Deconstructing the ADHD "epidemic"

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Feb262010

Friday, February 26, 2010 at 12:59PM

In 2000, The American Academy of Pediatrics stated that ADHD is an epidemic.
8% of school-aged children were reported to have an ADHD diagnosis by their parent in 2003.
Diagnosis of ADHD increased an average of 3% per year from 1997 to 2006.
The production of stimulant medications Adderall and Dexedrine increased by 4,516%, while the production of Ritalin also increased by 375% from 1993 -2003 (U.S.D.E.A., 2003).

A few years ago, the Ecuadorian mother of a boy I was treating told me that her son's teacher wanted her son tested for ADHD for talking out in class. My client's mother wanted to know more about "this ADHD." I brought out the DSM IV statistical manual of mental disorders and showed her the entry for ADHD, which describes multiple "behavioral" symptoms of inattention and impulsivity, using phrases such as "often does not seem to listen when spoken to directly," "often blurts out answers before questions have been finished" or "often has trouble waiting one's turn."

The mother seemed to be in a state of culture shock. "This is a definition of children," she said.

The mainstream scientific response to this mother would be that ADHD is a spectrum disorder pathological only at the far-end of the continuum. But when we are close to placing 10 percent of our children at the far end of this continuum, one begins to suspect that the diagnostic criteria for the disorder is overly inclusive or that it is simply being misdiagnosed -- or both.

To understand the true origins of our current ADHD "epidemic," we need to look at the medical history of ADHD as it dovetailed with the rising influence of the pharmaceutical industry. Hyperactivity was originally associated with brain damage. In 1940, scientists discovered that amphetamines improved the behavior of brain-damaged hyperactive children. The 50s and 60s witnessed the explosive growth of the pharmaceutical industry and the deployment of increasingly sophisticated marketing techniques. By 1970, what had been thought of as a hyperactivity brain-damage syndrome morphed into a developmental neurological disorder and got the new name Minimal Brain Dysfunction. Drug companies had already cooked up 31 amphetamine preparations, were now producing billions of pills a year and funding expensive research studies. By 1997 we had an even less stigmatizing name, Attention Deficit Hyperactivity Disorder, with a new type (inattentive) and an extension of the age-range into adulthood. By the new millennium, mainstream science firmly decided that ADHD is a hereditary neurological disorder best treated with stimulants.

If we consider the history of ADHD, we cannot help but note an expansion of the criteria defining the illness running parallel to the discovery, and later the marketing, of an amphetamine treatment. Since doctors are not constrained even by the DSM's loosened protocols, there is little doubt that children on the unimpaired area of the spectrum receive the diagnosis. This expansion of market-share for the drug-companies should come as no surprise. They had the perfect pitch, true or not, for over-worked, guilt-ridden parents. "You are not to blame. Your son simply has an hereditary neurological disorder best treated with stimulants." And who doesn't feel at fault for their child's misbehavior?

Drug companies continue to push the message hard. They now spend 20 to 30 thousand dollars per American physician on junkets, free meals, trips, trainings, cash rewards to "high-prescribers" and free samples. It is now nearly impossible to find a researcher who advocates stimulants for ADHD who is not on a drug-company's payroll. The most famous case involved Harvard psychiatrist and stimulant-treatment guru Joseph Biederman, who admitted to congressional investigators that he had failed to report 1.6 million in payments from drug companies. Even the brilliant Dr. Russell A. Barkley, who wrote the book on executive function and ADHD, acknowledged receiving 24 percent of his income in 2007 as a speaker/consultant for Eli Lilly Co., Shire and Novartic, the makers of Strattera, Vyvanse and Ritalin respectively. It is hard to imagine how these researchers can remain objective when their self-interest leans toward a particular finding.

Even more sinister is how pharmaceutical companies have begun to infiltrate patient advocacy groups. CHADD, the largest ADHD patient advocacy group in America, receives almost 26 percent of its funding from drug-companies. CHADD appears to be a neutral patient-centric organization offering information, support groups, classes for parents, conferences, even a free "CHADD discount prescription card," but in part also functions as a conduit of information between the drug-companies and the public, going so far as to produce with Ciba-Geigy money a public service announcement advocating the Ciba-Geigy product Ritalin.

In part due to CHADD lobbying efforts, the Department of Education in 1991 issued a memorandum mandating that students with ADHD receive special education and/or related services. Many believe that the DOE memorandum was responsible for the explosion of ADHD diagnoses in the 1990s, as frustrated, easily blamed teachers now became major referral sources.

So here we are in 2010. We have a research establishment at least partially co-opted by the pharmaceutical industry, reluctant to question assumptions about the hereditary nature of ADHD and the long-term effects of stimulants. We have a sizable number of pediatricians and psychiatrists paid to receive pharmaceutical company talking points. And due to the work of CHADD and other seemingly neutral groups, we have a population of parents and teachers open to interpreting impulsive behavior and spaceyness as symptoms of a brain disease.

It is my guess that only a small percentage of children are correctly diagnosed with ADHD -- meaning they have biologically driven delays in frontal lobe development that prevents them from thinking before acting. Many of the misdiagnosed are probably mistreated children, as the behavioral symptoms of trauma and neglect are almost identical to ADHD. The well-known trauma researcher Jennifer Freyd, Phd. recently published a study indicating that teachers, responsible for the majority of ADHD referrals in the US, frequently identify children suffering from maltreatment and neglect as exhibiting ADHD symptomatology. The study goes on to warn that "we have a responsibility to investigate whether we are medicating abused or neglected children for misdiagnosed ADHD." The rest are no doubt children who lie in the mid-range of the spectrum, difficult, fidgety children with maybe more of a present-tense bias to their temperament, but unimpaired.

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Reader Comments (7)

I'd like to take issue with just a few aspects of your blog on the ADHD "epidemic." First, I'd have to say that I never want to be an apologist for pharmaceutical marketing. It is out of hand in so many ways, and the issues are complicated. But I seriously doubt that the quest for medication sales is what is driving the increased awareness of ADHD. Desperate parents with children at risk are the driver.

Second, I think that CHADD deserves a fairer evaluation. I've been a member for over a decade, and it has not made me or anybody wealthy with big pharmaceutical company money. From very up close, I can assure you that corporate dollars are not what drives CHADD. To those who complain that CHADD accepts donations from pharmaceutical manufacturers, I can only ask, “How much have you donated to support research on children’s mental illnesses?”

Most importantly, I have to take issue with the "over-diagnosis" claim. This is a very appealing narrative that just doesn't ring true. Although the expected prevalence may be near 8%, that is not the percentage diagnosed across the country. There are a few counties with high diagnoses rates, but generally, the disorder is still hugely under-diagnosed. It does a great disservice to the many children who are seriously impaired with ADHD to minimize it as merely "childhood." When so many children for whom treatment is indicated are not getting it, it is irresponsible to dismiss the disorder as a manufactured problem. As I said, it's a popular and persistent narrative. It just doesn't happen to be true.

I appreciate your taking some time to reconsider your perspective.

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Daniel Goldin, MFT, PsyD