Ritalin’s Fallacy

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Diffusion MRI Tractography in the brain white matter.

Some drugs work well because they are designed to hit a single, well understood target. Consider penicillin.

In a simplified sense, penicillin destroys a single enzyme that bacteria need to divide and to infect you, thereby killing the harmful bacteria. But what about psychiatric drugs? Is there a comparable, single target in the brain to treat depression, anxiety, attention deficit disorder (ADD)? No.


So, it is no wonder that the popular drug Ritalin, used to treat ADD for millions of children and adolescents is, by some standards, a fallacy. In the long term, such drugs are at best placebos, and at worst could do more damage.

Here’s why: Our brains consist of some 100 billion neurons, and our understanding of how these cells communicate, are regulated and – more importantly – how they respond to our environment and what subset corresponds to a given psychological state, is in its infancy. Our brain’s “connectome” is shown to the right {is it not truly beautiful?}

From the insightful Op-Ed in today’s The New York Times by L. Alan Sroufe, professor emeritus of psychology at the University of Minnesota’s Institute of Child Development:

TO date, no study has found any long-term benefit of attention-deficit medication on academic performance, peer relationships or behavior problems, the very things we would most want to improve. Until recently, most studies of these drugs had not been properly randomized, and some of them had other methodological flaws.

But in 2009, findings were published from a well-controlled study that had been going on for more than a decade, and the results were very clear. The study randomly assigned almost 600 children with attention problems to four treatment conditions. Some received medication alone, some cognitive-behavior therapy alone, some medication plus therapy, and some were in a community-care control group that received no systematic treatment. At first this study suggested that medication, or medication plus therapy, produced the best results. However, after three years, these effects had faded, and by eight years there was no evidence that medication produced any academic or behavioral benefits.

However brain functioning is measured, these studies tell us nothing about whether the observed anomalies were present at birth or whether they resulted from trauma, chronic stress or other early-childhood experiences. One of the most profound findings in behavioral neuroscience in recent years has been the clear evidence that the developing brain is shaped by experience.

This is not to say that drugs such as Ritalin are useless. But Prof. Sroufe reminds us that we need to focus less on solving psychological problems with pills and more on a deeper understanding of environmental and societal impacts on that most complex and inscrutable part of us, our brain, and ultimately how to listen to and have empathy for those reaching out to us for help.

Comments

  1. #1 pom
    January 30, 2012

    Whatever early-childhood experience may have caused my nephew’s ADD (probably the birth of his sister), I’m glad Ritalin enables him to learn. He’s five now and he has been taking it for a year – and even if the effectiveness fades in the next two years the opportunities Ritalin created for him will have been worth it.

  2. #2 Leander1
    January 30, 2012

    @pom
    The genetic contribution to ADHD is routinely found to be among the highest for any psychiatric disorder (70%-95% of trait variation in the population). Other biological causes have been identified as well. I don’t think there’s much room left for early-childhood experiences, like the birth of your nephew’s sister, to be a cause of ADHD.
    Having ADD myself, I did try out medication similar to Ritalin. Unfortunately they didn’t have any positive effect.

  3. #3 Domestigoth
    January 30, 2012

    I’m happy to see more controlled studies appearing on the treatment of childhood mental illness — the tendency for decades has been to slap a label on it and give them a pill, something that’s often more harmful than helpful (as I myself found out the hard way as a teenager when my bipolar disorder was misidentified as depression and I got handed a prescription for Prozac … bad times).

    The trouble with something like ADD, though, is that it’s so often identified in kids who are very young. Too young, really, for traditional psychotherapy to be effective: talking to a therapist isn’t exactly going to bring them a new understanding of the way their mind functions when they’re still figuring out tying their shoes and using the toilet. And they’re not going to be able to communicate their own thoughts and feelings and frustrations very effectively when their grasp of the English language is limited to something along the lines of “See Spot Run”.

    So one is left asking, “what else can we do?” There must be solutions, but they’re probably not easy or fast ones. How does one convince a family that they need to change their entire way of interacting with their child (probably requiring major life changes of them), and that no, a pill won’t do the job right? It’s a tough problem.

  4. #4 Jeff
    January 30, 2012

    Thank you for your comment.

  5. #5 bob underwards
    January 30, 2012

    i was 14 when i got my Add diagnosis.. prescription Ritalin.. took it for 2 weeks felt nothing so i gave it back and told them if i had some problems I’d sort them out myself and i didn’t need their drugs…

    Im no doctor or professor now but i do have a decent life. I’m happy i was old enough to understand what was going on and what i was taking.throwing drugs at children is no way to solve an issue, just bury it till they get to be weirdo adults

  6. #6 Tercel
    January 30, 2012

    This post sends a very worrying message. Spreading this sort of fear and uncertainty is unwarranted and irresponsible. It risks reinforcing societies preexisting irrational misconceptions about medication, particularly psychiatric medication.

