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Q&A: The overuse of drugs for treating children with A.D.D.

Q&A: The overuse of drugs for treating children with A.D.D.

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The $7.4 billion dollar drug industry that provides treatment for children diagnosed with A.D.D. may be resting on dangerously insufficient evidence, according to expert L. Alan Sroufe.

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Are the medications that currently treat ADD (attention deficit disorder) and ADHD (attention deficit hyperactivity disorder) routinely abused? Many continue to debate the root causes of such disorders, attempting to find the answer that will lead to better and more accurate treatment. Some say the cause is physiological—an inborn trait—others argue the environment plays a stronger role than is currently recognized. Of course it may be a combination of both.

The incredible acceleration of the use of such drugs over the last two decades, not just for children but also for adults needing that concentration edge, has created a $7.4 billion dollar industry.

SmartPlanet spoke with L. Alan Sroufe, professor emeritus of psychology at the University of Minnesota's Institute of Child Development, to discuss his opinion that good scientific studies are severely lacking and that the current drug industry is resting on insufficient evidence.

SmartPlanet: You mention that three million Americans take drugs for problems in focusing, namely Ritalin and Adderall?

L. Alan Sroufe: Well, there are at least three million children who take such drugs. But in 2010 fifty-one million prescriptions were written. Keep in mind adults now use this medication a lot, and multiple prescriptions are written in the same year for the same person. And the total sales in 2010 was 7.4 billion dollars. One of the critical issues is how much money is involved here.

SP: You mentioned that in the thirty years there’s been a twenty-fold increase in the use of such drugs. But when such drugs are given to children over long periods of time, there is no evidence to show that it improves school achievement or behavior problems?

AS: Well you can’t prove the drugs don’t work. But with a medication or any kind of procedure we require evidence that the drugs do work. And that’s what’s lacking. The vast majority of the blowback I’ve received from some members of the public have to do with statements like, “But I know this thing worked for my child, or I’m a physician and I know it works for my patients.” Not a single person ever said, “But wait you missed this evidence, here’s this study that shows that the drugs are effective long-term.”

Many people criticize the studies that do exist, the long-term studies, and I would join them on that. They’re always imperfect. So one of the main arguments that people used against me were the studies I cited don’t really prove the drugs don’t work. Well I agree with that. But there is no single study that shows that they do work long-term.

SP: How long defines long-term?

AS: The study has to go on six months to have any credibility. Because we do know that stimulant medication increases an individual’s ability to concentrate in the short-term. That’s true for anyone. That’s why college students take stimulants when they’re studying. That’s why people drink caffeine. But when you then put children on these medications for years, then you have the question of whether the child has adapted to the medication and it’s no longer helping, or are the drugs still being effective? And that’s why you need a long-term study. The studies that I reviewed in 1973 and 1990, and then again this year all were at least six months long, and the best one was a study that was two years long with follow-ups at three years. And they are the ones that did the best control study and still found no effect.

SP: Could you describe what the “brain deficit hypothesis” is and why it may have triggered the actual trend of cognitive enhancement drugs?

AS: These stimulants are very much like a normal neurotransmitter called epinephrine, which is adrenaline in lay terms and when were doing studies early on we began to have hypotheses that these kids had some failure. Either they weren’t producing enough of this drug naturally, or they were failing to reabsorb it.

Now, there are no studies proving that these kids have this problem. There are studies that find that they have more or less of some neurochemical in their urine or blood. But you see, that could be either because they are sloughing it off or because they actually have a lot of that chemical, it’s not that they have a deficit, but rather it could be they have a lot of it.

Today we have brain scans. And low and behold the children’s brains light up differently than kids who don’t have a diagnosis of ADHD.

But if you think about it, of course they light up differently. We already know they have difficulties paying attention. How could it be that their brains don’t light up differently?

So that research does not show that they were born with this problem, because we know a tremendous amount about how the brain develops by now, and we know that the brain develops well or not depending heavily on the experience of the person. So it doesn’t tell you that they were born that way, and it doesn’t tell you that medication will cure the problem.

SP: So you question that some children inherently have a physiological problem?

AS: I don’t question that there are some children born with brain problems. I question that these three million children were born with brain problems. And I would not believe it until I saw some prospective longitudinal studies where you follow children from birth over time.

SP: Do you feel a lot of the attentional issues are triggered by environment and experience?

AS: Let me be clear, I’m not saying that we’ve proved children’s attention problems are always caused by environment. I’m saying in our study, limited as it was by only have two hundred children, and limited as it was by beginning in 1975 when fMRIs on children weren’t even done, we can’t prove that they don’t, some of them didn’t have inborn problems. All we can say is we had state of the art measures at the time and we didn’t find evidence that that was a substantial factor. And we did find evidence that the amount of stress in children’s lives, the amount of chaos in children’s lives did predict.

SP: You’ve written that, “What we found was 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.”

AS: Most of the studies say temperament predicts something. Let’s say a child is fifteen years old and they have conduct problems, and I give their parents a temperament interview and it came out on that interview that they’re very impulsive, you couldn’t let me conclude that their impulsive temperament caused their conduct problems because I measured both the temperament and conduct problems at the same time. But how did they become impulsive? You can only answer that if you studied behavior and physiology early. Most of the famous studies in the literature started at age three. In my view that is way too late to claim that you’ve measure inborn temperament.

SP: So the danger of this is that the government policy institutions that are supporting a potential physiological cause of ADD, may have given up on any possibility of there might be some pretty strong environmental triggers?

AS: Yes we need a broader net. The answer might turn out to be there are children who are born with neuro-physiological problems that make it very likely that they’ll develop what we call ADHD. There may be other children who are born with certain vulnerabilities that in the context of insufficient environmental support, they’ll develop ADHD. And maybe there are some children that are born perfectly normal physiologically who because of the chaos, stress, and difficultly in their lives develop ADHD. It might be all those things. And we need to know that.

SP: What are some of the side effects of these drugs?

AS: I want to be on record as saying that so far as medications go these are relatively safe. They’re much safer than barbiturates or anti-psychotics. Whether they cause health problems in the long run is still relatively unknown. My understanding is they come with a cardiovascular warning, and they certainly shrink growth and weight acquisition.

They may be problematic to take during adolescence, but nobody has in particular studied the long-range outcomes of these medications during adolescence.

It is clear that huge amounts of this medication make their way into the non-medical drug market. Kids sell these. They’re rampant on college campuses. Medical students take these drugs.

I think the major three problems are as follows: Number one, we’re telling all these kids they’re defective, that there’s something wrong with their brain.

The second thing is that I worry about our culture embracing a drug solution. If you lose a loved one you’re told you should take antidepressants. But why? You’re supposed to be depressed. It’s a normal phase to go through.

And finally this is my major issue: We’re not trying to find out how the kids really develop these problems. How do they develop them? What are the steps to developing ADHD? It doesn’t just pop up. It emerges step by step. And we can find out what puts kids on that path and how we can get them off that path. I really believe that. If we wanted that to be a priority, I don’t think it would be a terrible challenge.

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Christie Nicholson

Contributing Writer

Christie Nicholson produces and hosts Scientific American's podcasts 60-Second Mind and 60-Second Science and is an on-air contributor for Slate, Babelgum, Scientific American, Discovery Channel and Science Channel. She has spoken at MIT/Stanford VLAB, SXSW Interactive, the National Science Foundation, the National Research Council, the Space Studies Board and Brookhaven National Laboratory. She holds degrees from the Columbia University Graduate School of Journalism and Dalhousie University in Canada. She is based in New York. Follow her on Twitter. Disclosure