By posting this on a public forum I am most likely setting myself up for flaming in a big way but let me just preface my research by stating for the record that I do realize that ADHD is a real, and serious illness for some people. I just wanted to put this out there for the parents of school aged children. I have seen too many parents fall through the politics at work here and hopefully this can help someone out there or serve as a bit of food for thought.
ADHD, which stands for attention deficit hyperactivity disorder, is generally defined as a psychological disorder marked by symptoms such as impulsivity, hyperactivity, inattention, or some combination of these, affecting somewhere between five to fifteen percent of people in the U.S. Although this concept sounds easy enough to understand, the problem is that these terms are broad and, like most psychological illness, there is no lab test to confirm an ADHD diagnosis.
Many would counter this statement with references to research conducted by Dr. Xavier Castellanos. Just last year, he published a research study in the Journal of the American Medical Association claiming to have found evidence of atrophy in the brain of young people diagnosed with ADHD. Many such studies have been conducted in the past. However the significance of this one in particular is that it was performed in such a way as to address some of the longstanding concerns of those who disbelieve in the existence of ADHD. The most publicized of these criticisms is the fact that previous studies had not been properly controlled for the various affects that will occur with long term exposure to outside influences, most notably Ritalin, the drug most commonly used to treat this disorder. In response to these concerns, this particular study was controlled for stimulant use. The findings of this study were that, not only did these ADHD medicated have specific areas of the brain that were smaller in size, but the non- medicated ADHD sufferers also showed similar patterns of atrophy (Castellanos).
Castellanos, though making progress in having controlled for Ritalin use, would have a difficult time controlling for every type of exposure that could be responsible for causing shrinkage in the brain. In fact it would be almost impossible to control for in such a study, the ADHD opponents argued.
The purpose of this paper is not to argue the existence of this condition. However, the issues raised in the absence of an accepted method of testing for ADHD brings an important question to light; could it not follow that some of those diagnosed with this affliction are actually suffering from outward symptoms of physical illness?
In his book The Hyperactivity Hoax
Doctor Sydney Walker III claims that most of the children he sees have been previously labeled “hyperactive” (p.1). He goes on to explain that these patients are usually suffering from a deeper rooted and more elusive illness, to which attention deficit and the like are the outward symptoms of. Walker cites heavy-metal poisoning, iron and vitamin B deficiency, hyperthyroidism, Tourette’s Syndrome, seizures, parasites and cardiac conditions as just a few illnesses whose symptoms include those associated with ADHD (p.14-5). Of these, Vitamin B deficiency (Vitality Fair) and lead poisoning (New England Journal of Medicine in lead info.com) meet five of the six minimum criterion necessary for an ADHD diagnosis as outlined by the DSM IV, a medical reference guide (which we will explore in further detail shortly). Furthermore, groups such as the ADHD Parents Support Group Project and 4ADHD list many conditions that can closely “mimic” the symptoms of ADHD. Several of these will cause the brain to atrophy as well.
You may be wondering, how can such a thing be true? How can so many serious medical conditions go unnoticed and misdiagnosed? These questions bring me to my next point.
Doctors working under the managed care system usually lack the time, resources or motivation to give the level of care necessary to diagnose adequately what is ailing you. In today’s fast paced and for profit society, you are lucky to spend fifteen minutes with your doctor. Needless to say, this is hardly enough time for your physician to address your immediate symptoms, much less to, for example, focus on the various causal factors which could result in your symptoms. To make such an assessment would possibly require repeat visits, through exams, testing, probing, and possibly a visit to a specialist. Managed care makes these things difficult at best. We must get these procedures approved by “…non-medical business managers who frown on diligent and appropriate diagnostic efforts” (Walker p.18). This scenario is even worse for problem children.
In the case of a hyperactive child, the onset of school age usually brings the symptoms characteristic to ADHD to light (Walker p.75). Upon noticing these, a teacher or school counselor will generally notify the parents to request that the child be taken to a physician or psychologist for an evaluation. From there, this child will receive an assessment based on DSM standards (Walker p.21).
The DSM is a medical reference book published by the American Psychological Association. According to Walker, it is the most common means for diagnosing ADHD. Not only is this book utilized by mental health practitioners, but it is also used as a diagnostic tool by physicians, pediatricians, neurologists, etc. It is now the simple task of your doctor to choose from a list of symptoms which, to me, seem characteristic of any given child. For example, criterion A1a is: “Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities”. In addition Doctor Walker regards the DSM to be “… as much a political document as a medical document”. This is due to the fact that new versions are compiled every few years in which diagnoses are regularly voted in or out. He goes on to state that, “…the symptoms for virtually all DSM diseases change from revision to revision. Thus your hyperactive child might be mentally ill according to one DSM and perfectly normal according to the next edition six or seven years later” (p.21-3).
One may argue that the DSM medical reference series are based on copious amounts of research, and when utilized correctly, in addition to, but not in place of a working knowledge of current research in the field, they can be highly effective. This may be true, but it is highly idealistic in light of the facts. Managed care makes this theory highly unlikely.
