Stimulants: The Long View

When the ADHD literature speaks of scattered attention and defective inhibition, it uses terms with historical resonance. Ever since the Puritans, reformers have attached high importance to the regulation of attention. “Attend,” says the angel Raphael to Adam before instructing him in Paradise Lost, the great Puritan epic. When Benjamin Franklin set out to reform his vices one by one, the method he devised was to give “a week’s strict Attention to each of the virtues successively.” Along with regulated attention go disciplined work, planning and deferred pleasure—in brief, the Protestant ethic, of which Franklin served as Max Weber’s model. “No gains without pains,” says Poor Richard.

In time, concentrated labor acquired an importance comparable to its status in Puritan thinking and practice. Thus, according to the famous opening chapter of The Wealth of Nations, the division of labor improves production, thereby powering progress itself, exactly because it focuses the inventive mind on a single operation. The division of labor makes for undivided attention:

Men are much more likely to discover easier and readier methods of attaining any object, when the whole attention of their minds is directed toward that single object, than when it is dissipated among a great variety of things.

Here too concentrated effort and eventual gains (the “attainment” of an “object” lying some distance away) seem to go together. As factory-masters like Josiah Wedgwood—himself a Dissenter, that is, descendant of the Puritans—subdivided production to focus the worker on detail, the correction of sloppy attention became a kind of practical imperative. Like the early Protestants who interpreted their own self-denial and methodical effort as evidence of divine favor, reformers like Wedgwood acted with a sense of certainty.

Whereas Wedgwood maintained that regular attendance and careful attention were necessary for good work, which in turn contributed in the end to general prosperity, others came to argue that properly managed attention was the key to the moral progress that defined civilization. The habits of mind and awareness of distant connections fostered by the commercial way of life appear to have much to do with the birth of the anti-slavery movement and the rise of the humanitarian ethos. Wedgwood himself belonged to the Society for the Abolition of the Slave Trade; the president of the Pennsylvania chapter was Benjamin Franklin.

Arguably, only when the habit of making remote connections and projecting remote consequences was established by the growth of contract relations in the later 18th century did it become possible for many to extend their moral concern to humanity itself. Only then, too, did it become possible to claim that the civilized know how to control themselves and postpone their pleasures, while those lacking in self-control, including children, had to be taught to acquire it.

Anticipating the remote consequences of one’s actions was thought to require not only concentrated attention but also self-restraint and a capacity to delay gratification that the middle class found lamentably lacking in criminals, paupers, madmen, children—not excepting their own—and others who became objects of humanitarian concern. . . . The very possibility of feeling obliged to go to the aid of a suffering stranger . . . was enormously heightened by a form of life that made attention to the remote consequences of one’s acts . . . an emblem of civilization itself.¹

Promoters of the ADHD diagnosis aren’t the first to couple centered attention, self-control and deferred gratification, or to identify defects in this triad as prejudicial to human welfare, or to target children for reform. According to a leading ADHD campaigner, “For self-control to occur, the individual must have developed a preference for the long-term over the short-term outcomes of behavior.”² So said reformers, humanitarians, even the authors of children’s books from Wedgwood’s time through the Victorian era.

So what’s the rub?

The rub is that the standard treatment of ADHD—the use of stimulants—is designed for immediate, not eventual, benefits. It conflicts with its own rationale and eviscerates traditional arguments in favor of subordinating the present to the future. As if the medical literature itself suffered from short attention, only recently has it shown much interest in the distant outcomes (“remote consequences”) of stimulant treatment. Common in the literature are statements like “While the short-term efficacy of stimulants for ADHD is well established, information about their long-term effects is sparse.” Methodologically difficult and comparatively few, longer-term studies suggest that those treated for ADHD lag behind the general population on many indices, which is the sort of outcome one might expect if a medication intended as a behavioral aid or symptom palliative—in a word, a quick fix—were taken indefinitely. The labeling of ADHD, a potent act in itself, may also have unintended effects, and the process of diagnosis that initiates treatment is itself notoriously cursory, often consisting of nothing more than a brief checklist of leading questions. In one not especially flagrant case described in Alan Schwarz’s ADHD Nation, a diagnosis takes two minutes.³

In any discussion of ADHD it’s hard to avoid giving the impression that the disorder represents a well-defined entity rather than a diagnostic construct highly subject to fashion and inflation (such that estimates of the affected population vary over time by leaps and bounds). A long view of the ADHD phenomenon itself from its birth as ADD in DSM-III (1980) reveals a disorder of originally modest prevalence growing into a mass affliction. With this reservation, then, we may ask: if children diagnosed with ADHD need to acquire the habit of long-term thinking, how exactly does a drug like Ritalin or Adderall promote this virtuous practice? Illegal use of stimulants on college campuses is known to be rampant, with students fueling for cram sessions in the belief that the drugs enhance academic performance. In theory, the rewards come the next day. While the students’ hopes may be misplaced, how they came by them is no mystery.

