ADHD: Is Ritalin the Answer?

This story is often told, tongue in cheek:

Shaya, a young schoolboy, would act up each day in class. His teacher, at his wits’ end, advised the parents to medicate him with Ritalin. Shaya was embarrassed to be taking ADHD medication in school, for fear that he’d be teased. So the parents and the teacher devised a system: Each day, the teacher would ask Shaya to bring him a cup of coffee from the teacher’s lounge, and while Shaya was there, he would take his meds in privacy; no one would be the wiser.

After a few weeks, with the teacher reporting tremendous improvement in Shaya’s behavior, his father casually asked him about their system. “Shaya, how is it working out? What do you do each morning?”

“It’s simple, Tatty. Every morning, the teacher asks me to get him a coffee. I go into the teacher’s room, prepare his coffee, drop my pill into it, and since then, he and I have been getting along just fine!”

So, what’s the deal with ADHD?

Is it a diagnosis cooked up by parents and teachers who cannot handle children who have “ants in their pants”? Does ADHD only occur in boys? Does it last a lifetime, or do kids “outgrow” it? Would we have fewer instances of ADHD if we’d give our children more time to run around and play? And finally — are we overmedicating our children?

Three professionals in the field provide a rounded view of ADHD and its treatment:

Dr. Halana Rothbort — board-certified in Child, Adolescent, and Adult Psychiatry and is in private practice at the Center for Healthy Minds in Cedarhurst, New York.

Dr. Brett Blatter — Chairman of Adult Behavioral Health at Premium Health Centers and a former Assistant Clinical Professor of Psychiatry at Columbia University.

Dr. Alan Sroufe — an internationally recognized expert on early attachment relationships, emotional development and developmental psychopathology, and has published seven books and 140 articles on these and related topics.

‘Does My Child Have ADHD?’ — Defining the Disorder

According to the Diagnostic and Statistical Manual for Mental Disorders Fifth Edition (DSM-V), the diagnostic tool published by the American Psychiatric Association, the term ADD is no longer used, and the DSM-5 changed the criteria to diagnose someone with ADHD.

ADHD, attention-deficit/hyperactivity disorder, is divided into three types: hyperactive/impulsive, inattentive, or combined.

Dr. Halana Rothbort says that ADHD usually is diagnosed between the age of 5 and the late teen years. “The age at which ADHD presents in a child depends on multiple factors. One factor is the severity of the symptoms. A child with more severe symptoms of ADHD will often present younger than a child with milder symptoms. ADHD is often identified earlier in children with the hyperactive/impulsive type of ADHD than in those with inattentive ADHD,” she explains.

“When a child is very bright, ADHD is often diagnosed later, as the child can pick up information in school easily without paying too much attention, or compensates in other ways. But when they get to high school, where they need to listen carefully in class in order to understand the lesson, the ADHD will be more symptomatic, and the teen or parent will seek help.”

What are some of those less obvious signs? Dr. Rothbort identifies these behaviors: “A child or teen that is easily distracted, is often daydreaming, seems ‘out to lunch,’ or ignores or doesn’t seem to be listening when you talk to him or her directly. Many parents will also report difficulty in the morning: The child will start getting ready and then get distracted by something else and forget to continue. Parents will have no choice but to assist their older child, otherwise he or she will never get to school on time.

“Kids with ADHD will often get into a lot of trouble at school, whether for calling out or interrupting during class, doodling, walking around the classroom, and/or repeatedly forgetting their books and homework. They often receive a lot of negative feedback: ‘Sit down, stop fidgeting, stop talking …’”

Another overlooked issue that often accompanies ADHD is missed social cues, due to distraction. Combine that with a child who is hyperactive and impulsive and he or she will constantly be getting into fights with those around them and have a very hard time making or keeping friends.

Children with ADHD are on a constant quest for stimulation, and it affects their life at home too. “Parents will tell me, ‘My child thinks every day is Chol Hamoed! She’ll ask, “Where are we going today?” — every day!’ They also tend to be picky eaters, and demand an extraordinary amount of things, and everything is an emergency,” explains Dr. Rothbort. “If the child doesn’t get what he wants immediately, he may react negatively, which often leads to a vicious cycle of parents giving in to them to avoid conflict, creating yet a bigger problem. Having a child with ADHD is extremely challenging to families and schools.”

