Do ADHD drugs give caretakers a placebo effect?


[note: addition/corrections at bottom added an hour after orig post. additions underlined. deletions struckthrough. See *]

Meet the meta-placebo: A new study suggests that ADHD meds do much of their work by producing placebo effects -- and more constructive behavior -- among the parents, teachers, and other caretakers of the kids actually taking the meds. Via ScienceDaily:

A recent review of research by University at Buffalo pediatric psychologists suggests that [ADHD] medication, or the assumption of medication, may produce a placebo effect -- not in the children, but in their teachers, parents or other adults who evaluate them.

A placebo effect is a positive change in symptoms or behavior after a patient receives a "fake" medication or procedure; in other words, the belief can become the medicine. In this case, the review suggested that when caregivers believed their ADHD patients were receiving ADHD medication, they tended to view those children more favorably and treat them more positively, whether or not medication was actually involved.

"The act of administering medication, or thinking a child has received medication, may induce positive expectancies in parents and teachers about the effects of that medication, which may, in turn, influence how parents and teachers evaluate and behave toward children with ADHD," said UB researcher Daniel A. Waschbusch, Ph.D., lead author of the review.

"We speculate that the perception that a child is receiving ADHD medication may bring about a shift in attitude in a teacher or caregiver. They may have a more positive view of the child, which could create a better relationship. They may praise the child more, which may induce better behavior."

Such a placebo effect in caregivers could have both good and not-so-good results, Waschbusch added. "If teachers treat children more positively if they think they are on medication, that is a good thing. But if the child's medication is increased because caregivers think it is effective, that may not be a good thing."

This is not at all hard to imagine, as ADHD meds are generally prescribed because parents and teachers believe they'll solve behavioral problems -- and have a strong desire to see them work.

The big caveat here -- and it's a big'n -- is there seems to have been no controlled study; that is, no comparison of effects in kids getting the meds versus kids getting a placebo. It would be damned interesting to see such a study, the bigger the better. And if it works? That is, what if such a study found a strong placebo effect?*

So if placebos work, would it be ethical to prescribe placebos? And can you really prescribe placebos while still fully informing a patient? Lots of doctors do, actually. This slippery territory has been explored in the Times Magazine as well as quite a few scholarly pieces.

(Additional of salt: This write-up is from a press release, and I've not been able to get past the paywall to read the paper.)*

[added an hour after the original post]: *I struck these passages because a) this study, which was a review of literature, included reviews/analyses of placebo studies, and so took direct account of the placebo effect and b) DrugMonkey, who pointed out (a) in a comment below, was kind enough to send me a copy of the paper, which turned out to be more robust than the press release led me to believe.

I want to add, vis-a-vis DrugMonkey's comments below, that I'm well aware of the dangers of drawing conclusions based on press releases. (I find it frightening, in fact, how many bloggers blog heavily based on the press-release-news-stories published at ScienceDaily, treating them as news stories (shaky enough, often enough) rather than the press releases they are.) That's why I placed caveats and scattered salt grains throughout my post. Perhaps I should have headed it, "Interesting if true" -- a caveat that should be applied to almost any initial result and to many seemingly "confirmed" as well.

That said, I find this paper interesting, and wanted to draw attention to it, not so much because it's astonishing, but because it's not -- that is, because it looks directly at a dynamic, the role of expectations and motivations and desires among parents and teachers, among others, that logic and observation would lead us to expect a strong effect.

ADHD is a terribly complex problem; yet another in which the line between "normal behavior" and pathology, fuzzy enough to start with, is vulnerable to movement by all sorts of social forces. As with depression, there are clearly some cases that call for medication, despite medication's problemmatic efficacy and risk-benefit profile; cases, in other words, where the benefit stands to clearly outweight the risks. But there are others where the real problem is parental incompetence, neglect, confusion, or inexperience, or some other gap between the needs of an essentially healthy child and the capacities of the parents or school to meet them. Sometimes the gap gets filled by medication. It's interesting to see that the medication may fill the gap partly by changing the behavior of the caregivers, not just the child.

More like this

The big caveat here -- and it's a big'n -- is there seems to have been no controlled study; that is, no comparison of effects in kids getting the meds versus kids getting a placebo.

ahh, you are making no sense here. this is a review article, not a research article. as such it, you know, reviews the literature. some of which includes placebo-controlled studies...or how else would they be making any claims about the impact of placebo?

This write-up is from a press release, and I've not been able to get past the paywall to read the paper.

you might want to reconsider this approach.

By DrugMonkey (not verified) on 30 Jun 2009 #permalink

You might be interested in this, due to the complexity of the problem:
Some doctors believe that the placebo effect is mainly or purely physical and due to physical changes that promote healing or feeling better. So, what is the explanatory mechanism for the placebo effect? Some think it is the process of administering it. It is thought that the touching, the caring, the attention, and other interpersonal communication that is part of the controlled study process (or the therapeutic setting), along with the hopefulness and encouragement provided by the experimenter/healer, affect the mood, expectations, and beliefs of the subject, which in turn triggers physical changes such as release of endorphins, catecholamines, cortisol, or adrenaline. The process reduces stress by providing hope or reducing uncertainty about what treatment to take or what the outcome will be. The reduction in stress prevents or slows down further harmful physical changes from occurring.

"...If teachers treat children more positively if they think they are on medication, that is a good thing"

I find this statement baffling. I wonder why the author concludes this is a good thing. To me the research highlights the bias of teachers and parents who are undisciplined and inattentive to their own conditioned responses. Shouldn't we strive to positively reinforce children consistently and objectively based on the merit of their peformance and behaviour independent of whether or not we know they are medicated?

By Kevin Meddleton (not verified) on 02 Jul 2009 #permalink

I want to point out that I whole heartedly believe placcebos to change everyone involves outlooks and expectations in the children. My nephew was started on ADHD meds, and the teacher noticed a "huge difference" but no one else did. We stopped his prescribed pills and had him swallow a white tic tac mint every morning and he continued to recieve good reports from the teacher. His behavior was then addressed as "typical little boy" when he was unable to stay in his seat for any length of time. If he was given nothing to swallow in the morning, bad reports would be received-but him being able to say he DID actually swallow a pill was enough for good reports. I believe this should be looked into, because in the long run, what are the effects on our young children taking stimulant medications when they are NOT needed. Who decides where to draw the line between ADHD problem behaviors and rambunctious young children?

By Venus Hubbard (not verified) on 02 Nov 2009 #permalink

Very nicely explained the pros and cons of placebo. It seems to be very effective. I was not aware of this research. But now i think it is really a innovative and worthful concept for ADHD patients.