Attention deficit hyperactive disorder controversies

Overview


The psychiatric diagnosis of attention-deficit hyperactivity disorder (ADHD) has attracted an assortment of critical positions that individually challenge the ontology or preconceptions of the diagnosis as it is defined in the Diagnostic and Statistical Manual of Mental Disorders IV-TR. Among the criticisms are disagreements over the cause of ADHD, differences over research methodologies, and skepticism toward its classification as a mental disorder. Critics also express concerns over the effects of diagnosis on the mental state of patients and the effects of the medication used in the treatment of ADHD. Further, some critics suspect ulterior motives of the medical industry, which both authorizes the psychiatric definitions of mental disorders and promotes the use of pharmaceutical drugs for their treatment.

The ADHD diagnosis identifies characteristics such as hyperactivity, forgetfulness, poor impulse control, and distractibility, as symptoms of a neurological pathology. Critics point out that the etiology of this mental disorder is not yet well defined by neurology, genetics, or biology.

Status as a disorder
Many critics of the diagnosis of ADHD do not agree that it should be classified as a disorder even though there is a wide body of clincal evidence that indicates ADHD causes impairment in life functioning and that behaviour associated with ADHD has been clinically shown to be abnormal in those with ADHD. . These critics believe that it should be considered a difference in methods of thought and mental organisation, more akin to a distinctive physique than to an actual disorder. Arguments for this position include:

Utility of hyperfocus
The ADHD diagnosis provides symptoms of attention deficit, but identifies only chronic forms of distraction. What may be mistaken for distraction, however, may be a focused mental state. Hyperfocus is a term given to extended or increased attention to a subject. Hyperfocus is known to be useful for discerning details and thinking abstractly, yet it is sometimes taken as a symptom of attention deficit.

Skepticism towards diagnosis
The number of people diagnosed with ADHD in the U.S. and UK grew dramatically in the '90s. Critics of the diagnosis, such as Dan P. Hallahan and James M. Kauffman in their book Exceptional Learners: Introduction to Special Education, have argued that this increase is due to the ADHD diagnostic criteria being sufficiently general or vague to allow virtually anybody with persistent unwanted behaviors to be classified as having ADHD of one type or another, and that the symptoms are not supported by sufficient empirical data.

Publications that are designed to analyze a person's behavior, such as the Brown scale or the Conners scale, for example, attempt to assist parents and providers in making a diagnosis by evaluating an individual on typical behaviors such as "Hums or makes other odd noises", "Daydreams" and "Acts 'smart'"; the scales rating the pervasiveness of these behaviors range from "never" to "very often". Conners states that, based on the scale, a valid diagnosis can be achieved; critics, however, counter Conners' proposition by pointing out the breadth with which these behaviors may be interpreted. This becomes especially relevant when family and cultural norms are taken into consideration; this premise leads to the assumption that a diagnosis based on such a scale may actually be more subjective than objective (see cultural subjectivism).

A study by Adam Rafalovich has found that many doctors are no more confident in the diagnosis and treatment of ADHD than are many parents. Another source of skepticism is that most people with ADHD have no difficulties concentrating when they are doing something that interests them, whether it is educational or entertainment. However, these objections have been rejected by the American Psychiatric Association, the American Psychological Association, the American Medical Association, the American Academy of Pediatrics and the U.S. Surgeon General. Moreover the fact that comorbidity is common&mdash; somewhere between 60 and 80% of children diagnosed with ADHD have a second diagnosis&mdash;indicates that the nuances of diagnosis have not been adequately described. Simple uncomplicated ADHD may be different from ADHD with comorbid conduct disorder, and different again from ADHD with comorbid Tourette syndrome or Asperger syndrome to name but two of the conditions that commonly occur in conjunction with ADHD.

Another source of controversy is the lack of understanding about the physiological causes of ADHD. Xavier Castellanos M.D., head of ADHD research at the National Institute of Mental Health (NIMH) (interviewed October 10, 2000 on Frontline) was very explicit about biological knowledge. When Frontline asked him how ADHD works on the brain, he replied:"We don't yet know what's going on in ADHD." Despite the repeated references to the highly probable link between genetics and ADHD, according to Joseph Glenmullen, M.D., from Harvard Medical School "no claim of a gene for a psychiatric condition has stood the test of time, in spite of popular misinformation". Glenmullen belongs to the small minority of vocal antipsychiatry critics who question the existence of the disorder.

