The Cochrane Library recently conducted a study that revealed something that many mental health professionals, patients, parents and the public have suspected for some time: methylphenidate (Ritalin, Daytrana, Concerta) is not the best treatment for ADHD for a considerable number of people.
They determined this by analysing 185 studies assessing the efficacy of methylphenidate, and concluding that a great number of them were guilty of various kinds of bias. They also highlighted the prevalence of side effects for short-medium term use of the drug, suggesting that a study of long-term use would be advisable. In short, the study raised important questions about the use of methylphenidate—and drugs more generally—as the first port of call in the treatment of ADHD.
Methylphenidate has been permitted for use in children in the U.S. for over 50 years. Before then, it was marketed as a pep pill for tired housewives, overworked businessmen and the mildly depressed, as well as a stimulant for better psychoanalysis in institutionalized patients. Branded as being stronger than caffeine, but without the side effects of stronger amphetamines, it never matched the sales of the other nascent psychiatric drugs that emerged following the Second World War. This was despite Ciba’s extensive advertising campaigns in medical journals, such as the Journal of the American Medical Association. When the FDA allowed its use in children with what we now call ADHD, everything changed; by 1970, it was CIBA’s best seller.
Methylphenidate was popular because it addressed many needs. Psychiatrists liked that it was quick, inexpensive and tapped into the resurgent biological psychiatry of the time. Educators similarly saw it as a way to fix the perceived problems in the American education system highlighted painfully by the Soviet launch of Sputnik in 1957. Parents appreciated that the drug inferred a neurological origin to the problem: their child’s behavior wasn’t their fault; there was nothing that they could do that the drug couldn’t do better. Pharmaceutical companies, well, they not only approved of their creation, they also marketed the idea of ADHD itself, methylphenidate and ADHD being gateway drug and diagnosis for other conditions that might emerge later on in life.
But what about children? What did they get out of it all? They got a drug that emphasized the prevalent, yet myopic belief that their behavior was all due to what was happening in their brain. Environmental factors, including family stresses, malnutrition, environmental pollutants (including lead), rigid education systems, changing career expectations, too much screen time, lack of time for exercise and the arts, poverty, violence, etc., were brushed aside.
If there are questions about the efficacy and side effects of methylphenidate, perhaps a rethink is in order. Perhaps a better approach to utilising drugs as treatments for ADHD is to turn to it when many of these other factors have been honestly and thoroughly assessed and addressed. If all other factors can be checked off the list, then drugs can be considered. Such a revised approach might also provide a different way of thinking about ADHD more generally.
Currently, the National Institute of Health and Care Excellence in the UK (NICE) recommends drug use in only severe cases of ADHD. But what is severe ADHD? Perhaps severe ADHD treatment should be restricted to those children for whom environmental interventions have proven to be of no use and for whom drugs appear to be the only answer.
Accounting for all the potential environmental causes of ADHD in specific children takes time, effort and, perhaps most importantly, honesty. There will be no magic bullets. But addressing some of them might also have additional benefits for children in terms of their overall health and well-being. Rather than looking at children’s brains as the sole source of their problems and turning to drugs as the solution, perhaps we should reconsider their environment.
