Ritalin may not help children with ADHD?

A few days ago, the media had a frenzy over a new study about the use of Ritalin (methylphenidate – a stimulant medication) for Attention Deficit Hyperactivity Disorder (ADHD) (http://goo.gl/Ht9GKF).

ADHD is always good for a headline grab because it is so polarizing. It’s like the new HIV – everyone’s got an opinion on ADHD, and most of them are facile or just plain ignorant. That doesn’t stop the armchair experts from sharing their opinions, and this new Cochrane review into the studies of Ritalin for ADHD just gives them another chance to vent their fatuous spleens.

Like a couple of the comments posted at the end of The Australian article. One suggested that ADHD was a disease invented so they could find another drug to treat it, and suggested that mobile phone games were the problem. Another thought he was rather humorous when he trotted out the tired old chestnut that it’s all the parents fault: “ADHD has been nicnamed {sic} ‘Absent Dad At Home’ syndrome!”  Sorry, but no one’s laughing. 

We need to take a step back from the uneducated and unwarranted opinion of the self-titled experts, and look at what the study actually said. To do that, lets have a look at what the study was, what it looked at, and what the results were. We’ll then compare the results with some of the other options available for treating ADHD, so we can make an informed decision about how to best manage ADHD.

First, what study are we talking about? The study in question is a Cochrane Review lead by Storebo, titled “Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)” [1]. (You can read the official press release here: http://www.cochrane.org/news/researchers-urge-caution-prescribing-commonly-used-drug-treat-adhd or the abstract here: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009885.pub2/abstract)

Cochrane reviews are scientific works that pool the best research on a particular topic and combine it into a mega-study, to get the best results available for a particular topic. First, all the papers written about the topic in question are found. The poorest quality studies are discarded, leaving studies that are suitable quality and are fairly uniform in how they did their research, so that the results from each study can be combined into one uniform result.

This process of meta-analysis increases the statistical power of the results enormously. The Cochrane Collaboration has been at the forefront of meta-analysis and has developed specific rules about the quality of evidence it accepts for its reviews, making a Cochrane review as trustworthy as medical research can be.

So what did the meta-analysis of methylphenidate for children with ADHD actually show? In short,

  • A strong improvement in the Teacher-Rated Symptoms score,
  • A strong improvement in the Teacher-Rated Behaviour score,
  • Small-to-moderate improvement in the ADHD rating scale,
  • Small increase in minor side effects such as poorer sleep and appetite, and
  • No increase in serious harm from methylphenidate.

So … that sounds pretty positive overall. Why the big hullabaloo? Why are these experts supposedly urging caution?

The concerns the researchers had was with the quality of the studies. Overall, the research that’s been done thus far has been deemed low quality by Cochrane’s standards. So they were cautious about suggesting that the results were reliable given the quality of the studies they had to work with. And that’s fair enough. Better quality studies are required to confirm the findings of the current Cochrane review, and this should be done as a matter of priority.

Unfortunately, the reviewer’s cautious approach to the research has been misinterpreted as a concern about the drug itself.

There are two important points here: 1. Accepting the limitations of the quality of the research it’s based on, the review still found a moderate effect of methylphenidate, and 2. Other “treatments” for ADHD have been proven in separate meta-analyses to be wholly ineffective.

There’s a little bit of statistical interpretation required here, but the Standardised Mean Difference (SMD, or sometimes called Cohens d) for the Teacher-Rated Symptoms score and Teacher-Rated Behaviour score was -0.77 and -0.87 respectively. The negative value here doesn’t mean that it’s bad; it’s just the arbitrary direction the reviewers chose to show improvement favouring Ritalin. Then there’s the SMD itself. The SMD takes into account the variability of the results overall, using a specific formula to take that into account.

The SMD used here doesn’t equate to the other value the reviewers used for the side effect statistics, which they expressed as a relative risk. So you can’t look at the numbers given and directly equate the power of the improvements with the chance of side effects of the medication.

However, it’s been said that an SMD of 0.2 is a small effect size, 0.5 is moderate, and 0.8 is large [2], so the effect of Ritalin given by the study was actually a strong effect. In comparison, the relative risk of minor adverse effects given by the review was 1.29, or a 29% increased risk, which is relatively small.

Then there’s the important consideration of the effects of other treatments for ADHD. The effect of Ritalin maybe backed by low quality evidence, but there’s no evidence of any effect for the other so-called ‘treatments’ for ADHD. As per the review by Sonuga-Barke (2013), there is a tiny amount of evidence for supplementation with omega-3 and 6 fatty acids, but none for:

  1. Elimination diets (including those for ‘antigenic’ foods, specific provoking foods, general elimination diets and ‘oligoantigenic’ diets)
  2. Food colouring (including certified food colours, Fein-gold diets and tartarazine)
  3. Cognitive training (including working memory specific, and attention specific training)
  4. Neurofeedback, and
  5. Behavioural intervention [3]

So no matter how inane or facile the arm-chair experts may be, there is no evidence that Ritalin for ADHD is harmful. There is a small risk of minor effects such as reduced appetite and sleep, but there is evidence (albeit low quality evidence) that it has a strong positive effect. In comparison, there’s no evidence of improvement from any other treatment that’s been adequately studied.

