In reading a recent article in the New York Times by L. Alan Sroufe of Minnesota’s Institute of Child Development, I had a strong sense of deja vu. Based on his literature reviews of treatment programs for ADHD symptoms, along with 30 years’ experience conducting his own longitudinal studies, Dr. Sroufe concludes that there is no evidence to support the “inborn defect” theory of attention deficit disorder and no lasting benefit to be had from taking Ritalin, Adderall and other drugs commonly prescribed for attention deficit disorder. It so reminds me of the scientific controversy around the chemical imbalance theory of depression, detailed by Robert Whitaker in his book The Anatomy of an Epidemic, and his conclusion that there is no evidence to support it, and no lasting benefit from the long-term use of anti-depressants.
Ritalin and Adderall are central nervous symptom stimulants. For many years, it has been widely believed that they have a “paradoxical effect” on children who suffer from ADHD symptoms because those children have an “inborn defect”, as a result of which the stimulants calm them down and help them to focus rather than exciting them. Dr. Sroufe debunks this myth and shows that these drugs had exactly the same effect on radar operators during World War II; he also found that “all children, whether they had attention problems or not, responded to stimulant drugs the same way.” No inborn defect, no paradoxical effect. Ritalin and Adderall are amphetamines — “uppers”, as we used to call them when I was young — and anyone who has used them during exams week understands their short-term benefits. They help you focus your attention and engage in “boring” tasks (like studying for your chemistry final) for an extended period of time.
As the body habituates to these drugs, the short-term benefits eventually fade (just as the short-term benefits of taking anti-depressants fade after 6-8 weeks). They also have unpleasant side effects such as sleeplessness and loss of appetite; if you’ve read Whitaker’s book, you have to wonder whether there may also be long-term neurological damage if these drugs are taken continuously for years.
I found this portion of the article especially relevant: “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.” For similar reasons, the worsening of depression symptoms after discontinuing SSRIs often persuades patients that the drugs were “working”. In interactions with site visitors here, I find it almost impossible to dissuade people from this belief.
Dr. Sroufe does not target aggressive marketing by the APA and the pharmaceutical industry, as Whitaker does in his explanation of the widespread usage of psychiatric medications; instead, Sroufe faults the common belief/wish that psychiatric illness and societal ills might be cured by taking a pill. He also looks at the science on brain anomalies, used to support the theory that ADHD symptoms result from inborn defects, and makes the following important point: “Overlooked is the very real possibility that both the brain anomalies and the A.D.D. result from experience.”
Sroufe cites the recent neurological studies showing that early brain development is influenced by experience — “trauma, chronic stress or other early-childhood experiences.” (I discussed this issue in my series of posts about attachment theory). Since 1975, he and his colleagues have been conducting a longitudinal study of 200 children born into poverty and therefore more vulnerable to behavioral problems. What his and other epidemiological studies have found is 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.” What happens to you during infancy and early childhood will shape you for life.
I have very close friends with a son who suffers from ADHD symptoms. His was a premature birth and that experience colors his academic, peer and family relationships to this day. I’ve known others who suffer from attention deficit disorder and you don’t have to look far into their backgrounds to find the chaos and instability that likely influenced the development of their symptoms. Sroufe says there are many experiences in early childhood that my lead to behavioral problems such as attention deficit disorder: “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.” This point of view is a refreshing alternative to the simplistic “inborn defect” theory.
Of course, Sroufe’s view means there are no simple answers, no “magic bullet” that will fix it all, and for this reason I’m sure it will be unpopular. It’s much easier and deceptively comforting to think you can prescribe your way out of the problem, rather than attempting to address the highly complex interaction between societal ills, family dysfunction and brain development. Likewise, it’s much easier to believe an anti-depressant will cure your depression than to accept the need for long-term psychotherapy — difficult and often costly — in order to make any kind of meaningful different.