3 weeks of ADHD meds sets kids tweaking
Before ADHD became a cash cow for drug makers and doctors, a 1990 NIMH study found obsessions and tics in 76% of medicated boys
Just last week, Dr. Gabrielle Carlson, the president of the American Academy of Child and Adolescent Psychiatry (AACAP), slammed anyone audacious enough to question medicating kids she diagnoses with ADHD as “pathological.”
Dr. Carlson thinks the value of medicating kids for ADHD is painfully obvious. “If all you have to do is put the glasses on and that takes care of a lot of the problem, then for God’s sake put on the glasses!”
Dr. Carlson, along with everyone else quoted in the article, mentioned no risks of treatment. With her declaration still echoing in my ears, I decided to print out a study mentioned in the footnotes of Peter Breggin’s 2001 book Talking Back to Ritalin.
Breggin, now 81, is a well-known critic of ADHD diagnoses and medication. He has so vehemently attacked psychiatry’s accepted wisdom on both the ADHD diagnoses and medications that he’s often derided as a crank, even a psychiatric flat-earther.
Once you’ve dug through the details of the 1990 study, though, you may be convinced that it’s pro-drug psychiatrists like Dr. Carlson who are pathological.
The study Breggin footnotes is innocuously titled: “Motor/vocal tics and compulsive behaviors on stimulant drugs: is there a common vulnerability?”
Led by Breck Borcherding of the NIMH and published in the journal Psychiatry Research, the study applied levels of scrutiny that are unprecedented — before or since — to the behavior of a group of 45 boys receiving stimulants to treat ADHD. Though presented to parents as a study of drug efficacy, the study was actually designed to tally tics and compulsions resulting from two medications, which were essentially Ritalin and a proto-Adderall.
Based on the study’s title, it doesn’t look like a gun still, nearly 3 decades later, smoking in the hands of ADHD medication proponents. But it is.
The study delivered good news for doctors, parents and teachers: three weeks of drug treament “produced marked improvement in restless and inattentive behaviors.” Both drugs worked equally well.
The bad news: while closely monitoring 45 boys between the ages of 6 and 12 during three weeks on each medication, clinicians witnessed dozens of tics and compulsions. The boys had previously been vetted to be tic and obsession free.
More than half the boys exhibited compulsive behaviors. Some behaviors were extreme: nearly 18% exhibited behavior that was “perseverative,” which is to say they repeated something insistently or redundantly.
One boy spent 36 hours playing with legos. Another had a similar experience with video games.
Another child spent seven straight hours raking leaves, “after which he still felt compelled to rake individual leaves as they fell.”
Beyond these thought disturbances, physical symptoms abounded: 59% experienced jerks, twitches and other abnormal movements. One child threw his head to the side and back, explaining “I’m straightening out my neck, it’s stiff.” By week three, this behavior had increased to 10 times an hour. After the boy was taken off ADHD medication, the twitches decreased but did not cease. So he was put on an antidepressant.
A similar study footnoted by Breggin, published in 1989 in the Journal of the American Academy of Child and Adolescent Psychiatry, found that 8 of 19 kids given Ritalin had experienced preserverations.
These children gave many more responses following drug without producing a commensurate increase in the number of classes represented among the responses. This increase… was extreme in some cases, … the style of response appeared compulsive — the children seemed to have difficulty stopping after a reasonable interval. As the children continued, the quality of the responses appeared to decline, with an increase in the number of responses that did not make sense, were vague tangential or repetitive. This phenomenon was observed to occur at all dosages.
Such extreme findings today would be front page news, but at the time, the practice of medicating kids for ADHD was still on the medical fringe.
28 years and one meth epidemic later, some of the boys’ behavior as published in 1990 sounds remarkably like “tweaking,” slang for repetitive behaviors common among meth addicts. Here’s a definition of tweaking from Urban Dictionary:
Frantic and compuslive behaviour often associated with methamphetamine abuse (crank). People who regularly abuse crank may find themselves unable to stop a particular random activity like searching drawers, having sex, or putting things apart.
If you want examples of tweaking on meth, here’s a drug forum where users discusss their favorite tweaking obsessions. Sadly, 36 hours of legos and 7 hours of leaf-raking would fit right in.
Again, the 1990 study was doubled blinded — the doctors didn’t know who was medicated and who wasn’t. None of the 45 boys in Borcherding’s study had been diagnosed with OCD when the study started. More importantly, the hyper-attentive clinicians noted zero abnormal behavior in their two week onboarding without medication. (In a second, you’ll see why this observation is important.)
