Post by Amtram on Feb 13, 2014 14:50:11 GMT -5
Nature's article, Medication: The smart-pill oversell is all over Twitter. Twitter being Twitter, it's not surprising that people are reacting viscerally to the title and the first few paragraphs. The title could have been better, because one of the points of the article is not that stimulants are being overprescribed or they're not working, but that they're being sold as "smart pills" when the evidence shows they don't significantly improve academic performance.
Improving academic performance is a potential benefit for people whose ADHD makes it difficult to learn or stay on task, but that's not why we take the medications. Farther down, the article gets into a broader perspective:
And, of course, it also goes into more detail about how non-pharmaceutical therapies and accommodations make a difference as well (and how intelligence is still a bigger factor in school performance, with or without ADHD. And those, as well, are beneficial only for as long as they continue.
So, see? The article is pointing out not that the meds are oversold, but that their usefulness as intelligence enhancers is oversold. But people who want to deny the existence of ADHD are not going to read that far. Ironic that this person with ADHD read the whole thing. . .
Improving academic performance is a potential benefit for people whose ADHD makes it difficult to learn or stay on task, but that's not why we take the medications. Farther down, the article gets into a broader perspective:
Puzzling paradox
Researchers are beginning to address this paradox. How can medication that makes children sit still and pay attention not lead to better grades?
One possibility is that children develop tolerance to the drug. Dosage could also play a part: as children grow and put on weight, medication has to be adjusted to keep up, which does not always happen. And many children simply stop taking the drugs, especially in adolescence, when they may begin to feel that it affects their personalities. Children may also stop treatment because of side effects, which can include difficulty sleeping, loss of appetite and mood swings, as well as elevated heart rate.
Or it could be that stimulant medications mainly improve behaviour, not intellectual functioning. In the 1970s, two researchers, Russell Barkley and Charles Cunningham, noted that when children with ADHD took stimulants, parents and teachers rated their academic performance as vastly improved9. But objective measurements showed that the quality of their work hadn't changed. What looked like achievement was actually manageability in the classroom. If medication made struggling children appear to be doing fine, they might be passed over for needed help, the authors suggested. Janet Currie, an economist at Princeton University in New Jersey, says that she might have been observing just such a phenomenon in the Quebec study that found lower achievement among medicated students1.
And it may simply be that drugs are not enough. Stimulant medications have two core effects: they help people to sustain mental effort, and they make boring, repetitive tasks seem more interesting. Those properties help with many school assignments, but not all of them. Children treated with stimulants would be able to complete a worksheet of simple maths problems faster and more accurately than usual, explains Nora Volkow. But where flexibility of thought is required — for example, if each problem on a worksheet demands a different kind of solution — stimulants do not help.
Researchers are beginning to address this paradox. How can medication that makes children sit still and pay attention not lead to better grades?
One possibility is that children develop tolerance to the drug. Dosage could also play a part: as children grow and put on weight, medication has to be adjusted to keep up, which does not always happen. And many children simply stop taking the drugs, especially in adolescence, when they may begin to feel that it affects their personalities. Children may also stop treatment because of side effects, which can include difficulty sleeping, loss of appetite and mood swings, as well as elevated heart rate.
Or it could be that stimulant medications mainly improve behaviour, not intellectual functioning. In the 1970s, two researchers, Russell Barkley and Charles Cunningham, noted that when children with ADHD took stimulants, parents and teachers rated their academic performance as vastly improved9. But objective measurements showed that the quality of their work hadn't changed. What looked like achievement was actually manageability in the classroom. If medication made struggling children appear to be doing fine, they might be passed over for needed help, the authors suggested. Janet Currie, an economist at Princeton University in New Jersey, says that she might have been observing just such a phenomenon in the Quebec study that found lower achievement among medicated students1.
And it may simply be that drugs are not enough. Stimulant medications have two core effects: they help people to sustain mental effort, and they make boring, repetitive tasks seem more interesting. Those properties help with many school assignments, but not all of them. Children treated with stimulants would be able to complete a worksheet of simple maths problems faster and more accurately than usual, explains Nora Volkow. But where flexibility of thought is required — for example, if each problem on a worksheet demands a different kind of solution — stimulants do not help.
And, of course, it also goes into more detail about how non-pharmaceutical therapies and accommodations make a difference as well (and how intelligence is still a bigger factor in school performance, with or without ADHD. And those, as well, are beneficial only for as long as they continue.
When the MTA team examined the follow-up data, it found that many non-medical factors play a big part in whether improvements last. The best predictor of a child's response to treatment wasn't which treatment they were assigned, but a cluster of factors that were present at the start. Children with more advantages — higher intelligence, better social skills, intact families, higher parental education, fewer conduct problems or higher socioeconomic status — were likely to make big strides and hold onto them no matter what the treatment was, whereas children without these advantages typically progressed more slowly and regressed after treatment stopped2, 3, 4.
But disadvantaged children benefited when they received both medication and behaviour therapy. “The kids with the most problems needed the combination,” says Jensen, who adds that parents should have easier access to proven behaviour therapies. The effects of behavioural treatment don't seem to be longer-lasting than those of medication, however: once active treatment stops, they dissipate.
Future studies might explore whether medication offers subtle benefits that are not reflected in test scores or grades. Many researchers think that a stint on medication, when it is needed, can create an upward spiral of self-esteem that may make a crucial difference to a child's life — but there are no hard data to support this. “It may be that treatment doesn't translate into better grades” in the long term, Volkow says. “But what I'd like to see is, are those kids overall better integrated?”
Some experts think that the focus on academic achievement is misguided — that the point of the drugs has never been to improve children's grades, or increase their chances of admission to the best universities. “Medications are given for their short-term effects,” says Swanson. “Don't expect medication to get rid of every problem a child has. But if the problem right now is not passing the second grade, or not having any friends in the third grade, we can do something about that now.”
But disadvantaged children benefited when they received both medication and behaviour therapy. “The kids with the most problems needed the combination,” says Jensen, who adds that parents should have easier access to proven behaviour therapies. The effects of behavioural treatment don't seem to be longer-lasting than those of medication, however: once active treatment stops, they dissipate.
Future studies might explore whether medication offers subtle benefits that are not reflected in test scores or grades. Many researchers think that a stint on medication, when it is needed, can create an upward spiral of self-esteem that may make a crucial difference to a child's life — but there are no hard data to support this. “It may be that treatment doesn't translate into better grades” in the long term, Volkow says. “But what I'd like to see is, are those kids overall better integrated?”
Some experts think that the focus on academic achievement is misguided — that the point of the drugs has never been to improve children's grades, or increase their chances of admission to the best universities. “Medications are given for their short-term effects,” says Swanson. “Don't expect medication to get rid of every problem a child has. But if the problem right now is not passing the second grade, or not having any friends in the third grade, we can do something about that now.”
So, see? The article is pointing out not that the meds are oversold, but that their usefulness as intelligence enhancers is oversold. But people who want to deny the existence of ADHD are not going to read that far. Ironic that this person with ADHD read the whole thing. . .