Is ADHD a superpower? (part 2): The (rubbish) science of Ritalin
Scientific malfeasance and brain damage in a billion dollar industry
Part 1 here.
How well does Ritalin treat ADHD?
The pathways of (the cognitive style AKA) ADHD are myriad, and neuroimaging studies of the most complex object in the known universe can only tell us so much. The evidence most relevant to the pharmacological gaze pinpoints decreased levels of dopamine in the striatum (which is involved in planning, motivation and making decisions). Most ADHD medications increase the amount of dopamine available. I’ll be focusing on Ritalin, which does this by inhibiting the transporter that clears dopamine away from the synapse (and tends to be grape or cherry flavoured). Amphetamines such as Adzenys (orange favoured), Dyanavel (bubblegum flavoured), Vyvanse (strawberry flavoured) and plain old Adderall are arguably worse.
Poor quality of the evidence
It is difficult to say much with confidence as the research is of such poor quality.
The Cochrane Review (2023) concluded that 191 of the 212 trials surveyed were “at high risk of bias”, and that evidence for many of the therapeutic effects claimed was of “very low-certainty”. Though the NHS advises that “you may need to take methylphenidate for several months or even years”, the science has nothing to say regarding long-term (or even mid-term) use. This is because “there have been no clinical trials to evaluate the effectiveness of Ritalin for more than 4 weeks of treatment”.
Enlightened parents this side of the Enlightenment tend to defer to the science, so this is what I have to work with; I’ve focused on meta-analyses and large samples, and done my best to keep my sarcasm in check. Keen researchers will find studies presenting opposite conclusions, but take note of the funder: firstly, research funded by the pharmaceutical industry is “four times more likely to find positive results than research backed by other sponsors”; secondly, psychiatry journals are less likely to publish negative research; and, thirdly, “[w]ithholding the publication of unfavorable results… is not uncommon”.
Having added paranoia to my own list of symptoms, let’s see what this “the science” has to say.
Poor performance of Ritalin
Regarding quality of life, the largest meta-study found that it “may improve teacher‐rated ADHD symptoms and general behaviour in children and adolescents with ADHD. There may be no effects on serious adverse events and quality of life [italics mine].” A 2021 meta-analysis of 24 systematic reviews described evidence of the drug reducing symptoms as “of very low certainty”.
Data on academic performance are similarly unimpressive. A 2021 systematic review of 12,269 subjects found no evidence of benefits in academic improvement; indeed, there is some evidence pointing in the opposite direction. A study of 40 healthy participants found that the drug made them approach a cognitive task with more motivation but they took around 50% longer to complete it, and their accuracy dropped.
The 2021 review also found significant “underreporting of adverse events”, and that “none of the included reviews of good quality from our search mentioned the effects of withdrawal symptoms”. This is a glaring omission, revealing that “the science” is not only careless but heartless. Speaking from experience, being a neurodivergent 14-year-old is tough enough without having to deal with drug withdrawal.
In the absence of any decent studies, we must do what we did for millennia and rely on the observations of herbalists. My favourite practitioners are the Seed Sistas, who describe symptoms of withdrawal including sleep disruption, anxiety, restlessness and digestive problems. At the interface of teenage peer pressure and multi-million-pound campaigns from Satan’s own marketing agency, the potential for replacing grape-flavoured dopamine-boosting stimulant tablets with grape-flavoured dopamine-boosting stimulant vapes should be taken seriously.
Ritalin vs. placebo
Parking for a moment the objection that symptoms include not obediently doing things a child finds boring, a meta-analysis of 94 studies and 6,614 patients found that placebo sugar pills are responsible for “a 23.1% reduction in the severity of ADHD symptoms”. This is close to the 25% considered clinically relevant, but things get really interesting when you look closely at what is being measured. For example, a study (on Atomoxetine) found that placebo was almost as good as the drug at reducing irritability and arguing in the morning, but in the evening the drug far outperformed it.
