Parents are knocking on the doors of Head Teachers’ offices every day professing that their child is ADHD and in need of Ritalin. Why? Because when your child receives that diagnosis and takes the stimulant (Ritalin is a type of stimulant) three things happen; firstly, your kid becomes easier to control. Secondly, you become absolved of blame for their bad behavior. And thirdly, in some countries you receive extra benefit money every week from the government. I’m pretty sure those three things serve to encourage parents and teachers to jump on the Ritalin Bandwagon. However, I wonder whether parents and teachers (and some doctors for that matter) would be so quick to diagnose and prescribe if they were informed of the research investigating the effects of taking Ritalin in the long term.
But before we get to the research, let’s talk about what causes ADHD. Although the public may hear about research in which ADHD is presented as a biological disease, the truth is that its etiology is unknown. For example, Pediatric Neurologist Gerald Golden wrote ‘Attempts to define a biological basis for ADHD have consistently been unsuccessful’ and The National Institute of Health reiterated this in 1998 ‘After years of clinical research and experience with ADHD, our knowledge about the cause or causes of ADHD remains largely speculative’. It was first thought that ADHD was caused by brain abnormalities but it quickly emerged that the neuroanatomy of the brain in children diagnosed with ADHD is entirely normal. As with most psychological disorders it was also thought that ADHD might be caused by a chemical imbalance. Specifically it was thought that children diagnosed with ADHD might have an under-active dopamine system, and thus Ritalin works by increasing the dopamine in the child’s system to normal levels. But this seemed to be simply a marketing claim and has little evidence in its favor. For example the APA’s textbook of neuropsychiatry confessed in 1997 ‘efforts to identify neurochemical imbalances in children with ADHD have been disappointing’.
So here we have a situation where we are administering a drug to children that is designed to increase dopamine, and yet the child does not have abnormal levels of dopamine in the first place! It may come as no surprise therefore that research investigating the long-term effects of Ritalin use is not favorable. Notice my use of the words ‘long term’. As with my previous blog (the anti-depressant fairytale) we tend to lose sight of the long-term effects of a treatment if the short-term effects are favorable. This is also the case with Ritalin whose short-term effects are well documented. For example, in 1995 investigators from the National Institute of Mental Health (NIMH) said that ‘Stimulants are highly effective in dramatically reducing a range of core ADHD symptoms such as task-irrelevant activity (e.g., finger tapping, fidgetiness, fine motor movement, being off-task during direct observation) and classroom disturbance.’
However, in the early 1990’s researchers were also becoming aware of the long-term consequences of taking stimulants. For example, in 1994 the American Psychological Association’s Textbook of Psychiatry said ‘Stimulants do not produce lasting improvements in aggressivity, conduct disorder, criminality, education achievement, job functioning, marital relationships, or long-term adjustment’.
But that is hardly damning. Although the APA suggests that there are no long-term benefits, they do not mention any long-term harm associated with taking the drug. Which to me, given the positive short-term effects of taking Ritalin, suggests we might as well feed it to our kids. However pretty soon evidence did emerge suggesting that long-term use of stimulants do indeed have harmful effects. By 1999, the NIMH had published research that investigated long-term stimulant use. After 14 months medicated children had experienced greater reduction in ADHD symptoms than children given a behavioral treatment. After 3 years, however, medicated children displayed increased ADHD symptomology, were slightly smaller and had higher delinquency scores. After 6 years, medicated children had worse symptoms of hyperactivity-impulsivity and oppositional defiant disorder, and were reported to be experiencing greater overall functional impairment.
In more recent times (2009) Western Australia conducted a long-term study into the use of ADHD drugs. They found that medicated children were 10 times more likely to be identified by teachers as performing at below age level academically than those not medicated. They also found that medicated children experienced worse ADHD symptoms and had higher diastolic blood pressure. Their conclusion; long-term use of stimulants in the treatment of ADHD is not beneficial.
Both of these studies provide damning evidence that the long-term effects of stimulant use may be harmful. But they hardly cover the incredible amount of other issues that have been associated with Ritalin. Charles Bradley, a psychiatrist from the early part of the 20th century, noticed that children who take Ritalin have blunted emotions, in other words they are stilled and no longer take pleasure from activities. Pediatrician Till Davy described medicated children as having ‘lost their sparkle’. UCLA Psychologists described ADHD medicated children as ‘passive, submissive and socially withdrawn’. Whilst James Swanson, the director of an ADHD center at the University of California, said that some medicated children ‘seem zombie like’.
But that’s not it. ADHD children themselves report being ‘less happy, less pleased with themselves and more dysphoric’ according to University of Texas Psychologist Deborah Jacobvitz. These researchers added that medicated children made fewer friendships, had lower self-esteem and thought themselves as ‘bad’ or ‘dumb’ for having to take the pills. In addition to this, University of Minnesota Psychologist Alan Sroufe described how ‘reasoning, problem solving and learning’ are not positively affected in medicated children. Others, for example James Swanson, have since gone on to suggest that Ritalin use may ‘impair rather than improve learning’. There is also a host of other physical, emotional and psychiatric problems that tend to be associated with long-term stimulant use that I need not go in to here.
I am not an advocate of the diagnostic system. For me, the lines between a child diagnosed with ADHD and a naughty child have been muddled together, and this assertion is supported by the ever increasing numbers of children being told that they have the disorder. Nevertheless, I’m sure there are parents/teachers reading this blog pulling their hair out over their children who surely fall into this category of ADHD. I don’t wish to enter a debate about whether ADHD exists or not. It doesn’t really matter which words we use to describe the behavior. My point is that regardless of whether you take the stance that your child actually ‘is’ ADHD, or whether you take the stance that you have a child who simply displays problematic behaviors, be careful about jumping on The Ritalin Bandwagon as the long term effects of the drug are not positive. If I were you I would instead try to find a book about the way in which the principles of Applied Behavior Analysis can be used to change problematic behavior, I’d bet my mortgage that it would improve your chances of success.