In the previous three articles, we looked at the relatively simple explanation of ADHD as described in the DSM-5. We have seen that according to research the prevalence rate and manifestation of ADHD in South Africa closely resemble that of the US and Europe. We explored the challenges faced by professionals when diagnosing ADHD, and we looked at the different medications and up-and-coming therapies used to manage ADHD. But, despite all the information available on what ADHD is/could be/is not, many professionals are still of the opinion that ADHD is a fictitious disorder. How can this be?
In this article, we will explore some of the criticism against the existence of ADHD.
With the staggering amount of information available on ADHD, and the multiple treatment methods offered for ADHD, together with the amount of research funds being directed towards ADHD, it is hard to believe that there are still professionals who doubt the existence of such a debilitating disorder.
As we have seen, the leading ADHD professionals themselves are still trying to understand what ADHD is – other than speculating that it is not just the superficial list of behaviours described in the DSM-5. ADHD appears to be much more complex than the hyperactivity, inattention, and impulsivity people so often look for. From personal experience and anecdotes from friends, an ADHD diagnosis seems to be the diagnosis of choice as soon as a young child struggles to sit still and pay attention for long periods of time in a class setting only. I find the ease with which ADHD is diagnosed troubling.
According to Dr Russell Barkley, hyperactivity is an almost useless criterion to use for diagnosing ADHD in adults. The physical hyperactivity component disappears as the child becomes an adolescent, it becomes a more internal hyperactivity – an inability to stay with one idea at a time. Inattention may also not be the most reliable criterion as there are six different kinds of inattention, each with its own neurotransmitter and network. ADHD does not interfere with all six. For example, inattentiveness occurs in anxiety, depression, and learning disabilities, which are not affected by ADHD. Carelessly slapping an ADHD label on a child with anxiety, and then giving the incorrect medication can most likely lead to higher levels of anxiety, leading to higher doses of the incorrect medicine, creating a vicious cycle.
Dr Barkley states that a very important aspect, which is impaired in people with ADHD is the persistence towards a goal, or sustained behaviour over time. The ability to resist interference assists us in goal persistence. People with ADHD react to distraction. This is defined as a motor abnormality, not a sensory abnormality, because people with ADHD perceive stimuli the same as someone without ADHD, they are just unable to resist the distraction. Once distracted they are unable to return to the task at hand. Working memory is therefore implicated in ADHD, as working memory holds the information to assist with goal directedness.
To further the argument for ADHD, Dr Barkley states that the meta-analysis of 300 neuroimaging results were analysed and the scans (MRI, fMRI, PET scans and white matter connectivity scans) conclusively indicate that the brain structure and connections are different in individuals with ADHD. He is of the opinion that neuroimaging can assist in the diagnosis of ADHD in the next 2-5 years. The neuroimaging will be able to tell how ADHD is different from autism or learning disabilities. This will hopefully dramatically decrease the inaccurate diagnosis given for ADHD and help children to receive the correct treatment.
Advances in genetics postulate that between 20-45 sites in the genome can be responsible for ADHD. In addition, other neurotransmitters than just dopamine and norepinephrine, are implicated in ADHD. GABA and glutamate seemingly also play a role in ADHD. The different disciplines are now coming together to form a more holistic view of ADHD.
Another view on ADHD comes from the Amen Clinics. According to the Amen Clinics the French position on ADHD has a more social and situational slant, whereas the US views it as a biological-neurological disorder. The classification system used in France is the Classification Française des Troubles Mentaux de L’Enfant et de L’Adolescent (CFTMEA). Patients are assisted to identify, understand, and work through psychological disruption that may surface as ADHD symptoms. Dietary factors are explored and addressed. If a person is vulnerable to ADHD, a high-carbohydrate, low-protein diet typically makes their symptoms worse. According to the Amen Clinics dietary factors is a critical area to address. Cultural values and parenting styles should also be taken into consideration. French children are provided with clear boundaries and strict discipline is enforced. In contrast American parents set few boundaries for children. Some people believe ADHD is an excuse for bad behaviour – this belief is a myth. Using this holistic view, the French dramatically reduces the number of psycho-stimulant medication given to children.
