Better Environments And Less Drugs For Kids With ADHD?
A provocative essay published in the New York Times suggests that Ritalin (and other stimulant drugs) is essentially ineffective for treating ADHD when one looks at kids’ behavior over time – and that what’s missing (and what’s needed) is a much stronger focus on the psychosocial environment and not pharmaceuticals.
There are two parts to this argument that I agree with and wish to expand on.
First, even though ADHD is believed to be highly heritable (based primarily on twin studies), this does not mean that kids with ADHD will not respond to changes in their environment – or that genetic or biological treatment is the only form of effective treatment. In fact, much of the most salient research on kids’ behavior problems conducted over the last decade has shown that “risk genes” are in fact highly responsive to the environment. Some studies have shown that psychosocial interventions work especially well for kids who have a “risk gene” (or more technically in these studies an allelic combination that confers the highest risk for a given disorder – such as two copies of the short arm of the serotonin transporter gene when examining depression). While this work has not been applied yet to ADHD it is becoming clear that genes and environment come together in specific and sometimes counterintuitive ways – and that kids who are at high risk genetically may also be highly likely to benefit from positive changes in their environment.
Second, perhaps the most important contribution of the essay is to point out that drug treatments for kids need to be evaluated over time and sometimes over years in order to understand how effective they really are. Through this lens I think it would be irresponsible to say that drug treatments alone produce the most beneficial developmental outcomes for kids with ADHD – modifying and structuring their environment is critically important.
While I appreciate the strong sentiment expressed in the essay, I do take a more balanced view in that I understand that some kids respond well to drugs such as Ritalin. But I see drug treatments for kids as a last step in a complex process that should start with, and focus heavily on, discovering what changes can be made in the psychosocial environment. This process ideally involves a partnership between clinicians, parents, and teachers. Once that is in place and executed over time, rational decisions can be made about the added value of considering drug treatment. In some cases introducing a drug into the mix may in fact make all the environmental changes that much more effective.
The bottom line is that it’s become necessary to champion the environment in an era of science and treatment that is infatuated with DNA and biology. Virtually all behavioral traits and disorders not only reflect genetic and environmental influences – much of the cutting edge research shows how the expression of genes are often dependent on the quality of the environment. And in the case of ADHD, it’s very important to reorient thinking about treatment to be sure that the essential and powerful role of environmental change is not forgotten.