Monday, February 06, 2012

Ritalin Gone Wrong? Ritalin Results Gone Wrong

Newsweek, 1996: Ritalin on the ropes.
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 reported 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 households familiar with ADHD meds.  It confused me too which is why I rooted around the research to figure out why the heck the retired child researcher dissed the drugs. 

Although I admired his gumption, from the start I could see much was not-quite-right and some plain wrong in this seemingly well-meaning piece written by a psychologist who spent decades studying children and ADHD, a guy who asked us to reconsider why so many kids are using these medications. Fair enough but a lot has changed since the 1970's when he 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. 

Ah, the best intentions.

Let's get to Sroufe's main claim:
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 
The reality?

There are no studies that can answer whether Ritalin, Adderall or similar drugs work long-term. To date there is no scientific evidence about their long-term effectiveness. 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 that often gets misinterpreted as evidence of the drugs' short-term effectiveness, their long-term effectiveness, long-term inefficacy, the benefits of behavioral therapy, the benefits of a combination of drug and behavioral treatment. Psychologists have argued about the results for over 10 years since the first set of results were published back in 1999. The MultiModal Treatment of Attention Deficit Hyperactivity Disorder Study.  I do remember hearing the results on NPR and remembering they showed behavior programs and drugs as equally effective - which is not quite right either.

Here's the sordid affair.

In the early 1990s almost 600 children aged 7-9 diagnosed with ADHD were randomly assigned to either get drugs, behavioral therapy, both or a control group (basic 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 community care (that also included some drug treatment though far less time/attention to moderating meds).  Note those results refer to mainly ADHD symptoms (e.g., self-control, inattention).  The combo therapy was superior in some outcomes like family relations and school performance.   

It's starting to get complicated, no?  But the study didn't end there. 

The kids were observed for another 6 years in a "uncontrolled naturalistic follow-up study."  Meaning parents could do whatever they wanted and many discontinued the meds. When researchers looked at the data 6 years later there were no longer any significant differences between the original treatment groups.  There were no differences between the kids who originally got the meds and the rest of the lot.  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.  Some observers, like Professor Sroufe, could not resist thinking the results showed the meds stopped working.   

Why keep collecting the data?  It hopefully will offer valuable information about the progress of ADHD.  Results already show that children who responded well initially appear to have improved the most over the years. 

By the way, the general consensus in the mental health community seems to be that the drugs do work well over the long-term (as long as the kids take them) and many also advocate behavioral therapy too.  Though there's this from the NIMH website:
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.
Of course it's possible kids stopped taking it because they no longer needed it. Those who still did 8 years on very well may still have been benefitting from the meds. It's an empirical question and maybe the data is there and we'll read about it soon.  Over half the kids stopped taking the meds. 

Studies have shown the drugs to be quite safe. 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.  These do not exactly indicate "serious" side effects as purported by Dr. Sroufe.

Just found this great point by point refutation of Why Ritalin Is Wrong from Dr. Harold Koplewicz on Huffington Post.  Why "Ritalin Gone Wrong" Is Wrong

In the wake of the recent Ritalin drama I have two requests.  First, can the New York Times please start seriously fact-checking op-eds.  Second, can someone please stop me when I mention epigentic evidence  30 years from now.

A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder. The MTA Cooperative Group. Multimodal Treatment Study of Children with ADHD. Archives of General Psychiatry, 1999 Dec; 56(12):1073-86

The MTA at 8 years: prospective follow-up of children treated for combined-type ADHD in a multisite study. Journal of the American Academy of Child and Adolescent Psychiatry. 2009 May; 48(5):484-500

4 comments:

Awesome Mom said...

Interesting post. I think my niece would really benefit from medication for her ADHD but my SIL is fighting it tooth and nail. I will have to figure out a tactful way to point out the studies.

Polly Palumbo, Ph.D. said...

Good luck - but the behavioral training/pscho-social route seems to work for many too. Is your niece in kindergarten yet? There's also interesting research showing the risks of being diagnosed increase with being younger at the start of kindergarten.

Awesome Mom said...

She is 10 now so it is not that she is too young for Kindergarten. I just saw this article and was hoping you could take a loot at it and see if there really is the mountain of evidence that the researchers claim. http://health.yahoo.net/news/s/nm/spanking-kids-can-cause-long-term-harm-canada-study It seems to me that my bs detector is going off for this one. I am not saying that beating your kid is great but I have a hard time believing that spanking a kid now and then is going to turn them into an aggressive moron.

Polly Palumbo, Ph.D. said...

You're right by age 10 it becomes easier to accurately diagnose ADD. Is she struggling in school and friendships?

Thanks for the link - will check into it. A spanking study came out a couple years ago, posted on it. I don't think it was a well-controlled one meaning it's impossible to say whether the spanking "effects" came from the spanking or other parental characteristics or behavior (or even child ones).