ADHD Questions and Answers
ADD", default", ADHD and Psychotropic Medication, Questions and a Answers.
Between 1990 and 2000 there were 186 deaths from methylphenidate reported to the FDA MedWatch program, a voluntary reporting scheme, the numbers of which represent no more than 10 to 20% of the actual incidence
In 1998 at the National Institutes of Health Consensus on ADHD, the following statement was issued: "We do not have an independent, valid test for ADHD, and there is no data to indicate that ADHD is due to a brain malfunction".
Labels like ADHD, ADD, ODD, LD etc are in no sense true diseases. There are no reliable diagnostic methods. Psychiatrists cannot even agree among themselves about how to diagnose ADD/ ADHD. In addition, your child needs to, be put on a medication that is a close cousin to amphetamine because of the ADHD labeled.
See many of the Conditions that Mimic ADHD
Our 14-year-old Son Died from Ritalin Use
April 15, 2001 this website was created in hopes of providing parents and guardians with information about the truth behind ADHD and the drugs used to treat children diagnosed with ADD or ADHD.
We built this website because we didn't want other children to die or suffer side effects because of their parents lack of knowledge.
We did all we could to convince state and federal government about the methods used in the miss-diagnosing of thousands of children with in ADD - attention deficit disorder and ADHD hyperactivity disorder of ADHD and psychotropic drugging of children with Ritalin and other drugs.
Since the death of our 14-year-old son Matthew caused from the use of Ritalin prescribed for ADHD (Attention Deficit Hyperactivity Disorder) our family has been informing others world wide via the internet about ADHD and the dangers of psychotropic drugs in memory of our son and countless other children that have died over the years as a direct result of using psychotropic drugs.
We wish to expose the health risks, dangers, deaths and suicides that are a direct result of administering Ritalin and other psychiatric drugs to children.
We hope our story and information will in some way benefit your family and prevent our tragedy from being your families’ reality and nightmare.
Our fourteen year old son Matthew suddenly died on March 21, 2000. The cause of death was determined to be from the long-term (age 7-14) use of Methylphenidate, a drug commonly known as Ritalin.
According to Dr. Ljuba Dragovic, the Chief Pathologist of Oakland County, Michigan, upon autopsy, Matthew's heart showed clear signs of small vessel damage caused from the use of Methylphenidate (Ritalin).
*The certificate of death reads: "Death caused from Long Term Use of Methylphenidate, (Ritalin)."
I was told by one of the medical examiners that a full-grown man's heart weighs about 350 grams and that Matthew's heart's weight was about 402 grams. Dr. Dragovic said this type of heart damage is smoldering and not easily detected with the standard test done for prescription refills. The standard test usually consists of blood work, listening to the heart, and questions about school behaviors, sleeping and eating habits.
*What is important to note here is that Matthew did not have any pre-existing heart condition or defect.
Matthew's story started in a small town within Berkley, Michigan. While in first grade Matthew was evaluated by the school, who believed he had ADHD. The school social worker kept calling us in for meetings. One morning at one of these meetings while waiting for the others to arrive, Monica told us that if we refused to take Matthew to the doctor and get him on Ritalin, child protective services could charge us for neglecting his educational and emotional needs. My wife and I were intimidated and scared. We believed that there was a very real possibility of losing our children if we did not comply with the schools threats.
Monica further explained ADHD to us, stating that it was a real brain disorder. She also went on to tell us that the Methylphenidate (Ritalin) was a very mild medication and would stimulate the brain stem and help Matthew focus.
We gave into the schools pressure and took our son to a pediatrician that they recommended. His name was Dr. John Dorsey of Birmingham, Michigan. While visiting Dr. Dorsey with the schools recommendation for Methylphenidate (Ritalin) in hand, I noted that he seemed frustrated with the school. He asked us to remind the school that he was not a pharmacy. I can only conclude from his comment that we were not the first parents sent to him by this school. Dr. John Dorsey officially diagnosed Matthew with ADHD. The test used for the diagnosis was a five minute pencil twirling trick, resulting in Matthew being diagnosed with ADHD.
*It is important to note that the schools insistence and role in our son's drugging was documented in a letter written by Monica to the pediatrician stating: "We would have hoped you would have started Matthew on a trial of medication by now".
At no time were my wife and I ever told significant facts regarding the issue of ADHD and the drugs used to "treat it". These significant facts withheld from us inevitably would have changed the road that we were headed down by ultimately altering the decisions we would have made.
We were not told that The Drug Enforcement Administration had classified Methylphenidate (Ritalin) as a Schedule II drug, comparable to Cocaine.
We were not told that Methylphenidate is also one of the top ten abused prescription drugs.
At no time were we informed of the unscientific nature of the disorder.
We were not told that there was widespread controversy among the medical establishment in regards to the validity of the disorder.
