E. Clarke Ross, CEO of the patient advocate organization Children and Adults with Adult Deficit/Hyperactivity Disorder (CHADD), wrote a rather lame response to a criticism today in a USA Today editorial regarding the Multimodal Treatment Study for Attention Deficit/Hyperactivity Study (MTA) of ritalin versus psychotherapy for the treatment of childhood ADHD, which as I previously wrote on this site did not show that ritalin was more effective than psychotherapy after three years.

USA Today appropriately points out that maybe parents, doctors, and especially, teachers, shouldn’t be rushing to medicate kids who space out in class when they don’t fully appreciate the potential side effects, and when they, well, basically stop working after a couple of years.

The frought conflicts of interest of CHADD have been pointed out in the book Selling Sickness by Ray Moynihan and his co-author, and I recommend it to add to your pile of recent books documenting how the pharmaceutical industry has corrupted academic medicine (willingly on their part! Come on in guys the waters fine!) and the American medical system.

Ross writes:

It would be a mistake for parents to use the latest data from the MTA study as a reason to retreat from using proven treatments, including medication and structured behavioral interventions, for the disorder.

I mean come on, buddy. The MTA study was not designed to show that all treatments work well. It was designed to compare medication to behavioral treatment and treatment as usual. The study findings were that after three years medications were not better than either of the other two approaches.

I am psychiatrist with a son who was diagnosed with ADD and treated with ritalin. I never heard that there were useful behavioral treatments until… last week. If I got nothing but meds meds meds I am sure that most other people got the same.

Also, some of Mr. Ross’ arguments are at best lame and at worse false. He states that the follow was “after the end of the study.” What he means is that it was after the double blind phase of the study was over. However as far as we can tell the three year followup was also “part of the study”, not just some afterthought like he implies.

He also makes the argument that “lack of access to health care” might explain the lack of a difference between groups. However they measured how many kids were taking stimulants at three years, and 3/4 of the group originally treated with stimulants were still on them, while less than half of the psychotherapy treated group were, so this argument doesn’t wash.

Recently Senator Charles Grassley (R-Iowa) has asked another patient advocacy group, the National Association of the Mentally Ill (NAMI) to disclose payments from pharmaceutical companies. I used to be on the Scientific Advisory Board of a patient advocacy group in the area of anxiety disorders, and I asked them how much of their funding came from drugs companies. I never got a clear answer, so I sort of faded away from that group.

Patient advocacy groups and organizations like the American Heart Association (AHA) and the Osteoporosis Foundation of America are heavily funded by drug companies, and their “screen and identify” programs fit in with the drug companies agenda to expand their markets to the worried well, as well as providing a convenient front. It is time to take a careful look at these organizations and determine if they are doing more harm than good.

This has been knocked around in the blogosphere after an article in the Washingon Post publicized this week’s study results, however I thought I would give the study my usual thorough going over. The ongoing NIH funded Multi-site Multimodality Treatment of Attention Deficit Hyperactivity Disorder (MTA) study (updated in an article this week in the Journal of the American Academy of Child & Adolescent Psychiatry) showed that treatment with the stimulant medication Ritalin (methylphenidate) wasn’t any better than behavioral treatment after three years. As the parent of a child diagnosed with ADD who struggled for two years trying to cope on our own, going through hell for another two years with medications and their nightmare side effects (described in my book using a pseudonym) I sure would have liked to have known about these results (he’s off meds now and doing well), or in fact that behavioral treatment has been shown to be effective (I honestly didn’t know until today– blame myself). Thanks, National Institute of Health (NIH), for issuing a press release when these study results first came out in 2007 and glossing over the results by describing a “remarkable improvement in all groups” while euphemistically describing the result that Ritalin knocked an inch off of kids growth by stating that kids treated with behavioral treatment were “somewhat larger”.

Humph.

Anyhoo back to the study. Children received either Ritalin or behavioral treatment or a combination of both, or received “regular care” or community care, administered in a placebo controlled randomized study design. Behavioral treatment involved 27 group parent sessions, 8 individual parent sessions, an eight week summer treatment program, 12 weeks of classroom behavioral therapy, and 10 teacher consultation sessions. At one year Ritalin or combination worked better than behavioral treatment, a result that was much trumpeted by the study authors. After one year patients were followed for another two years without controlled treatment. Although some kids went off drugs and some originally treated with behavioral therapy went on drugs, at the two and three year followup there were still more kids on medication in the original medication treated group than in the behavioral therapy group.

The result? Children who were originally treated with medication did no better than those treated originally with behavioral treatment at three years after the original start of treatment.