Doctors today, if confronted by tics or obsessive behavior in a medicated ADHD patient, will explain that “OCD and ADHD are comorbid, so the new behavior is no surprise.”
Here’s how Georgetown clinical professor of psychiatry Dr. Larry Silver, writing on a drug-maker-funded “patient support” website, diagnoses and explains OCD behavior in a patient being treated for ADHD:
For reasons that are not known, stimulant medications may exacerbate an existing case of OCD. Or, if the OCD behaviors are minimal and not obvious to parents, a stimulant may make them clinically apparent. The first clue that someone has ADHD and OCD — or may have OCD rather than ADHD — is a significant increase in OCD behaviors after taking a stimulant medication.
Over the years, parents and professionals have been concerned that ADHD stimulants cause permanent tics. Research indicates that ADHD stimulants do not cause tics, but may evoke tics in genetically predisposed individuals.
Dodson offers Randy, a 10-year-old, as an example of his own treatment routine. Randy “did well on ADHD stimulant medication for three years, until he developed a repetitive sudden twisting of his neck and facial grimacing.” (Don’t miss footnote #5 below, with some details about Dr. Dodson’s financial ties to ADHD drug makers.)
Since Dodson is confident “ADHD stimulants do not cause tics,” he concludes that the best treatment for Randy is to add some new medications to his life:
Randy’s tics decreased dramatically after taking clonidine for three weeks. The tics were still present, but they no longer ruled his life. Randy was less fidgety and slept better. His grades improved. The addition of a small dose of Zoloft lowered his anxiety and the intensity of his compulsions.
That’s now the conventional wisdom. Stimulants don’t cause obsessions or tics, they unmask them. The new disfunction isn’t proof that a medication harms patients — it’s a chance to prescribe new medication(s) to treat a new disorder.
Sadly, doctors explaining obsessons and tics in ADHD medicated kids as “unmasked OCD” are actually conflating the underlying research, research focused on ADHD symptoms in OCD patients. Research finds that a disproportionate number of patients diagnosed with OCD often do have ADHD symptoms, but not the other way around. The correlation doesn’t run the other way. The diagnosed with ADHD pool is far bigger, and research finds OCD in just one in 13 ADHD patients. That ratio doesn’t come close to explaining the 76% incidence of abnormal thinking and behavior in Borcherding’s 1991 study.
Second, recent research suggests that “OCD and ADHD are so fundamentally different that they’re unlikely to coexist in the same person.” Compared with patients with classic ADHD symptoms, OCD patients have not displayed inattention, impulsivity, and hyperactivity since childhood.
But science be damned. As in the two examples above, doctors avoid blaiming ADHD medications for a patient’s obsessions or tics. It’s far less professionally embarrasing to declare that a patient’s OCD condition was present before treatment, just undiagnosed. And then, presto, the doctor can layer in some new medications to treat the new diagnosis!
Nearly 30 years after Borcherding’s study, why don’t doctors (or the president of the AACAP) mention abnormal thinking or behavior when promoting ADHD medications to journalists or parents?
In fact, the 1990 NIMH study foreshadows the convergance of multiple confirmation biases that have led researchers, doctors and parents to overlook or excuse the significant role played by ADHD medications in patients’ disturbed behavior and thinking.
1. You can’t see what you don’t look for.
Unlike other studies of ADHD medications before and since, the 1990 study was specifically designed to focus on obsessive behavior and tics. As Borcherding and co-authors put it, this group of boys was “subjected to very close scrutiny in a day hospital setting that is most unusual for these populations, ordinarily only seen as outpatients. With numerous presensitized observers, rather subtle and transient behaviors could be rated.”
After 1990 nobody has bothered to go looking, up close, for trouble. There are a few possible reasons for this:
- Sticking 45 kids in a hospital with an in-lab school and watching them closely for eleven weeks is expensive.
- Only novel findings get published. Borcherding had rung that bell on this topic. The study’s findings were so conclusive that later researchers had no reason to go looking for additional evidence that ADHD medications cause obsessional behavior and tics.
- And why bother? Parents and doctors wanted a fix, and even this study showed they got it. Researchers were eager for more grants and honoraria from drug companies. And drug companies were pushing to grow their potential markets. Why worry about something you can’t see or name? Since 1990, stimulant prescriptions for ADHD have risen nearly 200x.
