Children’s A.D.D. Drugs Don’t Work Long-Term
nytimes.com
nytimes.com
My larger point is this: Don't let prejudice of big pharma allow you to "throw the baby out with the bath water". No one benefits from that mentality.
>A lot of people not afflicted with A.D.D. like to give their armchair opinion on the effects, classification and understanding without having spent one day with A.D.D.
From the piece
>As a psychologist who has been studying the development of troubled children for more than 40 years...
From you
>I was diagnosed late in life, so I can't speak to the longer term, or even child-related effects of Concerta or Ritalin
From the piece
>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.
The author cites numerous studies in order to discuss the effect of medications on children. You cite a personal anecdote about an adult to explain why you take offense to what I found to be an incredibly reasonable and evidence oriented article about children.
-- edited to add --
The reason I'm stressing the child/adult dichotomy, and the reason I reacted tersely (and, to be honest, angrily. sorry) is that if you read the DSM IV's list of symptoms for adhd [1], they really do read like very typical behavior for children. I don't think I've ever met a 7 year old who couldn't qualify under a generous interpretation of the criteria. The vast majority of adults I've met simply wouldn't qualify.
I've met adults with ADHD, and I don't doubt that it's a real disorder. But just because it's a real thing doesn't preclude the possibility that it is over-diagnosed and/or over-medicated in children. I've seen a lot of evidence that it's both.
[1] https://www.msu.edu/course/cep/888/ADHD%20files/DSM-IV.htm They're under the heading "Diagnostic Criteria for the three subtypes..."
> 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.
Illusion? Plenty of professionals in the field believe there are a number of ways to combat the symptoms of ADD. Everyone knows that the drugs combat symptoms and don't provide a cure. He is providing a straw man here.
> But just because it's a real thing doesn't preclude the possibility that it is over-diagnosed and/or over-medicated in children. I've seen a lot of evidence that it's both.
it's almost a tautology that it is over-diagnosed. Since it is behavior based, there are going to be more false positives than misses.
You can google "adhd bibliography" if you want to read a bunch of studies. You can tell the bibliographies that come from places that are pushing a particular therapy (medication or otherwise) because they include no articles critical of their approach.
Edit: As a side note, damn that's a stupid editorial policy. The opposite should be true; any scientific claims in an op-ed should be required to have a citation, even if it's a poor one. I guess it's just one of those places where journalistic and scientific epistemology clash. Journalists say "this is what an expert thinks!", while scientists say "here is some data!"
Furthermore, the author refers to it as a "well-controlled study". It's not. The original 14-month study was controlled, and it showed short-term improvement. This study is a prospective follow-up. It's not a controlled trial. It's not trying to be a controlled trial.
Finally, looking at the full text, they appear to have used linear modeling. That's also a red flag. Obviously, sometimes a linear model is the right choice. But most often it is used because it is the convenient choice.
It's offensive because the diagnosis has finally reached a milestone of acceptance and now we're shaping opinion about treatment through bullshit.
>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.
Perhaps you are concerned about the lack of a citation (which is standard practice in op-eds, an editorial decision of the paper, and something which the author has no control over). Here is link to the study: http://www.ncbi.nlm.nih.gov/pubmed/19318991
"Medication use decreased by 62% after the 14-month controlled trial"
8 years later there was no controlled study and 62% of the subjects stopped medication at 14 months! Doesn't the article sound extremely dishonest now?
Also, I would like to point out that studies cannot force the patients to take medication. If the people taking the medication are terminating their own treatment, don't you think that's a little bit of a warning sign? I've seen recordings of interviews with kids where they talk about how much they hate their adhd meds, and how the meds affect their personalities. In contrast, adults don't seem to have the same pattern of disliking the effects. To the best of my knowledge, no one's figured that one out yet.
and
> Also, I would like to point out that studies cannot force the patients to take medication.
plus: "it was a well-controlled study"
= dishonest.
