Author Robert Whitaker reviews the history of the condition once known as hyperactivity, then as Attention-Deficit Disorder or ADD, and now as Attention-Deficit Hyperactivity Disorder, or ADHD. It is my conviction that hundreds of years from now historians will regard our obsession with drugging children to control their behavior the way we now regard witch hunts: What the Hell were those people thinking?
Read the evidence and decide for yourself. In 1980, the American Psychiatric Association published the third edition of its Diagnostic and Statistical Manual, which for the first time included Attention-Deficit Disorder. (In 1987, a revised version of DSM-III broadened the diagnostic criteria for this disorder and re-named it Attention-Deficit Hyperactivity Disorder) At one stroke, literally millions of children who might otherwise have been labeled as “naughty” or “fidgety” or, for that matter, perfectly normal, were now judged to be mentally ill and in need of powerful brain-altering drugs.
The drug of choice for this “disorder” is Ritalin, a stimulant similar to amphetamine in its chemical structure and to cocaine in its mode of action. At the time the diagnostic category ADD was invented, about 150,000 children were taking Ritalin for the condition then known as “hyperactivity.” Today that number has risen to 3.5 million. This is almost exclusively an American phenomenon, by the way. The United States, with less than five percent of the world’s population, accounts for a staggering 75% of stimulants consumed by children. This certainly has been a windfall for the drug companies. How did it work out for the rest of us?
Ritalin has been touted for its ability to change children’s behavior. And it sure does. A 1978 double-blind study of the effect of Ritalin on schoolchildren by Herbert Rie noted that children taking the drug:
“…appeared distinctly more bland or flat emotionally, lacking both the age-typical variety and frequency of emotional expression. They responded less, exhibited little or no initiative or spontaneity, offered little indication of either interest or aversion, showed virtually no curiosity, surprise, or pleasure, and seemed devoid of humor. Jocular comments and humorous situations passed unnoticed. In short, while on active drug treatment, the children were relatively but unmistakably affectless, humorless, and apathetic.”
All of which makes for a more manageable child in the classroom. Indeed, the diagnosis of ADHD normally is a response to teacher complaints, not parental concerns. But does this short-term increased tractability translate into any long-term benefits for the child?
According to Whitaker, the answer is a big fat NO.
The aforementioned Herbert Rie noted “[T]he major effect of stimulants appears to be an improvement in classroom manageability rather than academic performance.” A 2002 review published in the Canadian Journal of Psychiatry found “little evidence indicates that stimulants improve academic attainment, even after as long as 1 year of treatment.” The 1994 edition of the American Psychiatric Association’s Textbook of Psychiatry averred that “Stimulants do not produce lasting improvements in aggressivity, conduct disorder, criminality, education achievement, job functioning, marital relationships, or long-term adjustment.” A long-term study by the National Institute of Mental Health (NIMH) concluded “The long-term efficacy of stimulant medication has not been demonstrated for any domain of child functioning.”
At this point I can do no better than to quote Whitaker verbatim:
“[T]he NIMH found that over the long term there was nothing to be entered on the benefit side of the ledger. This leads only the risks to be tallied up, and so now we need to look at all the ways that stimulants can harm children.
“Ritalin and other ADHD medications cause a long list of physical, emotional, and psychiatric adverse effects. The physical problems include drowsiness, appetite loss, lethargy, insomnia, headaches, abdominal pain, motor abnormalities, facial and vocal tics, jaw clenching, skin problems, liver disorders, weight loss, growth suppression, hypertension, and sudden cardiac death. The emotional difficulties include depression, crying jags, irritability, anxiety, and a sense of hostility toward the world. The psychiatric problems include obsessive-compulsive symptoms, mania, paranoia, psychotic episodes, and hallucinations.”
The kids who are given these drugs feel a “sense of hostility toward the world?” I wonder why?
There is also strong evidence that stimulants as Ritalin are one of the causes of the epidemic of juvenile bipolar disorder sweeping the nation. I shall have more to say about that in my next post.
But I submit there is even more at stake here. What is at stake is an entire world view. Am I the only one who is horrified by this vision of ourselves as creatures who have no need for self-discipline, self-control, or free will? Just pump us full of the right drugs and we’ll do whatever our masters want.
If you do not accept that view, then all we are left with is the hard gritty work of building character, of learning from our mistakes and trying again. And it is my observation that most people do just that. The angry person learns to control his temper, the timid person learns to assert himself, the goof-off gets serious, and the introvert opens up to his fellow human beings. It is my observation that most people get better with advancing years. Watching this process unfold is one of the privileges of being human. To throw this away in exchange for a compliant, drugged child who may grow into a permanently damaged adult strikes me as the height of insanity.
I wonder if there is a pill we can take for that?
Photo via Wikimedia Commons
UPDATE 30 JANUARY 2012: The January 29 edition of the New York Times features an essay by L. Alan Sroufe, Professor Emeritus at the Institute for Child Development at the University of Minneota, which says in part:
“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 faded, and by eight years there was no evidence that medication produced any academic or behavioral benefits.”
UPDATE 31 JANUARY 2012: Dr. Sroufe has kindly directed my attention to the paper, “The MTA at 8 years: Prospective Follow-Up of Children Treated for Combined ADHD in a Multisite Study,” published in the May 2009 issue of the Journal of the American Academy of Child and Adolescent Psychiatry. 579 children at six sites diagnosed with ADHD were randomly assigned to one of four treatment groups: 1) Medication management, 2) Multicomponent Behavioral Therapy, 3) Medication + Therapy, or 4) Usual Community Care (whatever that means). After eight years, there were no statistically significant effects of treatment group assignment on any of 24 outcome variables tested.