    It’s true that there are plenty of holes in our understanding of psychiatric disorders and the drugs used to treat them, but those medications are tested like any other drug approved by the FDA, including demonstrations of efficacy. Maybe they don’t work as well in the long term as we thought, but there are parents out there who are already on the fence about medicating their children, who have been told by their friends and family that they can just fix the problem with diet or a good spanking. This is the sort of thing that results in those parents allowing their children to grow up as victims of anti-science, just like the anti-vax nonsense results in children growing up vulnerable to diseases we shouldn’t even have to hear about anymore.

    If you want to talk about how certain aspects of ADD need further research, or about the fact that one (of many) drugs used to treat ADD might not remain effective in the long run (Ritalin is usually not prescribed after childhood anyway, btw), I’m all for that. Information and research is always a good thing. But as an ADD sufferer myself, I find this to be yet another insulting episode in a series of ignorant attacks on the very idea that ADD exists and should be medicated. Anecdotal though it may be I can tell you, having lived with ADD for my whole life (I’m not 27 and a successful engineer) that it IS real, and that I would not be where I am today were it not for the fact that my parents did not give in to social stigma, and instead chose to address my problems, which included medication.

    I’m not claiming that everything is perfect and that we shouldn’t question the current way that ADD is diagnosed and medicated, and I’m not opposed to new information or further study; but the tone of this article seems to very carelessly cast doubt on an intervention that has had life changing positive impact for countless people, including myself. Please consider that before you throw around unsubstantiated and toxic statements like “In the long term, such drugs are at best placebos, and at worst could do more damage.” This isn’t a game and it affects real people.

  7. #7 Tercel
    January 30, 2012

    I hate typos. “I’m not 27 and a successful engineer” was of course intended to read “I’m now 27 and a successful engineer.”

  8. #8 Mark Bellis
    January 30, 2012

    Has there been any studies on the effects of ritalin on the developing brain of an infant? I’m very surprised that it can be given to a four year old.

  9. #9 Calli Arcale
    January 30, 2012

    I have to agree with Tercel. Dr Toney, you say that there is not “a comparable, single target in the brain to treat depression, anxiety, attention deficit disorder (ADD)” and then conclude that “In the long term, such drugs are at best placebos, and at worst could do more damage.” But that doesn’t follow.

    First, depression, anxiety, and ADD are clearly not the same disorder, so why would you expect them to have a single target?

    Second, that there is not a single *known* target for any one of these conditions does not mean that there is no target; it just means we haven’t found one yet.

    Third, and probably most importantly, it sounds as if you are saying that because the brain is complex, it is impossible to treat dysfunctions in it. This is transparently untrue. Anticonvulsants obviously work; lithium clearly helps people with bipolar mood disorder (though how is not known), so obviously the fact that the brain is complex does not, a priori, render medication pointless in all cases.

    You will need to do a bit more work than that to show that Ritalin is “a fallacy”.

    One point I’d like to address from the study (which I’ve seen before; this isn’t that new):

    “However, after three years, these effects had faded, and by eight years there was no evidence that medication produced any academic or behavioral benefits.”

    If I recall correctly from when I read this study before, it wasn’t that the children suddenly regressed back to how they were before treatment. It was that treatment no longer provided any benefits. Why is this bad? It means that eventually, most children with ADHD will figure out how to deal with the world — but obviously treatment makes their lives easier until they get to that point. And there’s another point worth making: if it took eight years for there to be no difference between the “treatment” and “just community support” groups, that’s a hell of a long time to be getting crappy grades in school. Eight years is a long time to a kid. The kid who didn’t get treatment may have spent five of those years convinced he was lazy and stupid. Will he be able to unlearn that in time to graduate high school with a decent GPA?

  10. #10 Calli Arcale
    January 30, 2012

    I have to agree with Tercel. Dr Toney, you say that there is not “a comparable, single target in the brain to treat depression, anxiety, attention deficit disorder (ADD)” and then conclude that “In the long term, such drugs are at best placebos, and at worst could do more damage.” But that doesn’t follow.

    First, depression, anxiety, and ADD are clearly not the same disorder, so why would you expect them to have a single target?

    Second, that there is not a single *known* target for any one of these conditions does not mean that there is no target; it just means we haven’t found one yet.