Furthermore, we were not provided with information involving the dangers of using Methylphenidate (Ritalin) as "treatment" for Attention Deficit Hyperactivity Disorder. One of these dangers includes the fact that Methylphenidate, Ritalin causes constriction of veins and arteries, causing the heart to work overtime and inevitably leading to damage to the organ itself.
We were not made aware of the large number of children's deaths, that have been linked with these types of drugs used as "treatment".
While Matthew was taking Methylphenidate (Ritalin), at no time, were we informed of any test: echo-cardiogram, MRI. These types of tests could have detected the damage done to his heart. These test are not considered "standard" in monitoring "treatment" of ADHD they are usually never administered to children. Sadly death is inevitable without the possibility of detection.
*I want to ask every parent to ask themselves these important questions: How different would your decisions be if information was withheld from you? How different would your decisions be if you receive only distorted data?
I, myself, know that our families and Matthews outcome would have been quite different had we received all information. If I had known certain facts I would have acted differently and my son would be alive today. This I am sure of.
Informed Consent", which states in part A person's agreement to allow something to happen (such as surgery) that is based on a full disclosure of the facts needed to make the decision intelligently; i.e. knowledge of risks involved, alternatives etc" and "the probable risks against the probable benefits"
The violation of parent's rights is when they are not told of the unscientific nature of so-called disorders such as ADHD or the risks of the treatments involving drugs like Ritalin, and they certainly are not told of alternatives to their child's behavior such as undiagnosed allergies or food sensitivities, which could manifest with the symptoms of what psychiatry calls ADHD.
*Here are some facts that are being withheld from parents that could possibly alter their life decisions and outcomes.
Did you know that schools receive additional money from state and federal government for every child labeled and drugged? This clearly demonstrates a possible "financial incentive" for schools to label and drug children. It also backs up the alarming rise/increase in the labeling and drugging that has taken place in the last decade within our schools.
Did you know that parents receiving welfare money from the government can get additional funds for every child that they have labeled and drugged? In this way, many lower socio-economic parents (many times single mothers) are reeled into the drugging by these financial incentives waved in front of them in hard times, making lifestyle changes possible.
Did you know that by labeling your child with ADHD, you are actually labeling them with a mental illness listed in the DSM-IV, the unscientific billing bible for psychiatry?
Did you know that a child taking a psycho-tropic, psycho-stimulant drugs like Ritalin after the age of 12 is ineligible for military service?
Did you know that the subjective checklists that are being used as criteria for diagnosis are very similar to the checklists used to determine Gifted and Talented Children? These two checklists are almost identical.
The Drug Enforcement Administration clearly states in their report on Methylphenidate: "However, contrary to popular belief, stimulants like methylphenidate will affect normal children and adults in the same manner that they affect ADHD children. Behavioral or attentional improvements with methylphenidate treatment therefore is not diagnostic of ADHD." (p.11) This statement thoroughly contradicts what is being told to many parents by the many "professionals" that have a vested stake in the diagnosis itself.
The DEA further states that: "Of particular concern is that most of the ADHD literature prepared for public consumption by CHADD and other groups and available to parents, does not address the abuse potential or actual abuse of methylphenidate. Instead, methylphenidate (usually referred to as Ritalin by these groups) is routinely portrayed as a benign, mild substance that is not associated with abuse or serious side effects. In reality, however, there is an abundance of scientific literature which indicates that methylphenidate shares the same abuse potential as other Schedule II stimulants." (p.4)
Did you know that groups like CHADD and others available to parents are being supported financially by pharmaceutical companies? This is a red flag and demonstrates a conflict of interest in the role that these groups have regarding our children's health and well-being.
Did you know that there are studies such as the Berkeley Study that contends that Ritalin and other stimulants further raise the risk of drug abuse? From the Wall Street Journal, Monday, May 17, 1999 by Marilyn Chase: "Nadine Lambert, a professor of education, followed almost 500 children for 26 years. She argues that exposure to Ritalin makes the brain more susceptible to the addictive power of cocaine and doubles the risk of abuse." This study seems to never make it into the hands of parents because it doesn't support the theories of those using the diagnosis to profit off of our children. What does seem to make it into many parents’ hands is research indicating that if children go "untreated", which corresponds with "unmedicated" they will "self-medicate" or end up as juvenile delinquents. Sadly many of these parents are not aware that many of this biased and unproven research (one such is the Beiderman study) infiltrating our schools are actually being distributed by pharmaceutical companies, such as Novartis. This in itself is another red flag and conflict of interest surrounding our children's health.