If they don't know for sure, then why are they reporting it as fact? Some people, as many have already said, are misdiagnosed with A.D.D., so it is no surprise that many people would stop medication as it would have not had a benefit to them.
> don't you think that's a little bit of a warning sign?
No. A lot of the time when that happens, in my experience, it has been due to other's opinion on the effect or usefulness of the medication. (i.e. you).
For a person with ADD, if there was a gun held to their head to stay on a task, they will soon forget that there's a gun and become distracted. They can't help it. Their mind is racing. The only way to stay on task is to be constantly tapped on the head with the gun. At this point, it's the periodic reminder that's doing the trick. This is why people with ADD often require external structure to keep them focused.
There's a lot of positives for people with ADD, such as increased creativity and out-of-the-box thinking. Problem is that a lot of societal institutions, such as school, are not adapted to it.
It's not so much about keeping focus it's the executive function part of it: keeping focused on the right thing. People with ADD can definitely focus, they just can't control it. That's why parents can easily dismiss it as lack of motivation. "he focuses just fine playing soccer" (a sport with adrenaline that gives results like stimulants)
The average person, given various antidepressants (or at least certain ones; I've not kept up on all the research) would not get any benefit. Desipramine, for example, is not some all-around, casual-use pick-me-up.
I think this is true for at least some ADD drugs; how does a person respond to stimulants? Do they calm down, or do they get wired? Ritalin and Adderall used to calm me down; so did black beauties when I was self-medicating. Eventually they stopped doing anything for me.
Unfortunately there is, to my knowledge, no objective marker for various mental conditions. You have to try things and consider the context and see what works or doesn't, and you may never really know exactly why, or what the underlying problem is.
ADD? Occasional distraction? Depression? Bad time in your life? Bi-polar?
The lines are blurry.
The ability to concentrate is like a muscle. If it's weak, the way to strengthen it is exercise. If you went to a gym and found you could only bench-press 20 pounds, would we say you have Muscular Weakness Syndrome and suggest medical treatment? While it's possible your weakness might be caused by some disease, and that should perhaps be looked into, it's also possible that the sole cause is that you don't get much exercise.
The way to exercise the concentration muscle is, of course, meditation.
This is just my opinion and I could be wrong, but I think it's a possibility that should be kept in mind.
qEEG has been very good at matching up people who have been diagnosed with ADD versus normal people. It's the first real test that provides some indication without going off behavior.
I thought this was one of the better comments regarding the diagnosis of A.D.D.
Why? I was diagnosed late, so I was missed – and yet, I cannot ignore the obvious over-diagnosis of A.D.D. It seems if you're hyper, you have attention deficits. For me, I was never hyper so I completely missed the radar. That's also why I feel that there is an over-diagnosis – and why people feel that it isn't a legitimate diagnosis.
I was diagnosed with a less-noticed blend of A.D.D., more commonly known as ADHD-PI or "predominately inattentive". I actually could sit still, I didn't move around all the time. But the slight movement of a foot in a classroom would completely take me away from any focus. Most people can say that they have those experiences, but these people can also get into extreme focus later on for other things they actually love to do. That's the marker, for me, as a diagnosis.
This is the crux of the article.
What do you find offensive exactly?
It doesn't say stimulants don't have any effect, it says (citing research) that the effect wears off, and that other strategies have to be devised.
The lying?
"Medication use decreased by 62% after the 14-month controlled trial"
The study wasn't controlled for 8 years. The link to the study was linked by other people.
No, it vaguely gestures at research without citing it. No citation is actually given in this entire piece.
Now it seems like anyone who says they have trouble concentrating is diagnosed and given pills.
It does seem like that if you listen to laymen and read the news. But is there actually good reason to believe it is true?
A) The drugs work in the short term, and in the absence of data, the null hypothesis is that they continue to work in the long term. Making a strong claim like "ADD drugs don't work in the long term" without strong evidence is nothing short of scientific malpractice.
B) The author claims there was "a well-controlled study" that showed "very clear" results that "medication" (which medication?) was ineffective after 8 years. Thankfully, we won't be burdened with analyzing this study for ourselves, because the author does not give a citation or any other way of tracking the study down.
