ADHD/Ritalin Long Term: Bad and Good News
By Lawrence Diller
The long-term outcomes for the millions of children who have taken Ritalin, the best known of the prescription stimulant drugs (that include Adderall and Concerta) for the treatment of attention deficit hyperactivity disorder (ADHD), have not been well studied until recently. Thousands of studies have indicated these drugs' effectiveness over 2 to 3 months in improving concentration and decreasing impulsivity and hyperactivity, but only about 400 children with ADHD have been followed into young adulthood.
The best of these studies paint a rather grim outcome for ADHD, whether or not medication was used in early childhood: very poor high school graduation rates; only 5% completing 4 years of college; poor employment records; and high rates of job firings, speeding tickets, and depression. The impression left by these studies is unmistakable: ADHD appears to be a lifelong condition requiring lifelong treatment.
But as a behavioral pediatrician who has evaluated and treated more than 3,000 children in 32 years of practice, I was troubled and confused by these gloomy outcomes. While I had not formally followed the children I had seen over the years, random encounters with them or their parents left me with the sense that they were doing better.
Upon the urging of a parent, I decided to track down 10 of the children who were featured in a book I had written 13 years ago over my concerns about the then-new ADHD epidemic. I specifically sought out those children who were at least 11 years old in 1997 and thus 24 in 2009 because I wanted to talk to young adults who should have been finished with their education by then.
I found all 10 and all agreed to speak with me. While 10 is not a very large number, and my survey not very scientific (no control groups, no formal psychometric testing, etc.), what I found is worth sharing because these former ADHD children, now young adults, as a group confirmed my suspicion that not all ADHD outcomes are so poor.
All my ADHD kids finished high school—some barely and some through alternative high school settings. But after high school, things actually began to get better for them when they were allowed to choose what they wanted to do. Five did go to college and graduate (it took one until age 27). Four of the other five received posthigh school training (two went to art school, one did vocational automotive training, and another attended a sheriff's academy).
Nine of the 10 had used Ritalin-type drugs. Eight of those nine had taken them for years. Only two of the young adults were taking Ritalin drugs regularly as adults. Six of the eight, looking back, thought overall the Ritalin had been helpful to them as children, even as they experienced side effects like not eating or sleeping as well. The drug, they said, kept them out of more trouble and helped them do better in school. Two said frankly, it kept them out of jail.
One of my kids has clearly struggled. He entered the army after high school, lied about his taking Ritalin, struggled in basic training, and then was discharged (not honorably). Several years later, he stabbed his girlfriend and spent 3½ years in the state penitentiary. Of the 10 adults, he and, curiously, the police officer are the only two I thought still struggling enough with impulsivity and poor organization to warrant taking Ritalin. Ironically, they are not the two adults taking the medicine in my small group. The formal studies suggest that over two thirds of the ADHD kids continue to be seriously impaired by their ADHD as adults. In my group, I estimate only two of the 10 were still suffering. What accounts for the difference? Having money is my best guess. The typical child in the formal studies came from the lower middle class and Medicaid population. The parents of my kids, seeing me in a private practice, had to have jobs, health insurance, or money.
ADHD kids coming from middle and upper middle class homes appear to be cocooned from the worst aspects of their condition. Special or alternative education, tutoring, child and family therapy, and consistent medication kept these kids in school, off the streets, out of jail, and off alcohol and drugs until they got to the age where they could choose their own paths. At that point, their own interests, motivation, and maturity made success more likely without taking medication. Parents of ADHD children should be heartened by this news. And society has a mandate to provide better care to those children whose parents are not as economically fortunate.
Lawrence Diller, MD, practices behavioral/developmental pediatrics in Walnut Creek, CA. He is the author of Remembering Ritalin: A Doctor and Generation Rx Reflect on Life and Psychiatric Drugs (Perigee, 2011).