As we touched on before, the advent of the Health Maintenance Organization, or HMO, has forever changed the way that we experience illness. The family physician of years past has been traded for a faceless, for profit industry head by managers who deal in business rather than medicine. The object of the game is to take as much money in from us, the healthcare recipient, while paying out the smallest amount possible in healthcare services. The most awful part about this business is that it does not care if some of us suffer ill effects in the process. In the case of ADHD for example, it costs healthcare providers between three hundred-sixty and seven hundred-twenty dollars to supply a person with Ritalin for a year. Compare this to the one thousand five-hundred dollars that it costs if you decide you would like to get a psychiatric analysis (Gray, par.24). Now, try (if you can) to put yourself in the mindset of a business manager for one of the big healthcare firms. You are a person whose career is comprised of cutting costs, raising efficiency, saving money, maxing out profit margins for you and your elitist colleagues, dreaming up ways to give yourself yet another million dollar raise, etc. If in fact, you were this person, what type of services do you think you would be more likely to authorize?
As if dealing with these HMO's ourselves, was not already enough, we also have to take into account the effects this system has on our healthcare providers.
For example, some health plans in the system are capitated, which means that the doctors are paid a set wage for treating a specified number of patients in a year. This, in effect, works out the best for physicians when they can get the patients in and out of the office as quickly as they can get away with. Were doctors to provide the best care to each of their patients, they could actually end up paying for some of this care out-of-pocket, or even worse, being fired by the managed care company (Walker, p.17). This is a sharp contrast to years past, when a doctor was an advocate for his patient, and the harder and more diligently he worked, the more he was rewarded.
Of course, these scenarios are not absolutes. There are still exceptional doctors out there that can be consulted and other diagnostic tests that can be performed. Nevertheless, the scary thing about ADHD, and many other psychological illnesses for that matter, is that the concept of them is so elusive. For example, if you go to the doctor complaining about tangible, physical symptoms and he gives you a diagnosis you are unsure about, you may be compelled to actively seek another opinion. However if you go to the doctor complaining about behavioral problems and your doctor says that you have this disorder called ADHD, you may just feel relieved that you finally have a label to explain the unusual behavior. After all, it is not so far-fetched to assume that strange behavior equals mental illness. Is this not what pop culture would have us believe?
Pharmaceutical companies only help to perpetuate these types of assumptions and generalizations. Selling drugs is what they are in business to do. In order to do this they need the same things as any company; advertisements, salesmen, consultants, etc. Without stretching the imagination, I can safely say that these people promote and profit from overdiagnosis. Drug companies also fund much ADHD research. This research is generally related to Ritalin use in children. Findings that are inconclusive or potentially hurtful to these sponsors are suppressed. A major scandal in the ADHD spotlight is the allegation that Novartis (the producers of Ritalin) funneled millions into the ADHD advocacy group CHADD, as a means of promoting Ritalin (before these companies were allowed to advertise to the public). The charges were later dropped. While this was going on, CHADD and Novartis were fighting the DEA for lesser regulation on Ritalin production. This battle was dropped as word of the Novartis/CHADD alliance began to leak out (Diller, par.32-9).
In addition to the above mentioned duplicity shown by the pharmaceutical companies, they also serve as drug pushers to the trusting and gullible. Ritalin and other stimulants used to treat ADHD are sensationalized. They are portrayed as miraculous wonder drugs that will make your ADHD troubles disappear. What most consumers do not know, (and surely are not told) is that Ritalin and the other similar stimulant drugs are categorized as Schedule II drugs, because of a high risk of physical or psychological dependence. Ritalin is very similar in effect to cocaine. The fact of the matter is that you could give Ritalin to someone who is perfectly healthy, and it would have the same effects you expect it to have on those who are diagnosed with ADHD: heightened focus and attention on even the most boring of tasks. This makes the “try it out and see if it works” attitude that many parents and physicians encompass a highly flawed one. This will make children more compliant and manageable in the short term, but may serve to cover a serious underlying problem. Additionally, consumers must take into account the potential adverse effects of stimulant use. The feeling of necessity for these important considerations are downplayed by physicians who tell their patients that such drugs are “perfectly safe” ( Martin, par.9) and unscrupulous drug companies that run ad campaigns for medication using cartoon characters (Thomas, par.21) to further perpetuate misconceptions and lend a feeling of normalcy to something that is potentially dangerous.
Finally, we must take into consideration the fact that the United States has the largest population of ADHD diagnosed than anywhere else in the world. We must ask ourselves, what significance does this information have?
Dr. Larry Goldman, in his 1997 report to the House of Delegates, makes the assessment that while doctors in the United States use the latest in diagnostic standards, (the revised DSM IV, for example), other countries, like the United Kingdom rely on older more stringent standards such as those outlined in the earlier DSM II. He goes on to say that once the physicians in the U.K. were instructed in giving a diagnosis according to American standards, they diagnosed ADHD with the same frequency as doctors in this country. His conclusion is that the higher frequency of ADHD in the U.S. is due to outdated diagnostic techniques utilized in other countries (Goldman, p.1105).
