Attention deficit hyperactivity disorder controversies

Attention deficit hyperactivity disorder (ADHD) controversies include concerns about its existence as a disorder, its causes, the methods by which ADHD is diagnosed and treated including the use of stimulant medications in children, possible overdiagnosis, misdiagnosis as ADHD leading to undertreatment of the real underlying disease, alleged hegemonic practices of the American Psychiatric Association and negative stereotypes of children diagnosed with ADHD. These controversies have surrounded the subject since at least the 1970s.^{[1][2]:p.23[3]}

The best course of ADHD management is major topic of debate. Stimulants are the most commonly prescribed medication for ADHD in the United States. The National Institute of Mental Health maintains that stimulants are considered safe when used under medical supervision,^[4] but there are concerns regarding the higher rates of schizophrenia and bipolar disorder, as well as increased severity of these disorders in individuals with a history of stimulant use for ADHD in childhood.^[5]

Status as a disorder

The controversy surrounding ADHD involves clinicians, scientists, teachers, policymakers, parents and the media with opinions regarding ADHD ranging from those who do not believe it exists to those who believe that there are genetic and physiological bases for the condition.^[6] While the existence of ADHD is generally accepted, controversy exists over the high rates of diagnosis in children and adolescents, the treatment of individuals with ADHD medically, educationally and legally, and whether treatment should continue into adulthood.^[7][8] The controversies around ADHD have been on-going at least since the 1970s.^[9] In the most accepted authority on clinical diagnoses of psychological behavior, the DSM-IV, ADHD is included as a genuine disorder while significant controversy surrounds how it is diagnosed and treated.^[8]

Researchers from McMaster University identified five features of ADHD that contribute to its controversial nature:

1. It is a clinical diagnosis for which there are no laboratory or radiological confirmatory tests or specific physical features.
2. Diagnostic criteria have changed frequently.
3. There is no curative treatment, so long-term therapies are required.
4. Therapy often includes stimulant drugs that have abuse potential.
5. The rates of diagnosis and of treatment substantially differ across countries.^[10]

Skepticism about the diagnosis

In 2002, Russell Barkley, a prominent researcher and author on the subject of ADHD, published The International Consensus Statement on Attention Deficit Hyperactivity Disorder (ADHD), signed by 86 psychiatrists and psychologists, including several of the most widely published and cited researchers in psychiatry, which asserts the existence of ADHD and denies the existence of controversy within the medical community.^[11] Two critiques of their statements have since been published in the peer reviewed literature questioning the negative tone they have used to describe researchers with views differing from their own.^[12][13] In 2010, Barkley published book ‘’ADHD in Adults: What the Science Says’’ where he stated that claims that ADHD is not a valid disorder are egregiously wrong and in the face of such overwhelming evidence to the contrary show either a stunning scientific illiteracy or a planned religious or political propaganda intended to deceive the uninformed or unsuspecting general public. Barkley points out numerous differences emerged in studies between those with ADHD and general population controls and between those with ADHD and Clinical control groups that make such assertions moribund.^[14]

In 2002, a survey among the general population in the U.S. found that of the 64% who had heard of ADHD, 78% believed it to be a "real disease".^[15] In the United States, African-American parents state that their friends and family are often unsure about the legitimacy of ADHD.^[16]

In 2002, 8 percent of readers of the British Medical Journal (BMJ) who answered an online survey listed ADHD as one of the 10 top "non-diseases". The BMJ survey defined non-diseases as meaning "a human process or problem that some have defined as a medical condition but where people may have better outcomes if the problem or process was not defined in that way." They did not deny that non-diseases do entail real problems or suffering. For example, obesity, hypercholesterolaemia, and menopause all received a greater number of votes on this survey.^[17][18]

In a June 2009 paper, the chair of the DSM-IV Task Force referred to one of DSM-IV’s unintended consequences as false "epidemics," attributing the sudden increases in the diagnosis of autism, bipolar disorder and ADHD to changes made in the DSM-IV definitions of those disorders.^[19]

