Article on CNN's website today about ADHD

Wow, check out this quote from the article:

“In another study, Ashtari found the brain irregularities diminished in children who had been medicated with stimulant drugs for an average of 2 1/2 years.

“The findings … indicate that the therapeutic effect of stimulants may involve a brain normalization process,” said co-researcher Sanjiv Kumra, a psychiatrist at Zucker Hillside Hospital in Glen Oaks, New York.”

Hmmm… If it is true that stimulants somehow improve this “brain abnormality”, then why don’t the symptoms diminish over time for medicated kids? Why doesn’t the childrens’ performance improve to the point that they don’t require the medication anymore? Why aren’t medicated ADHD kids having better long-term outcomes than the non-medicated kids? Something doesn’t add up here…

Gosh, Steve, I actually agree with you ;)

I’d have to know a lot more. Did they use non-medicated kids as controls?

Maybe it was just plain old maturity kicking in and 2 and 1/2 years of living ‘normalized’ teh brain

Glad someone is investigating with pictures however-makes sense to use the technology if we have it

[quote:dccc4ec7ad=”Steve”]Hmmm… If it is true that stimulants somehow improve this “brain abnormality”, then why don’t the symptoms diminish over time for medicated kids? Why doesn’t the childrens’ performance improve to the point that they don’t require the medication anymore? Why aren’t medicated ADHD kids having better long-term outcomes than the non-medicated kids? Something doesn’t add up here…[/quote]

Is there research showing that symptoms don’t diminish over time that, performance never improves to the point where meds aren’t required or that medicated kids don’t have better long term outcomes than non-medicated kids? If so, please post it. If not (which I suspect is the case) then we should all be crying out for the research to answer these valid questions. Remember this old doctor’s saw: Absence of proof is not proof of absence.

Sure there is! I have already posted on more than one occasion regarding the long-term studies not supporting the idea that medication improves outcomes. You can find reviews on the lack of long-term improvements in:

Swanson, J.S., et al., “Stimulant medication and the treatment of children with attention deficit disorder: A Review of Reviews,” Exceptional Children, 1993, Vol. 60, pp. 154-61.

Fox AM, Rieder MJ.
Drug Saf 1993 Jul;9(1):38-50. (Drugs ineffective in long-term outcome studies)

Satterfield, J.H. et al, Therapeutic interventions to prevent delinquency in hyperactive boys, J. Amer Acad Child Adol Psychiat, Vol. 26, No. 1, 1987. pg. 56-64.

Hechtam, L., Adolescent outcome of hyperactive children treated with stimulants in childhood: a review, Psychopharmacol Bull, Vol. 21, 1985. pg. 178.

There are others, including Russel Barclay’s own review in 1978. (See Barkley, R.A. and Cunningham, C.E., Clinical Pediatrics, Vol 17, P. 85-92.)

As to perfomance improvements, I don’t think anyone will argue that maturity does bring about some amelioration of symptoms, with or without medication, especially in the hyperactivity symptoms, but I doubt you will find anyone claiming that kids actually improve their symptoms OFF the drugs by taking the drugs long-term, as compared to unmedicated kids. I think if you read anything by Barclay (who is VERY pro-medication), you will find that he is in agreement on this point. I don’t have any references to hand - I guess I thought it was taken for granted in the research community by this time, since I have never seen any research that even implied the possibility of the contrary until now, even from the pharmaceutical companies.

I have to say, though, that I don’t appreciate your deprecating tone, assuming that I would post this without having any research to back me up. I am a scientist (chemist) by training, and I have familiarized myself with research on this matter going back to the mid-’70s, which is probably something few who post here can claim.

Furthermore, while I agree with your dictum that “absence of presence does not mean presence of absence”, this is one of the most researched areas in the educational/mental health arena. As Barclay himself says in his review, it is the responsibility of the people claiming a treatment effect to demonstrate it, not the responsibility of those who don’t believe a treatment effect exists to disprove it. That is the nature of scientific research - it SHOULD be inherently skeptical about EVERY theory. A theory can only be held to be true after rigorous attempts to DISPROVE the theory or to offer other, more effective explanations fail, and is only held to be true until a better theory comes along to replace it (witness Newton’s laws of motion being modified by Einstein).

