Last week, I reviewed an article by L. Alan Sroufe that had appeared in the New York Times, seriously questioning the effectiveness of Ritalin, Adderall and other stimulants used to treat children with ADHD symptoms. Two site visitors, including my friend Dr. Bob Dick, raised some strenuous objections to my post, and more importantly to Dr. Sroufe’s piece in the NYT. Both of their comments convinced me the issue deserved another look, and that because of my basic anti-medication bias, I’d been too quick to accept Sroufe’s report at face value.
Shortly after Sroufe’s article appeared, Harold S. Koplewicz MD, President of the Child Mind Institute, wrote a point-by-point rebuttal of it; if you’re interested in this issue, the article by Koplewicz bears reading. I won’t bother to summarize the whole piece, but suffice to say that he brings some fairly persuasive evidence in support of the effectiveness of stimulants to treat ADHD symptoms in children and raises important questions about the validity of the studies cited by Dr. Sroufe and the conclusions drawn from them.
I still have major objections to the current ways we think about and treat ADHD symptoms, however, and I’m not ready to write off Dr. Sroufe, as Koplewicz does. First of all, as Steven Brownlow PhD noted in a comment to my last post: “Any talk about ‘what is ADHD’ misses the point because ADHD is not a thing. It’s not a disease condition. As defined by APA, it’s a set of behavioral markers that are hypothesized to indicate a disease state, but in actuality could be produced by any number of different conditions, including genetic brain abnormalities, early insults, trauma, etc.” This is a cogent, clear-sighted description of a much larger problem: the way a set of “behavioral markers” or “symptoms” is presumed to indicate the presence of a “disease state”, be it a chemical imbalance in the brain and/or a genetic defect.
The disease model of the current DSM, along with marketing strategies employed by the pharmaceutical industry, contribute to the common misconception that an actual “disease state” has been identified for ADHD, depression and other psychological conditions. By and large, the effects of the most common psychiatric medications in use today were discovered by accident; once their actual neuro-chemical effects were better (though not entirely) understood, an underlying disease state was then hypothesized but never proven. As I continually state on this website, there is no evidence whatsoever to support the theory that depression symptoms are caused by insufficient serotonin in the neural synapses.
Even if we accept that ADHD symptoms result from different conditions, as Dr. Brownlow suggests, isn’t it possible that the stimulants currently prescribed remedy these symptoms, whatever their origin? Evidence from a great many scientific studies suggests that indeed they do. But I’m more skeptical about this kind of evidence than most people; whenever someone insists that a drug’s effectiveness has been “proven”, I want to ask what exactly that means. For the purposes of FDA approval, a drug’s effectiveness must be demonstrated via clinical trials designed in scientifically acceptable ways and there must be a statistically significant difference between results for groups receiving placebo vs. the actual drug; that doesn’t necessarily say a lot about the degree of the drug’s effectiveness, however.
For instance, new cancer drugs that extend the life of a terminal patient by only 3 months often receive FDA approval because that’s a statistically significant difference in outcomes, but such drugs certainly don’t cure or eliminate the illness. Koplewicz does make it clear that there is no cure for ADHD, but in my view, he doesn’t look hard enough at what these stimulants actually do and do not do for ADHD symptoms. How much do they help? Which symptoms do they remedy and which are unaffected? What are the side effects and do they outweigh the benefits?
Yes, these stimulants help you focus attention and perform repetitive mental work more easily — and for many, that alone is almost miraculous. They can also help enormously with problem behavior in the classroom. Over the past week, I’ve spent quite a bit of time visiting online forums where people discuss their reactions to Adderall, Ritalin and other stimulants. This may be anecdotal, unscientific evidence but there’s no question in my mind that these drugs have dramatically changed the lives of many, many people. I’ve also read a large number of accounts from people who felt dull, apathetic or zombie-like while taking these medications; many of them underwent disturbing personality changes and some had psychotic episodes.
In The Gift of ADHD, Dr. Lara Honos Webb describes a person on Ritalin as “like a horse with blinders, plodding along. He’s moving forward, getting things done, but he’s less open to inspiration.” While Adderall and Ritalin are undoubtedly helpful for a great many people, like all psychiatric medications they are a blunt instrument, inflicting all sorts of collateral damage. Koplewicz makes light of the side effects and insists there are no long term consequences of taking them; but if you want a scary read, take a look at the chapters on ADHD medications and the rise of childhood bipolar disorder in Robert Whitaker’s The Anatomy of an Epidemic.
What I found most troubling about Koplewicz’s rebuttal, however, was the contemptuous, short-shrift he gives to Dr. Sroufe’s thoughts about the role of environment. Let me quote this portion in detail:
“Perhaps the most distressing comment Dr. Sroufe makes in this piece is that ordinary parents who make ordinary mistakes during a child’s early development could produce the kind of brain changes we see in children with ADHD. He includes among these potential sources not only ‘family stresses like domestic violence, lack of social support from friends or relatives, chaotic living situations, including frequent moves,’ but also, bizarrely, ‘especially, patterns of parental intrusiveness that involve stimulation for which the baby is not prepared.'”
Why is it “bizarre” to wonder if intrusive parents who model or demonstrate distracting behavior can influence their child’s capacity to pay attention? Not to mention that this isn’t a case of “ordinary parents” making “ordinary mistakes” — or any kind of mistake, for that matter; these are influential patterns of behavior, likely based on the parent’s own psychological difficulties. In his work on attachment theory, Allan Schore has shown how failures of attachment cause the brain of an infant to develop abnormally. Is it such a leap to consider whether repetitive types of intrusiveness and distraction by parents might also affect the development of their child’s brain?
From a psychodynamic perspective, that not only seems plausible but I’ve worked with clients who have discussed such behavior by their parents and how it affected them. We believe that other types of parental behavior and parent-child interactions influence development; why is it so outlandish to believe that distractibility might be modeled? I think the larger issue here is one of guilt, and rescuing parents from the idea that they may have a role to play in their child’s condition.
In a piece for the online version of Time, Judith Warner argues that Sroufe’s ideas about the role of the environment are a giant step backwards, a return to blaming parents for their child’s condition in the way that responsibility for childhood autism was once laid at the feet of “refrigerator mothers.” This line of attack seems a little over-the-top to me; I think that Ms. Warner, like many people, can’t distinguish between blaming and attributing influence. Her article is full of words like “stigma”, “blame” and “victims”; surely there’s a middle ground between pointing accusatory fingers, on the one hand, and exploring how parent-child interactions might influence the development of ADHD symptoms. In the end, Ms. Warner’s critique devolves into ad hominem assaults on Sroufe’s character and motivation, not a terribly persuasive mode of argument to my mind.
In revisiting the question of ADHD symptoms and their origins, I came away feeling that the issue has not been settled. As always, I continue to believe that psychiatric medications have their uses, especially in the short-term, and I’ll try to keep an open mind about their usage in treating deficits in attention. But I’ll also continue to wonder about the psychological dimension, and whether explanations and eventual help may be found from a psychodynamic exploration of these issues.