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Dr. Sutton's Response to "Ritalin Gone Wrong"
Dr. Sutton's response to the controversy around the NY Times Op-Ed Article, "Ritalin Gone Wrong":

In a conversation I had with Steve Hinshaw when he was at my home for a discussion group I host with providers treating ADHD, he explained to me that the difference in effect with the MTA study kids (the longitudinal study that is referred to in the article), was that after the study, the medication group went into a "treatment as usual" context (rather than having the dosage and medication adherence being closely monitored). He is one of the principal investigators on the MTA study and explained that all of the children randomly assigned to intensive medication, behavioral, or combination treatments for the 14 months of the "clinical trial" portion of the study went back to being treated by pediatricians for their medication with inconsistent dosing, after the clinical trial ended (I asked if they looked at psychiatrists vs. pediatricians and he thinks it was 100% pediatricians, but is going to go back and check the data for me).

Part of the issue with ADHD is that it is highly heritable (.81 heritability coefficient in monozygotic twins, which is more hereditable than diabetes or schizophrenia, this was a study where I was a work study student with Bruce Pennington in my undergraduate training, this is compared to 29% of monzygotic twins, so that addresses the environmental issues). Also, there is a 57% chance (some studies place it more around 30-40%) that a child of an adult with ADHD may have ADHD and a 64% that a child with ADHD will have a parent with ADHD (32% chance for each parent). Thus, implementing a treatment plan, remembering to administer medication, make follow up appointments, etc can be inconsistent when a parent has ADHD too. Also, 80% of psychotropic medication is prescribed by general practitioners with no specialized training in mental health treatment. Thus, many of the children may be treated incorrectly.

There is the issue that of the people with ADHD that take medication, 80% find it effective. I talked with our adult psychiatrist in our Bay Area Center for ADHD, Joshua Israel, who works exclusively with adults with ADHD and reviews all the literature on ADHD. He explained that about 25-33% of the time, the medications do lose their effect over time. There is not much research on this that he is familiar with and this phenomenon is not clearly understood (there is some tolerance building as the medication is titrated, but usually finding the person the dosage is reaches a consistent effective level).

Also, I think the article touches on another controversial issue, which is diagnosis. Due to the difficulty of diagnosing ADHD (executive functioning is one of the first things to go when a child or adult has anxiety, not enough sleep, not eating well, depression, trauma, is spread too thin at work, is abusing substance, is going through a difficult period, has a learning disability, head injury, or a number of other issues), many children and adults can be misdiagnosed if not given a proper assessment. There was recent research done where phone calls were made at random and asked parents if their kids had ADHD. Some states had rates as high as 16% and other 5% prevalence rates, although there is the question of who is doing the diagnosing.

The best way to diagnose ADHD is through a thorough clinical interview, taking into account the history (a neuropsych can give a profile of strengths and weaknesses, help rule out learning disabilities of which 50% of those diagnosed with ADHD also have, but a neuropsych is not necessary for a diagnosis of ADHD) . Current DSM standards look at symptoms existing prior to age 7, but DSM-V will most likely change that to prior to age 12 (or particularly Barkley's recommendations are prior to the onset of puberty).

There is also discussion about what are the "real" prevalence rates? The current DSM symptoms are based on children 4-16 years old, with a cut off of 6 symptoms out of 9, which placed children at the 93rd percentile (1.5 standard deviations above the norm, remember, to be inattentive and impulsive at times is a normal human trait, but when it becomes significantly abnormal and significantly affects functioning, it is considered a disorder, that's how most of us can identify with ADHD symptoms from time to time). Unfortunately, this same criteria for young children creates over diagnoses (for example, all 18 month olds meet 6 symptoms due to the frontal lobe of the brain not being developed enough) and under diagnosing adults (adults are no longer seeming as if they're driven by a motor or climbing on furniture). Actually, Barkley explains that 4 out of 9 symptoms place adults at the 93rd percentile, which is another controversy in the changes in DSM-V.