I leave you with this question: How many more 11 year old Stephanie Hall's, 14 year old Matthew Smith's and 10 year old Shaina Dunkle's need to die before we realize what is happening and speak out and act to put an end to it? One toy might be recalled if 1 or 2 children die from it. How many children have to die from these drugs before we realize and put an end to this horror. Why should hundreds or thousands have to die before we are outraged and act? Is the profit of so many, worth more than our children's safety and lives? Sadly the deaths of these children have remained unexposed and suppressed for so long because there is a tremendous amount of money and profit at stake for so many. My son's voice will not be one of those suppressed and quieted.
Below is a copy of a letter sent to the doctor by our sons school social worker and psychologist asking the doctor for our six-year-old to be put on Ritalin.
IEP will be on December 6. We have recognized his learning difficulties. We'll likely give him maximum time in a resource room (3 hours/day).
Our concern is that his psychological testing has shown strong average intelligence. Sub-scores are weakest in the areas of attention and memory (which our psychologist believes are indications of ADHD)
He has had a long history of impulsive over-activity. We (social worker-psychologist witnessed this in Matt's pre-school at Miss Molly's, That's why we certified him eligible for PPI - pre- primary-impaired. He had his PPI year, then kindergarten year and now 1st grade.
Many environmental changes have been tried to help Matt concentrate and focus, yet he is still at a beginning kindergarten readiness. We believe his high level of distraction is even more of a handicap than his learning deficits.
We had hoped by September you and Matt's parents would have begun a trial of medication so that we could assess whether his learning would have benefited by increased focus and concentration.
Would you consider simultaneously having Matt begin his 3 hours in a resource room with a prescribed medical therapy? Parents indicate they would feel comfortable with this decision if you do.
We are so concerned that Matt has begun to see himself as "bad" and doing "bad things" I, as the school social worker, will continue to work with Matt on self-esteem and social skills.
Matthew supposedly needed this drug Ritalin because of a subjective diagnosis called ADHD until it silenced him forever on March 21, 2000, even sadder I have learned that thousands of children have died as a direct result of using psychotropic medications over the years.
Matthew's Voice in Death Will be
Heard by All
In closing we would like to say, We hope this
website has enlightened you.
Ritalin: Child Abuse on Prescription?
Study's failure to report on the crucial comparison between unmedicated and medicated ADHD subjects.
Family doctors are these days frequently under pressure (usually from teachers and social workers who know nothing about drug therapy and probably understand nothing about the way the international drug industry operates) to prescribe the drug called Ritalin for children who are accused of behaving badly, reported as not doing well at school and `diagnosed' as suffering from something called Attention Deficit Hyperactivity Disorder (known as ADHD).
For several decades now Ritalin, and other amphetamine type drugs, have been prescribed for children dysfunction and diagnosed as suffering from various types of brain hyperactivity. (Other psychostimulants which have, at one time or another, been regarded as competitors to Ritalin have included Dexedrine).
In my view the first problem is that Attention Deficit Hyperactivity Disorder (and other variations on the hyperactivity theme) is a rather vague diagnosis which is often leapt upon by teachers, social workers and parents to excuse and explain any unacceptable or uncontrollable behaviour.
Parents of children whose behaviour is in any way regarded as different or unusual are often encouraged to believe that their child is suffering from a disease for two simple reasons. First, it is more socially acceptable to give a child a pseudoscientific label than to have to admit that he or she may simply be badly behaved.
Second, when a child has been given a label it is possible to offer a treatment. Commonly it will be one, such as a drug, which offers someone a profit. ADHD, which is also known as Attention Deficit Disorder (or ADD), hyperkinetic child syndrome, minimal brain damage, minimal brain dysfunction in children, minimal cerebral dysfunction and psycho-organic syndrome in children, is a remarkably non specific disorder. The symptoms which characterise the disorder may include: a chronic history of a short attention span, distractibility, emotional lability, impulsivity, moderate to severe hyperactivity, minor neurological signs and abnormal EEG. Learning may or may not be impaired.
Read that rather nonsensical list of symptoms carefully and you'll find that just about any child alive could probably be described as suffering from ADHD.
What child isn't impulsive occasionally? What child doesn't cry and laugh (that's what emotional lability means)? What child cannot be distracted?
One big worry I have is that Ritalin could be recommended for any child who seemed bored and restless or who exhibited unusual signs of intelligence or skill. Read the biographies of geniuses and you may wonder what we are doing to our current generation of most talented individuals.
`Is Ritalin a drug in search of a disease?' wrote one author, and it isn't difficult to see why.
First Used In The 1960s
By 1966 the `experts' had come up with a definition of the sort of child for whom Ritalin could useful be prescribed. Children suffering from Minimal Brain Dysfunction (MBD), the first syndrome for which Ritalin was recommended, were defined as `children of near average, average or above average general intelligence with certain learning or behavioral disabilities ranging from mild to severe, which are associated with deviations of function of the central nervous system. These deviations may manifest themselves by various combinations of impairment in perception, conceptualization, language, memory and control of attention, impulse or motor function'.