On seemingly completely the other side of the ADHD fence are professionals like Dr Richard Saul, a behavioural neurologist in the US. Dr Saul believes that at some time or another most ‘normal’ people exhibit the behaviours associated with ADHD as described by the DSM-5, and they cannot all suffer from ADHD. According to him, through his 50 years in private practice, he has seen the diagnosis skyrocket in the last decade. More and more people are using stimulant medicine. To clarify this Dr Saul explains: “What I do deny is the generally accepted definition of ADHD, which is long overdue for an update. In short, I’ve come to believe, based on decades of treating patients, that ADHD — as currently defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM) and as understood in the public imagination — does not exist”.
According to Dr Saul, we still use more or less the same criteria to diagnose ADHD as set out by Dr Charles Bradley in 1937 when he discovered that children who displayed symptoms of attention deficit and hyperactivity responded well to Benzedrine, the first pharmaceutical drug that contained amphetamine. The label ADHD was first introduced to the DSM-III in 1980. Dr Saul further states: “regardless of the label, we have been giving patients different variants of stimulant medication to cover up the symptoms. You’d think that after decades of advancements in neuroscience, we would shift our thinking”. Over the course of his career, he has identified numerous conditions that can lead to symptoms of ADHD, each of which requires its own approach to treatment. Among these are sleep disorders, undiagnosed vision and hearing problems, substance abuse (marijuana and alcohol in particular), iron deficiency, allergies (especially airborne and gluten intolerance), bipolar and major depressive disorder, obsessive-compulsive disorder and even learning disabilities like dyslexia, to name a few. Anyone with these issues will fit the ADHD criteria outlined by the DSM, but stimulants are not the way to treat them. For his patients with severe attention issues, he requires a full evaluation to find the source of the problem. Usually once the original condition is found and treated, the ADHD symptoms fade away. For more information about his opinion on ADHD, read his book: ADHD does not Exist. The truth about Attention Deficit and Hyperactivity Disorder.
Other medical professionals have authored books which also deny the existence of ADHD. One such professional is Dr Fred Baughman, an adult and child neurologist and Fellow of the American Academy of Neurology. He has testified before the US Congress, the European Union, and the Parliament of Western Australia, that ADHD and all claims that psychiatric diagnoses are diseases, are fraudulent. He has testified in legal cases regarding psychiatry's false claims of "chemical imbalances" and "diseases”. Dr Baughman’s book ‘The ADHD fraud: How Psychiatry makes patients of normal children’, describes how dangerous Ritalin and similar stimulant medicines are for children. During 1990 and 2000, the Food and Drug Administration received 186 reports of death caused by methylphenidate (Ritalin and all other forms of the drug) through its MedWatch programme. He mentions that the ADHD plague has served as a template for increase of diagnoses of children with depression, anxiety, bipolar, and obsessive-compulsive disorder. He believes that children display behavioural problems in response to their environments, which are controlled by adults, not a dysfunction in their brain. “Troubled kids need real help, not chemical restraints administered by adults who refuse to address the true issues. When a child feels sad, distressed, or worried, when a child's moods go up and down, or she acts out with violence, sex, or drugs, there is surely something wrong that needs to be fixed”. He claims Big Pharma promotes childhood illnesses to gain financial benefit.
