ADHD Medications Improve Decision-Making, But Are They Being Over Used?

The latest studies show that while attention deficit/hyperactivity disorder (ADHD) drugs can be effective, some kids may be wrongly diagnosed — and therefore inappropriately treated — with the stimulant medications.

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The latest studies show that while attention deficit/hyperactivity disorder (ADHD) drugs can be effective, some kids may be wrongly diagnosed — and therefore inappropriately treated — with the stimulant medications.

ADHD is a developmental condition that makes it difficult for children who are affected to concentrate, keeping them fidgety, prone to daydreaming and impulsive behavior, all of which is correlated with problems in school and can lead to delinquent or even criminal behavior. But a large study published in the New England Journal of Medicine involving nearly 26,000 Swedish people with the disorder showed that medications such as Ritalin and Adderall can mitigate this effect; men taking the medications showed a 32% reduction in crime rates while they were taking the drugs compared to periods when they were not, and women showed a 41% lower rate of criminality. Another study of American and British children with ADH, published in the Journal of Medical Ethics, may hint at why: the youngsters in the trial believed the drugs improved their ability to make good choices.

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As beneficial as the medications can be, however, other research shows that they may be over-used, as awareness of ADHD has increased and as some seek quick-fix solutions in a pill to treat children’s challenging behaviors. In a recent study appearing in the journal Pediatrics, an analysis of prescriptions for ADHD shows that the youngest children in a class are 50% more likely to get a diagnosis, raising the concern that these children may simply be less mature than their older counterparts, and not experiencing ADHD at all.

The new research adds to the ongoing debate over the use of stimulant medications to treat ADHD, which has ballooned along with diagnosis of the condition.  Around 9.5% of children from four to seventeen have ever been diagnosed with ADHD, according to a 2010 study from the CDC.  And as of 2008, 5% of six to twelve year olds in the U.S. were taking stimulant medication to treat it, a percentage that has continued to rise since the 1980s.  Indeed, since 2007, the number of prescriptions written for youth aged from 10 to 19 rose 26%, to 21 million annually.

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Critics have long feared that stimulants simply drug children into submission, turning youngsters into compliant robots with no will to engage in defiant behavior. But few studies have documented the effect of the drugs from the perspective of the children taking them.

So that’s what Ilina Singh of King’s College London and her colleagues did.  In the Voices on Identity, Childhood, Ethics and Stimulants (VOICES) study, they interviewed 151 American and British children aged 9 to 14 who were taking medication for ADHD between 2008 and 2010. Their conclusion? “On balance, children report that stimulant drugs improve their capacity for moral agency,” Singh writes, explaining that most felt the drugs allowed them to make better choices.  As an American 11-year-old girl told the researchers, “With medication, it’s not that you’re a different person; you’re still the same person, but you just act a little better.  Medication will help you control yourself.”

A ten-year-old American boy put it this way: “Medication slows my brain down and makes good ideas stay longer.” Another 10-year-old boy described his ADHD as a “blocker” that prevented him from going the right way. “[The medicine] opens the blocker so you can go [the right] way.  But you still have the choice of going the wrong way,” he said.

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Around 8% of the children surveyed did have problems with their medication— but these were related to side effects, not to a sense that the drug made them comply when they wanted to resist or otherwise change their personality. “I just felt suckish all the time,” one British student said, while another reported, “My friends said I wasn’t myself; I didn’t laugh.”

Of course, the idea that a drug that works as a stimulant could help people make better choices by improving their impulse control seems counter-intuitive. But with ADHD, however, as the study participants report, the medications may give the students time to deliberate, which typically leads to more thoughtful— and therefore, typically better— decisions.  That, in turn, can open up more opportunities for success in relationships and careers.

The Swedish study on criminal behavior adds support to this perspective.  ADHD has long been linked with an elevated risk for crime and for drug addiction, which makes sense for a condition that can interfere with education and create impulsive, reckless and ill-considered behavior.  By helping people with ADHD to think and assess their actions, the drugs seem to help them avoid questionable and even criminal behavior.

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But since ADHD medication can be addictive as well as misused, its ultimate risks and benefits are still controversial. In the Swedish study, the researchers did not find any long term negative effects of the medication.  If the participants did not remain on the drugs, they increased their risk of crime regardless of their prior medication history. “We found associations suggesting the possibility of a protective effect for use of ADHD medication on concurrent rates of all types of criminality and no significant long-term reduction in the crime rate after termination of medication,” the authors write.

Taken together, the two studies support the use of medication for ADHD patients, particularly for those who have problems with impulse control. In these cases, appropriate use of the drugs not only improves their quality of life but lowers their risk of criminal behavior as well.

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That doesn’t mean that everyone benefits from treatment, however. The Pediatrics study suggests that caution in diagnosing children, particularly younger ones, is important. In in that analysis, scientists examined records for some 12,000 youth born between 1994 and 1996 in Iceland. Not only were children in the youngest third of their class 50% more likely to receive an ADHD diagnosis, but they also had nearly double the risk of receiving a very low test score in math and language arts at age nine.  By age 12, the same trends among the youngest were still measurable but less severe:  the risk of scoring low in both subjects was 60%.  The data correlate with earlier studies that found that students with the latest birthdays in their class are less likely to get into prestigious colleges or to excel at sports.

The fact that the youngest children were more likely to be diagnosed and treated for ADHD than older ones suggests that not all of their disruptive behaviors may be traced to ADHD. As the researchers write, “Educators and healthcare professionals should take relative age and gender into account when evaluating children’s performance in school and other criteria for ADHD diagnosis.  These findings can inform the decision of parents with children born close to birthday cutoffs for school entry.”

For this group of children, postponing decisions about ADHD treatment makes sense, until teachers, parents and doctors can make a more informed decision about whether behaviors are the result of immaturity or ADHD.

The series of studies continue to add to our knowledge about ADHD, and how best to treat symptoms to help students reach their full potential, both academically and socially. But they also highlight the complexity of the condition and the role of environmental factors, not just biology.  For those who definitely have the disorder and who do not have intolerable side effects from medication, the results are increasingly clear:  stimulant medications don’t turn kids into zombies, but they may prevent crime— and not by suppressing choice, but by allowing freedom from destructive impulses.  These drugs are far from a cure-all, but they are also not mere pacifiers.