Other symptoms which children might exhibit and which could be ascribed to MBD included: being sweet and even tempered, being cooperative and friendly, being gullible and easily led, being a light sleeper, being a heavy sleeper and so on and on.
Given that sort of list to work with it is difficult to think of a child who wouldn't benefit from Ritalin - though the official estimate seemed to be that only around 1 in 20 children were real MBD sufferers.
A Convenient Diagnosis
The head of the task force which identified and labeled MBD allegedly subsequently joined the company making Ritalin and produced their hand book for doctors on the condition. Commercially Ritalin and MBD became a huge success. By 1975 around a million children in the U.S. were diagnosed as suffering from MBD. Half of these were being given drugs and half of those on drugs were on Ritalin.
For the sake of completeness I should point out that Ritalin has not always been used exclusively in the treatment of badly behaved children.
When Dr Andrew Malleson wrote his book `Need Your Doctor Be So Useless' in 1973 he reported that the CIBA Pharmaceutical Company had suggested `to doctors the use of their habit forming drug Ritalin for `environmental depression' caused by `NOISE: a new social problem'.
Does Ritalin Work?
Well, I'm afraid that I can't answer that question. And I honestly don't think anyone else can either. Novartis, the drug company which is now responsible for Ritalin in the UK, admits that `data on...efficacy of long term use of Ritalin are not complete'.
With one in twenty children said to be suffering from MBD (or ADHD or ADD or whatever else anyone wants to call it), with Ritalin having been on the market and used for this condition for over three decades, and with some experts saying that a million children a year are given Ritalin in the U.S. alone you might find this a trifle disappointing.
Just how long does it take to find out whether or not a drug works? Am I being horribly cynical in suggesting that it might be against the drug company's interests to find out whether or not Ritalin really works? After all, if long term studies found that Ritalin didn't work a very profitable drug would, presumably, lose some of its appeal. Some research has been done. One five year study of hyperactive children who were given Ritalin at Montreal Children's Hospital found that the children did not differ in the long term from hyperactive children who were not given the drug. At least one investigator has reported that drugs like Ritalin may produce a deterioration in learning new skills at school and parents have reported that the symptoms of MBD have miraculously disappeared during school holidays.
The picture is confused by the fact that there may be a short term improvement in behaviour among children given Ritalin. But is this a real improvement? Or is the child simply drugged? Amphetamine type drugs reduce the variety of behaviour exhibited by children. A child taking Ritalin might have more focused behaviour. But although that might mean less disruption in the classroom does it really help the child? And should we give a child a powerful and potentially hazardous drug because they it keeps him quiet?
There is evidence suggesting that children who are genuinely hyperactive may have been poisoned by food additives or by lead breathed in from air polluted by petrol fumes. If this is so then is giving another potentially toxic drug really the answer to this problem?
Doctors who prescribe Ritalin, and who have the time and the inclination to read the warnings issued with the drug, will discover that Ritalin should not be given to patients suffering from marked anxiety, agitation or tension since it may aggravate these symptoms.
Ritalin is contraindicated in patients with tics, tics in siblings or a family history or diagnosis of Tourette's syndrome. It is also contraindicated in patients with severe angina pectoris, cardiac arrhythmias, glaucoma, thyrotoxicosis, or known sensitivity to methylphenidate and it should be used cautiously in patients with hypertension (blood pressure should be monitored at appropriate intervals). Ritalin should not be used in children under six years of age, should not be used as treatment for severe depression of either exogenous or endogenous origin and may exacerbate symptoms of behavioural disturbance and thought disorder if given to psychotic children.
The company selling it claims that although available clinical evidence indicates that treatment with Ritalin during childhood does not increase the likelihood of addiction chronic abuse of Ritalin can lead to marked tolerance and psychic dependence with varying degrees of abnormal behaviour.
Ritalin, it is warned, should be employed with caution in emotionally unstable patients, such as those with a history of drug dependence or alcoholism, because such patients may increase the dosage on their own initiative.
Ritalin should also be used with caution in patients with epilepsy since there may be an increase in seizure frequency.
And height and weight should be carefully monitored in children as prolonged therapy may result in growth retardation. (A child might lose several inches in possible height - though if treatment is stopped there is a generally a growth spurt). It is perhaps worth mentioning here my view that if a drug is powerful enough to retard growth it does not seem entirely unreasonable to suspect that the chances are high that it may be having other powerful effects upon and within the body.
Doctors are also warned that careful supervision is required during drug withdrawal, since depression as well as renewed overactivity can be unmasked. Long term follow up may be needed for some patients.