Another professional, Dr Peter R. Breggin a psychiatrist, medical-legal expert, and former Consultant at the National Institute of Mental Health (NIMH), strives to inform professionals and parents about the dangers of medicating children. In his 10-part series, Simple truths about Psychiatry, he discusses various issues related to psychiatry, psychology and the effects of medication (https://breggin.com/video-series/). In recordings number 7 to 9 he pays particular attention to the effects of stimulant medication on children, ADHD, and on considering a ban on giving children psychiatric medicine. He indicates that stimulant drugs do not cure anything, they cause biochemical changes in the brain that make children docile and possibly obsessive-compulsive. There is no proof that stimulants improve academic performance, or self-concept. It is his opinion that stimulant type drugs should never be given to children, and he goes as far as saying it is a form of child abuse. He describes the alarming side effects of all of the popular medications used to routinely treat ADHD which is never told to parents, for example, Atomoxetine sold as Strattera carries a Black Box Warning about causing suicidal thoughts or actions in children (Black Box Warnings are labels placed on pharmaceuticals in the USA, required by the Food and Drug Administration, when there is sufficient scientific evidence for causality with regard to serious adverse or life-threatening effects). Amphetamine and methylphenidate belong to Schedule II of the Drug Enforcement Agency’s (DEA) controlled substances list, of substances which have the highest risk of addiction and abuse. In South Africa, it is classified as a Schedule 7 drug along with morphine, pethidine and opiates (such as cocaine). Studies indicate that children treated with stimulants often develop atrophy of the brain. It suppresses the growth hormone cycle, it could also adversely affect the body’s organs. Stimulants have also been proven to induce depression and apathy in children. Children may develop tics and obsessive-compulsive like behaviour. Despite six decades of research, FDA labels still state “Long-term effects of amphetamines in children have not been well established”.
For more detailed information on which ADHD medication has a black box warning, and what the warning is for, follow this link http://newideas.net/adhd-medications/fda-warning.
Dr Keith Conners dedicated his professional life to legitimise ADHD. He developed the world-renowned Conners range of assessments to assist professionals in making an ADHD diagnosis. His assessments have excellent psychometric properties and provide a comprehensive overview of the child or adult’s possible difficulties. But even Dr Conners questions the validity of the frequency with which the diagnoses are now made. He notes that data from the Centres of Disease Control and Prevention (CDC) show that ADHD diagnoses have been made in 15% of high-school age children, and the number of children on medication has increased from 600 000 in 1990 to 3.5 million in 2013. He likened the soaring numbers to a ‘national disaster of dangerous proportions’. It equates to an epidemic. He further states that ‘this is a concoction to justify the giving out of medication at unprecedented and unjustifiable levels’.
In a New York Times article, it is postulated that the rise of ADHD diagnoses and prescriptions for stimulants over the years coincided with a ‘remarkably successful two-decade campaign by pharmaceutical companies to publicize the syndrome and promote the pills to doctors, educators and parents’. Like most psychiatric disorders ADHD does not have a definitive assessment and most experts agree that its symptoms are open to interpretation by parents, patients and doctors. The American Psychiatric Association (APA), which apparently receives significant financing from pharmaceutical companies, has gradually loosened the diagnostic criteria to include behaviour such as ‘makes careless mistakes’, or ‘often has difficulty waiting his/her turn’.
The New York Times article also mentions that the drugs used to treat ADHD are classified by the US government as among the most abused substances in medicine, largely because of their effects on concentration and mood, (https://www.deadiversion.usdoj.gov/schedules/). According to the same article, another questionable fact that is fed to the public is that parents of ADHD children also have ADHD. Even though a genetic link exists, studies have indicated that the vast majority of parents do not qualify for a diagnosis themselves. For more detail on the possible relationship between the rising ADHD diagnoses and the role pharmaceutical companies and their ad campaigns play therein, read the full article here: http://www.nytimes.com/2013/12/15/health/the-selling-of-attention-deficit-disorder.html.
In November 1998, the National Institutes of Health (NIH) held a three-and-a-half-day conference of non-advocate, non-federal experts, with the goal of establishing a professional consensus on a number of questions surrounding ADHD. Thirty-one experts presented their research findings before the consensus panel and an audience of over 1000 people. The consensus panel, which consisted of 13 experts representing the fields of psychology, psychiatry, neurology, paediatrics, epidemiology, biostatistics, education, and the public, wrote a consensus statement which remains the most comprehensive and unbiased evaluation of ADHD and its treatments. In short, some of the conclusions were:
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ADHD is a commonly diagnosed behavioural disorder of childhood. Children with ADHD have pronounced impairments and can experience long-term adverse effects on their academic performance, vocational success, and social-emotional development, which have a profound impact on individuals, families, schools, and society.