Robins and Guze's^[20] criteria assert that the validity of any diagnosis must derive from empirical research and that some of this research must examine the neurobiologic causes and correlates of disorders. The Robins and Guze criteria view the validity of diagnoses as arising from empirical studies demonstrating the following: 1) the diagnosis has well-defined clinical correlates, 2) the diagnosis can be delimited from other diagnoses, 3) the disorder has a characteristic course and outcome, 4) the disorder shows evidence of heritability from family and genetic studies, 5) data from laboratory studies demonstrate other neurobiologic correlates of the disorder, and 6) the disorder shows a characteristic response to treatment. A 2005 review recognizes the ongoing controversial nature of ADHD among both clinicians and the general public. It found that it fulfills the Robins and Guze criteria which support the idea that ADHD is a valid diagnostic category.^[21] A 2008 review, however, came to the opposite conclusion and states that: "Evidence for a genetic or neuroanatomic cause of ADHD is insufficient. [...] ADHD is unlikely to exist as an identifiable disease."^[22]

Concerns about methods of diagnosis

ADHD is controversial in part because most children are diagnosed and treated based on decisions made by their parents and clinicians with teachers being the primary source of diagnostic information. Only a minority, about 20 percent, of children who end up with a diagnosis of ADHD show hyperactive behavior in the physician's office.^[23][24][25]

The number of people diagnosed with ADHD in the U.S. and UK has grown dramatically over a short period of time. 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.^[26]

ADHD is purely a diagnosis by exclusion with no definitive physical test.^[27] This leads to situations where one doctor would say a child needs psychotropic medication while another doctor could say the child is perfectly normal.^[28] Concern exists that "elevated but still developmentally normal levels of motor activity, impulsiveness, or inattention" traits of childhood could be inappropriately interpreted as ADHD.^[29][30] Psychiatrist Dr. Peter Breggin of Ithaca College argued that "Psychiatry has never validated ADHD as a biologic entity."^[31]

Over / under diagnosis

Overdiagnosis typically refers to children who are diagnosed with ADHD but should not be. These instances are termed as “false positives”. However, the “presence of false positives alone does not indicate overdiagnosis”. There may be evidence of overdiagnosis if inaccuracies are shown consistently in the accepted prevalence rates or in the diagnostic process itself. "For ADHD to be overdiagnosed, the rate of false positives (i.e., children inappropriately diagnosed with ADHD) must substantially exceed the number of false negatives (children with ADHD who are not identified or diagnosed)." ^[32] Children aged 8 to 15 years living in the community, indicated an ADHD prevalence rate of 7.8%. However, only 48% of the ADHD sample had received any mental health care over the past 12 months.^[33]

Evidence also exists of possible differences of race and ethnicity in the prevalence of ADHD. The prevalence of ADHD dramatically varies across cultures despite the fact that the same methodology has been used. Some believe this may be due to different perceptions of what clarifies as disruptive behavior, inattention and hyperactivity.^[34]

It is argued that over-diagnosis occurs more in well-off or less heterogeneous communities, whereas under-diagnosis occurs more frequently in poorer and minority communities due to lack of resources and lack of financial access. Those without health insurance are less likely to be diagnosed with ADHD. It is further believed that the “distribution of ADHD diagnosis falls along socioeconomic lines”, according to the amount of wealth within a neighborhood. Therefore, the difficulty of applying national, general guidelines to localized and specific contexts, such as where referral is unavailable, resources are lacking or the patient is uninsured, may assist in the establishment of a misdiagnosis of ADHD.^[35]

Development can also influence perception of relevant ADHD symptoms. ADHD is viewed as a chronic disorder that develops in childhood and continues into adulthood. However, some research shows a decline in the symptoms of ADHD as children grow up and mature into adulthood. As children move into the stage of adolescence, the most common reporters of ADHD symptoms, parents and teachers, tend to focus on behaviors affecting academic performance. Some research has shown that the primary symptoms of ADHD were strong discriminators in parent ratings, but differed for specific age groups. Hyperactivity was a stronger discriminator of ADHD in children, while inattentiveness was a stronger discriminator in adolescents.^[36]

