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Dr. Hallowell’s Response to NY Times Piece “Ritalin Gone Wrong.”

Regarding the opinion piece “Ritalin Gone Wrong” written by Alan Sroufe, Ph.D., (NY Times, Jan. 29, 2012): As is usually the case when the use of stimulant medications like Ritalin makes it into mainstream media, the piece pushed emotional hot-buttons in a way that would scare the daylights out of uninformed readers and lead them to avoid ever using such medications or allowing their children to, thereby giving up on a class of medications with enormous potential benefits.
Let me offer a different point of view. I’m an M.D., a child and adult psychiatrist who’s been treating children who have what we now call ADHD for over 30 years. I was on the Harvard Medical School faculty for 20 years, and I still see patients in my offices in Sudbury, MA, and New York City every day. I have both ADHD and dyslexia myself. I’ve co-written, with John Ratey, the best-selling books on the topic of ADHD. I know this condition, and its various treatments, inside and out.
While I wince at the inflammatory rhetoric of Dr. Sroufe’s article, I actually agree with much of what he had to say. It is with his scare tactics and wrong-headed assumptions that I take issue. Let me quote and respond to several paragraphs from his article:

“First, there will never be a single solution for all children with learning and behavior problems. While some smaller number may benefit from short-term drug treatment, large-scale, long-term treatment for millions of children is not the answer.”

Who said there would be a single solution? No enlightened clinician offers medication as the single solution. We offer it as one tool that can help, but always as part of a comprehensive treatment plan which also includes other key elements like education of parent, child, and teacher; lifestyle modification, including sleep, diet, exercise, meditation and positive human interactions; coaching on how to better organize life; and ongoing follow up to monitor progress and offer encouragement and various specific tips on managing life with ADHD.
And what Dr. Sroufe cites as “some smaller number” is about 80% of individuals with ADHD who try medication. When these medications work, they do not solve the problem, any more than eyeglasses solve the problem of myopia. But they sure do help!

“Second, the large-scale medication of children feeds into a societal view that all of life’s problems can be solved with a pill and gives millions of children the impression that there is something inherently defective in them.”

It is a statement cited so endlessly as to become an accepted truth that we live in a society that believes all of life’s problems can be solved with a pill. But have you ever met anyone who actually does believe that? I haven’t. Furthermore, 19 out of 20 people who come to me for help for themselves or their child adamantly oppose the use of medication. Only when they fully understand the medical facts do many of them change their minds. Far being predisposed to the use of medication, the people who come to see me are predisposed in precisely the opposite direction.

Furthermore, no enlightened clinician prescribes the medication and leaves it at that, allowing the parent and child to imagine they have “something inherently defective in them.” I go to great lengths not only to present the medical facts but also to create a framework of understanding that describes ADHD in strength-based terms.  I tell the child that he is lucky in that he has a race car for a brain, a Ferrari engine. I tell him he has the potential to grow into a champion. I tell him (assuming it is a he, but he could just as easily be a she) that with effort he can achieve greatness in his life, and then I tell him about the billionaires, CEO’s, Pulitzer Prize winners and professional athletes with ADHD I’ve treated over the years. But I also tell him he does face one major problem. While he has a race car for a brain, he has bicycle brakes. I tell him I am a brake specialist, and one of the many tools I can use to strengthen his brakes is medication. I remind him he will have to do much more than take the medication to strengthen his brakes, but, if we’re lucky, the medication will help him in that effort.

The child and parents leave my office full of hope. Far from feeling defective, the child feels like a champion in the making. Which he most certainly can be!

“Finally, the illusion that children’s behavior problems can be cured with drugs prevents us as a society from seeking the more complex solutions that will be necessary. Drugs get everyone — politicians, scientists, teachers and parents — off the hook. Everyone except the children, that is.”

Once again, Dr. Sroufe assumes the clinician, parent, and society at large all buy the notion that “children’s behavior problems can be cured with drugs,” and that such a belief gets us “off the hook,” as if we politicians, scientists, teachers, parents, and heaven knows who all else were so sweetly deluded and so uncaring that we welcome any excuse to get us out of doing the deep probing into the “complex solutions” one is left to presume only Dr. Sroufe and his exemplary colleagues can or will attempt.