C) The author says that you can't fix all of the problems caused by ADHD with drugs. That's true, and any good doctor will tell you as much. Drugs are part of managing ADHD. They are not an entire solution.
D) The author claims that these drugs are habit forming. This is simply false at the dosages used to treat ADHD. For many ADHD drugs (e.g. atomoxetine), it is false at any dosage.
There's a more thorough destruction of the piece here: http://www.huffingtonpost.com/dr-harold-koplewicz/ritalin-go...
Very conspicuously, whenever I read "official" research on these medications, the studies were always short term like 6 weeks, maybe 12. One of the drugs I was prescribed had been out for years yet the only study available was for 6 weeks. Isn't that odd? Wouldn't you think that with the drug's having been on the market for years and with lots of online accounts of decrease in effectiveness after a few months that someone would have done a study? Doesn't the FDA require any follow-up studies be done after a drug is released to show a lack of side effects or continued efficacy?
It's really not surprising to me that now that medical practitioners are gaining years of experience prescribing these drugs that this long-term efficacy issue is going to become more of a subject of discussion.
Out of curiosity, have you had to increase your dosage significantly as an adult? It is common for people to need to increase their dosage during adolescence because their bodies change, and that's not necessarily indicative of a tolerance effect.
I took Ritalin or Concerta (a long release form of Ritalin) from 3rd grade to most of the way through college. And i can say for a fact that i would not have made it through high school with out it.
When i got to college im not sure what happened, i either outgrew the ADD, or adapted, i stopped taking it around the end of my 2nd year.
I'm still on the medication, though I only take it when I'm at work or need the concentration help.
We need to rethink public education before we start drugging everyone to fit a broken system. The way that college is taught is much more humane.
Good Noam Chomsky interview on the topic of education: http://www.youtube.com/watch?v=DdNAUJWJN08
Stated with such certainty. What evidence do you have that the commenter here in particular didn't develop in some way as they grew up?
This doesn't take away from your views that there may be problems with the education system but to declare that there are no cases of real medical issues in this area seems a bit presumptive.
No evidence, speaking from personal experience and the belief that ADD is over diagnosed.
I don't find it hard to believe there are millions of students unable to focus in public school. What I find hard to believe is that medication is the answer. Sure its an easy answer for those teachers to have their students sit quietly in the classroom for 50-90 minutes with little interruption and be expected to focus on subjects that relate little to their life with little or no control over what and how they study. I was diagnosed with ADD, and I had these views about 12 years ago to when I was diagnosed. I'll stick to cabbage, green tea, and the occasional meditation to help with my so called add.
"I therefore all" is clearly a fallacy although a very popular one. It is really a form of anecdote and deserves no more weight than any other particular anecdote.
My problems were real though. they manifested themselves mostly in math with basic multiplication and division. Reading took me a little longer to get the hang of before that, but once i got the basics i was reading Adult level (not young adult or Childrens) Star Trek Novels in 4th grade while everyone else was reading goosebumps or whatever was popular back then.
Nevertheless, we had him tested by a neurobehavioral specialist who believes he has ADD. The doctor recommended either drugs or neurofeedback. http://en.wikipedia.org/wiki/Neurofeedback
I'm very hesitant to give my 5-yo any medication, but we are considering neurofeedback. I'm curious if anyone here has any knowledge or experience with it.
It might make sense to find a more advanced program for him before you go do anything else. If he's as advanced as you say, boredom could be the major factor beyond anything else. If his behavior doesn't change after that, I'd consider the other options then.
Also, congratulations on having a kid who has problems in school because they're far ahead; as problems go, that's a pretty good one to have. :)
If I had a child with this problem, I wouldn't even consider drugs. I would do my best to challenge them with higher-level reading material, computer games, programming (Logo or something) as soon as they're ready, etc.
I would also try to get them to meditate with me. That is the best way to learn to manage a wayward mind.