    Third, and probably most importantly, it sounds as if you are saying that because the brain is complex, it is impossible to treat dysfunctions in it. This is transparently untrue. Anticonvulsants obviously work; lithium clearly helps people with bipolar mood disorder (though how is not known), so obviously the fact that the brain is complex does not, a priori, render medication pointless in all cases.

    You will need to do a bit more work than that to show that Ritalin is “a fallacy”.

    One point I’d like to address from the study (which I’ve seen before; this isn’t that new):

    “However, after three years, these effects had faded, and by eight years there was no evidence that medication produced any academic or behavioral benefits.”

    If I recall correctly from when I read this study before, it wasn’t that the children suddenly regressed back to how they were before treatment. It was that treatment no longer provided any benefits. Why is this bad? It means that eventually, most children with ADHD will figure out how to deal with the world — but obviously treatment makes their lives easier until they get to that point. And there’s another point worth making: if it took eight years for there to be no difference between the “treatment” and “just community support” groups, that’s a hell of a long time to be getting crappy grades in school. Eight years is a long time to a kid. The kid who didn’t get treatment may have spent five of those years convinced he was lazy and stupid. Will he be able to unlearn that in time to graduate high school with a decent GPA?

  11. #11 Jeff
    January 31, 2012

    Thank you for these comments. Of course there is no single target for multiple psychiatric conditions, much less ADD. I wish that the pharmacology were better understood to treat ADD, but our understanding of both the underlying biochemical mechanisms and of the effect of the environment and society is in its infancy. Short term benefit for Ritalin? Clinical data says yes, but long term? No. As with most of these treatments, cognitive therapy is often the most effective. Thus, I concluded:

    This is not to say that drugs such as Ritalin are useless. But Prof. Sroufe reminds us that we need to focus less on solving psychological problems with pills and more on a deeper understanding of environmental and societal impacts on that most complex and inscrutable part of us, our brain, and ultimately how to listen to and have empathy for those reaching out to us for help.

  12. #12 sue desheh
    January 31, 2012

    ritalin is not for all ADD sufferers. for some it does the trick as i have discovered in years of teaching. but ritalin needs to be accompanied by an insightful teacher who is guiding parents and siblings and the child him/herself. helping to cope with ADD is not merely popping a pill. and yes, even without an insightful teacher some children on ritalin alone ABSOLUTELY do better on proper dosage of ritalin in school and at home as i have seen in over 20 years of teaching children and observing teachers-in-training. DON’T THROW OUT THE BABY WITH THE BATHWATER. DO TEAMWORK, ADJUST THE DOSAGE – WHATEVER, perhaps not successful with all (so look for underlying causes) but properly administered as a joint effort helps many. there is no one-fits-all pill

  13. #13 damagedone
    January 31, 2012

    I believe this article is nothing but a fallacy; it draws conclusions from little scientific research and incorrect assumptions.

  14. #14 crack stitching
    February 1, 2012

    very interesting article. the problem with saying we have to solve the social issues, is alot deeper of an issue and a much harder one to solve. most likly why the drug is so widely used

  15. #15 Thomas King
    February 1, 2012

    After 35 years in this field, I am inclined to accept the hard facts and not the anecdotal stuff. Anyone interested in some real truth on this subject should, in my opinion, start with the journal Pediatrics 2010;126(2);214-221. People who want the quick fix, won’t like what they see. We make attention problems in the way we live and parent in the vast majority of cases. The rest, are probably undiagnosed processing problems best addressed with hard work and a clear understanding of the real problem by parents, and schools. What’s left over might just be something like an executive function disorder, and most of those have an underlying medical cause. Not sure there would be anything left after that. If there is, I’d like to meet that person. I’ve been waiting a very long time.

  16. #16 NotScience
    February 5, 2012

    Thomas King points us to an article from Pediatrics that associated screen time with attention issues. As a parent of multiple kids, including some with hyperactive type-ADHD, I can very easily explain this association. Parents allow more screen time for more demanding kids. My calmer kids have screen time limits that are pretty close to ideal. My more needy kids get to watch more videos (no tv or games in my house). It’s not so much a decision, it’s just a “babysitter” for when you, your house, your other kids…..when everyone needs a few quiet moments.

    ADHD is often comorbid with autism spectrum issues, and other processing issues. These kids benefit tremendously from visual learning. Often, that’s reading books with a parent. Sometimes it’s Sid the Science Kid.

    Ask any parent of an ADHD kid to explain this association. Everyone will tell you: TV doesn’t cause ADHD behavior, ADHD behavior causes TV.

