In the last month I had a couple of conversations with Raul Gainetdinov, a neuroscientist best known for a dopamine transporter theory of ADHD that I've discussed earlier in this blog. I called Gainetdinov, known for his work at Duke and now at the Italian Institute of Technology in Genoa, to try to get to the bottom of how stimulants work in ADHD (and to discuss the strange case of the cocaine-hypersensitive mice I talked about in the earlier entry).
What was most unexpected to me in these conversations was that despite having come up with one of the most compelling theories about why stimulants might work to counter hyperactivity, Gainetdinov's spin on drugs like Adderall and Ritalin was resoundlingly negative. One issue I had with his theory of the paradoxical calming effect of stimulants in young kids is that--for reasons too complicated to get into--it doesn't really work well in explaining why stimulants would work on ADHD in teenagers and adults.
In Raul's view, there's a very good reason for this: he thinks that when it comes to teens and adults, stimulants are a terrible treatment for ADHDs. As he sees it, his theory doesn't need to explain "why stimulants work" for all the conditions they're prescribed for because there's a good chance that they don't. In fact, Raul thought that even kids who do see a benefit from drugs like Adderall are likely to stop seeing it when they get to their teenage years.
Even when it comes to young children, Gainetdinov is extremely leery of how the drugs are used. One thing he pointed out is that even if he can explain how they work in some cases, it doesn't mean they work better than the alternatives. When I asked him if it was possible that SSRIs like Prozac might work just as well, Raul said he not only thought it was possible, but that in actual practice psychiatrists routinely prescribed SSRIs for hyperactivity, with what looked like very good effects. One of the ironies is that years of treating kids with stimulants (an approach based partly on early, shoot from the hip work with kids that no one would even think of doing today) have made it ordinary practice, while prescribing Prozac or Lexapro to kids is "off label" -- the drugs that are thought of as addictive and dangerous in adults are routinely given to kids, while those that in years of practice have proven extremely safe in adults are thought of as dangerous and insufficiently tested for children.
I'm not about to jump on an anti-Ritalin bandwagon here, but this is a basic point worth considering very seriously. In my earlier post I posed the question about stimulants as "how do they work?" But it's very reasonable to add to this "what happens when they don't?" and "what might work better?" These questions are harder to answer than you might think because, as Gainetdinov points out, what ADHD is remains contentious and badly defined. The funny thing about the host of stimulants out there is that we may have more hard data on what they do for air force pilots on all night missions than the effect they have on millions of kids.
PS: After several posts on drugs like Ritalin and Adderall, you may be wondering if I have tried them. The answer is yes (I've tried pretty much every non-prescription "smart drug" and supplement, too). I'll save that for later posts.
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