Another Open Letter to the Editor of the New York Times

Sent January 2, 2014. 

On December 29, 2013, the New York Times published another in its series of articles by Alan Schwarz arguing that medication is used excessively for treatment of ADHD. He cited a large research project sponsored by the U.S. National Institute of Mental Health twenty years ago which  compared medication treatment vs behavioral and vs combined medication/behavioral treatment of 7 to 9 year old children with ADHD over a 14 month period. Results of the study indicated that carefully managed medication was the most effective treatment for ADHD symptoms of those children over that time frame

Schwarz argued that this scientifically-controlled study oversold the benefits of medication treatment, distorted the debate over the most effective treatment, and failed to demonstrate adequately the longer term benefits of behavioral treatments for “teaching children, parents and teachers to create less distracting and more organized learning environments.”  He claimed that more recent studies have cast doubt on whether results of medication treatment last as long as those from behavioral therapy and offered brief quotes from several researchers involved in the NIMH study who shared thoughts about limitations of that research.

Unfortunately, this Schwarz article is seriously flawed in 3 important ways:

1)   The article seems to be based on an outdated understanding of ADHD. Current scientific understanding recognizes ADHD as a complex disorder involving developmental impairments of the brain’s cognitive management system, its executive functions.  These include chronic problems with activation and motivation, organizing and prioritizing tasks, sustaining effort for tasks, managing emotions, and utilizing working memory. Most of these problems, especially when experienced by older children or adults, are not improved adequately by behavioral treatments and are often, though not always, improved by carefully tailored medication treatment.

2)   It implies that creating “less distracting, more organized learning environments” would alleviate problems of ADHD. Impairments of this disorder certainly may be helped by environments that are well organized and not excessively distracting, but the essential impairments of ADHD are due to inherited problems in brain connectivity and brain chemistry; they are not caused by environmental distractions.

3)   It mentions that recent research studies “have also cast doubt on whether medication’s benefits last as long as those from (behavioral) therapy.”  Neither medication treatment nor behavioral therapy confers lasting remediation of ADHD symptoms any more than eyeglasses provide continuing remediation of vision problems after they are taken off.

It is unfortunate that this reputable newspaper continues to offer its readers information about ADHD which is so outdated, incomplete, and persistently biased as this series of articles by Alan Schwarz.

Thomas E. Brown, Ph.D.

Clinical Psychologist

Associate Director of Yale Clinic for Attention & Related Disorders

Dept. of Psychiatry

Yale University School of Medicine

www.DrThomasEBrown.com

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5 Responses to Another Open Letter to the Editor of the New York Times

  1. Adam Weiner says:

    I am 38 and in the process of self-diagnosis, in the hope that I’ll get around to seeing a specialist at some stage. My hyperfocused research leaves me with very little doubt that I qualify as a high potential ADHD-PI.

    It has been a powerful emotional experience to read certain testimonials by ADHD people – particularly with regard to the erosion of self-esteem in the face of being lazy, apathetic, irresponsible etc.

    An aspect of ADHD that I am now just begining to encounter and have also read about is the resistance people have to the reality of the condition.
    I have mentionned to a few people that I am becoming convinced that I am ADHD and have encountered a lot of dismissal. One very educated school-teacher (with degrees in anthropology and pedagogy) pointed to the fact that I have college-degrees as proof that I can’t possibly suffer from ADD. I pointed out that the obtention of my degrees was a nightmare of failures to meet deadlines and lack of revision for exams, invariably culminating in last minute hyperfocus that barely pulled me through, disappointing professors and family and, most of all, myself with low grades, though just enough to pass. She is actually a school-teacher at a special-needs school in Belgium (my country of residence), which is obviously a little disturbing, though perhaps it is her confrontation with severe cases of . My research has led me to the firm conclusion that ADHD is indeed quite real, but I too had much resistance to the idea before my own problems led me to take it at least seriously enough to investigate further. Someone else that I know who was diagnosed adult ADHD was told recently by a senior psychiatrist that it was not possible that she was ADHD because she succeeded at higher education. To me this is like telling a deeply driven one-legged man that he must have two legs because he climbed mount everest. I’d rather hear a “you succeeded in college in spite of ADHD? Well done!”. Apparently one can’t possibly be clever enough to scramble one’s way up the slopes of college, with the help of a capacity to hyperfocus.

    Being able to consider myself in this light, a quasi-hero of a less able group of people as opposed to a quasi-loser of a more able group, has been profoundly moving for me, and it pains me to be driven to doubt again with ideas like “kind of easy to pass off your laziness as a handicap isn’t it? everyone has a hard time getting down to work, you just have to do it. You don’t have enough problems so you invent some for yourself.” I would think that, at the very least a reasonable person would be open to this argument: “just imagine that you’re wrong, that there really is a condition of certain parts of the brain that makes it difficult to initiate work and remain focussed on it, just as there is a condition of the eye that makes it difficult to see. If that were the case, do you see how profoundly offensive you’re being to these people by telling them they’re just not trying hard enough to see? Surely the very least you can do is to study the research – the neurological research on the subject – and once you do that I am confident that you will see that you were mistaken.”

    Anyway, all this just to say that I realise now there is much work to be done to get people to understand that there really is a condition called ADHD, based in abnormal brain-function, that makes a lot of people’s lives very difficult.
    My impression is that it may require the development of clear and testable neurological diagnostic criteria. But certainly, articles like the NY Times has been running go a long way to slowing the process of educating the world.

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  3. Great points altogether, you just received a new reader.

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  5. Thank you for clearing up inaccuracies and standing up for those of us with ADHD. Journalism isn’t what it used to be.

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