[Vision2020] Ritalin Gone Wrong

[Art Deco]

 [image: The New York Times] <http://www.nytimes.com/>

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January 28, 2012
Ritalin Gone Wrong By L. ALAN SROUFE

THREE million children in this country take drugs for problems in focusing.
Toward the end of last year, many of their parents were deeply alarmed
because there was a shortage of drugs like Ritalin and
Adderall<http://www.nytimes.com/2012/01/01/health/policy/fda-is-finding-attention-drugs-in-short-supply.html?pagewanted=all>that
they considered absolutely essential to their children’s functioning.

But are these drugs really helping children? Should we really keep
expanding the number of
prescriptions<http://health.nytimes.com/health/guides/specialtopic/getting-a-prescription-filled/overview.html?inline=nyt-classifier>filled?

In 30 years there has been a twentyfold increase in the consumption of
drugs for attention-deficit disorder.

As a psychologist who has been studying the development of troubled
children for more than 40 years, I believe we should be asking why we rely
so heavily on these drugs.

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. The drugs can also have serious
side effects, including stunting growth.

Sadly, few physicians and parents seem to be aware of what we have been
learning about the lack of effectiveness of these drugs.

What gets publicized are short-term results and studies on brain
differences among children. Indeed, there are a number of incontrovertible
facts that seem at first glance to support medication. It is because of
this partial foundation in reality that the problem with the current
approach to treating children has been so difficult to see.

Back in the 1960s I, like most
psychologists<http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthtopics/psychology_and_psychologists/index.html?inline=nyt-classifier>,
believed that children with difficulty concentrating were suffering from a
brain problem of genetic or otherwise inborn origin. Just as Type I
diabetics need insulin to correct problems with their inborn biochemistry,
these children were believed to require attention-deficit drugs to correct
theirs. It turns out, however, that there is little to no evidence to
support this theory.

In 1973, I reviewed the literature on drug treatment of children for The
New England Journal of Medicine. Dozens of well-controlled studies showed
that these drugs immediately improved children’s performance on repetitive
tasks requiring concentration and diligence. I had conducted one of these
studies myself. Teachers and parents also reported improved behavior in
almost every short-term study. This spurred an increase in drug treatment
and led many to conclude that the “brain deficit” hypothesis had been
confirmed.

But questions continued to be raised, especially concerning the drugs’
mechanism of action and the durability of effects. Ritalin and Adderall, a
combination of dextroamphetamine and
amphetamine<http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthtopics/amphetamines/index.html?inline=nyt-classifier>,
are stimulants. So why do they appear to calm children down? Some experts
argued that because the brains of children with attention problems were
different, the drugs had a mysterious paradoxical effect on them.

However, there really was no paradox. Versions of these drugs had been
given to World War II radar operators to help them stay awake and focus on
boring, repetitive tasks. And when we reviewed the literature on
attention-deficit drugs again in 1990 we found that all children, whether
they had attention problems or not, responded to stimulant drugs the same
way. Moreover, while the drugs helped children settle down in class, they
actually increased activity in the playground. Stimulants generally have
the same effects for all children and adults. They enhance the ability to
concentrate, especially on tasks that are not inherently interesting or
when one is fatigued or bored, but they don’t improve broader learning
abilities.

And just as in the many dieters who have used and abandoned similar drugs
to lose weight, the effects of stimulants on children with attention
problems fade after prolonged use. Some experts have argued that children
with A.D.D.<http://health.nytimes.com/health/guides/disease/attention-deficit-hyperactivity-disorder-adhd/overview.html?inline=nyt-classifier>wouldn’t
develop such tolerance because their brains were somehow
different. But in fact, the loss of
appetite<http://health.nytimes.com/health/guides/symptoms/appetite-decreased/overview.html?inline=nyt-classifier>and
sleeplessness<http://health.nytimes.com/health/guides/symptoms/sleeping-difficulty/overview.html?inline=nyt-classifier>in
children first prescribed attention-deficit drugs do fade, and, as we
now know, so do the effects on behavior. They apparently develop a
tolerance to the drug, and thus its efficacy disappears. Many parents who
take their children off the drugs find that behavior worsens, which most
likely confirms their belief that the drugs work. But the behavior worsens
because the children’s bodies have become adapted to the drug. Adults may
have similar reactions if they suddenly cut back on coffee, or stop
smoking.

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.

Indeed, all of the treatment successes faded over time, although the study
is continuing. Clearly, these children need a broader base of support than
was offered in this medication study, support that begins earlier and lasts
longer.

