Ritalin Redux

I take issue with the opinion piece "Ritalin Gone Wrong,” written by Alan Sroufe, Ph.D. (The New York Times, January 29, 2012).

As is usually the case when the use of stimulant medications like Ritalin makes it into mainstream media, the article pushes emotional hot buttons that scares the daylights out of uninformed readers and leads them to avoid using such medications or allowing their children to. The end result? Giving up on a class of medications with enormous potential benefits.

I'm an M.D., a child and adult psychiatrist who’s been treating children who have what we call ADHD for over 30 years. I was on the Harvard Medical School faculty for 20 years, and I still see patients in my offices in Sudbury, Massachuseets and New York City every day. I have ADHD and dyslexia myself. I’ve co-written, with John Ratey, the best-selling books on ADHD. I know this condition, and its various treatments, inside and out.

While I wince at the inflammatory rhetoric of Dr. Sroufe’s article, I agree with much of what he had to say. I take issue with his scare tactics and wrong-headed assumptions. Let me quote and respond to several paragraphs from his article:

"First, there will never be a single solution for all children with learning and behavior problems. While some smaller number may benefit from short-term drug treatment, large-scale, long-term treatment for millions of children is not the answer.”

Who said there is a single solution? No enlightened clinician offers medication as the only solution. We offer it as one tool that can help, but always as part of a comprehensive treatment plan that also includes education of parent, child, and teacher; lifestyle modification, including sleep, diet, exercise, meditation and positive human interactions; coaching on how to better organize life; and ongoing follow-up to monitor progress and offer encouragement and various specific tips on managing life with ADHD.

While Dr. Sroufe says that "some smaller number may benefit from short-term drug treatment,” in fact, 80 percent of individuals with ADHD who try medication benefit. When these medications work, they do not solve the problem, any more than eyeglasses solve the problem of myopia. But they sure do help!

“Second, the large-scale medication of children feeds into a societal view that all of life’s problems can be solved with a pill and gives millions of children the impression that there is something inherently defective in them.”

This is cited so often that is has become an accepted truth. But have you ever met anyone who actually believes that? I haven’t. Nineteen out of 20 people who come to me for help for themselves or their child adamantly oppose the use of medication. Only when they fully understand the medical facts do many of them change their minds. Far from being predisposed to the use of medication, the people who come to see me are predisposed in precisely the opposite direction.

Furthermore, no enlightened clinician prescribes the medication and leaves it at that, allowing the parent and child to imagine they have “something inherently defective in them.” I go to great lengths not only to present the medical facts but also to create a framework of understanding that describes ADHD in strength-based terms.

I tell a child that he is lucky. He has a race car for a brain, a Ferrari engine. I tell him he has the potential to grow into a champion. I tell him (assuming it is a he, but he could just as easily be a she) that, with effort, he can achieve greatness in his life. Then I tell him about the billionaires, CEOs, Pulitzer Prize winners and professional athletes with ADHD I’ve treated through the years.

I also tell him he does face one major problem. While he has a race car for a brain, he has bicycle brakes. I tell him I am a brake specialist, and one of the many tools I can use to strengthen his brakes is medication. I remind him he will have to do much more than take the medication to strengthen his brakes, but, if we’re lucky, the medication will help him in that effort.

The child and parents leave my office full of hope. Far from feeling defective, the child feels like a champion in the making. Which he most certainly can be!

"Finally, the illusion that children’s behavior problems can be cured with drugs prevents us as a society from seeking the more complex solutions that will be necessary. Drugs get everyone — politicians, scientists, teachers and parents — off the hook. Everyone except the children, that is."

Once again, Dr. Sroufe assumes the clinician, parent, and society at large buy the notion that “children’s behavior problems can be cured with drugs,” and that such a belief gets us “off the hook.” He suggests that politicians, scientists, teachers, parents, and heaven knows who all else are so deluded and so uncaring that we welcome any excuse to get us out of doing the deep probing into the “complex solutions” that only Dr. Sroufe and his exemplary colleagues can or will attempt.

No clinician worth his or her salt believes that all problems can be cured with drugs. But neither does a responsible clinician deny the good that medications can do. When people ask me, “Do you believe in Ritalin?” I reply that Ritalin is not a religious principle. Ritalin, like all medications, can be useful when used properly and dangerous when used improperly. Why is it so difficult for so many people to hold to that middle ground?

And yet difficult it is. Ritalin continues to be a political football, a hot-button issue almost on a par with abortion or capital punishment. One is pushed to be for it or against it, while the right and good position is to be for whatever will help a child lead a better life, as long as it is safe and it is legal.

Used properly, Ritalin is safe, safer than aspirin. And it is legal, albeit highly regulated. As to its long-term use, apply common sense. Use it as long as it is helpful and causes no side effects. That may be for a day, or it may be for many years.

We need to address the complex issues that contribute to behavioral, emotional, and learning problems in children. I’ve written extensively about what I call “pseudo-ADHD,” children who look as if they have ADHD but in fact have an environmentally-induced syndrome caused by too much time spent on electronic connections and not enough time spent on human connections — family dinner, bedtime stories, walks in the park, playing outdoors with friends or relatives, time with pets, buddies, extended family, and other forms of non-electronic connection. Pseudo-ADHD is a real problem; the last thing a child with pseudo-ADHD needs is Ritalin.

But that is not to say that no child needs Ritalin, or that those who prescribe it are dimwits hoodwinked by drug companies to medicate children who do not need it. Sure, some doctors over-medicate, while other doctors never medicate because they “don’t believe in ADHD” and “don’t believe in Ritalin.”

Above all, children need a loving, safe, and richly connected childhood. The long-term study that Dr. Sroufe cited in his opinion piece does indeed show that over time, medication becomes a less important force in a child’s improvement and that human connections become ever more powerful. It is good and heartening to know that human connection—love—works wonders over time. Love is our most powerful and under-prescribed “medication.” It’s free and infinite in supply, and doctors most definitely ought to prescribe it more!

This doesn’t mean that, as Dr. Sroufe say, Ritalin has “gone wrong.” We may go wrong in how we use it, when we over-prescribe it, or when we use it as a substitute for love, guidance, and the human connection.

As long as we use it properly, it remains one of our most valuable — and tested — medications. Going back to the first use of stimulants to treat what we now call ADHD in 1937, stimulants have served us well as one tool — not the tool — for helping children and adults learn how to strengthen the brakes of their race car brains and become the champions they can be.