No drug is perfect, and that includes Ritalin. But it’s certainly not the devil in pill form either. It’s time to stop demonizing it, and ignorantly criticizing those children and their families who need it.


[1]       Storebo OJ, Ramstad E, Krogh HB, et al. Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD). The Cochrane database of systematic reviews 2015 Nov 25;11:CD009885.
[2]       Faraone SV. Interpreting estimates of treatment effects: implications for managed care. P & T : a peer-reviewed journal for formulary management 2008 Dec;33(12):700-11.
[3]       Sonuga-Barke EJ, Brandeis D, Cortese S, et al. Nonpharmacological interventions for ADHD: systematic review and meta-analyses of randomized controlled trials of dietary and psychological treatments. The American journal of psychiatry 2013 Mar 1;170(3):275-89.


The Prospering Soul – Just what is mental health?

When Paul wrote to the church at Thessalonica a couple of thousands years ago, he said, “May God himself, the God who makes everything holy and whole, make you holy and whole, put you together—spirit, soul, and body—and keep you fit for the coming of our Master, Jesus Christ.” (1 Thessalonians 5:23 -The Message)

The modern western church has two out of three. As modern Christians, we have the fitness of the Spirit pretty well down, and we’re not too shabby on our physical fitness either. Unfortunately, we still have a way to go on the Soul thing.

In 2013, Rick Warren stood in front of his church after the suicide of his son, and promised he would work to reduce the stigma of mental illness in the Christian church (http://swampland.time.com/2013/07/28/rick-warren-preaches-first-sermon-since-his-sons-suicide/). Rick Warren experienced the stigma and destruction of poor mental health first hand. So have many others in the church, as have I.

It’s my passion to help the Christian church prosper, our bodies, our spirits, AND our souls.   Over the next few months, I’ll be doing a series of blogs on mental health, to encourage and help those in the church battling mental illness, and everyone else in the church to know how to assist them in their battle.

Together, we can help to eliminate the stigma and destruction that mental health can bring into the lives of Christians, and that we may prosper in all things and be in health, just as our soul prospers (3 John 1:2).

To start with, it would help if we knew what it meant to be in good mental health, and what separates mental health from mental illness. The distinction isn’t always so obvious. There are a few ways to define or conceptualise mental health and illness, but to cut through the thousands of words of medical and scientific jargon, the difference between good mental health and bad mental health is often to do with changes to our thinking, mood, or behaviour, combined with distress and/or impaired functioning. [1] Our mental health is intimately linked with our physical health, and often physical illness will lead to changes to our thinking, mood, or behaviour, combined with distress and/or impaired functioning too, although strictly speaking, that’s not a pure mental health disorder.

What IS important for the average church goer to understand is that we all experience some changes to our mental health at different times in our lives. For example, we all experience grief and loss at some time in our lives, and at that time, it’s normal to experience extreme sadness, sleeplessness, anger, or guilt. What differentiates grief from depression is the trigger, and the time the symptoms take to resolve. In general, how we perceive our thoughts and behaviours, and how much any signs and symptoms affect our daily activities can help determine what’s normal for us.

There are some common signs that can help in knowing if professional help may be needed. This isn’t an exhaustive list, but if you or a loved one experiences:

  • Marked change in personality, eating or sleeping patterns
  • Inability to cope with problems or daily activities
  • Strange or grandiose ideas
  • Excessive anxiety
  • Prolonged depression or apathy
  • Thinking or talking about suicide
  • Drinking alcohol to excess or taking illicit drugs
  • Extreme mood swings or excessive anger, hostility or violent behaviour

then consult your family doctor or psychologist, or encourage your loved one to seek help. With appropriate support, you can identify mental health conditions and explore treatment options, such as medications or counselling.

Many people who have mental health conditions consider their signs and symptoms a normal part of life or avoid treatment out of shame or fear. If you’re concerned about your mental health or a loved one’s mental health, don’t hesitate to seek advice.

If you or a loved one have, or still struggle with, mental illness, I welcome your comments.

I can’t give specific counselling or advice in this forum, but if you are suffering from mental health problems and need help, see your GP or a psychologist, or if you’re in Australia, 24 hour telephone counselling is available through:

Lifeline = 13 11 14 – or – Beyond Blue = 1300 22 4636


  1. National Institute of Mental Health, Mental Health: A Report of the Surgeon General, U.S. Department of Health and Human Services, Editor 1999, U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services: Rockville, MD.