Primary care physicians, educators, and psychologists are faced with a virtual flood of children who are referred for evaluations for attention deficit disorder (ADD) or attention deficit/hyperactivity disorder (ADHD) and/or learning problems, most through their preschool or school. These children have been identified as having some combination of inattentive or impulsive behavior and underperforming academically in school. Many have been given a "screening test" in school and the results interpreted as suggesting ADD. Their parent(s) have been advised to get their child "tested" for ADD. This, of course, ignores the fact that there is actually no true test for ADD-only questionnaires describing relevant behaviors in subjective terms and results interpreted with arbitrary cutoffs to distinguish normal from supposedly disordered.
My busy pediatric practice is no exception. I have faced the mounting pressure to diagnose and medicate increasing numbers of these children, all the while intuitively sensing that there must be a better way to help them than to rely on medical diagnoses and giving medication as the primary means by which they are enabled to restrain their behavior and to pay attention in school. This concern has increased when I am asked by a parent of a child who has been on stimulant medication for a number of years already, "Dr. Ravenel, when will we be able to stop [ Johnny's] medication?"
My heart sinks because I know that a truthful answer to this question is that this child may well "need" to rely on his medication for an indefinite number of years, and with the now exploding diagnosis of "ADD" in adults, he may well never develop sufficient self-control and self-discipline without these medications. Furthermore, I know that I am presented with a dilemma to tell the parent that there is no reliable research on the potential risks from the long-term use of these medications if taken for years or even decades, as has become increasingly common. This lack of long-term properly designed scientific evidence for safety and effectiveness of methylphenidate (and other stimulants) has been noted by Australian researcher Natalie Sinn in her comments relating to her research on providing nutritional supplements to help with the behaviors that define ADD discussed later (Sinn, 2007).
The two most frequent diagnoses I encounter with regard to otherwise normal children who display common problems of behavior and learning are ADD or ADHD and oppositional defiant disorder (ODD). The prevailing medical model for conceiving and managing these children assumes that there is a neurological or biological cause, with strong genetic influence, and effectively relies completely on psychotropic medications. Although this medical model for ADD gives lip service to the idea that one should "try behavioral methods first," in reality this is seldom done or, if it is done, relies on ineffective reward-based approaches. The flaws in interpretation of existing research that characterize the medical model and the logical and evidence base suggesting an alternative explanation for the causes of the behaviors that define ADD and ODD can be found elsewhere (Furman, 2005; Ravenel, 2002; Ruff, 2005).
One of the most widely quoted research studies quoted by proponents of the prevailing medical approach is known as the "MTA study" (Multimodal Treatment Study for ADHD), widely accepted among prescribing practitioners as the "definitive" study to date. The behavioral approach used in this experimental project was so intensive and expensive as to be impractical for widespread application-yet even this rigorous attempt to manage these children without medication led to virtually no improvement in the core behaviors defining ADD. It is understandable that behavioral management of ADD and ODD behaviors is generally ignored or receives only token commitment. The prevailing rewardbased behavioral approach, modeled after that used by researchers in the MTA study, has been found inadequate for highly inattentive or misbehaving children. …