The most important part of a clinical assessment for ADHD is obtaining information about the early years, even when diagnosing an adult, which means talking to a parent (I've talked with parents in their 70s with adult clients in their 50s). One of the hardest differential diagnoses is when there are additional issues in childhood, such as trauma, family conflict, poverty, etc. Often, the behavioral, cognitive, and family treatments are the same (organizational skills, skills for distraction management, regulate sleep, healthy eating, exercise, school accommodations, therapy for the anxiety, family, depression, trauma), but the biggest difference is whether medication is prescribed.

As a therapist, who does not prescribe medication, I work with adolescents and adults who are both on and not taking medication. Behavioral therapy helps and medication helps. The standard of care is using both in combination, and making sure the medication is being monitored by a specialist in ADHD. At our Bay Area Center for ADHD, we provide individual, family, couples, and educational therapy as well as medication management. We've got great psychiatrists who work closely with the therapists to monitor and titrate medication and David May, our child psychiatrist, works very closely with families, emailing with parents daily during the beginning of medication treatment to ensure a proper dosage. He also works very well with parents wary of medication and often will not prescribe.

I think that it's very important to not throw the baby out with the bathwater regarding medication and ADHD. ADHD is a real, debilitating problem that if not properly diagnosed (or even when properly diagnosed), can lead to difficulties throughout the life time. The majority of adults that I work with experience a great deal of shame for not being able function at the level of others. One of the best interventions for a child with ADHD is the child and family understanding what ADHD is, how it impacts them, and working to help prevent the shaming that can happen from the difficulties ADHD brings and also to give them hope, since there are so many successful people with ADHD (e.g., Charles Schwab, Michael Jordan, Richard Branson, just google famous people with ADHD).

As with all other mental health problems, a mutlimodal approach is the best approach. Medication, in combination with healthy eating, exercise, adequate sleep, family/partner intervention, educational accommodations, and skills. When the diagnosis is not clear (history of ADHD but also history of trauma, family conflict, depression), then I collaborate with clients to determine if they would like a medication evaluation from a psychiatrist and treat the symptoms just as I would ADHD (even if its trauma, you help the person build coping skills to be more functional, then treat the trauma, just as you would if they had both ADHD and trauma). Often times, once we've treated the depression, sleep problems, anxiety, etc. and still find there are problems associated with ADHD, then the client might go for a medication evaluation. I tend to be conservative in my diagnoses of ADHD as it is such a difficult diagnosis.

Another interesting point is that there is much criticism of over medication of ADHD, but Barkley reports that studies have found 2% of the population on medication for ADHD. With a prevalence rate of 5-7%, that would mean only 28-40% of those with ADHD are on medication. In Hallowell's response to the NY Times article, he points out that 19 out of 20 parents that he sees are wary of medication (and many opposed), not eager to put a child on stimulants for a "quick fix".
I've seen adults in tears in my office, when they finally have learned that they had ADHD and took medication. They realize all the years they were being told they were lazy, the years they were yelled at by teachers, and the years their parents struggled with them could have been different if they knew what was going on and that there was something to treat it. I've also seen parents and families transform when they understand that their child has ADHD and is not being defiant with their schoolwork. Through medication, family therapy, cognitive skills, and educational skills, the family is able to heal some of the pain that occurred during the struggle to help the child function.

But just as any medication, its not the sole answer. Just as a child who needs glasses will be able to read better, a child with ADHD with medication can focus, be less hyperactive, and initiate more in classwork. If they don't have the remediation in school, the structure at home to get homework done, or the skills to keep organized and do their work, the medication alone will not equal success. Again, just as a child who is behind on reading because no one realized they needed glasses, they will still need remediation to catch up on their skills, the doctor will have to keep checking the glasses to make sure they are the correct prescription as the child ages, the child and parents will have to remember to send the child to school with the glasses, and they'll still have to provide the proper structures at home to get all the homework done and checked, while wearing glasses.

To read the NY Times Article, click here:

To read some responses to the articles, click the links below:

written by
W. Keith Sutton, Psy.D.
Bay Area Center for ADHD/ADD Psychologist providing therapy for adolescents, adults, couples, and families and providing neuropsychological assessments.

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