Nevertheless, findings in neuroscience are being used to prop up the
argument for drugs to treat the hypothesized “inborn defect.” These studies
show that children who receive an A.D.D. diagnosis have different patterns
of neurotransmitters in their brains and other anomalies. While the
technological sophistication of these studies may impress parents and
nonprofessionals, they can be misleading. Of course the brains of children
with behavior problems will show anomalies on brain scans. It could not be
otherwise. Behavior and the brain are intertwined. Depression also waxes
and wanes in many people, and as it does so, parallel changes in brain
functioning occur, regardless of medication.

Many of the brain studies of children with A.D.D. involve examining
participants while they are engaged in an attention task. If these children
are not paying attention because of lack of motivation or an underdeveloped
capacity to regulate their behavior, their brain scans are certain to be
anomalous.

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.

It is certainly true that large numbers of children have problems with
attention, self-regulation and behavior. But are these problems because of
some aspect present at birth? Or are they caused by experiences in early
childhood? These questions can be answered only by studying children and
their surroundings from before birth through childhood and
adolescence<http://health.nytimes.com/health/guides/specialtopic/puberty-and-adolescence/overview.html?inline=nyt-classifier>,
as my colleagues at the University of Minnesota and I have been doing for
decades.

Since 1975, we have followed 200 children who were born into poverty and
were therefore more vulnerable to behavior problems. We enrolled their
mothers during pregnancy<http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthtopics/pregnancy/index.html?inline=nyt-classifier>,
and over the course of their lives, we studied their relationships with
their caregivers, teachers and peers. We followed their progress through
school and their experiences in early adulthood. At regular intervals we
measured their health, behavior, performance on intelligence tests and
other characteristics.

By late adolescence, 50 percent of our sample qualified for some
psychiatric diagnosis. Almost half displayed behavior problems at school on
at least one occasion, and 24 percent dropped out by 12th grade; 14 percent
met criteria for A.D.D. in either first or sixth grade.

Other large-scale epidemiological studies confirm such trends in the
general population of disadvantaged children. Among all children, including
all socioeconomic groups, the incidence of A.D.D. is estimated at 8
percent. What we found was that the environment of the child predicted
development of A.D.D. problems. In stark contrast, measures of neurological
anomalies at birth, I.Q. and infant temperament — including infant activity
level — did not predict A.D.D.

Plenty of affluent children are also diagnosed with A.D.D. Behavior
problems in children have many possible sources. Among them are family
stresses like domestic violence, lack of social support from friends or
relatives, chaotic living situations, including frequent moves, and,
especially, patterns of parental intrusiveness that involve stimulation for
which the baby is not prepared. For example, a 6-month-old baby is playing,
and the parent picks it up quickly from behind and plunges it in the bath.
Or a 3-year-old is becoming frustrated in solving a problem, and a parent
taunts or ridicules. Such practices excessively stimulate and also
compromise the child’s developing capacity for self-regulation.

Putting children on drugs does nothing to change the conditions that derail
their development in the first place. Yet those conditions are receiving
scant attention. Policy makers are so convinced that children with
attention deficits have an organic disease that they have all but called
off the search for a comprehensive understanding of the condition. The
National Institute of Mental Health finances research aimed largely at
physiological and brain components of A.D.D. While there is some research
on other treatment approaches, very little is studied regarding the role of
experience. Scientists, aware of this orientation, tend to submit only
grants aimed at elucidating the biochemistry.

Thus, only one question is asked: are there aspects of brain functioning
associated with childhood attention problems? The answer is always yes.
Overlooked is the very real possibility that both the brain anomalies and
the A.D.D. result from experience.

Our present course poses numerous risks. First, there will never be a
single solution for all children with learning and behavior problems. While
some smaller number may benefit from short-term drug treatment,
large-scale, long-term treatment for millions of children is not the
answer.

Second, the large-scale medication of children feeds into a societal view
that all of life’s problems can be solved with a pill and gives millions of
children the impression that there is something inherently defective in
them.

Finally, the illusion that children’s behavior problems can be cured with
drugs prevents us as a society from seeking the more complex solutions that
will be necessary. Drugs get everyone — politicians, scientists, teachers
and parents — off the hook. Everyone except the children, that is.

If drugs, which studies show work for four to eight weeks, are not the
answer, what is? Many of these children have anxiety or depression; others
are showing family stresses. We need to treat them as individuals.

As for shortages, they will continue to wax and wane. Because these drugs
are habit forming, Congress decides how much can be produced. The number
approved doesn’t keep pace with the tidal wave of prescriptions. By the end
of this year, there will in all likelihood be another shortage, as we
continue to rely on drugs that are not doing what so many well-meaning
parents, therapists and teachers believe they are doing.

L. Alan Sroufe is a professor
emeritus<http://www.cehd.umn.edu/icd/faculty/sroufe.html>of psychology
at the University of Minnesota’s Institute of Child
Development.

  [image: DCSIMG]

-- 
Art Deco (Wayne A. Fox)
art.deco.studios at gmail.com
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