So while the research posted is certainly interesting and provocative, I think we are obligated to regard this new research with skepticism if we are to discern whether or not it is true. Knowing what I know, it seemed immediately suspect to me that improvements were happening in brain structure, when everything I have ever heard from even the most pro-medication factions states that “ADHD can’t be cured” and that stimulants “are effective in treating the core symptoms, but should not be the sole intervention”, not to mention the research cited above.

Sorry if I sound a little miffed, but I guess I am. I would appreciate a polite question in the future, rather than the implication that I am making this up. I am not. Read the references if you don’t belive me. And do some research of your own, and draw your own conculsions. I encourage you to post what you find out, but don’t start casting stones if you are living in a glass house.

Perhaps an apology is in order?

Steve,

I certainly had no intention of demeaning you. However, I really don’t think it is unreasonable to ask you to support your argument. How do I know that you are what you say? How can I tell whether your facts are correct unless I check them for myself. I don’t believe everything I read in the newspaper, let alone everything I read on the internet, even if it is posted by a guy named Steve. I seem to recall you ( or a person with your name) making similar requests from time to time.

In that vein, is there any chance you can post some links to these studies you posted about? I could only find an abstract for the Fox, Rieder article. It is reproduced elow. The abstract, at least, does not appear to address the questions we were discussing, which were whether children treated with stimulants have a better outcome than children who are not so treated and whether stimulants provide long-term improvement. With all due respect, your citations really shed no light on those questions, which is why I am asking you for a link or at least a quote.

I think we agree that there is no research demonstrating that medication improves long-term outcomes. We disagree, however, on whether that means there is no long-term improvement in kids who take stimulants. I take it that your position is that the research demonstrates that long-term outcomes are NOT improved. My position is that we still don’t know whether these medications provide long-term improvements because the matter has not yet been studied. Once again, this is the absence of proof/proof of absence issue. Studies like the one that prompted this discussion are interesting but certainly are not conclusive, as you and others have pointed out. They are merely a starting point. We need research that compares long-term outcomes of treated vs. untreated children. We need those studies to include a large number of participants. We need them to be double-blind and properly controlled so that confounding factors are weeded out or accounted for. And, after they are done, we need the results to be replicated in other rigorously conducted studies. Only then will be really know what we are dealing with.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8347290&dopt=Citation Drug Saf. 1993 Jul;9(1):38-50. Related Articles, Links

Risks and benefits of drugs used in the management of the hyperactive child.

Fox AM, Rieder MJ.

Child Health Research Institute, University of Western Ontario, London, Canada.

Childhood hyperactivity is a common behavioural complaint. The therapeutic options for physicians caring for children with hyperactivity are considerable and varied; current recommendations call for a multidisciplinary approach, including when necessary the use of drug therapy. Central nervous system stimulants are the primary agents used in the therapy of hyperactivity. The majority of children with hyperactivity diagnosed using careful clinical criteria will demonstrate short term benefits in cognitive and behavioural terms, but long term efficacy remains controversial. There appears to be a subset of patients who do not demonstrate a beneficial response to stimulants, although there is controversy as to whether this may be dose dependent. The adverse effects of most concern are suppression of growth, the development of tics and the potential for abuse. Antidepressants and clonidine are useful agents for the therapy of patients resistant to stimulant therapy. Although the most frequent adverse events of antidepressant therapy are associated with the anticholinergic activity of these agents, the most common serious adverse events are associated with antidepressant overdose. Concern has been expressed because of case reports describing an association between antidepressant therapy for hyperactivity and sudden death. A number of other therapies have been used for hyperactivity. Although these therapies may be effective in subsets of patients with hyperactivity, there is little research detailing how to identify patients who might be expected to respond to such treatment.

Steve,

I certainly had no intention of demeaning you. However, I really don’t think it is unreasonable to ask you to support your argument. How do I know that you are what you say? How can I tell whether your facts are correct unless I check them for myself. I don’t believe everything I read in the newspaper, let alone everything I read on the internet, even if it is posted by a guy named Steve. I seem to recall you ( or a person with your name) making similar requests from time to time.

In that vein, is there any chance you can post some links to these studies you posted about? I could only find an abstract for the Fox, Rieder article. It is reproduced elow. The abstract, at least, does not appear to address the questions we were discussing, which were whether children treated with stimulants have a better outcome than children who are not so treated and whether stimulants provide long-term improvement. With all due respect, your citations really shed no light on those questions, which is why I am asking you for a link or at least a quote.