Disease mongering in ADHD
The term Disease mongering has been used by mainly antipsychiatry and scientology critics to question the validity of ADHD.

Sub-clinical ADHD
Another source of skepticism towards making the diagnosis of "ADHD or not ADHD" may arise from the rising diagnosis of subclinical forms of ADHD. So called 'Shadow-syndromes' or 'sub-syndromes' stand for weaker forms of ADHD and are described in various degrees by John J. Ratey and Catherine Johnson in their book Shadow Syndromes: The Mild Forms of Major Mental Disorders That Sabotage Us.

Another explanation comes from a common misconception of the symptoms that leads to an incorrect diagnosis. For example, an employee of a school might think that a student has ADHD simply because the child cannot be controlled in the classroom. A teacher may think a student whom they cannot control has ADHD, but in reality the problem may be a lack of discipline. The same teacher might not notice a child who forgets their papers, stares (entranced) at the carpet for long periods of time, or shows many of the recognized symptoms.

However, the results achieved in clinical tests with medication and anecdotal evidence of parents, teachers, and both child and adult sufferers has been taken as proof that there is both a condition and successful treatment options for most people who meet the criteria for a diagnosis. But critics point out that neurological differences exist among individuals just as with any human trait, such as eye color or height; and that stimulants have an effect on anyone, not just those diagnosed with ADHD. . Many critics also point to the reality that often, these 'clinical tests' are organized by drug companies, and that placebo effects, along with possible temporary stimulation may allay symptoms but may also cause other problems. Some also assert that parents and teachers may not want to take responsibility for contributing to the problem, and suggest that this is overlooked due to adultism and authoritarianism.

The validity of "subthreshold ADHD" is questioned by healthcare professionals. In a well-known clinical study that also looked at the age of onset, another group with three or more, but fewer than six, symptoms as defined by DSM-IV, a) did not exhibit a consistent pattern of genetic transmissibility, and b) had milder functional impairment, raising doubts about the validity of "subthreshhold" or "subclinical ADHD."

Etiology of syndrome
A further problem is that ADD and ADHD are syndromes, associations of symptoms. There is no well established cause for the condition. This means that it may actually be a blanket term covering a multitude of conditions with a variety of causes (although this is true of many physical and mental illnesses). In fact, genome scans have identified several gene alleles which are prevalent among individuals diagnosed with ADHD, but no single allele can account for all cases, and not all cases have been explained genetically.

Confusion may also arise from the fact that ADD/ADHD symptoms vary with each individual, and some mimic those of other causes. A known fact is that, as the body (and brain) matures and grows, the symptoms and adaptability of the individual also change. Many individuals diagnosed with ADD/ADHD successfully develop coping skills, while others may never do so.

There are numerous, often contradictory, claims that the brain is physically different in children with ADHD. However, even if this eventually is confirmed, by no means does it establish that the condition is biological. Behavior can cause changes to the structure of the brain. For example, learning Braille causes enlargement of the part of the motor cortex that controls finger movements. After they have passed their licensing exam, London taxi drivers have been found to have a significantly enlarged hippocampus compared to non-taxi drivers. Patients abused during their childhood with post traumatic stress disorder will have a flattened out hippocampus. Professional musicians have brains that are different from non-musicians. Monks who meditate show measurable differences in their prefrontal lobes.) So diminished concerted effort when confronted with tasks thought to be drudgery (homework, paying attention to teachers, and the like) even if not caused by differences in the brain, could have brain changing effects.  Also a recent study  found childhood television viewing was associated with attention problems in adolescence, independent of early attention problems and other confounders. These results support the hypothesis that childhood television viewing may contribute to the development of attention problems and suggest that the effects may be long-lasting.

Views from neurodiversity
Another view is that while there does exist a phenotype that corresponds roughly to the ADHD diagnostic criteria, this phenotype should not necessarily be described as a pathology. Some psychiatrists have argued that ADHD may represent an evolutionary advantage. There are many phenotypes considered normal-variant, which have liabilities, and perhaps some advantages as well, such as homosexuality and left-handedness. In other words, ADHD may be better seen as a form of neurodiversity.