Issues with comorbidity is another possible explanation in favor of the argument of overdiagnosis. As many as 75% of diagnosed children with ADHD meet criteria for some other psychiatric diagnosis.^[34] Among children diagnosed with ADHD, about 25% to 30% have anxiety disorders, 9% to 32% have depression, 45% to 84% have oppositional defiant disorder, and 44% to 55% of adolescents have conduct disorder.^[36] Learning disorders are found in 20% to 40% of children with ADHD.^[34]

Another possible explanation of over-diagnosis of ADHD is the “relative-age effect,” which applies to children of both sexes. Younger children are more likely to be inappropriately diagnosed with ADHD and treated with prescription medication than their older peers in the same grade. Children who are almost a year younger tend to appear more immature than their classmates, which influences both their academic and athletic performance.^[37]

The debate of underdiagnosis, or giving a "false negative," has also been discussed, specifically in literature concerning ADHD among adults, girls and underprivileged communities. It is estimated that in the adult population, rates of ADHD are somewhere between 4% and 6%.^[38] However, as little as 11% of these adults with ADHD actually receive assessment, and furthermore, any form of treatment.^[39] Between 30% and 70% of children with ADHD report at least one impairing symptom of ADHD in adulthood, and 30% to 50% still meet diagnostic criteria for an ADHD diagnosis.^[40]

Research on gender differences also reveals an argument for underdiagnosis of ADHD among girls. The ratio for male-to-female is 4:1 with 92% of girls with ADHD receiving a primarily inattentive subtype diagnosis.^[34] This difference in gender can be explained, for the majority, by the different ways boys and girls express symptoms of this particular disorder.^[41] Typically, females with ADHD exhibit less disruptive behaviors and more internalizing behaviors.^[32][42] Girls tend to show fewer behavioral problems, show fewer aggressive behaviors, are less impulsive, and are less hyperactive than boys diagnosed with ADHD. These patterns of behavior are less likely to disrupt the classroom or home setting, therefore allowing parents and teachers to easily overlook or neglect the presence of a potential problem.^[41] The current diagnostic criteria appear to be more geared towards males than females, and the ADHD characteristics of men have been over-represented.^[43] This leaves many women and girls with ADHD neglected. Studies have shown that girls with ADHD, especially those with signs of impulsivity, were three to four times more likely to attempt suicide when compared with female controls. Additionally, these girls were two to three times more likely to engage in self-harming behaviors.^[42]

As stated previously, underdiagnosis is also believed to be seen in more underprivileged communities. These communities tend to be poorer and inhabit more minorities. More than 50% of children with mental health needs do not receive assessment or treatment. Access to mental health services and resources differs on a wide range of factors, such as “gender, age, race or ethnicity and health insurance”. Therefore, children deserving of an ADHD diagnosis may never receive this confirmation and are not identified or represented in prevalence rates.^[32]

In 2005, 82 percent of teachers in the United States considered ADHD to be over diagnosed while three percent considered it to be under diagnosed. In China 19 percent of teachers considered ADHD to be over diagnosed while 57 percent considered it to be under diagnosed.^[44]

Changing diagnostic criteria

For over seventy years in the United States, symptoms of what is now called ADHD have had different labels.^[45] The fact that the diagnostic criteria and the name used to describe the set of characteristics that make up ADHD have changed over time has led to concerns.^[3][46]

Suggestions have been made for a potential revision of the DSM-IV to prevent misdiagnosis, specifically for ADHD. A revision would help with deciphering between the common clinical profiles of “pure ADHD” and ADHD with comorbid externalizing behaviors, like conduct disorder and oppositional-defiant disorder, and internalizing behaviors, like anxiety.^[36] A reason for this distinction is due to behaviors exhibited by children with ADHD that are actually related to functional impairment caused by symptoms of comorbid disorders.^[47]

Views of ADHD outside North America

In 2009, the British Psychological Society and the Royal College of Psychiatrists, in collaboration with the National Institute for Clinical Excellence (NICE), released a set of diagnosis and treatment guidelines for ADHD.^[2] These guidelines reviewed studies by Ford et al. that found that 3.6 percent of boys and 0.85 percent of girls in Britain qualified for a diagnosis of ADHD using the American DSM-IV criteria.^[48] The guidelines go on to state that the prevalence drops to 1.5% when using the stricter criteria for the ICD-10 diagnosis of hyperkinetic disorder used mainly in Europe.^[49]