No clinician worth his or her salt believes that all problems can be cured with drugs. But neither does a responsible clinician deny the good that medications can do. When people ask me, “Do you believe in Ritalin?” I reply that Ritalin is not a religious principle. Ritalin, like all medications, can be useful when used properly and dangerous when used improperly. Why is it so difficult for so many people to hold to that middle ground?

And yet difficult it is. Ritalin continues to be a political football, a hot-button issue almost on a par with abortion or capital punishment. One is pushed to be for it or against it, while the right and good position is to be for whatever will help a child lead a better life, as long as it is safe and it is legal.

Used properly, Ritalin is safe, safer than aspirin. And it is legal, albeit highly regulated. As to its long-term use, apply common sense. Use it as long as it is helpful and causes no side effects. That may be for a day, or it may be for many years.
Of course we need to address the complex issues that contribute to behavioral, emotional, and learning problems in children. I’ve written extensively about what I call “pseudo-ADHD,” children who look as if they had ADHD but in fact have an environmentally-induced syndrome caused by too much time spent on electronic connections and not enough time spent on human connections, i.e., family dinner, bedtime stories, walks in the park, playing outdoors with friends or relatives, time with pets, buddies, extended family, and other forms of non-electronic connection. Pseudo-ADHD is a real problem; the last thing a child with pseudo-ADHD needs is Ritalin.

But that is not to say that no child needs Ritalin, nor that those who prescribe it are dimwits hoodwinked by drug companies to medicate children who do not need it. Sure, some doctors over-medicate, while other doctors never medicate because they “don’t believe in ADHD” and “don’t believe in Ritalin.”

Above all, children need a loving, safe, and richly connected childhood. The long-term study that Dr. Sroufe cited in his opinion piece does indeed show that over time, medication becomes a less important force in a child’s improvement and that human connections become ever more powerful. It is good and heartening to know that human connection–i.e., love–works wonders over time. Love is our most powerful and under-prescribed “medication.” It’s free and infinite in supply, and doctors most definitely ought to prescribe it more!

But that is not to say, as Dr. Sroufe does, that Ritalin has “gone wrong.” We may go wrong in how we use it, when we over-prescribe it, or when we use it as a substitute for love, guidance, and the human connection.

But as long as we use it properly, it remains one of our most valuable–and tested–medications. Going all the way back to the first use of stimulants to treat what we now call ADHD in 1937, stimulants have served us well as one tool–not the tool–for helping children and adults learn how to strengthen the brakes of their race car brains and become the champions they can be.


11 Responses to “Dr. Hallowell’s Response to NY Times Piece “Ritalin Gone Wrong.””

  1. doriswoodruff says:

    Thank you for this explanation! As an adult who is married to an ADHD adult who has struggled for years I really understand the multifaceted problem and solutions that must be worked with and agree totally that LOVE always is the best medicine. I thank you for Abe and I both for your books, constant encouragement to explore possibilities and be our best in the circumstances. I know from personal experience with you how important it should be to understand the whole picture and not be sensational in the “only cure”.
    I personally have yet to find a psychiatrist in Dallas who truly “gets it” and we have to continually become more informed through your websites/books etc and researching on our own.
    My husband now teaches in Special Education…a new career for him at 62 and he LOVES it. He truly understands the needs of these children and appreciates their individual needs as well as strengths that many others do not see!
    MY LARGEST COMPLAINT: WHO is treating the majority of children we see locally being given Ritalin or many other drugs…..the Pediatric DOCTOR…usually NOT a psychiatrist, nor are most of them told they must explore family counseling with trained in adhd psychologists! Psychiatrists children or adult here don’t seem to get either that meds are not the only solution and most of them DO NOT utilize the psychologist.
    I honestly feel we know way more than any Doctor abe has seen here!!! Why on earth are PEDIATRICIANS being allowed to treat these kids? None of them seem to have valid training to deal with the special ed kids in general and adhd ones in particular much less help the parents. They are all prescribing meds without any other help usually.
    I know I am “preaching to the choir” when I say this to you but maybe someone who reads this blog it might help to realize how little doctors know without having the background Dr. Hallowell has and lifelong study on the subject.
    Keep up the good fight! We appreciate you so very much giving others hope!

