Good NY Times piece today by Paul Tough on the controversy surrouding ADHD and its treatment with stimulants. It begins with James Swanson, one of the early experts on the problem and one of the first to experiment with giving stimulants to patients. In the mid 1990s, he was part of a major, NIH-funded study:
Swanson was in charge of the site in Orange County, Calif. He recruited and selected about 100 children with A.D.H.D. symptoms, all from 7 to 9 years old. They were divided into treatment groups — some were given regular doses of Ritalin, some were given high-quality behavioral training, some were given a combination and the remainder, a comparison group, were left alone to figure out their own treatment. The same thing happened at five other sites across the continent. Known as the Multimodal Treatment of Attention Deficit Hyperactivity Disorder Study, or M.T.A., it was one of the largest studies ever undertaken of the long-term effects of any psychiatric medication.
The initial results of the M.T.A. study, published in 1999, underscored the case for stimulant medication. After 14 months of treatment, the children who took Ritalin every day had significantly fewer symptoms than the ones who received only behavioral training. Word went out to clinics and pediatricians’ offices around the country: Ritalin worked. . . .
Though Swanson had welcomed that initial increase in the diagnosis rate, he expected it to plateau at 3 percent. Instead, it kept rising, hitting 5.5 percent of American children in 1997, then 6.6 percent in 2000. As time passed, Swanson began to grow uneasy. He and his colleagues were continuing to follow the almost 600 children in the M.T.A. study, and by the mid-2000s, they realized that the new data they were collecting was telling a different — and less hopeful — story than the one they initially reported. It was still true that after 14 months of treatment, the children taking Ritalin behaved better than those in the other groups. But by 36 months, that advantage had faded completely, and children in every group, including the comparison group, displayed exactly the same level of symptoms. Swanson is now 80 and close to the end of his career, and when he talks about his life’s work, he sounds troubled — not just about the M.T.A. results but about the state of the A.D.H.D. field in general. “There are things about the way we do this work,” he told me, “that just are definitely wrong.”
This exactly matches our experience in this house. Our eldest son is a classic ADHD case – and since we have two other sons, we know the difference between that and normal boyishness. We put him on Ritalin for a while, and he showed immediate changes: he did better in school, started reading books, bothered his siblings less. At first he was excited about this, but after some time – a couple of months, maybe? – he started to complain that he didn't like the way the meds made him feel, so we took him off them. After that we left the decision about taking them entirely up to him, and he used them on and off over the next few years, we think taking them when he got anxious about his grades.
As I have written here many times, I think the human quest for drugs that change how we feel is ancient and unending, and that this says something important about how evolution has shaped us. It presumably also says something important about our society, in which the ability to sit still and concentrate on demanding work is very highly valued. So in principle I see nothing wrong with drugs that help some people sit still and concentrate. But I do not think we really understand what we are doing, or what the long-term consequences might be. So I very much appreciated this, from British neuroscientist Edmund Sonuga-Barke, who says that so far as he can tell "people with ADHD" is not a real category with definable boundaries:
Tough's piece covers many of the current controversies including whether ADHD patients should be sorted into different groups that are treated differently, whether the medications have unpleasant side effects, and whether the real answer is to let kids study what interests them. I recommend it. For me it strongly reinforced my basic assumption about all psychological issues, that you should never trust anyone who claims to have the answers.I’ve invested 35 years of my life trying to identify the causes of A.D.H.D., and somehow we seem to be farther away from our goal than we were when we started. We have a clinical definition of A.D.H.D. that is increasingly unanchored from what we’re finding in our science.
1 comment:
I'm coming to believe that "we do not really understand what we are doing" is a deep truth about human life in general. Likewise, "never trust anyone who claims to have the answers" is, I think, good advice all around, especially if those answers are simple and hopeful. On the other hand, I would insist that a lack of definable boundaries does not in itself reduce a category's usefulness. Many, many categories in history and the social sciences--such as "the state," "class," "history" itself, etc., etc.--have been attacked, probably for centuries, for not having definable boundaries, without any practical effect, precisely because they are useful and reflect phenomena one can't get away from (or, that the critics who complain about lack of boundaries haven't taught us not to perceive). I suggest psychology belongs with history and the social sciences in this, as in many other regards. I say this without having any interest in undermining Sonuga-Barke specifically or in defending ADHD as a category.
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