I think we agree that there is no research demonstrating that medication improves long-term outcomes. We disagree, however, on whether that means there is no long-term improvement in kids who take stimulants. I take it that your position is that the research demonstrates that long-term outcomes are NOT improved. My position is that we still don’t know whether these medications provide long-term improvements because the matter has not yet been studied. Once again, this is the absence of proof/proof of absence issue. Studies like the one that prompted this discussion are interesting but certainly are not conclusive, as you and others have pointed out. They are merely a starting point. We need research that compares long-term outcomes of treated vs. untreated children. We need those studies to include a large number of participants. We need them to be double-blind and properly controlled so that confounding factors are weeded out or accounted for. And, after they are done, we need the results to be replicated in other rigorously conducted studies. Only then will be really know what we are dealing with.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8347290&dopt=Citation Drug Saf. 1993 Jul;9(1):38-50. Related Articles, Links

Risks and benefits of drugs used in the management of the hyperactive child.

Fox AM, Rieder MJ.

Child Health Research Institute, University of Western Ontario, London, Canada.

Childhood hyperactivity is a common behavioural complaint. The therapeutic options for physicians caring for children with hyperactivity are considerable and varied; current recommendations call for a multidisciplinary approach, including when necessary the use of drug therapy. Central nervous system stimulants are the primary agents used in the therapy of hyperactivity. The majority of children with hyperactivity diagnosed using careful clinical criteria will demonstrate short term benefits in cognitive and behavioural terms, but long term efficacy remains controversial. There appears to be a subset of patients who do not demonstrate a beneficial response to stimulants, although there is controversy as to whether this may be dose dependent. The adverse effects of most concern are suppression of growth, the development of tics and the potential for abuse. Antidepressants and clonidine are useful agents for the therapy of patients resistant to stimulant therapy. Although the most frequent adverse events of antidepressant therapy are associated with the anticholinergic activity of these agents, the most common serious adverse events are associated with antidepressant overdose. Concern has been expressed because of case reports describing an association between antidepressant therapy for hyperactivity and sudden death. A number of other therapies have been used for hyperactivity. Although these therapies may be effective in subsets of patients with hyperactivity, there is little research detailing how to identify patients who might be expected to respond to such treatment.

Steve,

I certainly had no intention of demeaning you. However, I really don’t think it is unreasonable to ask you to support your argument. How do I know that you are what you say? How can I tell whether your facts are correct unless I check them for myself. I don’t believe everything I read in the newspaper, let alone everything I read on the internet, even if it is posted by a guy named Steve. I seem to recall you ( or a person with your name) making similar requests from time to time.

In that vein, is there any chance you can post some links to these studies you posted about? I could only find an abstract for the Fox, Rieder article. It is reproduced elow. The abstract, at least, does not appear to address the questions we were discussing, which were whether children treated with stimulants have a better outcome than children who are not so treated and whether stimulants provide long-term improvement. With all due respect, your citations really shed no light on those questions, which is why I am asking you for a link or at least a quote.

I think we agree that there is no research demonstrating that medication improves long-term outcomes. We disagree, however, on whether that means there is no long-term improvement in kids who take stimulants. I take it that your position is that the research demonstrates that long-term outcomes are NOT improved. My position is that we still don’t know whether these medications provide long-term improvements because the matter has not yet been studied. Once again, this is the absence of proof/proof of absence issue. Studies like the one that prompted this discussion are interesting but certainly are not conclusive, as you and others have pointed out. They are merely a starting point. We need research that compares long-term outcomes of treated vs. untreated children. We need those studies to include a large number of participants. We need them to be double-blind and properly controlled so that confounding factors are weeded out or accounted for. And, after they are done, we need the results to be replicated in other rigorously conducted studies. Only then will be really know what we are dealing with.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8347290&dopt=Citation Drug Saf. 1993 Jul;9(1):38-50. Related Articles, Links

Risks and benefits of drugs used in the management of the hyperactive child.

Fox AM, Rieder MJ.

Child Health Research Institute, University of Western Ontario, London, Canada.