What is significant here, doctor – that kids become more tetchy when tired? That’s obvious to anyone who knows a child, and it’s obvious that stimulants will reduce it too – but so would more sleep, better screen hygiene, more attentive parenting perhaps… Another factor is that it is often the parents who assess their children on highly subjective parameters. We might equally conclude that parents are more irritable when they are tired, more likely to get into fights with their kids, and more likely to blame them for it. Most studies reporting that symptoms “improve” fail to indicate which symptoms, which makes them all suspect if you take issue with the idea that being obedient and uncritically tolerating boring tasks is a good thing.
The meta-study also noted that “placebo response in ADHD increased by 63% between 2001 and 2020”, which is to say that things are improving for sugar pill-swallowing youths with ADHD diagnoses. Similar trends have also been noted for mania and psychosis. This is the exact opposite of what is observed with psychiatric medicine, at least in trials for depression; drugs have become less effective over time as the hype for new ideas fades and the marketing machine moves on to something else.
The power of placebo is curious, to say the least, active even in an open-label trial where children were told they were taking a placebo rather than a drug. This isn’t the place to take a wrecking ball to the whole edifice of science (my book Science Revealed does that). But it does seem rather boring and conservative – one might even say nautistic – to look at data that reveals something extraordinary about the weird and wonderful nature of our body-minds and conclude that our kids are best served by putting stimulants in their Wheetos.
Highs and lows of Ritalin
Ritalin was named after its inventor’s wife Rita, who was pleasantly surprised by its effect on her tennis game (because it’s a stimulant and it does what it says on the tin). Like other stimulants, the potential for abuse is high because larger doses than prescribed produce euphoria, and the kids are well aware of that; one study found that “16% of the children had been approached to sell, give, or trade their medication.”
Apparently, Ritalin also makes you feel good at normal doses (though I wouldn’t know as I don’t take it). Coffee certainly does (while messing with my sleep and digestion and helping me talk nonsense). In defence of coffee, my favourite herbalists administer it to help with Ritalin withdrawal, and another friend uses it to focus the mind of her highly neurodivergent son. We wouldn’t expect a paediatrician to recommend it, however. As the American Academy of Child and Adolescent Psychiatry puts it, “there is no proven safe dose of caffeine for children”. There’s no proven safe dose for Ritalin either, and yet the American Academy of Pedriatrics recommends it for children as young as four.
The drug’s reputation has completely flipped since 1971, when doctors raised concerns about Ritalin to the US Senate and described it as the no. 1 drug abuse problem in Seattle. There may have been good reason, because the flip side to stimulants can be brutal. With Ritalin, there is a “temporal relationship between depression and methylphenidate use in young people with ADHD”.
Parents should have the right to give their kids coffee and wine, ice cream and iPhones, to cut their hair, pierce their ears, to vaccinate them or not, to educate them at home or to send them to Sunday school, to give them high heels regardless of the effects on a developing spine and Ritalin regardless of its effects on a developing brain – basically to do whatever they feel is best regardless of other people’s opinions. This is deeply problematic, of course, but not as problematic as allowing politicians to make and enforce those choices. “Drug abuse” is in the eye of the beholder and I don’t have a problem with it, at least, nothing I can’t handle. I have a problem with state-sanctioned hypocrisy and incoherent thinking that actively promotes chemically modifying the behaviour of children via means that may cause brain damage (I mean this literally, as we will see below).
Side effects of Ritalin
Novartis, the manufacturer of Ritalin, notes that “common” side effects include
“nervousness, insomnia… anxiety, restlessness, sleep disorder, agitation, depression, aggression,… dyskinesia, tremor, headache, drowsiness, dizziness… tachycardia [elevated heart beat], palpitation, arrhythmias [irregular heart beat], changes in blood pressure and heart rate,… nausea… abdominal pain, vomiting, dyspepsia [indigestion], toothache… rash, pruritus, urticaria, fever, scalp hair loss, hyperhidrosis… arthralgia [joint pain]… Raynaud’s phenomenon”
Meta-analysis with sample sizes of over 10,000 reported that:
[T]the proportion of participants on methylphenidate with any non‐serious adverse events was 51.2%… These included difficulty falling asleep, 17.9%… headache, 14.4%… abdominal pain, 10.7%… and decreased appetite, 31.1%.