There have also been reports that children have committed suicide after drug withdrawal. And one study has shown that children who are treated with stimulants alone had higher arrest records and were more likely to be institutionalized. Long term use of Ritalin has been said to cause irritability and hyperactivity (these are, you may remember, the problems for which the drug is often prescribed). In a study published in Psychiatric Research and entitled Cortical Atrophy in Young Adults With A History of Hyperactivity brain atrophy was reported in more than half of 24 adults treated with psychostimulants (though I don't think anyone can say for sure whether or not the psychostimulants caused the brain atrophy the possible link should make prescribers, teachers and parents who are fans of Ritalin stop and think for a moment).
In Johannesburg a study of 14 children is said to have produced a response in only 2 children. One child showed some deterioration and another showed marked deterioration.
The final insult is, surely, the fact that the company selling Ritalin tells doctors that `Data on safety and efficacy of long term use of Ritalin are not complete.' For this reason they recommend that patients requiring long term therapy should be monitored carefully with periodic complete and differential blood counts, and platelet counts.
I regard this as an insult because Ritalin is not a new drug.
I have not, at the time of writing this, been able to find out exactly when it was first introduced but I have been able to trace it back to 1961.
Now, maybe I'm being rather demanding but it does seem to me that when a drug has been on the market for well over a quarter of a century it isn't entirely unreasonable for the drug company involved to have completed studying the data on whether or not it works and is safe.
Cancer In Mice
Here, once again, is yet more proof of the total worthlessness of animal experiments and the ruthless and cynical attitude shown by drug companies and those government departments which allegedly exist to protect the public from unsafe drugs.
I have frequently argued that when drug companies perform pre clinical tests on animals they do so knowing that if the tests show that a drug doesn't cause any problems when given to animals they can use the results to help convince the authorities that the drug is safe.
On the other hand when a drug does cause a problem when given to animals the results can be ignored on the grounds that `the significance of these results to humans is unknown'.
The question here is a very simple one: if the experiments on mice which showed that Ritalin causes cancer were of value why is the drug still available on prescription for children? And if the experiments can safely be ignored (on the grounds that animals are so different to human beings that the results are irrelevant) why the hell were the tests done in the first place?
Ignorance And Misplaced Trust
Years of experience mean that I am not in the slightest bit surprised to find such crass stupidity exhibited by social workers. I am, however, more surprised to find school teachers showing such a potent mixture of ignorance and misplaced trust. Some observers claim that Ritalin can be considered for a children when tests and clinical examinations have shown the existence of a clear neurological disorder - with abnormal brain wave patterns.
Psychiatrist, psychologist, health visitor, teachers, GP and parents should, it is said, all be considered before considering treatment.
Even the company selling Ritalin says that `Ritalin treatment is not indicated in all children with this syndrome and the decision to use the drug must be based on the physician's evaluation of the child's history and the duration and severity of symptoms'.
However, despite this, when a team of researchers from the United Nationals International Narcotics Control Board examined the records of nearly 400 pediatricians who had prescribed Ritalin they found that half the children who had been diagnosed as suffering from MBD (or ADD or whatever) had not been given psychological or educational testing before being given the drug. The United Nations concluded that frustrated parents, teachers and doctors were too quick to stick a label of ADD onto children with behavioural problems (or, to be more accurate, to children whose behavioural was annoying the parents, teachers and doctors).
Less Than Enthusiastic
You might have guessed by now that I wouldn't prescribe Ritalin for anyone - for anything.
But other doctors clearly don't agree with me. Some observers have described Ritalin as a drug that can unlock a child's potential. And although estimates about the number of children taking Ritalin vary in the U.S. alone it has been claimed that up to 12 % of all American boys aged between 6 and 14 are being prescribed Ritalin to treat various behavioral disorders. In 1990 the world wide production of the drug was less than three tones. By 1994 production of the drug had virtually trebled. It is now not unknown for schools to arrange for children to be treated with Ritalin without obtaining parental permission.
It is worth remembering that although doctors, parents and teachers have for over thirty years now been enthusiastically recommending the use of Ritalin (and similar drugs) in the treatment of MBD there are still a number of unanswered questions.
We still do not know whether the drug works and nor do we know whether it causes any permanent long term damage. We do not know whether the listed potential side effects do more damage than any possible good the drug might do. And, perhaps most astonishing of all, despite the fact that millions of children have been diagnosed as suffering from ADHD, ADD or MBD, and treated with powerful drugs, we do not even know whether any of these conditions - or hyperactivity - really exist.
Back in 1970 the Committee on Government Operations of the U.S. House of Representatives studied the use of behaviour modification drugs on children. At that time around 200,000 to 300,000 children a year in the U.S. were being given these drugs and the point was then made that hyperactivity is considered a disease because it makes it difficult for schools to be run `like maximum security prisons, for the comfort and the convenience of the teachers and administrators who work in them...'.
