Long-Term Benefit of ADHD Drugs Questioned

July 10, 2013

Recent research is raising questions about the long-term effects of stimulant medicines on school performance among children with attention problems. The studies compare children with attention-deficit hyperactivity disorder (ADHD) who do and do not take these medicines. The drugs include Ritalin, Adderall and others. They can improve attention and focus. Some types of memory also may be improved. But newer studies find similar test scores and grades in the long run for kids who do and don't take the drugs. The Wall Street Journal wrote about the issue July 9. A study published last month focused on nearly 4,000 students for an average of 11 years. Boys who took ADHD drugs had worse school performance than those with similar symptoms who did not take them. Another study, involving 579 children, randomly assigned them to 3 treatment groups or a "control" group that got no medicine. In the first year, those who took medicines had improved symptoms and school performance. But by the third year the differences went away. After 8 years, researchers still report no advantage for those who took the medicines.

By Mary Pickett, M.D.
Harvard Medical School

What Is the Doctor's Reaction?

About 2.7 million children (and some adults, too) take medicine for attention-deficit hyperactivity disorder (ADHD). ADHD kids sometimes improve dramatically with medicines. They often show better behavior and what seems to be more focused attention in school.

But studies disagree about whether these drugs help school performance in the long run. A new Wall Street Journal article takes a look at this issue.

Some studies show exciting gains. For example, a study published this March showed improved reading scores, fewer absences from school and less chance of being held back in grade level. But other studies don’t show any convincing benefits, particularly long-term benefits.

A large study on this topic was published several weeks ago. This study looked at 4,000 students who were treated with ADHD medicines. They were compared with students who had equally severe ADHD, but did not have insurance that could pay for drug treatment. In this study, students who took ADHD medicines did not appear to be helped. In fact, they had lower math scores. They were more likely to drop out of school or to repeat a grade level. Particularly among girls, they also had more emotional problems.

This uncertain benefit means decision-making about medicines can be difficult. Stimulant medicines for ADHD can improve a child's behavior. But as a child grows up, how long do you continue them?

Among kids with ADHD, 29% will have symptoms as adults, too. Common symptoms include problems with attention or concentration. Is stimulant medicine helpful for adult ADHD? Is it helpful for college? For your career?

Methylphenidate (Ritalin) and similar stimulant medicines probably do help some people with adult ADHD. But they are less likely than children to respond to these medicines.

I am a primary care doctor for adults. Some of my patients take medicine for ADHD, but it can be hard for me to sort out whether they are truly having a benefit. For some patients, the benefit seems clear. For others, it is not.

What Changes Can I Make Now?

If you are a child or adult with ADHD, medicine might or might not help you. The way to know might be to try it for a while. Watch closely for differences in your productivity and your social relationships.

These medicines have serious potential side effects. So consider treatment only if a doctor has recommended it for you or your child. Stimulant medicines do not help students who have not had typical ADHD symptoms since childhood.

Be honest about how much "inattention" you can blame on ADHD. This is especially true for adults, who might have learned to blame their ADHD for times when they were poorly performing.

I have one patient who asked me to restart his ADHD medicine because he was "feeling out of it." He told me he was certain his symptoms came from ADHD. But a few questions later, I knew he was a new father. He had been up multiple times at night with his crying newborn baby. He was also drinking more than he had been before, and was overwhelmed by a job transition. His symptom was not the result of ADHD -- and ADHD medicine was not the way to correct it.

If you do use stimulant medicine for ADHD, do not be afraid to stop it and to see if you can do all right without it. Considering the amount of disagreement between studies, if there is a benefit from the drugs -- particularly for adults -- it is likely to be a small one.

Even if you do respond to ADHD medicine, you can't safely use stimulants as an adult if you have either of these two medical issues:

1. Addiction troubles: If you are battling one addiction, you do not belong on a stimulant medicine. They can be habit-forming.
2. Heart disease: Stimulants are not safe for use with most heart disease. If you take a stimulant for ADHD, make sure you have an EKG (electrocardiogram) done to check for silent heart disease.

Recent research shows that the antidepressant medicine bupropion (Wellbutrin) may be helpful in ADHD. This drug is not hazardous to use for those with addictions or heart disease. But your doctor will need to pay attention to possible interactions between Wellbutrin and common heart drugs, such as metoprolol and carvedilol.

What Can I Expect Looking to the Future?

Adult ADHD did not exist as a diagnosis before the late 1970s. It was not a common diagnosis until this decade. But now a growing number of adults are recognized as having this problem -- and, of course, this group is aging. We do not have a clear plan about how long stimulant medicines should be continued. They become less safe over time, as the heart and blood vessels age. Long-term treatment of ADHD seems to offer less benefit than we might hope for. It will be interesting to watch how treatment advice evolves for adults who have ADHD.