Questions about the falsifiability of the disorder
A minority but vocal number of critics have stated that ADHD is not falsifiable and that ADHD is simply a list of symptoms. Yet, theories for the origin of ADHD behaviour were made as far back as 1902 by George Still. He believed these behaviours could be explained a "notion of defective volitional inhibition and moral regulation of behavior". Numerous theories from other researchers have been made since then with most current theories focusing on inhibition as the core deficit of ADHD. These critics have not addressed the history of the disorder nor have they addressed the numerous examples of theories of ADHD in any of their writings.

Some critics also believe that even if a sharp objective difference is found between ADHD and non-ADHD groups, that this does not prove that the difference constitutes a disorder. They point out that behavior that is considered normal-variant like homosexuality or left-handedness, likely has a neurochemical or neuroanatomical basis as well.

The scientific community issued an International Consensus Statement on ADHD in January 2002 that rebutts this material:

Genetic basis of hyperactivity
Evidence suggests that hyperactivity has a strong heritable component. Candidate genes include dopamine transporter (DAT), dopamine receptor D4 (DRD4), dopamine beta-hydroxylase (DBH), monoamine oxidase A (MAOA), catecholamine-methyl transferase (COMT), serotonin transporter promoter (SLC6A4), 5-hydroxytryptamine 2A receptor (5-HT2A), and 5-hydroxytryptamine 1B receptor (5-HT1B).

Genome wide surveys have shown linkage between ADHD and loci on chromosomes 7, 11, 12, 15, 16, and 17. If anything, the broad selection of targets indicates the likelihood that ADHD does not follow the traditional model of a "genetic disease" and is better viewed as a complex interaction among genetic and environmental factors. As the authors of a review of the question have noted, "Although several genome-wide searches have identified chromosomal regions that are predicted to contain genes that contribute to ADHD susceptibility, to date no single gene with a major contribution to ADHD has been identified."

Chromosomes disaffecting health or life expectancy are not expressed by everyone with the same DNA, and have only been found in combination with one or more other chromosomes. One reason for this may be that nature selects against genetic abnormalities that do not have any advantage.

Although many theories exist, there is no definitive biological, neurological, or genetic etiology for "mental illness." The concept of mental illness has been criticized by authors such as Thomas Szasz in The Myth of Mental Illness. Szasz points out that diseases infect tissues, and in some cases perception, but not beliefs. From this perspective, neither belief, nor mental life in general, may have a biological basis.

Advocates of neurodiversity argue that heritable traits with no definitive biological pathology (for example, autism) are natural variations of biology. Additionally, heritable or inheritable behaviors that are often regarded as abnormal, such as hyperactivity, eccentricity, absentmindedness, or homosexuality are not disorders but natural variations of behavior. According to this view, neither hyperactivity nor inattention is a disorder. According to this view, the institutional designation of these characteristics as Attention Deficit Hyperactivity Disorder is an unfounded prejudice akin to social stigmas for red hair or short stature.

Lifestyle-related causes
Dr. Mary Megson argued in her presentation to the House Government Reform Committee on Autism and Vaccines (2000) that the apparent increases in both ADHD and autism are a result of the increasing use of vaccines that deplete vitamin A stores, combined with a G-protein defect. This is especially likely in a family where at least one parent suffers night blindness, she claimed. However, no research to substantiate her claims has appeared in any major peer-reviewed medical journal, and the "vaccine-vitamin hypothesis" is not generally accepted.

It has been suggested that the causes of the apparent ADHD epidemic lie in cultural patterns that variously encourage or sanction the use of drugs as a simple and expeditious cure for complex problems that may stem primarily from social and environmental triggers rather than any innate disorder. Some critics assert that many children are diagnosed with ADHD and put on drugs as a substitute for parental attention, causing massive disruption to other individuals and relationships, as well as to environments with dysfunctionally structured relationships such as are manifest in many classrooms. This criticism also includes the use of prescription drugs as a substitute for parental duties such as communication and supervision.