Since then the only thing that has changed is that the popularity of Ritalin has continued to rise and rise and rise inexorably.
Prescribing Ritalin is, in my view, authorized child abuse on a massive, global scale.
But it is clear that the prescribing of powerful mind altering drugs for small children is big business.
In the US the use of antidepressants and stimulants among toddlers aged between two and four tripled between 1991 and 1995. The period between birth and four years of age is a time of great change in the human body. Most importantly it is a time when the brain is maturing. Heaven knows what effect these drugs have on those tiny developing brains.
Ritalin is now widely prescribed for toddlers. So are many other antidepressants, stimulants and other powerful drugs. Remember: typical symptoms of this alleged disease include `restlessness' and `inattentiveness'.
I am delighted that my protests and complaints about these absurd and obscene prescribing habits have drawn a number of vicious complaints from doctors.
In my view every doctor who prescribes such drugs for children with alleged ADHD should be defrocked, given a good thrashing with genetically engineered stinging nettles and forced to emigrate to the USA.
The Truth Behind Brain Scans
Study's failure to report on the crucial comparison between unmedicated and medicated ADHD subjects.
©2004 The Institute of Mind and Behavior, Inc.
An Update on ADHD Neuroimaging Research
Since the publication of a critical review on ADHD neuroimaging in a past issue of this journal (Leo and Cohen, 2003), several relevant studies have appeared, including one study that had a subgroup of unmedicated ADHD children (Sowell, Thompson, Welcome, Henkenius, Toga, and Peterson, 2003). In this update to our earlier review we comment on this last study's failure to report on the crucial comparison between unmedicated and medicated ADHD subjects. The issue of prior medication exposure in ADHD subjects constitutes a serious confound in this body of research, and still continues to be dismissed and willfully obscured by researchers in this field.
In a previous issue of this journal, we reviewed the attention-deficit/hyperactivity disorder (ADHD) neuroimaging research (Leo and Cohen, 2003). We pointed out the difficulty in drawing meaningful conclusions from this body of research because of a significant confounding variable: prior or current medication use by the ADHD patients. As we documented, in the large majority of ADHD neuroimaging studies, researchers have compared brain scans from normal control subjects to brain scans from medicated ADHD subjects. This makes it difficult to know if between-group differences reported by researchers might result from an idiopathic organic brain defect - as implied or stated in most studies - or from brain changes resulting from prior drug use by the subjects diagnosed with ADHD. Critics over the past decade pointed out that prior medication use constitutes an important potential confounding variable that limits the validity of these studies, but most researchers have continued to use medicated patients in their studies, sometimes without acknowledgement of the issue.
Despite the dismissal of the issue of prior medication use in published reports, the issue must have been quite sensitive in the minds of researchers nonetheless. Indeed, immediately upon the publication of a large study (n=291) by Castellanos, Lee, Sharp, Jeffries, Greenstein and Clasen (2002), that included a subset of ADHD patients who had never taken medication, the sponsor of that study, the National Institute of Mental Health (NIMH), released a press briefing declaring: "Brain Shrinkage in ADHD Not Caused by Medications" (NIMH, 2002). This announcement rested on results of a subgroup comparison between 103 medicated and 49 unmedicated ADHD subjects, which found that, just like their medicated peers, unmedicated youths also demonstrated statistically significant smaller brain volumes than normal control subjects. There was no mention in this study about the specifics of the medication history of the medicated children. In our earlier review (Leo and Cohen, 2003) we discussed several problems with the Castellanos et al. study. The following is a brief summary of that discussion:
Since our review appeared, several ADHD neuroimaging studies have been published. Unfortunately, by failing to exercise appropriate control over the variable of prior medication, these studies perpetuate the confusion and uncertainty that, we argued, characterizes findings in this body of research. For example, Mostofsky, Cooper, Kates, Denckla, and Kaufmann (2002) had 12 ADHD subjects in their study, ten of whom had a prior history of medication.
MacMaster, Carrey, Sparkes, and Kusumakar (2003) entitled their study "Proton Spectroscopy in Medication-Free Pediatric Attention-Deficit/Hyperactivity Disorder," yet eight of their 9 ADHD subjects had a prior history of medication: three stopped taking their medication 48 hours before the scan, and five stopped taking it one to 3 weeks before the scan. Taking medicated ADHD subjects off their medication before the imaging and then classifying them as "medication-free" is unsound. We cannot emphasize enough that a study wishing to reach conclusions about the neuropathology of ADHD needs to recruit a control group of medication-naïve subjects, especially given the well-documented neuropathological effects of psychotropic medication (Leo and Cohen, 2003).
