User:Sifaka/Attention-deficit hyperactivity disorder: controversies

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PET scans show which parts of the brain are being used at a particular moment. In this example, the parts of the brain being used by someone diagnosed with ADHD is compared to the brain activity of a person not diagnosed with ADHD when both have been assigned a task requiring attention. The controversial issue is that the dramatic nature of this photograph is often used to "prove biological causality"^{[citation needed]} whereas it simply may represent the expected, ie persons with ADHD are not attending to the assigned task

The mainstream scientific consensus is that Attention-deficit hyperactivity disorder (ADHD) is a genuine disorder which impairs functioning^[1], and that many adverse life outcomes are associated with ADHD. There are an assortment of critical positions that individually challenge the ontology or preconceptions of the diagnosis as it is defined in the the American handbook, The Diagnostic and Statistical Manual of Mental Disorders IV-TR.

The ADHD diagnosis identifies characteristics such as hyperactivity, forgetfulness, poor impulse control, and distractibility, as symptoms of a neurological pathology^{[citation needed][2]}

Among the issues are disagreements over the cause of ADHD, differences over research methodologies^[3], and skepticism toward its classification as a mental disorder.^[4] Critics also express concerns over the effects of diagnosis on the mental state of patients^[4] and the effects of the medication used in the treatment of ADHD ^[5].

Some movements deny the existence of ADHD altogether and question virtually all that is believed about ADHD. Many are social critics mainly from the Antipsychiatry movement. Certain religions, especially Scientology, are highly skeptical that the diagnosis denotes a genuine impairment. Individual medical professionals and other prominent media personalities also question the disorder. Antipsychiatry and Scientology 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^[4].

[edit] Status as a disorder

Scientific researchers have found ADHD causes impairment in life functioning and that behaviour associated with ADHD has been clinically shown to be abnormal in those with ADHD.^[6].

[edit] Skepticism towards diagnosis

ADHD is widely recognized by national mental health institutions as being a disorder. ^{[7] [8] [9]} Since its inclusion in the DSM-IV, the number of people diagnosed with ADHD in the U.S. and UK grew dramatically in the '90s. Still, a vocal minority of social 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 contrary to the mainstream scientific consensus^[10][11], the symptoms are not supported by sufficient empirical data.^[12]

Behavior checklists, such as the Brown scale or the Conners scale, may be one component of information used in a competent diagnosis. Yet, a minority of social critics point out that these behaviors may be interpreted subjectively, especially when family and cultural norms are taken into consideration. These critics believe that a diagnosis based on such a scale may actually be more subjective than objective.^[13] (see cultural subjectivism).

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.^[14] 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.^[15]

Those with ADHD commonly have another comorbid condition estimated at roughly 60 and 80%.^{[citation needed]}. Psychiatrists and social critics believe that this indicates that the nuances of diagnosis have not been adequately described; i.e. ADHD may be different from ADHD with other comorbid conditions such as conduct disorder or Tourette syndrome. ^{[citation needed]}

[edit] Sub-clinical ADHD

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."^[16]

[edit] Genetic basis of ADHD

Research indicates that there is a highly probable link between genetics and ADHD. Research suggests that ADHD is a heterogeneous disorder and that a large majority of ADHD arises from a combination of various genes.^[17] 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." ^{[citation needed]}

[edit] 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.^[18] However it has held steady since then.^[19] Some^{[weasel words]} 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.^[20] 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.^[21]

Some^{[weasel words]} parents and professionals have raised questions about the safety of drugs used to treat ADHD, particularly methylphenidate.^[22] Despite belief to the contrary, no significant effects have been observed on the emergence of tics. [2] However, a recent study suggest that "long-term use of the drugs could stunt children's growth."[3] Moreover, the same study, "The Multimodal Treatment Study of Children with ADHD study concluded that while drugs such as Ritalin and Concerta worked in the short term, there was no demonstrable improvement in children's behavior after three years of medication."[4]

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.^{[citation needed]} 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.[5]

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.[6] 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.[7]

A new concern, raised by a small-scale 2005 study, is that methylphenidate might cause chromosome aberrations [8], 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.^{[citation needed]}

[edit] Alternative theories concerning ADHD

[edit] ADHD as a social construct

ADHD has been explained as a social construct rather than an objective 'disorder' by the social critic Timimi.^[23]. 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.^{[citation needed]}

Proponents of the social construct theory see invocation of this evidence as a misunderstanding, nonetheless.^{[citation needed]} 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 [9] 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.^{[citation needed]}

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.^{[weasel words]} 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.^{[citation needed]} Such criteria are generally fulfilled by well-understood medical diseases.^{[citation needed]}

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^{[citation needed]}, yet in such societies (which supposedly favor child obedience and passivity) one would expect higher rates of ADHD if this theory were correct.^[clarify] 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.^{[citation needed]} 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.^[24]

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.

[edit] Evidence questioned

Critics have questioned the objectiveness of many of the studies regarding the existence and prevalence of ADHD, as well as clinical trials of ADHD medications. A common assertion by critics is that drug company involvement in clinical trials has created an inherent conflict of interest. Critics routinely dismissed any positive results observed during clinical trials of ADHD medications as manifestations of the placebo effect.

Critics may^{[weasel words]} attribute anecdotal evidence from parents and teachers to avoidance of responsibility, adultism, or authoritarianism.

[edit] Scientology/ antipsychiatry attempts to create 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."^[25] 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%.^[25]

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".^[25]

Two of the most famous Ritalin critics Fred Baughman and Peter Breggin would be considered part of the Anti-Psychiatry movement.^{[26][27][28][29]} 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.^{[30][31][32][33][34][35]}

[edit] See also

• Anti-psychiatry
• Biopsychiatry controversy
• Oppositional Defiance Disorder
• The Gene Illusion

[edit] Notes

[edit] External links

• ScienceDaily: ADD and ADHD News
• Simon Sobo, MD, "ADHD and Other Sins of Our Children"