Childhood hyperactivity is a common behavioural complaint. The therapeutic options for physicians caring for children with hyperactivity are considerable and varied; current recommendations call for a multidisciplinary approach, including when necessary the use of drug therapy. Central nervous system stimulants are the primary agents used in the therapy of hyperactivity. The majority of children with hyperactivity diagnosed using careful clinical criteria will demonstrate short term benefits in cognitive and behavioural terms, but long term efficacy remains controversial. There appears to be a subset of patients who do not demonstrate a beneficial response to stimulants, although there is controversy as to whether this may be dose dependent. The adverse effects of most concern are suppression of growth, the development of tics and the potential for abuse. Antidepressants and clonidine are useful agents for the therapy of patients resistant to stimulant therapy. Although the most frequent adverse events of antidepressant therapy are associated with the anticholinergic activity of these agents, the most common serious adverse events are associated with antidepressant overdose. Concern has been expressed because of case reports describing an association between antidepressant therapy for hyperactivity and sudden death. A number of other therapies have been used for hyperactivity. Although these therapies may be effective in subsets of patients with hyperactivity, there is little research detailing how to identify patients who might be expected to respond to such treatment.

Steve,

I certainly had no intention of demeaning you. However, I really don’t think it is unreasonable to ask you to support your argument. How do I know that you are what you say? How can I tell whether your facts are correct unless I check them for myself. I don’t believe everything I read in the newspaper, let alone everything I read on the internet, even if it is posted by a guy named Steve. I seem to recall you ( or a person with your name) making similar requests from time to time.

In that vein, is there any chance you can post some links to these studies you posted about? I could only find an abstract for the Fox, Rieder article. It is reproduced below. The abstract, at least, does not appear to address the questions we were discussing, which were whether children treated with stimulants have a better outcome than children who are not so treated and whether stimulants provide long-term improvement. With all due respect, your citations really shed no light on those questions, which is why I am asking you for a link or at least a quote.

I think we agree that there is no research demonstrating that medication improves long-term outcomes. We disagree, however, on whether that means there is no long-term improvement in kids who take stimulants. I take it that your position is that the research demonstrates that long-term outcomes are NOT improved. My position is that we still don’t know whether these medications provide long-term improvements because the matter has not yet been studied. Once again, this is the absence of proof/proof of absence issue. Studies like the one that prompted this discussion are interesting but certainly are not conclusive, as you and others have pointed out. They are merely a starting point. We need research that compares long-term outcomes of treated vs. untreated children. We need those studies to include a large number of participants. We need them to be double-blind and properly controlled so that confounding factors are weeded out or accounted for. And, after they are done, we need the results to be replicated in other rigorously conducted studies. Only then will be really know what we are dealing with.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8347290&dopt=Citation Drug Saf. 1993 Jul;9(1):38-50. Related Articles, Links

Risks and benefits of drugs used in the management of the hyperactive child.

Fox AM, Rieder MJ.

Child Health Research Institute, University of Western Ontario, London, Canada.

Childhood hyperactivity is a common behavioural complaint. The therapeutic options for physicians caring for children with hyperactivity are considerable and varied; current recommendations call for a multidisciplinary approach, including when necessary the use of drug therapy. Central nervous system stimulants are the primary agents used in the therapy of hyperactivity. The majority of children with hyperactivity diagnosed using careful clinical criteria will demonstrate short term benefits in cognitive and behavioural terms, but long term efficacy remains controversial. There appears to be a subset of patients who do not demonstrate a beneficial response to stimulants, although there is controversy as to whether this may be dose dependent. The adverse effects of most concern are suppression of growth, the development of tics and the potential for abuse. Antidepressants and clonidine are useful agents for the therapy of patients resistant to stimulant therapy. Although the most frequent adverse events of antidepressant therapy are associated with the anticholinergic activity of these agents, the most common serious adverse events are associated with antidepressant overdose. Concern has been expressed because of case reports describing an association between antidepressant therapy for hyperactivity and sudden death. A number of other therapies have been used for hyperactivity. Although these therapies may be effective in subsets of patients with hyperactivity, there is little research detailing how to identify patients who might be expected to respond to such treatment.

Sorry, I don’t know why my post repeated .

The demeaning part was the ASSUMPTION that I would post such information without support, rather than asking. I appreciate your clarification. I definitely think it is appropriate to ask for the basis for any such information that is posted, for exactly the reasons you state.

I am glad we are in agreement that there is no proof of a long-term treatment effect. To clarify my position a little furtner, there has been intensive research going on for over 40 years on the effects of stimulants on ADHD symptoms and outcomes. There have been many in the field who have been certain that there would be improvements in those outcomes, and were invested in documenting those improvements. After 40 years, these improvements have not been shown to exist. There have been more recent reviews that draw the same conclusion.