In our view, the most significant recent report was of a relatively large study involving 27 ADHD and 46 normal control subjects, conducted by the Laboratory of Neuroimaging at the University of California, Los Angeles (LONI). Sowell, Thompson, Welcome, Henkenius, Toga, and Peterson (2003) reported that the ADHD children had smaller frontal lobes compared to normal controls subjects, but overall the ADHD subjects had more cortical grey matter. In our view, this study's significance derives not necessarily from this result, but - as with several previous ADHD neuroimaging studies - from important comparisons that researchers could have made, but did not.
As in the Castellanos et al. (2002) study, some of the ADHD subjects in the Sowell et al. (2003) study were apparently medication-naïve. We say "apparently" because specific descriptions were not provided: "15 of the 27 patients were taking stimulant medication at the time of imaging" (p. 1705). It is unclear how to categorize the remaining 12 patients. Did they have a history of medication and then stop taking it for 48 hours, or some other arbitrary time period, before imaging? It surprises us that a study published in Lancet could be so vague about one of the most important variables in the study.
Conclusions based on a comparison of normal control subjects to medication- naïve ADHD subjects would be very different than conclusions based on a comparison of control subjects to ADHD subjects with varying durations of medication exposure and with some patients undergoing abrupt withdrawal.
The issue becomes considerably more muddled and confusing due to a brief discussion of the potential role of stimulant medication on their findings at the end of Sowell et al.'s (2003) paper. The authors first appropriately acknowledged that, since 55% of their ADHD children were taking stimulants, "the effects of stimulant drugs could have confounded our findings of abnormal brain morphology in children with [ADHD]" (p. 1705). The simplest way to properly evaluate this confounding effect would have been to compare the 15 medicated ADHD children with the 12 unmedicated ADHD children. However, Sowell et al. consciously chose to not make that comparison: "We did not directly compare brain morphology across groups of patients on and off drugs because the sample size was considerably compromised when taking lifetime history of stimulant drugs into account" (p. 1705).
The authors further explain that this comparison, between unmedicated and medicated ADHD children, is not needed because a prior study by Castellanos et al. (2002) suggested that medications do not affect brain size [a contention which ignores the problems we identified in our lengthy review].
Sowell et al.'s methodological choice, and its justification, is both unconvincing and puzzling. First, although one can obviously sympathize with their judgment that "taking lifetime history of stimulant drugs into account" compromised their sample size, this judgment ignores that for thirty years ADHD neuroimaging researchers have deemed it perfectly acceptable to compare ADHD subjects and normal controls regardless of medication history (Leo and Cohen, 2003). Indeed, virtually all the studies Sowell et al. cite to contextualize their study and interpret their results exemplify this practice. Thus, it is difficult to see why Sowell et al. would feel that they should not compare medicated and unmedicated ADHD subjects. Clearly, just as they acknowledged limitations to their main study results, Sowell et al. could obviously have reported the results of the more specific comparison with an acknowledgement of appropriate limitations.
Second, Sowell et al. cite Castellanos et al. to support the methodological choice of not comparing medicated and unmedicated ADHD subjects. But, Castellanos et al. made that very comparison regardless of medication history!
Third, and most important, Sowell et al.'s data appear directly relevant to either support or refute the conclusions that Castellanos et al. (2002) drew from their comparison. Put another way, the results of Castellanos et al.'s comparison of brain volumes of medicated and unmedicated ADHD children were deemed worthy of a major press release by the NIMH concerning stimulant drugs' effects on developing brains, yet the same comparison in the Sowell et al. study is considered insignificant and not even reportable.1 For the above reasons, we suspect that the comparison of medicated with unmedicated ADHD subjects in Sowell et al.'s study might have produced results that would have diluted the findings that Sowell et al. chose to emphasize instead.
Following the publication of the Sowell et al. (2003) study, the media paid significant attention to it. In one interview, the study's last author stated: "The next phase of the work will be to see whether the magnitude of the abnormalities in these individuals might influence the course of the condition, their response to medication, and which medications different children respond to" (cited in Edelson, 2003, italics added). We assume that this next phase of investigation will involve a comparison of medicated with unmedicated children - but how this will differ from their previous study, or from most ADHD neuroimaging studies, remains completely unclear.
Scientific literature, professional publications and the media. In several discussions with imaging researchers since our review appeared, we have heard repeatedly that the media is the culprit when it comes to "reading too much" into a study. However, examples of oversimplification abound within the professional and scientific literature. For instance, in a recent article about the Castellanos et al. study on the Internet site Medscape, excerpted from the 2004 Child and Adolescent Psychiatry Meeting, the author declares: "On an anatomic level, total cerebral volume is approximately 3% smaller in youth with ADHD" (Gutman, 2004). It is hard to conceive of a more fitting example of a complex study being presented in an overly simplistic manner.