  17. #17 JPGK
    February 7, 2012

    Unsurprising to see anecdotal arguments from a user (aptly) named “NotScience”…I’m sorry, but your parenting techniques do not generalize to children outside of your household, and certainly do not trump a published study which involved over a thousand children.

    “Ask any parent of an ADHD kid to explain this association. Everyone will tell you: TV doesn’t cause ADHD behavior, ADHD behavior causes TV.”

    No. I will not ask any parent of “an ADHD kid” to explain it, I don’t care what “everyone will tell you,” and neither should you or anyone else. I’m going to ask the researchers who spend years studying the phenomenon over large populations, and I’m going to look at their data – not their stories from home.

    That said -

    Dr. Toney, this was a fine article, and your call to turn our attention to “a deeper understanding of environmental and societal impacts on that most complex and inscrutable part of us, our brain” is both poignant and proper. Hopefully we can get more people focused on the underlying source(s) of the issue and less on ultimately ineffective treatments.

  18. #18 BugDoc
    February 7, 2012

    There is a well informed point-by-point response to Dr. Sroufe’s NYT article that is worth the read: http://www.childmind.org/en/posts/articles/2012-1-30-adhd-righting-record-stimulant-medications. If the link doesn’t work, go to childmind.org under the advice & support section, and look for the “Righting the Record on Ritalin” article.

  19. #19 Tracy Warren
    February 7, 2012

    Too often the psychological problems that we are trying to solve in children are created by the environment we expect them to perform in. We make normal behavior abnormal by our expectations. Children stop exhibiting behavior that has been labeled ADD because they grow up. Which begs the question, did they really have ADD? ADD is a real problem but probably not as pervasive among children as is reported.

    Neuroscience is in its infancy. We don’t know how these drugs work and we don’t know the long term consequences of giving them to children. If the drug effect is placebo, there are certainly less expensive methods of producing and delivery placebos. If the drug effects are damaging we certainly need better clinical trials with more transparency from drug companies testing psychoactive drugs to make this determination. We also need to recognize that behavioral change often requires work. Drugs are not a cure-all when it becomes to behavioral change.

  20. #20 Hyperion
    February 8, 2012

    I posted a comment a few days ago, it appears that it is stuck in moderation. I suspect that this may be an automatic thing as I had included several links in the comment (links to PubMed, which I assume is acceptable).

    The short summary was that the statement that Ritalin is less effective than a placebo is by definition false if we’re talking about short-term effects, as FDA approval requires that it be demonstrated to be more effective than a placebo.

    The long-term study mentioned is the Multimodal Treatment Assessment (MTA). The initial findings of that study, it deserves to be mentioned, found that the medication-only group did far better than the therapy-only group, with the combined group doing slightly better than the medication-only group. It is only the long-term followup to the study that is mentioned here. The problem with this is that for the long-term followup, the groups were no longer randomized, making the long-term findings difficult to interpret. Parents and patients were allowed to switch groups after the initial portion of the study, so it adds in some complicating factors. Whether these complications affect the long-term outcome of the study is beyond my pay grade.

    I also made some mention of neuroimaging studies. While the technology is still in its infancy, there are a number of published papers that demonstrate that there are some structural and functional neurological differences in patients with ADHD in specific areas. Neuroimaging patients after taking medication seems to demonstrate that it has an effect in these areas. Obviously this is not the same as finding a “single comparable target” (other than in the purely pharmacodynamic sense), but it is incorrect to imply that these drugs do not affect the underlying neurobiology of the disorder.

    I also probably should have briefly mentioned the twin studies, as well as numerous genetic studies. According to OMIM, while there are likely multiple different mutations that can result in ADHD, I believe they have it listed as an autosomal dominant condition.

    Having empathy for those reaching out for help is admirable. Actually helping them is somewhat more admirable. If medication helps, then it should be used. If it does not help, then obviously it shouldn’t.

  21. #21 Sesli Chat
    February 20, 2012

    Obviously this is not the same as finding a “single comparable target” (other than in the purely pharmacodynamic sense), but it is incorrect to imply that these drugs do not affect the underlying neurobiology of the disorder.

  22. #22 NotScience
    April 9, 2012

    It seems that JPGK didn’t realize that my comment was in response to Thomas King’s comment. I find that study ( Pediatrics 2010;126(2);214-221) irritating for the same reason I find this post frustrating. Not knowing enough about how it works has never been cause to question a treatment.

    Since I was called-out for writing all folksy-like, I’ll say something specific about the study. The study data was gleaned from a study on obesity interventions. The data is entirely from surveys that are either self-reported, parent reported and teacher reported. The 13-month follow up rate for parents was 70%.

    Does anyone here think this study adds to our understanding of ADHD?

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