A systematic review of the literature in 2007 found that the worldwide prevalence of ADHD was 5.29 percent, and that there were no significant differences in prevalence rates between North America and Europe. The review did find differences between prevalence rates in North America and those in Africa and the Middle East, but cautioned that this may be due to the small number of studies available from those regions.^[50]

Norwegian National Broadcasting (NRK) broadcast a short television series in early 2005 on the extreme increase in the use of Ritalin and Concerta for children. Sales were six times higher in 2004 than in 2002. The series included the announcement of a successful group therapy program for 127 unmedicated children aged four to eight, some with ADHD and some with oppositional defiant disorder.^[51]

Anti-psychiatry and critical psychiatry movement

Members of the anti-psychiatry movement such as Fred Baughman and Peter Breggin^{[52][53][54][55]} have extensively used the popular media, as well as made a comment^[56] on medical literature to criticize ADHD and medications used for ADHD. They have testified at Congressional hearings on the use of Ritalin and supported legal challenges such as the Ritalin class action lawsuits. There is also a movement called critical psychiatry that often refers to their writings, but in contrast to Scientologists (see below), they are not "anti-psychiatry," but critics of some of its practices and offer alternative models and perspectives.^[57]

Scientology

The Church of Scientology, which opposes all forms of psychiatry, has vocally criticized ADHD and its treatments^[58] and played a leading role in the anti-Ritalin campaign in the late 1980s.^[59] The church states that treatment merely lessens the symptoms rather than addresses the underlying cause,^[60] "mental and behavioral problems are largely incorrect diagnoses that cover symptoms and don't handle the real problems, which may be physical or spiritual".^[61]

Personality trait

Some believe that many of the traits of those diagnosed with ADHD are personality traits and are not indicative of a disorder. These traits may be undesirable in modern society, leading to difficulty functioning in society, and thus have been labeled as a disorder.^[62] Some conservatives see ADHD as being an attack on masculine traits and the diagnosis and treatment of ADHD as an attack on traditional management of behavioral traits such as by discipline as well as intervention of the state into the sanctity of the family and the private citizen.^[63]

Questions concerning the cause

The pathophysiology of ADHD is unclear and there are a number of competing theories.^[64]

ADHD as a biological illness

A controversial issues regarding ADHD is whether it is wholly or even predominantly a biological illness leading to a chemical or structural defect in the brain. The predominance of opinion in 2001 in medicine was that ADHD is a mixture of genetics and the environment however the pathophysiology was unclear at that time.^[65] Xavier Castellanos, the former head of ADHD research at the National Institute of Mental Health (NIMH), was "firmly convinced that ADHD is a biological illness" in 2000, but he also noted, regarding ADHD and the brain, "We don't yet know what's going on in ADHD."^[66] Neuroimaging and genetic studies have revealed associations with ADHD, however according to NICE ADHD itself does not represent a neurological disease.^[2]

Frequently observed differences in the brain between ADHD and non-ADHD patients have been discovered,^[67] but it is uncertain if or how these differences give rise to the symptoms of ADHD. Results from various types of neuroimaging techniques suggest there are differences in the brain, such as thinner regions of the cortex, between individuals with and without ADHD.^[68]

Although ADHD is said to be highly heritable and twin studies suggest genetics are a factor in about 75% of ADHD cases, it has been argued that ADHD is a heterogeneous disorder^[69] 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 in 2004 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.",^[70] although many further studies have occurred since. The Online Mendelian Inheritance in Man (OMIM) database has a listing for ADHD under autosomal dominant heritable conditions, claiming that multiple genes contribute to the disorder. As of 2014, OMIM listed 6 genes with variants that have been suggested to contribute to ADHD.^[71]

Hunter vs. farmer hypothesis of ADHD

The hunter vs. farmer hypothesis is an idea proposed by author Thom Hartmann about the origins of attention-deficit hyperactivity disorder (ADHD), who believes that these conditions may be a result of adaptive behavior of the species, his theory states that those with ADHD retain some of the older hunter characteristics.^[72]