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Despite progress in the assessment, diagnosis, and treatment of ADHD, this disorder and its treatment have remained controversial, especially the use of psychostimulants for both short- and long-term treatment.
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Although an independent diagnostic test for ADHD does not exist, there is evidence supporting the validity of the disorder.
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Short-term studies (approximately 3 months), including randomised clinical trials, have established the efficacy of stimulants and psychosocial treatments for alleviating the symptoms of ADHD and associated aggressiveness, and have indicated that stimulants are more effective than psychosocial therapies in treating these symptoms.
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There is a need for long-term studies (beyond 14 months) with drugs and behavioural modalities and their combination. Although trials are under way, conclusive recommendations concerning treatment for the long-term cannot be made presently.
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There are wide variations in the use of psychostimulants across communities and physicians, suggesting no consensus regarding which ADHD patients should be treated with psychostimulants.
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A more consistent set of diagnostic procedures and practice guidelines is of utmost importance.
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Finally, after years of clinical research and experience with ADHD, our knowledge about the cause or causes of ADHD remains largely speculative. Consequently, we have no documented strategies for the prevention of ADHD.
As with most things in life there are always two schools of thought, but the argument of whether ADHD exists or not, is a lot more nuanced than just that. It seems like the two greatest concerns about ADHD are the superficial internationally accepted diagnostic criteria; and the dangers associated with stimulant drug therapy. Parents and professionals seem oblivious to these dangers and prescribe them with ease. It is also clear that there is something legitimate about ADHD, even if the description fails to accurately describe the core symptoms……which are what exactly?
We can only hope that the promising research around neuroimaging will lead to it becoming the preferred method of diagnosis in the near future. I hope, maybe a bit ignorantly, that the ‘big pharma’ conspiracy is imagined and that truly harmful drugs are not promoted to the most vulnerable in society for the sake of money. Hopefully research will further explore and substantiate alternative treatment methods which actually have a lasting impact on behaviour.
References:
ADHD rewired. (2017, January 24). Russell Barkley Ph.D., Science, research, and advice for those who love adults with ADHD [Video file]. Retrieved from https://www.youtube.com/watch?v=hZBDAEyk0N4
Biofeedbacknews. (2013, October 30). New Focus on ADHD/ADD: Neurofeedback training explained and compared to medication [Video file]. Retrieved from https://www.youtube.com/watch?v=vK31_B59fpI
Breggin, P. R. (2014). The rights of children and parents in regard to children receiving psychiatric diagnoses and drugs. Children and Society, 28(3), 231-241.
Cowan, D. (2011, April 11). FDA back box warning labels on ADHD medications. Retrieved from http://newideas.net/adhd-medications/fda-warning
NIH Consensus Statement Online. (1998, November 16). Diagnosis and treatment of attention deficit hyperactivity disorder. Retrieved from https://consensus.nih.gov/1998/1998AttentionDeficitHyperactivityDisorder110html.htm White, G. (2016, January 29). Doctor: ADHD is a fraud, psychiatry makes patients of normal children! Retrieved from http://www.medicine.news/2016-01-29-doctor-adhd-is-a-fraud-psychiatry-makes-patients-of-normal-children.html Amen Clinics. (2017, July 21). The French secret to healing ADHD without medication. Retrieved from http://www.amenclinics.com/blog/the-french-secret-to-healing-adhd-without-medication/ Saul, R. (2014, March 14). Doctor: ADHD does not exist. Retrieved from http://time.com/25370/doctor-adhd-does-not-exist/ Schwarz, A. (2013, December 14). The selling of Attention Deficit Disorder. Retrieved from http://www.nytimes.com/2013/12/15/health/the-selling-of-attention-deficit-disorder.html