When we think of a child with ADHD, we usually picture a child who can’t sit still for a minute. ADHD is more often identified in children with the hyperactive/impulsive type, while the inattentive type is sometimes overlooked. Just because a child is not acting up in a hyperactive way, that doesn’t mean she is not suffering from ADHD. Some children can sit quietly in class but not absorb the material because they cannot focus on what the teacher is saying. Although their symptoms are more likely to be overlooked, it doesn’t mean ADHD affects them less.

Dr. Brett Blatter stresses the importance of obtaining a correct diagnosis. Unlike a physical illness, where definitive diagnostic tests are available, diagnosing psychiatric issues is more complex. “When a patient complains that he or she can’t focus, I would be doing them a disservice if I would just treat them for attention issues. We need to explore it first: Maybe he is depressed, and that’s why he can’t concentrate. Maybe it’s an underlying anxiety or psychosis that’s causing the symptoms. Treating the symptoms without discovering the root cause can make symptoms worse,” he says.

Dr. Blatter will often refer patients to a neuropsychologist for further testing, but it’s expensive and not always covered by insurance.

“If you have a provider you trust, discuss your symptoms with him or her. Be diligent in searching for a mental health professional who will take the time to make the right diagnosis. And remember, you can always get a second opinion,” says Dr. Blatter.

‘Okay, My Child Definitely Has ADHD. Do We Need Medication?’

Once a diagnosis has been reached, it’s time to decide on treatment options. Most children with ADHD benefit from a combination of medication and therapy.

Some parents of patients ask Dr. Rothbort, “What did people do 50 years ago without medication? They all survived!” Another common complaint is that the yeshivah system is too rigid, and if children would have more time to play outside, there would be fewer cases of ADHD.

While no one disputes the importance of time to move around, for children with ADHD, it just isn’t enough. Dr. Rothbort explains, “A long schedule and rigid expectations aren’t the cause of ADHD, but they certainly magnify its symptoms. Children with ADHD will have a hard time focusing, whether they are in yeshivah all day or in public schools that end at 3:00. We have effective ways to help them, and we should.” While changes in the child’s environment such as switching to a less-demanding school, can help, they won’t cure ADHD.

The most common type of medication prescribed for ADHD is a stimulant, such as Ritalin, Concerta or Adderall. There are nonstimulant medications available for ADHD, but both Dr. Rothbort and Dr. Blatter agree that they aren’t nearly as effective as stimulants. In some cases, patients have no choice because stimulants don’t agree with them, and in some cases patients use stimulants in conjunction with nonstimulants for the best effect.

Mrs. L., mother of a teenage son with ADHD, shared, “Ritalin isn’t a magic bullet. But without it, I shudder to think where my son would be. If he goes to class without taking his meds, he doesn’t learn anything that day. He still needs therapy and tutoring, but taking the medication allows him to focus long enough to absorb the help he gets.”

But what about side effects? Should parents be scared to medicate their children?

“We pushed off medicating our son because we were scared of side effects, but in retrospect, it was a mistake in our case to wait,” relates Mrs. L. “My son does experience side effects, but they are nothing compared to the damage caused by his failure in school and his misbehavior at home. I would advise parents of a child with a similar diagnosis to — with apologies to the city of Chicago — medicate ‘early and often.’ It’s much more difficult to rebuild the self-esteem of a child who has already tasted so much academic failure and social ostracism.”

The most common side effects of ADHD medication are headaches, upset stomach, anxiety, loss of appetite and insomnia. There is also some evidence that long-term use can stunt growth, possibly as a result of the appetite loss or hormonal changes. As with any medication, the question is if the side effects or risks are worth the benefit. But untreated ADHD also comes with many risks, chief among them an increased risk of drug abuse.

Used under a doctor’s care, studies show that stimulant medications are not a gateway to drug abuse. “I monitor my patients carefully for side effects and any signs they are becoming dependent on stimulants. When necessary, we’ll switch medications,” says Dr. Rothbort.

So the question to ask is not just about the potential side effects of medication, but the potential consequences of not medicating a child with severe ADHD. The answer will depend on the individual child’s circumstances, but the question must be asked.

The Other Side of the Coin

Dr. Alan Sroufe, a clinical psychologist who spent 50 years researching child development at the University of Minnesota — up until his retirement — takes a different approach. Dr. Sroufe participated in a number of studies on stimulant medications, including longitudinal studies that followed children before birth and throughout their lives, for more than 40 years.

“Longitudinal studies give us a vantage point that other studies can’t,” he says. “It’s true that if you do an MRI on children with ADHD versus children without ADHD, you’ll see a difference in their brain. Our brains are shaped by our experience, and it’s obvious that children with ADHD have differences. But that still doesn’t tell us what causes ADHD.”