With this having been said, it is only appropriate to wonder why these countries use more stringent standards than we do.
While Canada almost matches the United States in cases of ADHD (Goldman p.1105), most other countries have differing views on what normal childhood behavior is. For instance, in France and other European countries, a child’s misbehavior is more likely to be seen as “eccentric” rather than a problem that must be treated (Diller, par.10).
Do not these cultural discrepancies suggest that a hyperactivity “problem” may be a subjective one, according to the social standards of a given place? Is it possible that we live in a society that is hooked on quick fixes for our every problem?
The information leads me to believe that, rather than spending time probing the diagnostic criterion of other countries, we need to redirect these efforts toward introspection, with an emphasis on the collective attitude of our society. I mean, at what point exactly did an attention deficit become problem enough to justify the marginalization of these children? Do not misunderstand, I do realize that there are many out there with serious problems, but in viewing facts such as these leaves no doubt in my mind that the majority of those diagnosed with ADHD are not ill. In a word this is overdiagnosis.
As critical as these pages sound, I feel the need to emphasize that the moral of the story here is a positive one. Even though the main issue here is ADHD, overdiagnosis can happen to anyone without the right tools. First and foremost of these is information. With a proactive and informed approach, you can reduce the chances of finding yourself amidst controversy; within a “growing epidemic” or an illness that “does not exist.”
Works Cited
Castellanos, F. Xavier. “Developmental Trajectories of Brain Volume Abnormalities in C Children and Adolescents With Attention-Deficit/Hyperactivity Disorder.” JAMA
Diller, Larry. “Coca-Cola, McDonald’s and Ritalin”
Mar. 2003 http://www.docdiller.com/new/
Diller, Larry. “ADHD: Real Disease or ‘American Myth’”
http://www.docdiller.com/mod.php?mod=userpage&menu=16&page_id=3
Goldman, Larry S. “Diagnosis and Treatment of Attention-Deficit/Hyperactivity
Disorder in Children and adolescents.” JAMA
Gray, Phyllis. “What is Behind the Alarming Increase in Ritalin Use Among U.S. Children”
Martin, Glen. “My Son Nick” neurotherapy.com
Thomas, Karen. “Back to School for ADHD Drugs” 28 Aug.2001.
Vitality Fair. “Vitamin B”VitalityFair.com. 15 May 2003 https://www.vitalityfair.com/showarticle.asp?aid=29
Walker III, M.D., Sydney. The Hyperactivity Hoax. New York:
1 comments:
There are many incorrect assertions in your blog post, but a couple of them are so commonly repeated, it's no wonder you, too, are wrong.
I will skim though a couple of them and then go on to my main point. First, AD/HD is not a psychological disorder; it is a brain disorder. Second, while childhood behavior is viewed differently in different places, the subjectivity you describe is the least important. What is crucially important is the subjective experience of the child or adult who suffers from AD/HD. It is the most disabling of mental conditions known except for schizophrenia. AD/HD is not a school or learning disorder. It is a 24 hour per day disorder and it lasts for the whole of a person's life.
No other disorder that I know of sparks so much controversy, and frankly, it isn't something you believe in, like God or ghosts. Nor is it anyone's business what people and their doctors work out in the way of treatment. Often - too often - treatment is inadequate, but not because doctors don't have the time. It is because they don't have the expertise or the real understanding of the importance of fine-tuning for cognitive function, not for behavior.
So, though you have played fast and loose with some “facts,” I will now make my main point, which threatens to blow a big hole in your argument for AD/HD being cheaper to treat than something else; even a thorough workup.
Ritalin, while cheap, is not prescribed so much anymore, as it has been replaced by better formulations that last longer, and by newer medications altogether. At my house, the AD/HD medications for two people cost, per month, $1,277. This is not for multiple medications; just two – one for each person. Multiply that dollar amount by 12 months and you get $15,324. Our HMO charges us $15. per prescription for a 3-month supply. Double that for two people and you have $30. per quarter. Times 4, and we pay $120. for a year.
What this means, of course, is that we are costing our HMO a great deal of money, even if they do have a deal with the manufacturer. That would apply to only one of the medications, though, because the other is not on the HMO formulary and the patient is provided it anyway because it is the most effective.
The diagnostic evaluations for the two people cost the HMO many doctor-hours, as they were not perfunctory at all, and in both cases involved specialists.
I don’t care to defend any of this to you or anyone. But I do find it fascinating and inappropriate that this disorder and its treatments, among all others, seem to be open to public debate. No one would write about another disorder in such a way. Nor would the diagnostic methods be denigrated. “Gee, I can’t see the cancer the doctors say you have in your pancreas, how long did the doctor take to diagnose it? Did you know, the symptoms of it are nearly identical to the symptoms of at least two other ailments, and one of them is, strangely, in the head? Wow, maybe it’s not even real.”
Got any ideas why this is so?
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