_____ Community Care ..... Meds __ __ __ Combo __ .. __ .. Behavioral Rx ____ ____ Normal

What’s interesting about this study that was not noticed in the press coverage is that based on the study results it isn’t clear if any kind of treatment is better than just leaving the kids alone for a couple of years. It’s hard to know though because the “community care” group also got treated with various medications and psychotherapies, but we really don’t know which ones.

Another thing is that by doing a press release that put a positive spin on the results borderlines on fraud. Back in 2007 the authors wrote that there was a “remarkable improvement in all the treatment groups” which glossed over the fact that the study showed that medications were not better than behavioral treatment after three years. Even now when one of the study authors, William E. Pelhem MD, stated the obvious conclusion that medications are no different than behavioral treatment after three years, he was accused by co-author Peter S. Jensen MD of being “biased against medications”. Here is a quote of Dr. Jensen, read and make your own judgment:

Jensen said Pelham was the only member of the team of researchers who took away “the silly message” that the study raised questions about the long-term utility of drugs.

Back in 2007 in the NIH press release Jensen made the following absurd comment:

Our results suggest that medication can make a long-term difference for some children if it’s continued with optimal intensity, and not started or added too late in a child’s clinical course.

What’s with these guys, anyway?

I say why does the Washington Post feel the need to get expert opinions? Look at the graph and decide for yourself. There is NO DIFFERENCE.

That said this study was a really goofy study design, one year of randomized treatment followed by two years of letting people drift. The only explanation for how they came up with such a goofy study design is that they were going with Harvard’s Joseph Biederman’s pronouncements that ADHD is a chronic condition which never gets better (which obviously isn’t true. I had to bite my lip the other day when our pediatrician sat there and told us that ADHD was a permanent condition and if our son was doing well now off meds that he would probably need to take meds again next year if his class wasn’t as interesting. Grrr.) and that treatment gains at one year would hold up at three years (which they didn’t). They must have been surprised at the findings and came up with all kinds of goofy explanations and press releases and stuff and then were relieved when they got away with it. I know that if I had read the paper in 2007 (I didn’t) I wouldn’t have let them get away with that. I don’t know if this study tells us that much, other than that giving your kids Ritalin at age 9 for a year won’t make a difference when he’s 12 over doing behavioral treatment. Looking at this data I was starting to wonder if behavioral treatment was worth the effort or whether kids just got better on their own, however I found this study by Pelham et al 2005 that showed that intensive behavioral treatments were better than doing nothing. I just wish someone had told me that such treatments were useful. I guess that’s what I get for putting my faith in pediatricians and child psychiatrists. It’s all drugs, drugs, drugs.

Another thing is that letting authors say things like “all treatment groups showed a remarkable improvement” rather than “the medication treatment group was no better than the other groups” made me wonder who was responsible for allowing this rot to get published. The current study, the 2007 study, and the infamous Study 329 of SSRIs in kids, all share in common publication in, guess what, publication in the Journal of the American Academy of Child & Adolescent Psychiatry. I started to wonder, what is going on here? And so I looked up the editor, who comes from, surprise, the Yale Child Study Center, home of the fun with Doug crowd, and knowing those guys, the appointment as editor comes more as political payoff than a decision based on merits, which is all the more dissapointing since in this case kids are put at risk.

Maybe we should compare Ritalin to treatment with a wet noodle. Hiyah!

Book Review: Is It You, Me, or Adult ADD? by Gina Pera (Alarm Press, 2008)

I know someone with childhood attention deficit hyperactivity disorder (ADHD) whom I describe as Jack in my book in order to describe all of the possible side effects you can get with drugs like Adderall. However I didn’t know much about Adult Attention Deficit Disorder (ADD) before I started reading Gina Pera’s well written and highly informative book.

For starters, of course, Mrs. Bremner had to take that survey of Adult ADD partners to see if I qualify. Here is how it went (maybe you can take it too):

• Scatter-brained or absent minded: check
• Immature: check
• Dysfunctional family background: check
• Selfish: check
• Passive, lazy or introverted: (last one, check)
• “Free spirit” or eccentric: check
• Passive-aggressive: not really
• “That’s how men are”: (confused look, not in Italy)
• Deceptive/sneaky: No
• “Hyper” high strung or extroverted: No
• History of bad luck: check
• Thrill seeker: No (writing a blog can be thrilling, I say)
• “That’s how creative people are”: I guess
• Workaholic: No (at least not compared to Mrs. Bremner)
• Rebel: check
• Past/current substance abuse: No (didn’t inhale)

I had to take my Dad off of my email list because of #3 (sigh).

Anyhoo two thumbs up for this book!

Gina also writes an entertaining blog related to Adult ADD called ADHD Roller Coaster.