Social construct theory of ADHD

It has been argued that even if it is a social construct, this does not mean it is not a valid condition, for example obesity has different cultural constructs but yet has demonstrable adverse effects associated with it.^[73] A minority of these critics maintain that ADHD was "invented and not discovered". They believe that the disorder does not exist and that the behavior observed is not abnormal and can be better explained by environmental causes or just the personality of the "patient."^[74]

Concerns about medication

The National Institute of Mental Health recommends stimulants for the treatment of ADHD, and states that, "under medical supervision, stimulant medications are considered safe".^[4] A 2007 drug class review found no evidence of any differences in efficacy or side effects in the stimulants commonly prescribed.^[75]

Frequency of stimulant use

Between 1993 and 2003 the worldwide use of medications that treat ADHD increased almost threefold.^[76] Most ADHD medications are prescribed in the United States.^[76] In the 1990s, the US accounted for 90% of global use of stimulants such as methylphenidate and dextroamphetamine. By the early 2000s, this had fallen to 80% due to increased usage in other countries.^[77] In 2003, doctors in the UK were prescribing about a 10th of the amount per capita of methylphenidate used in the US, while France and Italy accounted for approximately one twentieth of US stimulant consumption.^[77] These assertions appear to contradict the 2006 World Drug Report published by the United Nations Office on Drugs and Crime, which indicate the US constituted merely 17% of the world market for dextroamphetamine.^[78] They assert that in the early 2000s amphetamine use was "widespread in Europe."^[78]

In 1999, a study constructed with 1,285 children and their parents across four U.S. communities has shown 12.5% of children that met ADHD criteria had been treated with stimulants during the previous 12 months.^[79] On May 2000, the testimony of DEA Deputy Director Terrance Woodworth has shown that the Ritalin quota increased from 1,768 kg in 1990 to 14,957 kg in 2000. In addition, IMS Health also revealed the numerous use of Adderall prescription have increased from 1.3 million in 1996 to nearly 6 million in 1999.^[80]

Concerns about side effects and long-term effectiveness

Some parents and professionals have raised questions about the side effects of drugs and their long-term use.^[81] Magnetic resonance imaging studies suggest that long-term treatment with amphetamine or methylphenidate decreases abnormalities in brain structure and function found in subjects with ADHD, and improves function of the right caudate nucleus.^[82][83][84]

Reviews of clinical stimulant research have established the safety and effectiveness of long-term amphetamine use for ADHD.^[85][86][87] An evidence review noted the findings of a randomized controlled trial of amphetamine treatment for ADHD in Swedish children following 9 months of amphetamine use.^[88] During treatment, the children experienced improvements in attention, disruptive behaviors, and hyperactivity, and an average change of +4.5 in IQ.^[88] It noted that the population in the study had a high rate of comorbid disorders associated with ADHD and suggested that other long-term amphetamine trials in people with less associated disorders could find greater functional improvements.^[88] On February 9, 2006, the U.S. Food and Drug Administration voted to recommend a "black-box" warning describing the cardiovascular risks of stimulant drugs used to treat ADHD.^[89] Subsequently, the USFDA commissioned studies which found that, in children, young adults, and adults, there is no association between serious adverse cardiovascular events (sudden death, myocardial infarction, and stroke) and the medical use of amphetamine or other ADHD stimulants.^{[90][91][92][93]}

A 2008 review found that the use of stimulants improved teachers' and parents' ratings of behavior; however, it did not improve academic achievement.^[94] The same review also indicates growth retardation for children consistently medicated over three years, compared to unmedicated children in the study.^[94] Intensive treatment for 14 months has no effect on long-term outcomes 8 years later.^[95] No significant differences between the various drugs in terms of efficacy or side effects have been found.^[96][97]

Long-term effects

The effects of amphetamine on gene regulation are both dose- and route-dependent.^[98] Most of the research on gene regulation and addiction is based upon animal studies with intravenous amphetamine administration at very high doses.^[98] The few studies that have used equivalent (weight-adjusted) human therapeutic doses and oral administration show that these changes, if they occur, are relatively minor.^[98] The long-term effects on the developing brain and on mental health disorders in later life of chronic use of methylphenidate is unknown. Despite this, between 0.51% to 1.23% of children between the ages of 2 and 6 years take stimulants in the USA. Stimulants drugs are not approved for this age group.^[99][100]

