Attention-deficit hyperactivity disorder controversies

Overview
Attention-deficit hyperactivity disorder (ADHD) is a developmental, neurobehavioural disorder, widely recognized by the medical and scientific community as causing impairment, especially in children. The diagnosis and treatment of Attention deficit–hyperactivity disorder (ADHD) remains a controversial disorder, despite it now being a well validated clinical diagnosis. Continued claims that the diagnosis and treatment of the disorder deserve greater scrutiny are made by some news sources, social critics, religions, individual medical professionals, and the United Kingdom government. Ethical and legal issues with regard to treatment have been key areas of concern. The UN's International Narcotics Control Board issued warnings in 1996 about the dramatically increasing use of methylphenidate, primarily in the United States although the use of medication has leveled off. They were concerned that the use of Ritalin was being actively promoted by an influential parent association, which had received significant financial contributions from the preparation's leading United States manufacturer. In response to their own concern that ADHD was being diagnosed too often, in May 2000, after more than two years of deliberation, the American Academy of Pediatrics (AAP) issued a more careful set of standards and guidelines to aid clinicians than merely using DSM-IV. Among the other issues are: disagreements over the cause of ADHD, differences over research methodologies, skepticism toward its classification as a mental disorder, and the effects of diagnosis on the mental state of patients,.

Some movements deny the existence of ADHD altogether and question virtually all mainstream beliefs about ADHD; among these are social critics. Certain religions, especially Scientology, which is against almost all aspects of psychiatric practice are highly skeptical that the diagnosis denotes a genuine impairment.

Skepticism towards ADHD as a Biological Illness and alternative theories concerning ADHD
One of the most controversial issues regarding ADHD is whether it is wholly or even predominantly a biological illness, a defect in the brain. The current predominance of opinion in medicine is that this is the case, but scientists can't conclusively state what causes ADHD. Examples of this ongoing disagreement are found wherever research will support or not support the biological argument. There are radically different opinions between researchers in the field and other critics about whether there is a genetic basis. While there have been repeated articles citing physical differences in the brain of those with ADHD most of these have not stood up. Xavier Castellanos MD, then head of ADHD research at the National Institute of Mental Health (NIMH), and firmly convinced that ADHD is a biological illness,  acknowledged that little ia known about ADHD in the 2000 interview with Frontline. Critics of Dr. Castellanos’ own research have pointed out that the differences he was claiming do exist could have been the result of medication taken. ( He has since been working on eliminating this variable) However, even if differences in the brain will be found, an important issue is that the physical brain  can be changed by patterns of behavior. Thus 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 ( e.g. homework, paying attention to teachers, and the like) even if not caused by differences in the brain, could have brain changing effects. In “Rethinking ADHD: International Perspectives” an alternative paradigm for ADHD argues that, while biological factors may obviously play a large role in  difficulties sitting still and/or  concentrating on schoolwork in some children, the vast majority of children manifesting this behavior do not have a biological deficit. For a variety of reasons they have failed to integrate into their psychology the ability to work at chores that are expected of them. Their restlessness and daydreaming is similar to the behavior of other, normal children when they are not engaged, and are bored and trapped by circumstances. Very frequently, children with ADHD/ADD have no difficulty concentrating on activities that they find to be interesting, or fun, (for example video games, which require enormous attention skills). When they are taught by a charismatic entertaining teacher, they similarly can concentrate.

Genetic basis of ADHD
Current research suggests that ADHD is a heterogeneous disorder caused by a complex interaction of genetic and environmental factors and thus cannot be modeled accurately using the single gene theory. Authors of a review of ADHD etiology 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." Critics debate the genetic basis of ADHD, for example Dr. Joseph Glenmullen has focused his criticism based on the single gene theory, "no claim of a gene for a psychiatric condition has stood the test of time, in spite of popular misinformation". Although many theories exist, there is no definitive biological, neurological, or genetic etiology for "mental illness."

Increase in use of stimulant medication on children
Over a decade ago, outpatient treatment for ADHD in the US grew from 0.9 children per 100 in 1987 to 3.4 per 100 in 1997. However it has held steady since then. There is concern about the rising use of methylphenidate (Ritalin), mainly to treat ADHD and similar disorders, in the UK. 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.

Drug safety
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 the emergence of tics.

Past studies suggested that "long-term use of the drugs could stunt children's growth." . However, more recent studies suggest that children eventually do reach normal height and weight. According to Wilens (2004), treated children with ADHD tend to grow at a slower rate but catch up during adolescence and adulthood. Psychostimulant medication can decrease appetite (they are from the same family as diet pills (Adderall is pure amphetamines) so it is important for parents to monitor their children's weight and to make sure they eat enough. If a child is not growing adequately, a popular practice is to put them on drug holidays, or planned stretches of time off medication.

The Multimodal Treatment Study of Children with ADHD study concluded that while drugs such as Ritalin and Concerta (a delayed release form of Ritalin) worked in the short term, there was no demonstrable improvement in children's behavior after three years of medication." Wilens and other professionals have successfully shown, however, that the controlled use of medication can reduce the likelihood of substance abuse later on.