A small study found that 3.6% of subjects had side effects serious enough to warrant “immediate discontinuation of medication”. Even so-called “non-serious side effects” may have profound impacts. Decreased appetite, for example, is considered “non-serious”, but could it partly explain why Ritalin is stunting children’s growth by “approximately 1cm/year during the first 1-3 years of treatment”?
What else is not developing normally?
The Lancet reports that reduced nutritional content in adolescents affects not just musculoskeletal growth but also cardiorespiratory fitness, immunity and the development of the brain. In normal brain development, there is a period of remodelling that peaks from 13-15, which are also peak Ritalin years. The frontal lobes continue maturing until the mid-twenties and are involved in inhibiting urges and moderating instincts such as risk-taking behaviours and the sex drive. Could developmental stunting of inhibitory systems explain why Ritalin has caused spontaneous ejaculation, hypersexualism, and “prolonged and painful erections, sometimes requiring surgical intervention”?
Was that grape or cherry flavour?
Brain damage
In people without ADHD, Ritalin was found to cause:
“changes in brain chemistry [that] were associated with serious concerns such as risk-taking behaviors, disruptions in the sleep/wake cycle and problematic weight loss”
Another study concluded that “chronic Ritalin intake may result in permanent brain damage if prescribed in childhood”.
One pathway has been established in rats given Ritalin: oxidative stress. High dopamine levels cause oxidative stress and this kills brain cells, contributing to various diseases including Parkinson’s. And sure enough, people with ADHD diagnoses are more likely to develop Parkinson’s and other degenerative brain diseases. The jury is still out on whether the Parkinson’s is caused by the medication or something native to ADHD brains, but it’s a relatively new drug with poorly understood pathways that kill brain cells. I wouldn’t trust that jury with my brain!
Does it help, and whom does it help?
Speaking generally (ie. rigidly applying a loose category to make my point in an almost nautistic fashion and ignoring the fact that I do know a psychiatrist who isn’t a nutjob): if psychiatrists cared about what their prescriptions do to brains, they would follow the research, but the trend is going in the opposite direction. Polypharmacy, for example, is the use of several drugs together, and it can cause all kinds of eventualities in a complex system. Despite extremely scant research, polypharmacy prescriptions have trebled over the last 20 years, particularly for ADHD. “More than 80% of US youths with reported psychotropic polypharmacy had an ADHD diagnosis”. Certainly, this helps drug manufacturers. But does it help you?
Summing up so far: working from assessments that are often made by teachers and parents rather than the kids on drugs themselves, Ritalin seems to work fairly well if the goal is to make children obedient. There is no good evidence, however, that it makes them happier, and nor does it seem to improve academic performance – it may in fact impair cognitive skills. As well as bringing kids into contact with drug trafficking, it has a long list of adverse effects: it causes depression, stunts growth, subjects the brain to oxidative stress and likely contributes to degenerative brain damage. And “the science” doesn’t care enough about children’s mental health to study the effects of taking it for more than four weeks, nor to measure withdrawal symptoms.
Your experience may tell you that Ritalin makes your life better, and it is important to take your experience seriously. Firstly, it might be an idea to reflect on how it makes life better. For example, it might make monotonous tasks easier to complete, and you may be obliged to perform monotonous tasks. In this case, one might say that Ritalin helps you cope with your subjugation and wage slavery, much as gin helped poor Londoners cope with theirs in the 1700s. Or perhaps it makes you better at remembering things, in which case are there other times when your memory works better? – when you’re on holiday, for example, or getting plenty of sleep, or not exhausted from constantly modifying your language and behaviour to conform to norms that make you abnormal?
Secondly, we make better experience-based decisions when our experience is broad – so how broad is yours? Once you have spent a few weeks experimenting with the herbal medicines and techniques described below, you will be in a position to judge from your experience which serves you better, and whether the collateral damage that Ritalin does is worth the reward.
My own experience is that herbal medicine helps me out, and scientific evidence would seem to support that conjecture.
Part 3 is about traditional approaches to neurodiversity, both in terms of understanding it and managing it.
