Have We Been Thinking About A.D.H.D. All Wrong?
Even as prescriptions rise to a record high, some experts have begun to question our assumptions about the condition — and how to treat it.
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In the early 1990s, James Swanson was working as a research psychologist at the University of California, Irvine, where he specialized in the study of attention disorders. It was a touchy time for the field. The Church of Scientology had organized a nationwide protest campaign against the psychiatric profession, and Ritalin, then the leading medication prescribed to children diagnosed with attention deficit hyperactivity disorder, was one of its main targets. Whenever Swanson and his colleagues gathered for a scientific conference, they were met by chanting protesters waving signs and airplanes overhead pulling banners that read, 'Psychs, Stop Drugging Our Kids.'
It was true that prescription rates for Ritalin were on the rise. The number of American children diagnosed with A.D.H.D. more than doubled in the early 1990s, from fewer than a million patients in 1990 to more than two million in 1993, almost two-thirds of whom were prescribed Ritalin. To Swanson, at the time, that increase seemed entirely appropriate. Those two million children represented about 3 percent of the nation's child population, and 3 percent was the rate that he and many other scientists believed was an accurate measure of A.D.H.D. among children.
Still, you didn't have to be a Scientologist to acknowledge that there were some legitimate questions about A.D.H.D. Despite Ritalin's rapid growth, no one knew exactly how the medication worked or whether it really was the best way to treat children's attention issues. Anecdotally, doctors and parents would observe that when many children began taking stimulant medications like Ritalin, their behavior would improve almost overnight, but no one had measured in a careful, large-scale scientific study how common that positive response was or, for that matter, what the effects were on a child of taking Ritalin over the long term. And so Swanson and a team of researchers, with funding from the National Institute of Mental Health, began a vast, multisite randomized controlled trial comparing stimulant treatment for A.D.H.D. with nonpharmaceutical approaches like parent training and behavioral coaching.
Swanson was in charge of the site in Orange County, Calif. He recruited and selected about 100 children with A.D.H.D. symptoms, all from 7 to 9 years old. They were divided into treatment groups — some were given regular doses of Ritalin, some were given high-quality behavioral training, some were given a combination and the remainder, a comparison group, were left alone to figure out their own treatment. The same thing happened at five other sites across the continent. Known as the Multimodal Treatment of Attention Deficit Hyperactivity Disorder Study, or M.T.A., it was one of the largest studies ever undertaken of the long-term effects of any psychiatric medication.
'We have a clinical definition of A.D.H.D. that is increasingly unanchored from what we're finding in our science.'
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