- As time went on, doctors and researchers took comfort from the falsehood propogated by drug manufacturers — that because ADHD symptoms are common in OCD patients, “masked” OCD was common in ADHD patients.
2. We see what we look for. We describe what we have words for.
Labels are powerful. They can either enable or limit what we can see and describe.
Is a child obsessive or focused? It depends on who is looking and what they want to see.
Even in 1990, the abnormal behaviors being studied were only flagged by trained clinicians who were pre-equiped with a conceptual framework for describing what they were seeing — “most of the movements and compulsive behaviors were seen only by staff sensitive to these possible effects.”
Parents, watching the same children, lacked negative clinical categories to use in describing their kids behavior. After all, what parent has even heard of the word “preseverative,” much less know its meaning?
Moreover, some of the behaviors flagged in 1990 by trained medical staff as being clinically excessive included “perfectionism,” “cleaning room compulsively,” “lining up crayons,” “making lists,” “overly neat,” “repetitive checking of work.”
Parents didn’t identify these behaviors as odd. After all, they thought their kids were participating in a study about stimulant effectiveness. If anything, the new behaviors were a relief, a blessing. As the study noted, “overfocused and compulsive behaviors may seem to be positives signs in some cases, and teachers and parents may thus overlook them or not report them unless specifically asked to do so.”
For aparent who desparately wants a child to stop bouncing off the walls and to start focusing— either so the child doesn’t flunk third grade math or does get into Harvard — it becomes fairly easy to identify and celebrate “focus” and “determination” as soon as medication kicks in.
Even if the behavior seems a little intense. Even, maybe, if the child rakes leaves for seven hours, returning to sweep up individual leaves after they fall.
Faced with the relentless accumulation of professional psychiatry’s confirmation bias, Borcherding’s startling 1990 paper has disappeared from view. The kid who jerked his head once every six minutes has vanished, as has the kid who went on a 36-hour-lego-spree.
All 34 of the patients who experienced twitches or obsessive thinking during just three weeks of ADHD medication in 1990 are forgotten. They’ve been buried by an avalanche of industry-funded research catering to doctors and parents eager to celebrate the benefits of ADHD medications.
- It’s important to note that Borcherding’s 1990 article about tics and obsessions was itself pro-treatment — after all, symptoms of ADHD were eliminated by medication, and the malfunctions were classified as manageable side-effects. Even the paper’s name — “Motor/vocal tics and compulsive behaviors on stimulant drugs: is there a common vulnerability” — signals this pro-medication bias; the paper’s title suggests that ‘patients are vulnerable to abnormal behaviors’ rather than ‘drugs cause abnormal behaviors.’
- One of Breggin’s chief antagonists in his 2001 book is a Harvard professor named Joseph Biederman. In the decade after Breggin’s book was published, Biederman went on to publish one paper every two weeks, some of bipolarity in children, some supporting the ADHD diagnosis and medication. In 2009 Biederman was disciplined by Harvard for not disclosing $1.4 million in payments from drug manufacturers. Perhaps not coincidentally, Biederman co-authored much-cited papers highlighting ADHD symptoms in some OCD patients — conclusions that many doctors rely on to avoid blaming medications for OCD behaviors.
- The 1990 study’s participants were 46 boys 6–12 years of age, recruited using the ADHD (then ADDH) diagnosis from DSM-III, a diagnosistic standard that’s much stricter than today’s. Mean age was 8.6 years, mean IQ was 106. The boys scored two standard deviations above their age norms for hyperactivity when rated by their school teachers.
- Since the 1990 paper, prescriptions for ADHD medications have risen 200 fold.
5. Here’s how Dr. Dodson showed up in a 2013 New York Times article about the over promotion of ADHD mediations:
In an interview last month, Dr. Dodson said he makes a new diagnosis in about 300 patients a year and, because he disagrees with studies showing that many A.D.H.D. children are not impaired as adults, always recommends their taking stimulants for the rest of their lives.
He said that concern about abuse and side effects is “incredibly overblown,” and that his longtime work for drug companies does not influence his opinions. He said he received about $2,000 for the 2002 talk for Shire. He earned $45,500 in speaking fees from pharmaceutical companies in 2010 to 2011, according to ProPublica, which tracks such payments.
“If people want help, my job is to make sure they get it,” Dr. Dodson said. Regarding people concerned about prescribing physicians being paid by drug companies, he added: “They like a good conspiracy theory. I don’t let it slow me down.”