Hunter in a Farmer's Society theory
Proposed by Thom Hartmann, this evolutionary psychology theory holds that ADHD was an adaptive behavior for the "restless" hunter before agriculture became widespread. This idea may be used as either a working hypothesis or merely a mental model for approaching the condition. Scientific concern around Hartmann's theory revolves around the mismatch between the behaviours symptomatic of ADHD, and those he describes as being adaptive for hunters, which better fit a diagnosis of hypomania. A positive feature of the theory is the idea that thinking in terms of attentional 'differences' rather than attentional 'disorders' may direct effort toward utilizing an affected individual's strengths and uniqueness. Conversely, it could also reinforce a person's denial and refusal to seek treatment.

ADHD as a social construct
As with many conditions in the field of psychiatry, ADHD can be explained as a social construct rather than an objective 'disorder', see f.e. (Timimi, 2002). Critics who follow this view say, that while the traits that define ADHD exist and may be measurable, they lie within the spectrum of normal healthy human behaviour and are not dysfunctional.

In this view, in societies where passivity and order are highly valued, those on the active end of the active-passive spectrum may be seen as 'problems'. Medically defining their behaviour (by giving a label such as ADHD) serves the purpose of removing blame from those 'causing the problem'. This model would require removing "non-hyperinteractive" forms of attention deficit into a completely distinct diagnosis. Evidence presented against the social constructionist view comes from a number of studies that demonstrate significant differences between ADHD and typical individuals across a wide range of social, psychological, and neurological measures as well as those assessing various areas of functioning in major life activities. More recently, studies have been able to clearly differentiate ADHD from other psychiatric disorders in its symptoms, associated features, life course, comorbidity, and adult outcome adding further evidence to its view as a true disorder.

Proponents of the social construct theory see invocation of this evidence as a misunderstanding, nonetheless. The theory does not state that individuals across a behavioral spectrum are identical neurologically and that their life outcomes are equivalent. It is not surprising for PET scan differences to be found in people at one end of any behavioral spectrum. The theory simply says that the boundary between normal and abnormal is arbitrary and subjective, and hence ADHD does not exist as an objective entity, but only as a 'construct'.

Nor does evidence of successful treatment persuade the social constructionist; for example the American National Institute on Drug Abuse reports that Ritalin is abused by non-ADHD students partly for its ability to increase their attention. Evidence showing that ADHD is associated with certain liabilities does not appear to undermine this view either; normal-variant behavior could have certain liabilities as well, and a life outcome cannot be predicted with certainty for any given diagnosed individual.

Critics of the social constructionist view contend that it presents no evidence in support of its own position. Theories must present their details and mechanisms in as precise a manner as possible so that they are testable and falsifiable, and this theory is said to provide no such details. But proponents of the view disagree that criteria for falsifiability are lacking. One way, for example, is to show that there exists an objective characteristic possessed by virtually all diagnosed individuals which does not exist in any non-diagnosed individual. Current candidates for falsifiability include PET scans, genes, neuroanatomical differences, and life outcomes. However, none of these have been shown to be precise predictors of a diagnosis or lack thereof. Such criteria are generally fulfilled by well-understood medical diseases.

Critics of this view also assert that it is not consistent with known findings. For instance, they claim that ADHD is as frequent in Japan and China as in the US, yet in such societies (which supposedly favor child obedience and passivity) one would expect higher rates of ADHD if this theory were correct. However, this is also disputed on the grounds that more aggressively obedient societies may suppress 'symptoms' of rebellion or 'ADHD'. Of course, whether or not the societies of Japan and China value "passivity and obedience" is not experimentally verified; calling them such amounts to stereotyping. Additionally, rates of medical diagnoses in China cannot be a reliable indicator of ADHD prevalence, especially for such non-life-threatening disorders as ADHD, due to the large peasant population in that country who cannot easily seek the services of a trained child psychologist. Timimi's view has been seriously criticized by Russell Barkley and numerous experts in Child and Family Psychology Review (2005). In any case, it has been shown that Chinese and Indonesian clinicians give significantly higher scores for hyperactive-disruptive behaviors than did their Japanese and American colleagues when evaluating the same group of children.

Significant differences in the prevalence of ADHD across different countries have been reported, however (Dwivedi, 2005). Timimi himself cites a range of prevalence that goes from 0.5% to 26% as support for his theory.