At a certain point, the inability to demonstrate a benefit despite rigorous efforts to do so by people who believe such a benefit exists has to lead to the conclusion that there is no benefit. How else does one prove the lack of a benefit than by repeated attempts to show a benefit having failed? I think that in 40 years of scrutiny, if there were some long-term benefit, it would certainly have been evident by now. Even the most optimistic studies that have come back show marginal academic improvement, which reviewers have concluded could easily result from the subjects simply reading the test questions more carefully as a result of being under stimulant treatment. One can always go on hoping, but I don’t think it is really even a question in the research field anymore. I was re-reading some of the reviews after my post this morning, and as far back as 1979, the researchers were already concluding that stimulants were a poor bet to increase academic accomplishments in the long term. That was 15 years ago. There is nothing that I have seen or heard since that would argue to the contrary. I think that objective scientific scrutiny would have to lead a reasonable person to conclude that there is no academic benefit long-term to stimulants overall. This doesn’t mean that some individuals might not benefit academically - it just means that when you average it all out, any individuals that benefitted are balanced by an equal number of individuals who did worse. But most people can probably expect very little effect on long-range outcomes.

I am afraid I do not have links to these articles. I went to the local medical library and did a search, asking for “retrospective studies” “ADHD” and “Ritalin”, and this is what came back to me. I have tried doing online searches, and can get titles, but seldom can I get actual research articles without having to fork up some bucks, so direct links are not available. I have also read a number of books on the subject that have added to my reference list, which is certainly far from complete. I was actually somewhat taken aback by the results of my search! The only conclusion I could draw was that stimulants made it easier to pay attention in school, but that, for these kids at least, paying attention in school did not translate into more or better learning.

This research was a very important part of my decision making regarding my sons’ schooling. I have two “ADHD” boys, both of whom were homeschooled or sent to alternative schools, and neither of whom were ever on medication. Both are doing quite well, though the younger (age 9) is still kind of oppositional and emotionally immature in some circumstances. But they are both very bright, easily bored, highly active and curious, and would have done horribly in a regular public school classroom, at least in elementary school. My oldest actually chose to return to public school in 6th grade, after 4 years of homeschooling, and he did very well academically, though he had some social problems initially. He graduated from a regular high school with honors, and no one ever suggested that he had ADHD, despite his extremely hyper and distractible and impulsive behavior as a young child.

So it is easy for me to believe now that there is not necessarily an academic benefit in taking stimulants, having seen the success of my own two “untreated” sons in school. I think the stimulants help the child cope with the standard school classroom, but I think alternative educational approaches work better for ADHD kids (see Jacob, J.G. et. al. “Formal and Informal Classroom Settings: Effects on Hyperactivity; J Abnormal Child Psychol. 1978, #6, p. 47-59 and also Flynn and Rapaport, “Hyperactivity in Open and Traditional Classroom Environments, J. Special Education 1976, #10, p. 285), so that’s what we did, and it worked very well for us. Not everyone is willing or able to homeschool for extended periods, and alternative schools are not available in every district, but I recommend considering these options whenever they are available.

Hope that clarifies my position and some of my personal experiences as well as some of the research that supports it.

Sorry, 1979 was 25 years ago! My bad…

Thanks, Steve. I appreciate the clarification and expansion of the basis for your views. I also have two kids with ADHD. One takes medication, the other doesn’t. The reason for the difference is that the first child really cannot function academically without medication, while the second child manages quite well when he applies organizational strategies we have taught him. The child who takes stimulants also has LDs but did not respond well to any interventions until he began the medication. He now is a straight student and in gifted programming. His only accomodation at this point is the use of an alphasmart. When he grew last year and, unknown to us, he needed a higher dose, his grade suddenly tumbled to Cs and Ds and he became frustrated, anxious and just generally emotional. With a slight increase, the first in 5 years, he got back on track. The child who does not take stimulants is a B/A student, also in gifted classes. He might well be more focused and more able to maintain As on medication, but we don’t think that is enough to justify using medication. So, my personal experience is that some kids need and do well on medication and some kids don’t. We are trying vision therapy for both right now, but we have not seen any reduction in ADHD symptoms. We have seen big improvements in motor performance, however.

http://rsna2004.rsna.org/rsna2004/V2004/conference/event_display.cfm?em_id=4414822