An increasing number of behavioral genetic studies of ADHD consistently show it to have a large genetic contribution (averaging 70 percent to 80 percent) and an extraordinarily modest contribution of shared environmental factors (averaging 5 percent to 10 percent). Coupled with recent neuroimaging studies localizing ADHD to the prefrontal lobes and striatum, one has even further justification for at least considering medication treatments for ADHD.
The totality of the evidence on ADHD, then, may justify considering stimulant medications as a first-line treatment for many (though not all) cases of ADHD. This may relegate psychosocial treatments to the adjunctive status once held by stimulant medication. Apart from any conceptually driven shift in treatment priorities, such a reordering of those priorities may already be occurring, for a more pragmatic reason: the disappointing results of research programs studying nearly ideal multimodal treatment programs have begun to be reported at scientific meetings. While one is typically obliged to still chant that "medication should never be used alone," continued findings along the current direction in treatment research for ADHD may serve to muffle the chant.
Such findings would lift some of the guilt faced by practitioners, particularly in rural settings with little or no access to multimodal care, concerning their predominant or even singular use of stimulant medication for their patients with ADHD. They could at least know that the one treatment they do have available is turning out to be the most effective for the majority of ADHD children (and adults) under their care.
Ritalin and the Media Moreover, such a shift in treatment priorities also reveals the superficial nature with which most of the popular media have approached the
methylphenidate(Drug information on methylphenidate) (Ritalin) story over the past year. Such accounts rarely reflect the true complexities inherent in the rise in stimulant use. Instead, many writers seemingly prefer to cast the story as a sporting event, creating scandal where little or none likely exists, sensationalizing the presentation in true tabloid fashion.
The work of antimedication prophets- typically from outside the mainstream of legitimate scientific research- has appeared alongside that of the far more highly credentialed scientists who have maintained that, within our science at least, there exists little or no "Ritalin controversy." Though this format may have created the facade of balanced journalism, it grossly misrepresented the true status of the clinical scientific literature, reflecting a serious scientific illiteracy on the part of some journalists. The stimulant medications have demonstrated their efficacy in several hundred well-controlled scientific studies, making them not only one of the few success stories in child psychiatry this century but the best-studied of any psychiatric (and other) medication prescribed for children.
Thus, from the standpoint of both the treatment efficacy literature and the potentially shifting reconceptualization of ADHD noted earlier, a rise in medication use for ADHD would not only be expected, but justifiable. If 5 percent to 7 percent of the childhood population (Szatmari) has ADHD and stimulant medications are proving to be our most effective management methods, then reports that 1 percent to 2 percent of school-age children are taking stimulant medications would not, by itself, be cause for scandal. From a public health perspective, one might say that the real disgrace arises in the untreated percentage, for it is suggested that the most effective tools of management for the disorder are not being used by the majority of those afflicted with it.
Recent Ritalin 'Shortage' Many stories simply fail to place the rise in stimulant use in historical context and to explore the topic with a sense of proportion, as journalist James Fallows so often criticizes his colleagues for doing (e.g., his
Breaking The News: How the Media Are Undermining American Democracy, recently published by Pantheon Books). Like "stenographers with amnesia," many of these reports fail to note that their own periodicals or television programs reported a mere year or so earlier that the scandal then was the impending shortage of Ritalin for needy and disabled ADHD children. And nearly all failed to see the adversarial relationship between the Drug Enforcement Agency and CH.A.D.D. (Children and Adults with Attention-Deficit Disorder), the largest advocacy and support association for ADHD involved in both of these stories.
Practitioners should realize that the scientific and theoretical literature on ADHD is changing rapidly, amassing large amounts of published research at a striking pace. Staying abreast of that literature is critical- through newsletters, periodic workshop attendance, national conferences, abstract services or journal subscriptions. The changing world view of ADHD and its treatment have significant clinical and social implications deserving of not only scientific but wider public debate as well.
If research increasingly points to ADHD as a predominantly inherited disorder of human self-regulation, a story of great social import should be told. Even more widespread, however, should be the findings that genetics makes a disproportionately large contribution to the variation in self-control observed in the population. But the issues raised therein cannot get the public attention or debate they deserve if much of the popular media persist in putting sizzle over substance, petulance over proportion and controversy over context.
