Every once in a while a study emerges that fundamentally changes a particular aspect of medicine. A long term study which shows that the assumptions underpinning a particular course of treatment, are shown to be wrong. One example was the Women’s Health Initiative in 2002 that changed our view on hormone replacement therapy for women. It had been assumed for close to 20 years that the benefits outweighed the risks. Then a long-term study showed the exact opposite and almost overnight the routine recommendation to menopausal women to take HRT was changed. Today it is only used where the benefit to the individual can be assessed as outweighing the risks.
This week the same fundamental overthrowing of assumptions has happened with Attention deficit Hyperactivity Disorder (ADHD). For the last 25 years we have seen a significant increase in the number of children diagnosed with this condition and an exponential increase in the use of drugs to treat it. These “stimulant” drugs such as Ritalin and Dexamphetamine are amphetamine derivatives and are potent. They have been known to have significant side effects particularly affecting the heart and cardiovascular system. Their use has generally been defended on the basis that the benefits outweighed the risks.
One of the main perceived benefits has been improved academic performance. Paradoxically, the use of stimulant medication seems to tranquilize to some degree children with ADHD making them more docile and more attentive in class settings. In turn it has been assumed that children treated with the drugs would do better in school than those that were not medicated.
The study released this week from the well-respected Raine Foundation is the worlds first long term research into drug use in ADHD. The children were followed for nine years. The results showed that not only did the medicated group not do better than the non-medicated group; they did worse by a factor of ten fold! Children who had been medicated had a ten fold higher rate of being identified by teachers as performing below average for age then those who had never been medicated.
The other justification for medication has been improved behavior in the child. The study showed no significant improvement in the medicated children. Their behavior was no “worse” but not better. There was a slightly increase likelihood of depression in the medicated group.
So essentially the two reasons that have been used to promote the use of stimulant medication in children have been shown to be fundamentally wrong. The strength of this study is that is long term (9 years) .It is often easy to show benefits from medication in the short term for a variety of reasons including the placebo effect. Long term is where the truth comes out
Furthermore, the children who had been medicated had a significantly higher diastolic blood pressure, which was not a short-term effect. The drugs are known to elevate blood pressure whilst in the body but it was thought that this wore off. This study showed that medicated children had ongoing higher blood pressure even after the medication was ceased. This potentially increases their risk of hypertension and heart disease in adult life.
So what does this mean for parents whose children are on these medications? The short answer is that one should be looking at getting them off. This needs to be done in consultation with your doctor. Importantly each case is different and there will be cases where for various reasons the benefits are judged to outweigh the substantial risks. However we will expect see a drastic reduction in the use of these potent drugs in our children.
In an upcoming piece I will outline other ways to manage and deal with behavioral issues in children.