Many speak out against the drugs used to treat ADHD. We checked whether they ‎actually work (certainly, but not for everyone), if there is a conspiracy to distribute ‎them (no) and what are the risks.‎

The press and the media often cast doubt over the effectiveness of ADHD treatments. The scientific data, however is pretty conclusive. A detailed review of studies published in the British Journal BMJ in November did come to a clear conclusion: “That among children and adolescents with a diagnosis of ADHD, methylphenidate may improve symptoms of ADHD, general behaviour and quality of life”

Nevertheless, the article sparked an active debate among scientists regarding the most common drug treatment, with responses both for and against it. We need to reflect on why this is the case?

The article conducted a “meta-analysis”, i.e. gathered a large number of similar historical studies to create a very large sample, this time specifically regarding Ritalin. For decades Ritalin has been used clinically to treat ADHD with thousands of studies conducted on it. Among them were several meta-analyses, but none using the tough standards of the Cochrane Database for Systematic Reviews.

This time researchers worked under very strict inclusion codes and examined in depth the risk of biases within the trials. Surprisingly, all were rated with a “high risk for bias”, but one should be mindful that this is specifying only a “risk”, not a definite bias, and in some cases the definition was given due to incomplete data.

However, keep in mind this review included 185 different studies with varying degrees of risk for varying degrees of bias. Such a review with large amounts of data should actually help reduce the overall risk of bias. And this examination maintained consistent results that methylphenidate treatment showed an improvement in the tested measurements such as evaluations done by parents on their children’s performance, as well as teachers' assessments, which are considered to be more objective.

So with all this information, why is there still an issue? The difficulty lies in assessing the intensity of the effect. For example, Ritalin can have a wide range of effects on different children, or depending on the type of ADHD. Also, researchers did not differentiate between different types of medication given (i.e. rapid release or delayed), which can also have different effects on a child. Therefore, some children may not respond well to treatment with Ritalin while others will benefit greatly from it, with a variety of reasons specific to each child.

Moreover, since Ritalin has known side effects, such as appetite suppression and sleep disorders, it is important to thoroughly examine the selection of appropriate treatment for each child diagnosed with ADHD – something which is done currently anyway. Researchers concluded, as per usual, it is important to carry out further research, with an emphasis on long-term studies.

Both press in Israel and abroad have made several claims relative to Ritalin that need addressing:

Claim 1: There is a conspiracy by the pharmaceutical companies and the medical community to market drugs for ADHD.
The answer: There is no conspiracy.

The original patent for Ritalin expired a long time ago. Other patents for the mechanisms for delayed release of the drug also expired in recent years, so the market will soon be flooded with low-cost generic drugs. Therefore there is actually no special interest for companies marketing Ritalin and Concerta; it would be more beneficial for them to invest in drugs with a distant patent expiration date.

Those who believe in this conspiracy suggest that the cooperation between the medical community and pharmaceutical companies is manifested in expanding the age range for identification of the first signs of ADHD, according to the medical definitions. Indeed the DSM, which is the most common psychiatric evaluation guide, has been updated over the years with modified definitions and diagnostic tools. It is absurd to stick to the guidelines from the original 1952 document for attention-deficit disorder, ignoring any progress in research made since then.

Claim 2: it is not clear how Ritalin acts on the brain.
The answer: The mechanism of action of methylphenidate was solved years ago.

Attention deficit disorder is characterized by abnormally low activity of dopamine in the brain. Dopamine is a neurotransmitter – a material that is used for communication between nerve cells. It has important roles in various regions of the brain, and if its levels are insufficient it can negatively affect a person's functioning, among other things causing difficulty concentrating. Ritalin decreases dopamine reuptake, enabling it to have an influence for longer.

Newspapers refer to a paper published in the Journal of the American Medical Association in 2009 that studied the relationship between dopamine and attention deficit disorder in adults. However, contrary to the argument, the research was actually done on cocaine (which is also a stimulant) and not on Ritalin. Furthermore, the paper did not doubt the need for methylphenidate, but rather demonstrated that in an adult’s mature system ADHD is the result of a shortage of dopamine. The researchers even suggested treating adults with stimulants like methylphenidate, in addition to other treatments.

Claim 3: Methylphenidate increases the risk of heart disease.
The answer: it is not yet known if this is true.

Despite contraindications published in 2006 by the Food and Drug Administration (FDA), in 2011 the same body published a comprehensive study concluding that there no correlation between treatment with methylphenidate and severe heart disease was found.

In 2012, a review of studies on the issue explained that since the rate of fatal heart disease in children and adolescents is particularly low, it is very difficult to reach sample sizes large to find significant effects. Therefore, the large sample sizes required can increase the risk of finding a false positive result. The same survey found that six out of seven studies on children and adolescents did not find a definite link between methylphenidate-based treatments and heart disease, in the absence of risk factors. In adults a correlation between methylphenidate treatment and heart disease was found in two studies out of three, but both were biased and therefore more research is needed to confirm or deny any risk.

So what are parents supposed to do when their children are diagnosed with ADHD?
The first thing you should do is consult with a specialist, do preliminary tests for heart health as recommended by the Ministry of Health and allow the expert physician to determine the treatment protocol: should treatment include drugs or not, and of course exactly which medications to take and at what dose. Namely, exactly what you would do for any other health condition. According to my own personal experience, treatment of children with ADHD is complex enough without being drowned in false fears and conspiracy theories created by people without any real knowledge or understanding of the field.