or needed by all. NIMH, March 2009
Some kids might have stopped taking the drugs because they no longer needed them. Some who still took them 8 years on might have still been benefitting from the meds. They might have looked worse had they stopped popping the pills. It's also possible some kids stopped taking them who needed them and the reverse. Maybe we'll see more data.
For now the general consensus seems to be the drugs do work well over the long-term. Many also advocate behavioral therapy often in combination with meds and also recognize some children may learn to cope well without meds. As far as Sroufe's claims about safety, there's some evidence of stunted growth in the first year but a recent study found these kids catch up after few years. The lack of appetite and sleep disturbances tend to disappear after a few months. As a social psychologist by training witnessing the ascent of the genome I'm heartened by the retired professor's plug for the power of parents and parenting. Yet in light of recent epidemiological knowledge, his theory about poor parenting, poverty and stress as the primary roots of the disorder seems downright retro.
Still, the retired child psychologist makes a reasonable request in asking us to reconsider why so many kids are using these medications. Let's just get the evidence right first.