While ADHD is associated with an increased risk of substance abuse, stimulant medications have been shown to reduce the risk of subsequent development of substance abuse.^[101][102]

A review found that young ADHD patients taking stimulant medication may have a reduced rate of height and weight gain during adolescence, but these effects become lesser over time and stimulant medication may not have an effect on the ultimate weight and height of the medicated patient.^[103] It is unclear whether the delay in growth is due to stimulant medication or ADHD itself; ethical problems in giving stimulant medication to children without ADHD as experimental controls makes such studies problematic.^[104] Some patients will take a period of time off of medication, called a "drug holiday," in hopes of allowing the normal rate of height and weight attainment to resume.^[104] Stimulant medication may also inhibit cartilage growth, liver development and central nervous system growth factors.^[104] Periodic CBC, differential, and platelet counts are recommended during prolonged use of methylphenidate.^[105]

Dr. Fred Baughman wrote that "there is absolutely no scientifically valid evidence that compliant-drugged students learn faster."^[106]

Coercion

It is often not a child's decision to take medication, especially those under the age of six, a group that is seeing a dramatic increase in the prescription of psychiatric medications. Some schools have attempted to require treatment with medications before allowing a child to attend school.^[107] The United States has passed a bill against this practice.^[107] Thus ethical concerns regarding forced treatment or coercion of minors arise. Some suspect that children are using stimulants as a cognitive enhancer at the request of their achievement-oriented parents.^[108]

Non specific nature

Stimulants are often seen as cognitive enhancers or smart drugs. Their effects are non-specific with similar results seen in children and adults with and without ADHD. One finds improved concentration and behavior in all.^[109][110] Due to their non-specific activity, stimulants have been used by writers to increase productivity,^[111] as well as by the United States Air Force to improve concentration in combat.^[112] A small number of scientists recommend widespread use by the population to increase brain power.^[108]

Stimulant misuse

Stimulants are controlled psychotropic substances. They are classified as Schedule II substances (Schedule II: Potential for abuse; potential for psychological or physical addiction; currently accepted medical use).^[113]

Controversy has surrounded whether methylphenidate is as commonly abused as other stimulants with many proposing that its rate of abuse is much lower than other stimulants. However, the majority of studies assessing its abuse potential scores have determined that it has an abuse potential similar to that of cocaine and d-amphetamine.^[114]

Both children with and without ADHD abuse stimulants, with ADHD individuals being at the highest risk of abusing or diverting their stimulant prescriptions. Between 16 and 29 percent of students who are prescribed stimulants report diverting their prescriptions. Between 5 and 9 percent of grade/primary and high school children and between 5 and 35 percent of college students have used nonprescribed stimulants. Most often their motivation is to concentrate, improve alertness, "get high," or to experiment.^[115]

Stimulant medications may be resold by patients as recreational drugs, and methylphenidate (Ritalin) is used as a study aid by some students without ADHD.^[116]

Non-medical prescription stimulant use is high. A 2003 study found that non prescription use within the last year by college students in the US was 4.1%.^[117] A 2008 meta analysis found even higher rates of non prescribed stimulant use. It found 5% to 9% of grade school and high school children and 5% to 35% of college students used a nonprescribed stimulant in the last year.^[115]

Substance use disorders

Studies investigating whether stimulant medication can lead to drug abuse later in life found that despite the higher rate of substance abuse among ADHD patients as a whole, stimulant medication use in childhood did not affect or lowered, the risk for substance of abuse in adulthood compared to unmedicated individuals with ADHD.^[118]

A 2009 review, and a 2006 study, found that those who had received stimulants during childhood showed the highest number of cocaine abusers in adulthood, twice that of the other groups thus suggesting that stimulant use during childhood was associated with sensitising or predisposing children to cocaine abuse later in life. Smoking tobacco also appeared to increase the risk of cocaine abuse in this population but even after controlling for tobacco exposure cocaine abuse was still significantly higher in adults who had been medicated with stimulants as children. This risk was still present 15 years after stimulant medication exposure.^[119][120]