  2. Mary says:

    Thank you, thank you & thank you again, for putting into words much of what I felt when I read this “opinion”. It bothered me so much that I haven’t been able to stop thinking about it.

    I’ve read many blatantly biased and just WRONG pieces on the subject of ADHD: the deniers and conspiracy theorists, etc… but always thought that anyone who knows ANYthing about the subject would be able to see right through …

    Somehow this was different. It was more subtle in the way it played on the fears so many have about the way they are raising their children, their doubts about their decision to use medication… what it says about them.

    People who I respect read it and identified because of their struggles to find the right medication, and also because frustration exists that there doesn’t seem to be as much attention payed to finding treatments that don’t involve prescription medications (which are increasingly difficult to find for some of us – a fact he made light of) or other alternatives whose cost doesn’t put them out of reach for most folks (not including sleep, diet and exercise of course).
    I didn’t understand how anyone could ignore everything else he said and not find it as damaging as I did.

    Anywho …. Thank you again! It was important to me that there be thoughtful, comprehensive responses to this ~
    Mary Graser

  3. abaker39 says:

    Thank you Dr Hallowell.

    After agonizing over the best thing to do for our son, it is hard to hear condemnation from the uninformed and willfully ignorant. To have someone who should know better add to the misinformation that is already out there is downright demoralizing.

  4. cpassmore says:

    Thank you Dr. Hallowell. I agree that the protocol for treating those with ADHD can benefit from medication but the additional treatment that you suggested should always be added to it. Unfortunately from my experience MOST doctors do not adhere to ANY of the suggestions that you recommend. In the northeast, I have seen too much proscribing of ritalin with nothing else and schools also just telling parents to get their child medicated like that is the only answer. NO modifications or coping skills are put in place unless a parent kicks and screams. So I felt this article was very much needed to allow parents to begin to question the medication only treatment plan that is so common.

  5. reldawn says:

    Dr. Hallowell, as a 34 year old adult with ADHD, i believe i have enough experience with positive results of proper medication to know how helpful it can be. I received both medication (Adderall) and therapy for many years, and I know how fulfilling it can be to finally “live up to your potential” when you started out believing that the potential your parents and teachers talked about didn’t really exist. For me, it has truly been a lifesaver, and i believe that Adderall, in part, has helped me to be a happy, productive adult, something i never would have believed possible when i was a teen.

    Unfortunately, as someone else mentioned, it seems that the percentage of clinicians that are “enlightened”, to use your phrasing, is disturbingly low. I can’t tell you how many cinicians i’ve encountered, due to geographical and PPO changes, that have happily prescribed me Adderall after little more than me saying “I have Add, and here’s what i’ve been taking with my last doctor”. No therapy requirement, no requests for proof or verification from prior doctors, just my descriptions which i could easily have gotten from books or the internet. Those are not the clinicians that i continued to see. I didn’t believe it would be in my best interest.

    I also have a family member whose child was diagnosed with ADHD. While i am not a qualified clinician, i do have some experience with the subject, and while this boy may or may not have ADHD, there are clearly other issues that are not being addressed, including obvious learning disabilities, lack of any rules or discipline in his household, addictions to video games and poor sleep habits. He occasionally goes to therapy, but does not seem to have been given any help with managing or organizing his home and school life, and from what i’ve been told, which may or may not be accurate, his mother was told it was okay to medicate him at her discretion. Incidentally, the medication has impaired his appetite so badly that he looks emaciated. Though this is an extreme example, and one where the blame is equally shared by the clinician and the parents, is serves to illustrate (to me, at least) how wrong things can go when this kind of medication is prescribed without proper follow-up and/or supervision.

