There is consensus in the medical community that the long term brain effects of the medications now being used to treat ADHD is not well documented or well understood. Considering the fact that as of 2016, 6.1 million children and adolescents were diagnosed with ADHD and about 62% receive medication for it, I would say we have a major public health issue. There are some non-stimulants that are being prescribed as well (which we know even less about), but for here we will be focusing on the more commonly prescribed stimulants.
Ritalin was approved by the FDA in the 1950s for treatment of “hyperactivity” but was not really prescribed frequently until the 1960s. It was not being prescribed to children regularly until 1991, when it really seemed to explode. Adderall was not approved by the FDA until 1996. One other consideration is the criteria that was required for approval of these drugs. In my opinion, the requirements for approval were not thorough enough, and sample sizes were not large enough considering the fact that millions of children, adolescents, and adults are now using these drugs. Bourgeois, Mandi, & Kim, 2014 state:
- There were a total of 32 clinical trials done for the approval of 20 different drugs with each averaging only 75 study participants (Bourgeois et al., 2014).
- Eleven of the drugs were approved after less than 100 participants were studied
- Fourteen drugs were approved after less than 300 participants were studied
- The median trial length prior to FDA drug approval was 4 weeks with five of the approved drugs studied for even less time than that.
- Six drugs were approved with requests to provide additional data on safety, effectiveness, and optimal usage after the drug was put on the market, called a post-marketing trial. Only two out of the six provided post-marketing trial data.
- Them minimum age for most trials was 6 years old (only 3 drug studies had a minimum age of 3 years old — Adderall, Biphetamine, and Dexedrine).
- Only 5 studies out of the 32 (representing 3 drugs) were done to study the safety.
- Only 8 out of the 32 have been published in medical literature (which would put them under the scrutiny of other doctors/scientists).
“Clinical trials conducted for the approval of many ADHD drugs have not been designed to assess rare adverse events or long-term safety and efficacy.” – Bourgeois, Mandi, & Kim, 2014
For more disappointing information about how these drugs got onto the market, I encourage you to read this study.
Now that we have discussed the prevalence of ADHD, the shocking reality of how these drugs are approved, and the utter lack of long term safety and efficacy data, let’s look at what we are now learning about the long term effects of stimulants.
According to Bottelier et al. (2017), early stimulant medications (treatment started at less than 16 years of age) has long lasting effects on the human brain and behavior, possibly indicating fundamental changes in the dopamine system. These effects are only fully expressed when the system reaches maturation (when the person reaches adulthood) (Bottelier et al., 2017). The dopamine system as well as the GABA neurotransmitter system are still developing during childhood and adolescence. Another study by Luccasen et al (2017) demonstrates that early stimulant exposure lowers baseline GABA neurotransmitter levels in adulthood. Similar to the study by Bottelier et al., the effects on the GABA system are only seen with the full maturation of adulthood.
Should Teachers Be Recommending Evaluations?
“In more than one-half of ADHD cases, it is the educator who requests that a child be assessed for ADHD.” – Ford-Jones, Paediatrics & Child Health Journal, 2015
Even I was surprised when I learned that ADHD medications are known to cause psychotic symptoms in children such as hallucinations, delusions, confused or disturbed thoughts, and lack of self-awareness. I wonder how many teachers have a real understanding of these drugs when they make a suggestion to parents or school psychologists that a child should be evaluated for ADHD. Elementary school teachers usually don’t have any medical background. Schools do not require staff to be educated on ADHD vs appropriate age maturity and behavior, the history of ADHD medications, potential adverse medication side effects and events, and the negative long term effects on neurological function.
What they do know is that once those children are on medication they are easier to handle, they pay attention, they sit down when asked, grades and test scores improve; and when test scores improve, so does school funding. I am not trying to villainize teachers here. I am merely pointing out that educators need to be educated. If teachers are allowed to recommend evaluation, shouldn’t they know a bit about the history of these drugs, and how the drugs may affect the child’s brain development long term? Don’t you think they should be able to ask parents what they do when they get home from school? More sitting, perhaps? Too much screen time? High carbohydrate diet? If a teacher can recommend evaluation for ADHD, should they be able to recommend evaluation by a nutritionist for childhood obesity? Childhood obesity leads to far more dangers than ADHD (although I don’t think obesity harms test scores). 56
There is significant concern for overdiagnosis followed by unnecessarily medicating children, and about 20% of the children that take medication for ADHD are misdiagnosed (Elder, 2010; Ford-Jones, 2015).
If educators were educated on all of these factors we have discussed, maybe they would think twice before recommending evaluation for a “hyperactive” child. My hope is that educating the educators would lead to a significant drop in the ADHD diagnosis rate.
If you have any questions or comments, or if you feel it is necessary to correct something that you read here, feel free to do so below. I appreciate any and all of your contributions. If you think this post could help a friend, share it. You just might change their life.
Related articles that I am working on and will post at a later date:
Top 10 Natural Therapies for ADHD (Subscribe to be notified of this post and others)
Cannabidiol (CBD Oil) for ADHD (Subscribe to be notified of this post and others)
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Bottelier, M., Bouziane, C., Bron, E., Klein, S., Kooij, J., Reneman, L., & Rombouts, S. (2017). Long-term effects of stimulant exposure on cerebral blood flow response to methylphenidate and behavior in attention-deficit hyperactivity disorder. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5880865/
Bourgeois, F., Mandi, K., & Kim, J. (2014). Premarket Safety and Efficacy Studies for ADHD Medications in Children. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4090185/
Centers for Disease Control and Prevention. (2018). Retrieved from https://www.cdc.gov/ncbddd/adhd/features/national-prevalence-adhd-and-treatment.html
Elder, T. (2010). The importance of relative standards in ADHD diagnoses: Evidence based on exact birth dates. Retrieved from https://msu.edu/~telder/2010-JHE.pdf
Ford-Jones, P. (2015). Misdiagnosis of attention deficit hyperactivity disorder: ‘Normal behaviour’ and relative maturity. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4443828/
Lucassen, P., Puts, N., Schrantee, A., Solleveld, M., & Reneman, L. (2017). Age-dependent, lasting effects of methylphenidate on the GABAergic system of ADHD patients. Retrieved from https://www.sciencedirect.com/science/article/pii/S2213158217301365