Gutman discusses no problems or limitations of the Castellanos study; she simply asserts to a huge audience of clinicians that it is a fact that ADHD children have smaller brains. The website includes a test that clinicians can take after reading the article if they wish to earn continuing medical education credits, and one of the questions reads: "When looking at ADHD and cerebral volume in children, researchers have found . . . " - and the "correct" answer is given as: "Total cerebral volume is approximately 3% smaller in youth with ADHD." It is deeply troubling to us that a professional society can propagate such a statement based on a single study with major limitations. Ruling out the effects of psychotropic medication is merely one of the tasks confronting researchers conducting neuroimaging research with ADHD patients. Even if the field accomplishes this task, several other important tasks remain. One of these will involve trying to make sense of findings of brain abnormalities or differences among some individuals diagnosed with ADHD.
And in this task, a few observations will deserve serious consideration, though they are very rarely discussed in the ADHD neuroimaging literature. One exception is an article by Rubia (2002), from which we find it useful to quote at some length, despite our disagreement with the author's characterization of ADHD as a "disorder": Neurodevelopmental psychiatric disorders, as opposed to neurodegenerative disorders, are known to be dynamic and are very likely to be even more dynamic than currently assumed . . . . Only about a third of children with ADHD still meet criteria for ADHD in adulthood . . . . A highly dynamic interplay between nature and nurture is likely and the causalities between them may be bi-directional rather than unidirectional.
Until today, it has been erroneously assumed that biological correlates of abnormal behavior are necessarily the cause of brain "basis" of abnormal behavior. Recent reports from neuroscience point towards a much more plastic concept of the brain-behavior relationship with bi-directional causalities . . . . Use-dependent functional and structural reorganization in sensory cortices, for example, has been observed in skilled subjects, pianists and musicians.
Post-traumatic stress disorder in war veterans and victims of child abuse causes smaller hippocampi and abnormal amygdala activation. Amputation studies show that function is necessary for structure to develop. These examples show that behavior, experience, and function can alter and determine brain structure. This has fundamental implications especially for psychiatric research, given that psychiatric disorders are characterized and defined by deviation from normal functioning. (Rubia, 2002, p. 49)
In sum, brain differences (or "abnormalities") may be related to the state rather than the trait of the syndrome or behavior in question, and this fundamental issue will require immense creativity and rigor to tackle. By comparison, the issue of prior medication is extremely uncomplicated: to rule out effects of medication exposure on brain volume, one simply needs to compare a group of ordinary medicated ADHD patients with a control group of ordinary, age- and weight-matched unmedicated ADHD patients. A single study of this type with no more than 60 subjects could practically settle the question. Unfortunately, given how the ADHD neuroimaging field has so far treated this simple issue, it is doubtful to expect that researchers in this field will make progress on the more significant scientific challenge ahead.
Developmental trajectories of brain volume abnormalities in children and adolescents with attention-deficit hyperactivity disorder. Journal of the American Medical Association, 288, 1740-1748.
Edelson, E. (2003). Better brain images could lead to better ADHD treatment. Parent Center News Gutman, A. (2004). Introduction to new research: Navigating complex treatment options for ADHD (March 2004). Medscape from WebMD.
464787 Leo, J.L., and Cohen, D. (2003). Broken brains or flawed studies? A critical review of ADHD neuroimaging studies. The Journal of Mind and Behavior, 24, 29-56.
MacMaster, F.P., Carrey, N., Sparkes, S., and Kusumakar, V. (2003). Proton spectroscopy in medication- free pediatric attention-deficit/hyperactivity disorder. Biological Psychiatry, 53, 184-187.
Mostofsky, S.H., Cooper, K.L., Kates, W.R., Denckla, M.B., and Kaufmann, W.E. (2002). Smaller prefrontal and premotor volumes in boys with attention-deficit/hyperactivity disorder.
Biological Psychiatry, 52, 785-794. NIMH. (2002). Brain shrinkage in ADHD not caused by medications.
Rubia, K. (2002). The dynamic approach to neurodevelopmental psychiatric disorders: Use of fMRI combined with neuropsychology to elucidate the dynamics of psychiatric disorders, exemplified in ADHD and schizophrenia. Behavioral Brain Research, 130, 47-56.
Sowell, E.R., Thompson, P.M., Welcome, S.E., Henkenius, A.L., Toga, A.W., and Peterson, B.S. (2003). Cortical abnormalities in children and adolescents with attention-deficit hyperactivity disorder. The Lancet, 362, 1699-1707.
Request for reprints should be sent to Jonathan Leo, Ph.D., Department of Anatomy, Lake Erie College of Osteopathic Medicine Bradenton, 5000 Lakewood Ranch Blvd, Bradenton, Florida 34211. Jonathan Leo may be reached at firstname.lastname@example.org ; David Cohen may be reached at David.Cohen@fiu.edu
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