    I have seen so many examples of cases like this, both more and less extreme, that i find it no wonder that articles such as the one you are responding to are being written. I wholeheartedly agree with your take on the tool that a medication such as Ritalin (or in my case, Adderall) can be, but unfortunately, not all clinicians are as “enlightened” as they should be. It is these clinicians that are creating the perceptions that need to be fought, that are over medicating and under supervising, that need to be addressed if the perceptions are to change. By their actions, they are perpetuating the belief that the first thing to try is medicating an unruly or troubled or struggling child, and hence, we end up with kids that should never have been medicated, or at least, not with Ritalin.

    In essence, the only thing i disagree with in you piece is your apparent optimism about clinicians and how many of them are like you in their ethics and methodology, versus how many seem to be out there just to get a quick fix for the child and a paycheck for themself. And please note, i mean no offense to any clinician to whom this does not apply – i have dealt with, in my opnion, both some of the best, and some of the worst, and the good ones can truly be life changing miracle workers. I just think it’s too bad that those wo aren’t can ruin so much for the rest.

  6. imiranda says:

    Thank you Dr. Hallowell and I have to add a thank you to Reldawn who make a comment that give me peace in my mind at last.
    I have ADD since I can remember in pre-K not able to listen to the teacher because I was in many places far away, I learned the vowels by the age of 6, but I was very created and artistic. When I grow up I was the star of the family and they all applause how good I was in ballet, singing, art and what a good imagination I had. However, no one in my family though of me to be an intelligent person and they never even bother to ask me if I want to go to college (that was not for me). Adding the fact that in my culture for a woman the priority was being a good house wife (you can tell English is my second language in my writing style) I am Puerto Rican. I have struggles so much wanting to go to college and learn, but it was so difficult, I cannot read one paragraph when I already been in more than 10 different thoughts and has gone through many different places. Memorization was not good at all, and to summarize I pass my MBA in probation, not because I did not dedicated time to my study but because it takes me so long do do my homework that by the time I was done was 5 am and I have to go to work. Now lets not forget that I cannot type without making mistakes, because always my letters go backwards just like I do it, in hand writing.
    After I found my self in so much desperation (and consider that for those who born in the 1960s ADD was resolve by a slap in your head)and not been able to figure out what was wrong with me I bought your book “Delivering from Distraction” I read it, auto analyse my self and find out that in deed I am an ADD person. I am glad I find out after reading the book, this gives me hope and understanding of the illness. I went to my doctor and he prescribe me Adreall. I start taking the medication but feeling guilty. I was not happy knowing that I was medicated, it makes me feel sick, not a healthy person. Also the doctor recommend me to use it only when I need it. I am working on my JD now, I am in my 2L and decided that the only way to do law school with my condition was by getting some help. The first half of the year I was doing terrible, but once I start taking the medication my improvement was unbelievable. However (and here is where the Thanks to your blog comes)I was refusing to continue taking the aderall. I always been a healthy person, don’t like prescriptions, eat as natural as I can, don’t smoke or drink successively and have a great health, I wanted to continue that way. So, today I went to my 1st session of Cognitive Therapy. I am glad to know that medications like aderall are successful and safe. When I read the comments and your blog makes me feel I am not the only person struggling with this condition. We want to be good and productive people, we just can’t by our self. And if I can work this in conjunction with other resources and be the best I can be,I am satisfied. I don’t think that propaganda that takes our only hopes and put it in a negative way should be. Yes, there is abuse in many things, but not everyone takes medication to abuse then, some of the have no other choice.
    Thanks so much for explaining and providing me with this information, I was feeling so guilty for taking Aderall, but thank you the most for being the angel watching for us in this labyrinth, guiding us the correct path.

