<br clear="all">
<div class="header">
<div class="left">
<a href="http://www.nytimes.com/"><img src="http://graphics8.nytimes.com/images/misc/nytlogo153x23.gif" alt="The New York Times" hspace="0" border="0" vspace="0" align="left"></a><br clear="all"></div></div><br><hr size="1" align="left">
<div class="timestamp">January 28, 2012</div>
<h1>Ritalin Gone Wrong</h1>
<span><h6 class="byline">By L. ALAN SROUFE</h6></span>
<div id="articleBody">
<p>
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 <a href="http://www.nytimes.com/2012/01/01/health/policy/fda-is-finding-attention-drugs-in-short-supply.html?pagewanted=all">shortage of drugs like Ritalin and Adderall</a> that they considered absolutely essential to their children’s functioning. </p>
<p>
But are these drugs really helping children? Should we really keep expanding the number of <a href="http://health.nytimes.com/health/guides/specialtopic/getting-a-prescription-filled/overview.html?inline=nyt-classifier" title="In-depth reference and news articles about Getting a prescription filled." class="meta-classifier">prescriptions</a> filled? </p>
<p>
In 30 years there has been a twentyfold increase in the consumption of drugs for attention-deficit disorder. </p>
<p>
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. </p>
<p>
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. </p>
<p>
Sadly, few physicians and parents seem to be aware of what we have been
learning about the lack of effectiveness of these drugs. </p>
<p>
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. </p>
<p>
Back in the 1960s I, like most <a href="http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthtopics/psychology_and_psychologists/index.html?inline=nyt-classifier" title="Recent and archival health news about psychologists." class="meta-classifier">psychologists</a>,
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. </p>
<p>
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. </p>
<p>
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 <a href="http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthtopics/amphetamines/index.html?inline=nyt-classifier" title="Recent and archival health news about amphetamines." class="meta-classifier">amphetamine</a>,
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. </p>
<p>
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. </p>
<p>
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 href="http://health.nytimes.com/health/guides/disease/attention-deficit-hyperactivity-disorder-adhd/overview.html?inline=nyt-classifier" title="In-depth reference and news articles about Attention deficit hyperactivity disorder (ADHD)." class="meta-classifier">A.D.D.</a> wouldn’t develop such tolerance because their brains were somehow different. But in fact, the <a href="http://health.nytimes.com/health/guides/symptoms/appetite-decreased/overview.html?inline=nyt-classifier" title="In-depth reference and news articles about Appetite - decreased." class="meta-classifier">loss of appetite</a> and <a href="http://health.nytimes.com/health/guides/symptoms/sleeping-difficulty/overview.html?inline=nyt-classifier" title="In-depth reference and news articles about Sleeping difficulty." class="meta-classifier">sleeplessness</a>
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. </p>
<p>
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. </p>
<p>
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. </p>
<p>
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. </p>
<p>
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. </p>
<p>
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. </p>
<p>
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. </p>
<p>
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 <a href="http://health.nytimes.com/health/guides/specialtopic/puberty-and-adolescence/overview.html?inline=nyt-classifier" title="In-depth reference and news articles about Puberty and adolescence." class="meta-classifier">adolescence</a>, as my colleagues at the University of Minnesota and I have been doing for decades. </p>
<p>
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 <a href="http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthtopics/pregnancy/index.html?inline=nyt-classifier" title="Recent and archival health news about pregnancy." class="meta-classifier">pregnancy</a>,
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. </p>
<p>
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. </p>
<p>
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. </p>
<p>
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. </p>
<p>
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. </p>
<p>
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. </p>
<p>
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. </p>
<p>
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. </p>
<p>
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. </p>
<p>
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. </p>
<p>
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. </p>
<div class="authorIdentification">
<p>L. Alan Sroufe is a<a href="http://www.cehd.umn.edu/icd/faculty/sroufe.html"> professor emeritus</a> of psychology at the University of Minnesota’s Institute of Child Development.</p> </div>
<div class="articleCorrection">
</div>
</div>
<br>
<center>
</center>
<noscript>
<div><img alt="DCSIMG" id="DCSIMG" src="http://wt.o.nytimes.com/dcsym57yw10000s1s8g0boozt_9t1x/njs.gif?dcsuri=/nojavascript&WT.js=No&WT.tv=1.0.7" height="1" width="1"></div>
</noscript>
<br>-- <br>Art Deco (Wayne A. Fox)<br><a href="mailto:art.deco.studios@gmail.com" target="_blank">art.deco.studios@gmail.com</a><br>