Concerns about the impact of labeling
Dr. Thomas Armstrong, a prominent critic of ADHD as an objective disorder, has said that the ADHD label is a "tragic decoy" which erodes away the potential to see the best in every child. Armstrong is a proponent of the idea that there are many types of "smarts" and has adopted the term neurodiversity (first used by autistic rights activists) as an alternative, less damaging, label .Thom Hartmann became interested in ADHD when his son was diagnosed; Hartmann has said that the brain disorder label is "a pretty wretched label for any child to have to bear". Others have expressed concern that the brain disorder label can harm the self-esteem of a child and effectively become a self-fulfilling prophecy mainly through self-doubt. Even if the description of individuals with ADHD accurately fits many children and adults, the possibility that characteristics are not biological, but rather the result of failures in upbringing, brings into question whether laws should protect these individuals, who are labelled with "disabilities" such as impulsivity or poor focus on assigned tasks.

Dr. Russell Barkley expounds on labelling being a double-edged sword. He believes that there are many pitfalls to labelling but that by using a precise label, services can be accessed. He also believes that labelling also leads to greater understanding for the individual and how best to deal with the disorder with evidence based knowledge. Furthermore studies also show that the education of the siblings and parents has a signifcant impact on the outcome of treatment. Finally, Barkley states this about ADHD rights: "..because of various legislation that has been passed to protect them. There are special education laws with the Americans with Disabilities Act, for example, mentioning ADHD as an eligible condition. If you change the label, and again refer to it as just some variation in normal temperament, these people will lose access to these services, and will lose these hard-won protections that keep them from being discriminated against. . . ."

Concerns about medication
In the United States outpatient treatment for ADHD has grown from 0.9 children per 100 in 1987 to 3.4 per 100 in 1997. However it has held steady since then. Some have asserted that methylphenidate (Ritalin) is overprescribed; however, the incidence of ADHD is estimated at three to five percent of the population, while the number of children in the United States taking Ritalin is estimated at one to two percent. In a small study of four American communities, the reported incidence of ADHD varied from 1.6% to 9.4%. The study also found that only 12.5% of the children reportedly meeting the DSM-III-R ADHD criteria for ADHD had been treated with stimulants during the past year.

Many parents and professionals have raised questions about the safety of drugs used to treat ADHD, particularly methylphenidate. Despite belief to the contrary, no significant effects have been observed on physical stature or the emergence of tics. There is also concern that the use of stimulants, which increase the pulse rate, in those with heart or hypertension problems might cause serious health issues. Deaths attributed to methylphenidate are extremely rare, and are believed to be caused by interactions with other drugs. Matthew Smith died at age 14 after long-term use of Ritalin. The medical examiner determined that Smith died from Ritalin usage, but medical experts dispute this. The examiner also argued that it was likely that diabetic children were at higher risk for cardiac problems.

The Pediatric Advisory Committee of the Food and Drug Administration (FDA) released a statement on June 30, 2005, identifying two possible safety concerns regarding Concerta and other brands of methylphenidate: psychiatric adverse events and cardiovascular adverse events. After looking into the deaths of 25 people, including 19 children, the FDA advisory panel voted, on February 9, 2006, in favor of requiring Ritalin and other stimulant drugs to carry a strong "black box" warning.

A new concern, raised by a small-scale 2005 study, is that methylphenidate might cause chromosome aberrations, and suggested that further research is warranted considering the established link between chromosome aberrations and cancer and considering that all the children in this study showed suspicious DNA changes within a very short time. A team from the Food and Drug Administration (FDA), the National Institutes of Health (NIH) and the Environmental Protection Agency (EPA) went to Texas on May 23, 2005 to evaluate the methodology of the study. Dr. David Jacobson-Kram of the FDA said that the study had flaws in its methods but that its results could not be dismissed. Flaws cited are (1) that the study did not include a control group on placebo, and (2) that it is too small. Several research teams will attempt to replicate the study on a larger scale.

Addiction
People with ADD appear to be more likely to be addicts in adulthood. A 2006 study found that those affected by ADHD are naturally at an increased risk of substance abuse and cigarette smoking, but treatment of ADHD decreases that risk. A 2003 project also suggests that boys with ADHD who are treated with stimulants like methylphenidate are actually less likely to abuse drugs (including alcohol) later in life.