Advertising

In 2008 five pharmaceutical companies received warning from the FDA regarding false advertising and inappropriate professional slide decks related to ADHD medication.^[121] In September 2008 the FDA sent notices to Novartis Pharmaceuticals and Johnson & Johnson regarding advertisings of Focalin XR and Concerta in which they overstated products' efficacies.^[122][123] A similar warning was sent to Shire plc with respect to Adderall XR.^[124]

Financial conflicts of interest

Russell Barkley, a well-known ADHD researcher, received payment from pharmaceutical companies for speaking and consultancy fees. There are concerns that this may bias his publications.^[125]

In 2008, it was revealed that Joseph Biederman of Harvard, a frequently cited ADHD expert, failed to report to Harvard that he had received $1.6 million from pharmaceutical companies between 2000 and 2007.^[126][127] E. Fuller Torrey, executive director of the Stanley Medical Research Institute which finances psychiatric studies, said "In the area of child psychiatry in particular, we know much less than we should, and we desperately need research that is not influenced by industry money."^[127]

Children and Adults with Attention-Deficit/Hyperactivity Disorder, CHADD, an ADHD advocacy group based in Landover, MD received a total of $1,169,000 in 2007 from pharmaceutical companies. These donations made up 26 percent of their budget.^[128] This has been viewed by some as a major conflict of interest.^[129]

Concerns about the impact of labeling

Russell Barkley believes labeling is a double-edged sword; there are many pitfalls to labeling but 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.^[130] Furthermore studies also show that the education of the siblings and parents has at least a short-term impact on the outcome of treatment.^[131] 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. ..."^[130] Psychiatrist Harvey Parker, who founded CHADD, states, "we should be celebrating the fact that school districts across the country are beginning to understand and recognize kids with ADHD, and are finding ways of treating them. We should celebrate the fact that the general public doesn't look at ADHD kids as "bad" kids, as brats, but as kids who have a problem that they can overcome".^[132] However, children may be ridiculed at school by their peers for using psychiatric medications including those for ADHD.^[133]

Politics and the media

North America

In 2001 in the USA, PBS's Frontline ran a TV show titled "Medicating Kids."^[134] The program included a selection of interviews with representatives of various points of view. In a segment called "Backlash," Fred Baughman, retired neurologist, and Peter Breggin, founder of the International Center for the Study of Psychiatry and Psychology, the two of whom PBS described as "outspoken critics who insist [ADHD] is a fraud perpetrated by the psychiatric and pharmaceutical industries on families anxious to understand their children's behavior,"^[135] were interviewed on the legitimacy of the disorder. Russell Barkley and Xavier Castellanos, then head of ADHD research at the National Institute of Mental Health (NIMH), defended the viability of the disorder, although Castellanos stated that little is scientifically understood.^[136]

The validity of the work of many of the ADHD "experts" (including Biederman) has been called into question by Marcia Angell, former editor in chief of the New England Journal of Medicine,^[137] in her book review, "Drug Companies & Doctors: A Story of Corruption."^[138] Newspaper columnists such as Benedict Carey, science and medical writer for The New York Times, have also written controversial articles on ADHD.^[139][140]

In 1998, the US National Institutes of Health (NIH) released a consensus statement on the diagnosis and treatment of ADHD. The statement, while recognizing that stimulant treatment is controversial, supports the validity of the ADHD diagnosis and the efficacy of stimulant treatment. It found controversy only in the lack of sufficient data on long-term use of medications and in the need for more research in many areas.^[141]

In 2013, a long-term study, with an impressive sample of 15, 871 children, by Princeton economist Janet Currie et al. on the effect of increased use of Ritalin among children in Quebec due to a policy change suggested that the effect on average was negative, both in the short and long run.^[142][143]

United Kingdom

The National Institute for Health and Care Excellence (NICE) concluded that while it is important to acknowledge the body of academic literature which raises controversies and criticisms surrounding ADHD for the purpose of developing clinical guidelines, it is not possible to offer alternative methods of assessment (i.e. ICD 10 and DSM IV) or therapeutic treatment recommendations. NICE stated that this is because the current therapeutic treatment interventions and methods of diagnosis for ADHD are based on the dominant view of the academic literature.^[2]:p.133 NICE further concluded that despite such criticism, ADHD represented a valid clinical condition,^[2]:p.138 with genetic, environmental, neurobiological, and demographic factors.^[2]:p.139 Although the diagnosis has a high level of support from clinicians and medical authorities,^[2][144] a number of alternative theories^[145][146] explaining the symptoms of ADHD have been proposed; these views include the hunter vs. farmer hypothesis and the social construct theory of ADHD.