Regardless of the cause, living with ADHD certainly impacts an individual’s life, and Dr. Sroufe agrees that they should receive help. But what should that help be?

“When I wrote my first paper on ADHD in 1973, there were about 150,000 children with ADHD taking stimulants in the United States. Today it’s over five million! Some of the increase can be attributed to population growth and better diagnoses, but that’s a lot of children,” he says. He wrote in a 2012 New York Times op-ed that we don’t have evidence that stimulant medications are effective in the long term for these children, because the only long-term studies that have been done fail to find positive effects. Sure, he says, studies are flawed, but that should lead us to the conclusion that more study is needed, not that the drugs work!

“Stimulants do improve focus and attention in the short term for everyone, including those without ADHD, just like, say, coffee. So should we give everyone stimulants? If the side-effects of Ritalin wear off, who is to say the benefits don’t wear off too? The fact that children’s behavior deteriorates when they’re taken off stimulants should not be used as a barometer to measure whether children need it. As any coffee drinker will tell you, they also have withdrawal symptoms if they stop drinking coffee,” he says.

Dr. Sroufe makes it clear that he doesn’t blame individual parents for putting their child on stimulants, because, as our current system stands, it may be the only choice they have. However, he does blame our society that does not make education of our children its highest priority.

“The truth is, if we’d limit our classroom size to 20 kids and have two teachers — one of whom is a behavioral specialist — in each classroom, we’d probably see more success in our children. I’m not arguing that no child needs medication, but that if we as a society say that millions of children need it, we’re doing something wrong, and that they might not need it if educators and parents had more resources.”

Dr. Sroufe says that, unlike diabetes where there is a clear biological marker, ADHD is a heterogenous label. “Each child is different, and often ADHD is comorbid with conduct issues, anxiety and depression. It’s a name we made up for a collection of behaviors in kids who are struggling. We need to be working harder on understanding the great variety in these children and explore ways to help them without medication.”

Practically speaking, though, if your child has to be on stimulant medication, Dr. Sroufe recommends that he be on it for the shortest time possible, stay off it in the summer and on weekends, when he isn’t in school, and gradually wean off the medication as early as he can.

‘Will He Outgrow It?’ — ADHD in Adults

When Mrs. L.’s son was diagnosed with ADHD, she found herself wondering about — herself. “Each time my son’s Rebbi or my husband pointed out a symptom, I would say, ‘But I did that as a kid and I turned out OK,’ until it slowly dawned on me that I might have ADHD too. Although I was never hyperactive, as a child I never could keep up with homework assignments, and my room was a perpetual disaster zone. Now, as a mother, I find it almost impossible to keep my house in order, even though I am very successful in my job and other areas of my life.”

After learning more about stimulant medications when researching treatment for her son, she decided to investigate if they could help her too. “I felt funny speaking to a psychiatrist about ADHD when I already have teenage children, but she explained that adults can have ADHD as well, and although I made it through school OK, I would benefit from a combination of therapy and medication.”

It used to be thought that children outgrow ADHD, says Dr. Blatter, but that is not true. Left untreated, adults with ADHD will find it difficult to hold down a job or sustain a marriage relationship. However, some adults with ADHD can thrive, even without medication, if they learn the skills they need and they are able to modify their environments.

While children have little leeway in their schedules, adults with ADHD can find a niche where their particular strengths are appreciated and even valued. They can become entrepreneurs, for example, and outsource their scheduling and organizing tasks to support staff.

Dr. Blatter also mentions a program run by a major New York hospital which treats college students with ADHD, without medication. “It’s a 12-week course that teaches young adults with ADHD valuable skills such as time management. Learning these techniques can really help adults navigate life with ADHD.”

But for some, especially those who are only diagnosed as adults, finding the right medication can be life-changing.

‘Are Stimulants Overprescribed?’

The rate of prescriptions for ADHD medications has certainly increased, but that may also be because of increased awareness of ADHD on the part of parents and school staff. “Often, parents whose oldest child was diagnosed with ADHD will come in with another child in the family who is much younger because they recognize the symptoms,” says Dr. Rothbort.

It’s likely that stimulants are overprescribed in the United States and around the world. But for parents, does it really matter? The important thing is to get a proper diagnosis for your child if he or she is experiencing any symptoms that make learning and daily life more difficult. And the next step is making sure the child gets the necessary assistance, whether this includes stimulant medication or not, to reach their full potential.