In the 1950s, a quarter century before the enshrinement of ADD in DSM-III, Ritalin (methylphenidate) was portrayed as a kind of immediate-action drug. “CIBA went so far as to develop a liquid version that psychiatrists could inject into their patients right there in the office.”⁴ To this day Ritalin and its cousins yield rapid short-term benefits. The child diagnosed with ADHD takes a stimulant to get through the day. Time is measured in hours. It’s an index of the contraction of time in the ADHD universe that the advent of extended-release stimulants some years ago was acclaimed as a major advance over pills with a shorter half-life. Medication could now be given once daily, with no need for a booster dose during school hours. Moreover, the new formulations built in a “ramp effect,” whereby the level of stimulant in the brain rises quickly. Thus does ADHD therapy use speedy delivery in the service of deferred gratification.

Much as extended-release stimulants are designed “to ensure an immediate . . . response”⁵—that is, to be quick-hitting as well as persisting through the day—so they promise an instant pay-off for the teacher by reducing the disruptive symptoms of ADHD more reliably than their predecessors. That the drug treats symptoms while leaving the theorized disorder itself untouched isn’t the teacher’s problem. The suppression of symptoms is just what the teacher requires, and many an ADHD diagnosis originates with the teacher, concerned as he or she is with the management of classroom behavior.

As with other psychoactive drugs, clinical trials of stimulants tend to run only a few weeks; it’s these studies that underwrite the claim that “administering stimulant medication to children with ADHD typically results in lower behavior problems, at least in the short term.”⁶ Compared with the prescription of stimulants for years on end, including the critical years of childhood and adolescence, such trials represent brief exercises and, indeed, foreshorten analysis. Buoyed by the ambitious assumption that coverage throughout the day somehow serves “the overarching goal” of reducing the burden of the disorder “across the individual’s lifespan,”⁷ the literature lacked much information about the long-term effects of stimulants even as the more consumer-friendly preparations facilitated the habit of taking them.

A notable exception to the rule of brief trials without follow-up provokes more questions than it answers. Designed to remedy in part the neglect of “longer term outcomes,” the MTA study ran three ADHD treatments—an intensive medication regimen, behavioral therapy, and a combination of the two—against each other as well as ordinary care, but not against placebo, for 14 months. At that cut-off, 68% of the children receiving combination therapy had improved to the point that they were “normalized,” as opposed to 56% on medication alone. Only 25% of the ordinary-care group showed comparable improvement even though most were also taking stimulants. Why this disparity?

In addition to receiving higher dosages, the medication group enjoyed a degree and kind of medical attention that went well beyond routine care. For example, “during half-hour monthly medication visits, pharmacotherapists provided support, encouragement and practical advice,” as well as adjusting the child’s medication if necessary.⁸ (By contrast, in a catastrophic case recounted in Schwarz’s ADHD Nation, a young man faking ADHD has monthly med checks of five minutes.⁹ In the MTA study itself, the ordinary-care group and their families suffered a “general disconnect” with their doctors, meeting with them to review prescriptions only twice a year.)¹⁰ When the protocol came to an end and the MTA study became “naturalistic,” the superior outcomes of the medication group began to decay; by two years they had halved and by three years vanished.¹¹ Interim results failed to hold up under uncontrolled conditions.

While difficult to interpret, this narrative of lost efficacy suggests that as the elaborate ritual structure supporting the medication collapsed, the value of the medication itself declined. The MTA story reminds us that offstage factors including the character of care may have much to do with the efficacy of the pills that fixate public attention as well as that of medicine.

The pharmaceutical treatment of a distraction disorder has the effect of distracting attention from the human context and short-circuiting long-term considerations. While noting that “the long-term goal of pharmacotherapy is to reduce the functional impairments associated with ADHD,” a 2013 review defines a relevant study as one with a follow-up of “at least 24 weeks”—surely a short measure of the long run. The review concludes that the literature base is “small and naturalistic” and, at that, possibly distorted by publication bias—deficiencies that don’t deter the authors from finding that ADHD medications protect against most of the disorder’s dismal outcomes.¹²

As in this case, the ADHD literature has a way of pointing to dire sequelae of childhood ADHD while suggesting that stimulants somehow avert them. That they actually do is far from clear. A year before the ADD diagnosis entered the world, investigators noted “a disconcerting disparity between short-term medication effects and long-term outcomes [of stimulant treatment] in both academic and interpersonal realms.”¹³ Almost three decades later, one of the co-authors of the MTA study went on record as saying, “In the short run [medication] will help the child behave better, in the long run it won’t.”¹⁴ How ironic that the ADHD literature includes preachments about the importance of long-term thinking and descends from a reform movement deeply concerned with distant goals and connections.

Finally, the medical literature never seems to ask itself: What’s the effect of growing up with and thereby internalizing the message that you suffer from a hard-wired defect of self-regulation? Messages matter greatly in medicine, as any good doctor well knows; and a message more subversive of self-regulation per se than this one is difficult to imagine. The message is reinforced with every pill. That the great majority of ADHD cases appear to fall in the mild to moderate range,¹⁵ while long-term outcomes in general appear bleak, suggests that something in the handling of this perversely popular disorder has gone awry. All too many, it seems, end up living out their imputed defect.

When ADHD crusaders use phrasing like “a preference for the long-term over the short-term outcomes of behavior,” their words resonate precisely because, like the body of a violin, they’re hollow. These are terms that once meant something.