  7. eggplant says:

    I was disappointed with the New York Times for publishing an article with such prejudice against using a medication that, along with parent involvement, school accomodations and behavioral therapy, changes lives. I am glad for Dr. Hallowell’s response. My two sons have ADHD. When the oldest one was in 5th grade, he came home in tears because he said, “I thought I was smart.” Parent/teacher conferences became teachers lecturing me on how my son should be doing better, didn’t apply himself, and read library books in class rather than paying attention. He started on medication, and here he is in 12th grade, taking a calculus class and preparing for college. Stimulant medication is one of the essential supports that has helped him be a success, and reach his goals. My youngest son’s teachers are so amazed with how he improves, not just in paying attention and school work, but also becomes more social, greeting teachers and students, remembering to say “thanks”, learning names, his reading improving by one grade level, when his stimulant dose goes up. It’s a dream come true for me. My brothers didn’t have the benefits of diagnoses and stimulants when they were in school. My oldest brother, diagnosed as an adult, was a chess champion in high school, graduated from high school with a C- average, although he put hours into homework every day. It is a shame to see so many kids struggling, because institutions such as the New York Times promote a societal bias against stimulant medicines.

  8. crocdoc says:

    This author proves that being a PhD doesn’t make you unbiased, only able to spin your bias as expertise. Even though you can’t “fix diabetes” with (only) insulin, that’s no reason to say that there is no need for insulin, or that it is used too much. And any doctor who just gives a patient an insulin pen and a glucose meter and thinks that’s all there is to treating diabetes is a really poor physician. I believe it all really leads back to the “since ADD isn’t really a disease, medication for it isn’t necessary” argument of pompous ‘experts’ or health practitioners who know much, much less than they think. Diet ALONE isn’t appropriate for all diabetics, nor is weight loss (alone), exercise (alone), glucose monitoring (alone), or education (without behavior change and all the rest.) As to the “ADD is just a fad diagnosis given too often” belief of equally unenlightened and pompous “authorities” or practitioners shows them to be poor diagnosticians as well as biased. FAILURE TO CONSIDER DIAGNOSES is what makes SO MANY DOCTORS poor at what they do. (Not to say that many doctor are equally poor and DO over-diagnose ADHD.) But if the point of the PhD’s long-winded error is to say Ritalin is wrong, he is clearly as qualified as lawyers or insurance company executives to actually make decisions involving patients, even if he scares too many while claiming to be an authority. Challenging this idiot directly as to his clinical experience and his last-century attitude is an absolute must if organized/ institutionalized ignorance of ADHD is ever to end. Accepting the reality of the problem and its treatment has incredible ramifications in dealing with addiction, criminal behavior as well as issues of poor workplace or academic performance, self-esteem, even marriage and family failure and unemployment. For PhD’s in ivory towers to claim to be experts (instead of simply admitting bias) and to be allowed an audience willing to believe in that expertise is what needs to be confronted and stopped, not the use of effective medication for a neurological illness, whose appropriate use can dramatically improve the performance and outlook of those with ADHD.

  9. Craig A. Knippenberg, LCSW, M.Div. says:

    Fifteen years ago, I did a lecture for a group of managed health care pediatricians. I was emphasizing the importance of a thorough family evaluation before prescribing medication when one of the docs said, “I only get 20 minutes to meet with a new parent who is asking me about medication for their child’s behavior. The mom is desperate for a solution. What do I do, write a prescription and hope she will seek additional counseling?” Until health care allows pediatricians to spend real time with their children and families, we will have an over use of medications.

  10. Craig A. Knippenberg, LCSW, M.Div. says:

    Dr. Hallowell’s response was right on when he agreed with the fact that family love and connection is the long- term need for all children. That’s very tough when you have a child with ADHD. The proper use of medication has allowed countless families to bond more effectively with their children when they are stripped of the daily conflicts and frustrations that arise from ADHD driven behavior.

  11. hello says:

    Thank you so much for this response. I wish that more people who actually understood this condition would articulate their views more often. For so many years, I felt “defective,” even when I was diagnosed and finally treated for my ADHD with stimulant drugs at the age of 17. A truly holistic approach does need to be taken, and more doctors need to realize how ADD/ADHD can negatively affect one’s self image. That being said though, drugs can be good. Without stimulant drugs, I never would have graduated with straight A’s in college and gotten into one of the country’s top law schools. It is only now, at the age of 23, that I’ve come to terms with the fact that my brain is faster than most people’s, and it’s not “defective,” just different.

    Thank you.

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