Has "Ritalin Gone Wrong"? Hallowell Response to NY Times Article

In the 1/28/12 edition of the New York Times, L. Alan Sroufe, a professor emeritus of University of Minnesota's Institute of Child Development, published an article entitled Ritalin Gone Wrong suggesting that current research indicates that there is no reason to treat children with ADHD with Ritalin and suggesting that as a society we are too eager to medicate our children.  The tone of the article, along with some of what it suggested, was alarming.  Therefore, Dr. Hallowell drafted a response to it, which is below.

Dr. Hallowell's Response

Regarding the opinion piece “Ritalin Gone Wrong” written by Alan Sroufe, Ph.D., (NY Times, Jan. 29, 2012): As is usually the case when the use of stimulant medications like Ritalin makes it into mainstream media, the piece pushed emotional hot-buttons in a way that would scare the daylights out of uninformed readers and lead them to avoid ever using such medications or allowing their children to, thereby giving up on a class of medications with enormous potential benefits.

Let me offer a different point of view.  I’m an M.D., a child and adult psychiatrist who’s been treating children who have what we now 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, MA, and New York City every day.  I have both ADHD and dyslexia myself.  I’ve co-written, with John Ratey, the best-selling books on the topic of 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 actually agree with much of what he had to say.  It is with his scare tactics and wrong-headed assumptions that I take issue. 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 would be a single solution?  No enlightened clinician offers medication as the single solution.  We offer it as one tool that can help, but always as part of a comprehensive treatment plan which also includes other key elements like 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.

And what Dr. Sroufe cites as “some smaller number” is about 80% of individuals with ADHD who try medication.  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.”

It is a statement cited so endlessly as to become an accepted truth that we live in a society that believes all of life’s problems can be solved with a pill.  But have you ever met anyone who actually does believe that?  I haven’t.  Furthermore, 19 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 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 the child that he is lucky in that 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, and then I tell him about the billionaires, CEO’s, Pulitzer Prize winners and professional athletes with ADHD I’ve treated over the years.  But 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 all buy the notion that “children’s behavior problems can be cured with drugs,” and that such a belief gets us “off the hook,” as if we politicians, scientists, teachers, parents, and heaven knows who all else were so sweetly deluded and so uncaring that we welcome any excuse to get us out of doing the deep probing into the “complex solutions” one is left to presume 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. 

Of course 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 had 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, i.e., 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, nor 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--i.e., 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!

But that is not to say, as Dr. Sroufe does, that 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.

But as long as we use it properly, it remains one of our most valuable--and tested--medications.  Going all the way 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.