Neurofeedback, if I understand correctly, is a kind of electronically-assisted meditation. As such I think it might be worth trying if they just weren't ready for more self-directed forms.
I'm not a believer in ADD medication, even though I've been diagnosed and prescribed ADD medication. It just becomes a new state, most of the problem lies in finding healthy ways to deal with the issues. Try meditation and yoga to start with.
To be clear, my son is not at pre-school for the academics. We feel that it is important for him to experience a social atmosphere, and although he is ready to learn at a kindergarten or 1st-grade level, I don't know that putting him in a class with children much older than himself would be beneficial.
I've never felt there is "something wrong" with him, but it would be good if he could operate within the norms of a classroom.
I would like to homeschool, but my wife does not feel up to it. (I'm not putting her down at all, it's a big task and requires buy-in from both of us)
For academics, I continue to teach him at home interactively, and he also loves self-directed study.
The real difficulty for him is listening to the teacher, and not running around when he should be sitting, not screaming when he doesn't get his way, etc. At home, if he has something interesting to work on he can sit and concentrate easily for an hour or longer.
Edit: My fossilized list of recommendations: http://www.kidslikemine.com/archive/supportontheweb.shtml
It isn't remotely current. I am very out of the loop. But Hoagies is linked there and she should have more current info.
Ritalin is nearly 60 years old.
Congratulations on your doctorate! Did you go for an MD or a PhD?
Why would you think you would be diagnosed with an executive function disorder?
Trust your instincts. Maybe this environment isn't right for him? How would you want him to behave in this kind of environment?
Is anyone aware of any studies of ADD and related conditions that control for these factors?
> Sometimes he would stand up from his computer and perform a set of twenty or so jumping jacks, explaining to anyone present that short bouts of physical activity served a certain neurobiological function that made stimulant drugs unnecessary.
I would also contend the fact we are now a "knowledge economy" is the reason why its become prevalent.
We have to sit at desks longer and focus on singular tasks. Which is the bane of ADD.
There's a reason for that. "My kid has celiac" is the new fad, but the fad doesn't "cure" ADD.
This, at least, is not the case.
http://theincidentaleconomist.com/wordpress/sugar-and-candy-...
Worse, the author of this piece is a known axe-grinder on the issues he writes about, and doesn't even have the respect of many of his colleagues in the Department of Psychology (he himself is in the Department of Child Development) at the University of Minnesota, where I attend the behavior genetics seminar most weeks during the school year. He is still stuck in the old days of child development theories that have since been abandoned.
On the other hand, I will agree with the author, relating both to ADD and to other diagnoses, that most human behaviors have to be influenced by treatments that focus on the specific behaviors in addition to prescribed medicines. A both-and approach of supportive help for the behavior as well as the best validated medical treatment works better than merely taking the medicines. Learning to focus and direct attention appropriately is not easy, especially when many immediate relatives of the child, perhaps including both parents, may have many of the same issues. Slow and steady wins this race.
I am currently pursuing an academic career but I really feel that I would have been better at doing something simpler, like sports. Short tasks, competition, and recognition are very important for me.
http://www.reddit.com/r/explainlikeimfive/comments/16joxj/pe...
I would be a bigger fan of moderating the drugs. Don't use the drugs on weekends or holidays; use lower doses on days where it is OK to goof off a bit or days where the workload is light. I suspect that doing this with children would be a good lesson in and of itself, in that they can see that work and play can be separated and that the withdrawal symptoms from a drug can be overcome (this could also serve as a way to identify people who have some innate problem with drug dependence before they get into trouble).
Of course, there is also the matter of school being so boring and so undesirable that children need to have pristine focus just to survive. Perhaps it would be best to solve that problem first, before using drugs to keep children focused on "busy work."
You do know that ADD is much more than focus issues, right? It's more of an executive function disorder. They can't focus on the right things when the want to. I'm betting most if not all can hyperfocus and lose track of time when doing something that engages them. What they can't do is manage priorities and turn that focus on and off when they want to.