Illicit use
Some people use/abuse methylphenidate recreationally by crushing the tablets and snorting them thus changing the typical therapeutic delivery system. The "high" results from the rapid increased rate of dopamine transporter blockade due to quicker absorption into the bloodstream. When used recreationally, the effect of Ritalin is similar to that of cocaine or amphetamine and can lead to addiction. When taken orally in prescribed doses, methylphenidate has a low addiction liability and rarely produces a "high". Both the United States Drug Enforcement Administration (DEA) and the United Nations International Narcotics Control Board have expressed concern about the ease with which legally prescribed methylphenidate is diverted to the illicit market. According to the DEA, "The increased use of this substance [MPH] for the treatment of ADHD has paralleled an increase in its abuse among adolescents and young adults who crush these tablets and snort the powder to get high. Youngsters have little difficulty obtaining methylphenidate from classmates or friends who have been prescribed it."

Volkow et al. (1995) found that the slow clearance of methylphenidate from the brain may discourage the repeated self-administration found in other addictions, reducing the addictive liability of methylphenidate.

In some areas, particularly where other illicit stimulants such as amphetamines are not as common, methylphenidate is popular amongst intravenous drug users. While not all available tablets can be readily prepared for injection, the standard brand name Ritalin tablets can be dissolved easily in water, making them ideal for intravenous use. This can be quite dangerous, however, as many available methylphenidate tablets use talc as a filler. The intravenous injection of talc can result in serious health problems, particularly pulmonary granulomas, which can lead to pulmonary fibrosis and pulmonary hypertension. This often leads to problems breathing, and in some cases, death.

A study conducted by the University of Michigan's Substance Abuse Research found that in a survey of over 10,000 college students, up to 25% of them had used Ritalin non-medically. The demographic of these students also admitted they were more likely to smoke cigarettes and marijuana, as well as take cocaine, ecstacy, and other drugs.

Street names for Ritalin include: vernies, diet coke, kiddie cocaine, kiddie coke, vitamin R, R-ball, poor man's cocaine, rids, ritz, skittles, R-pop, baby blow, coke junior, smarties, and study buddies.

Street names for Adderall include: Addy, smarts, brain food, red (or Orange) fix, little speedy, and Altoids.

Scientology/ antipsychiatry and the ADHD Controversy
According to a 1990 article by Joel Sappell and Robert W. Welkos in the Los Angeles Times, part of a series of articles about Scientology, "the uproar over Ritalin was triggered almost single-handedly by the Scientology movement." The Citizens Commission on Human Rights, an anti-psychiatry group formed by Scientology in 1969, conducted a major campaign against Ritalin in the 1980s and lobbied Congress for an investigation of Ritalin. Cass Ballenger, a member of the House Education and Labor Committee who met with the Citizens Commission said that "some of the information they provided did not 'add up.'" For example, the article mentions that the Committee claimed a figure of 10-20% of students under age 10 on Ritalin in a particular school district, to which the manager of health services for the district replied, "if they are saying that is the statistic ... they are lying," stating that the percentage of students taking Ritalin or any stimulant for hyperactivity was actually under 1%.

Scientology publications identified the "real target of the campaign" as "the psychiatric profession itself" and claimed the campaign "brought wide acceptance of the fact that (the commission) [sic] and the Scientologists are the ones effectively doing something about [...] psychiatric drugging".

Two of the most famous Ritalin critics Fred Baughman and Peter Breggin would be considered part of the Anti-Psychiatry movement. . They both testified at the Congressional hearing on Ritalin in 2000 and both played a major role in conveying the Anti-Psychiatry message to the public in the popular media during that era and continue to do so. Breggin also played a major role in the failed Ritalin class action lawsuits. While both doctors had associations with Scientology in the past, neither belongs to the church. Baughman worked as a medical expert for the CCHR and Breggin had ties to the church but cut off all associations with Scientology in 1974. Baughman, Breggin, and the CCHR share the same ideas and also share content. Breggin and Baughman have written a paper together, while Baughman contributes content to the CCHR. Breggin is also often cited as a reference on CCHR webpages and written material. .