Report from the National Institutes of Health Consensus Conference on the Diagnosis and Treatment of Attention Deficit Hyperactivity Disorder, Bethesda, MD, November 16-18, 1998. I attended the three day event including the press conference at the end.
Thirty one presenting experts gave it their best shot to 12 impartial scientists specifically not involved in the field of ADHD. In what had elements at times of an out of control town meeting, the jury decided that America has a major public health crisis of a disorder that no one can clearly define or determine who exactly has it. Furthermore, while the jury concluded that Ritalin is probably safe and works to improve childrenís behavior and performance in the short term (14 months), the diagnostic threshold at which the benefits of Ritalin outweigh its risks is also undetermined.
I believe the conference represented a major disappointment to advocates of an either/or nature or nurture position on ADHD. The biologically oriented psychiatrists and self-help groups will have to closely review their statement ADHD is a neurobiological disorder because the NIH said that it remains unclear what causes ADHD. Anti-medication proponents and alternative treatment types were likely also disappointed (the panel said Ritalin was safe and effective on the short term) but probably less so because they couldnít have been expecting much from this convocation of mainstream researchers.
From my point of view, I was surprised that Eugene Arnold, reviewing the diet and alternative treatments was more neutral and supportive than I would have expected. Perhaps for children under five with symptoms, there is enough evidence to suggest an additive elimination diet. For all other alternative therapies Arnold simply said there was not enough evidence to support their use but neither could they be entirely written off. My concern is two fold. Iím ready to support some diet changes in younger children but I imagine that opens the door to major dietary strategies for all children and I still donít believe the evidence justifies the effort. More good use of parental and family energies could be spent on getting Johnny to pick up his toys rather than keeping him from eating a candy bar (I expect a wave of angry email for that statement). The call for more research was expected but it is very hard to prove a negative (e.g. diet doesnít work). For support look up Mark Wolraich's very good studies on sugar and ADHD or check out the alternative therapy section in the Ritalin Nation chapter of Running on Ritalin.
The other new information was a bit more disturbing. Once again animal studies showing changes to the synapses of their brains on exposure to Ritalin were presented. Rat and other animal studies also demonstrate that pre-exposure to Ritalin sensitized these animals to later addict faster and harder to Ritalin when offered the opportunity to self-administer the drug (an animal addiction model). Nadine Lambert attempted to show that in her prospective study of following ADHD children into adolescence more children who took Ritalin used cocaine as teenagers compared to those who didnít take Ritalin. Unfortunately her presentation (and data) were unconvincing.
Nevertheless, the animal studies are of concern. The brain studies may not be comparable to humans (for example thalidomide didnít affect pregnant rats but had a devastating effect on humans or the carcinogenic effect of Ritalin on rat livers simply hasn't panned out in the human experience with the drug). And the meaningful clinical effect that early exposure to Ritalin in childhood predisposes to later stimulant addiction is either non-existent or very small. However, these studies do give pause and once again behoove the physician to weigh the immediate clear benefits from this and any medication with the known and unknown long-term risks of a drug. Primum non nocere - first do no harm.