Baroness Susan Greenfield, a leading neuroscientist, wanted a wide-ranging inquiry in the House of Lords into the dramatic increase in the diagnosis of ADHD in the UK and its possible causes.^[147] This followed a BBC Panorama programme in 2007 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.^[147][148] In the UK medication use is increasing dramatically. Other notable individuals have made controversial statements about ADHD. Terence Kealey, a clinical biochemist and vice-chancellor of University of Buckingham, has stated his belief that ADHD medication is used to control unruly boys and girls behavior.^[149]

The British Psychological Society said in a 1997 report that physicians and psychiatrists should not follow the American example of applying medical labels to such a wide variety of attention-related disorders: "The idea that children who don't attend or who don't sit still in school have a mental disorder is not entertained by most British clinicians."^[29][150] In 2009, the British Psychological Society, in collaboration with the Royal College of Psychiatrists, released a set of guidelines for the diagnosis and treatment of ADHD.^[151] In its guideline, it states that available evidence indicate that ADHD is a valid diagnosis and that medication should be the first-line treatment for adults, for children with severe ADHD, or for children with mild ADHD who do not respond to non-medication interventions. However, it states that the diagnosis lack any biological basis and that "controversial issues surround changing thresholds applied to the definition of illness as new knowledge and treatments are developed and the extent to which it is acknowledged that clinical thresholds are socially and culturally influenced and determine how an individual's level of functioning within the 'normal cultural environment' is assessed". It further states that "the acceptable thresholds for impairment are partly driven by the contemporary societal view of what is an acceptable level of deviation from the norm."^[151]

Scientology

An article in the Los Angeles Times stated that "the uproar over Ritalin was triggered almost single-handedly by the Scientology movement."^[152] The Citizens Commission on Human Rights, an anti-psychiatry group formed by Scientologists in 1969, conducted a major campaign against Ritalin in the 1980s and lobbied Congress for an investigation of Ritalin.^[152] Scientology publications identified the "real target of the campaign" as "the psychiatric profession itself" and said that the campaign "brought wide acceptance of the fact that (the commission) [sic] and the Scientologists are the ones effectively doing something about [...] psychiatric drugging".^[152] However, Robert Whitaker in his book, Anatomy of an epidemic stated that ever since Eli Lilly used Scientology to their benefit to dismiss concerns regarding Prozac, pharmaceutical companies have successfully conditioned the public and the media to associate criticisms and controversies surrounding psychotropic drugs to being part of a Scientology conspiracy against their products and psychiatry in general.^[153]

The well-known Scientologist Tom Cruise's interview with Matt Lauer was widely watched by the public. In this interview he spoke about the use of medications for mood disorders and also referred to Ritalin and other medications as being "street drugs." The sale of stimulants on campuses is not uncommon; they are used by non ADHD students to tackle drudgery.^[154]

Imitation of symptoms

The symptoms of ADHD can be faked fairly easily; possible motives include access to stimulant drugs and/or academic resources.^[155][156]

See also

• Biopsychiatry controversy
• Chemical imbalance theory
• DAMP
• Nootropic
• The Gene Illusion
• Ethical problems using children in clinical trials

References

Bibliography

• Dr Jennifer Erkulwater; Dr Rick Mayes; Dr Catherine Bagwell (2009). Medicating Children: ADHD and Pediatric Mental Health. Cambridge: Harvard University Press. ISBN 0-674-03163-6. 

External links

• ScienceDaily: ADD and ADHD News
• Simon Sobo, MD, "ADHD and Other Sins of Our Children"
• The New England Skeptical Society: Defending ADHD
• http://www.icspp.org International Center for the Study of Psychiatry and Psychology

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