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. Ephedrine, which was being sold in health food stores as a stimulant (and is a weaker version of this form of drug) caused enormous reaction from public health officials for this very quality. Pseudoephedrine, which is similar, has been attacked for its use in cold medicine given to children. Deaths attributed to methylphenidate are extremely rare, and are believed to be caused by undetected heart abnormalities and/or interactions with other drugs. Matthew Smith is purported to have 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 in 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 in 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.

Concerns about the impact of labeling
Parents are generally concerned that telling children they have a brain disorder will harm their self-esteem. Social critics believe that this knowledge can effectively become a self-fulfilling prophecy mainly through self-doubt. Dr. Thomas Armstrong states that the ADHD label is a "tragic decoy" which severely erodes the potential to see the best in a 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 has said that the brain disorder label is "a pretty wretched label for any child to have to bear."

Dr. Russell Barkley believes labeling is a double-edged sword; there are many pitfalls to labeling but that by using a precise label, services can be accessed. He also believes that labeling can help the individual understand and make an informed decision how best to deal with the disorder using evidence based knowledge. Furthermore studies also show that the education of the siblings and parents has at least a short term impact on the outcome of treatment. Dr. Russell 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. . . ."

Media Coverage of the ADHD Controversy
In recent years the media has reported on the controversies about the treatment of ADHD. Dr Terence Kealey a clinical biochemist and Vice-Chancellor of the University of Buckingham wrote a highly critical opinion article for The Times. Following a BBC Panorama programme which highlighted US research. (The Multimodal Treatment Study of Children with ADHD by the University of Buffalo showing treatment results of 600) suggesting drugs are no better than therapy for ADHD in the long-term. Baroness Susan Greenfield, a leading neuroscientist, took a strong stand about the controversy regarding ADHD in the House of Lords. . PBS' Frontline ran a story  which has a large selection of interviews with important representatives of the various points of view. Included in this program is an interview with Xavier Castellanos then head of ADHD research at the National Institute of Mental Health (NIMH) which contradicts many statements made on this page about what we know and don't know about the biology of ADHD. .

Frontline did a second program about the controversies in the widespread diagnosis of children

Benedict Carey has written a number of critical articles in the New York Times on the practice of psychiatry, especially with children diagnosed with bipolar disorder and/or ADHD, for example, Parenting as Therapy for Child's Mental Disorders or What’s Wrong With a Child? Psychiatrists Often Disagree, Debate Over Children and Psychiatric Drugs

ADHD as a variably adaptive or maladaptive cognitive trait
Attempts have been made to reconcile the traditionally held social-science and neuroscience views. Genetic differences in dopamine receptors provide biological evidence of lower motivational effects of "low reward" activities in those with ADHD. This finding is nicely reconciled with the positive effects of more robust motivational reinforcement in those with ADHD and with the normalization of learning parameters to normal levels when the ADHD subject finds the material to be learned sufficiently stimulating. Taken together, the "ADHD phenotype" could be seen as a character trait which if harnessed correctly can lead to "highly ambitious" behavior on the one hand and an "amotivational state" on the other. In other words this phenotype of novelty-seeking could be a powerful driving force to spectacular success or alternatively could lead to a lack of desire to participate in anything in which the subject does not excel or find fascinating (author's comment).

The controversy involves the question of whether ADHD is maladaptive, and, if it is maladaptive, do we change the child or the environment? The medical model strongly favors changing the child with interventions that include medication and behavior modification.

Conversely, schools and the medical model force children to conform to a narrow, predefined standard of child development. The argument in regard to ADHD derives from concerns that medical professionals and individuals within the USA education system are pushing a dangerous viewpoint; namely, that children with ADHD are mentally ill, abnormal, disabled, maladaptive, etc., because they do not conform to a socially constructed norm. Some people including retired neurologist and CCHR medical expert Fred Baughman have suggested that this viewpoint is ultimately being pushed by the pharmaceutical industry in order to sell Anti-ADHD drugs. Moreover, the argument against ADHD asserts that changing the child through medication regimes may cheat them of certain unique and positive personal characteristics that in turn may limit our collective future. For example, Ben Franklin was notorious for being a failure in the public education system yet became a highly regarded scientist, statesman, and public servant. Hartmann (2003) points out that had Ben Franklin been forced to fit in, the American Revolution may have never happened.

Social critics and claims of controversy
In 1990, a series of articles about Scientology were written in the Los Angeles Times. One article stated, "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. 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". Scientology still claims, "the controversy over the many deaths and irreversible damage caused by psychiatric drugs prescribed for children labeled with... ADHD continues to grow". The church contends that mental disorders don't exist and that, "mental and behavioral problems are largely incorrect diagnoses that cover symptoms and don't handle the real problems, which may be physical or spiritual". The Desert Morning news states that, "Scientologists are not afraid of hyperbole".

The social construct theory of ADHD is supported by both Scientology and critics in the Anti-Psychiatry movement such as Fred Baughman and Peter Breggin. 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 has been 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.