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Attention deficit hyperactivity disorder controversies

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Ritalin 10mg Pill (Ciba/Novartis)

Attention-deficit hyperactivity disorder (ADHD) is one of the most controversial psychiatric disorders despite being a well validated clinical diagnosis.[1][2] ADHD and its treatment have been considered controversial at least since the 1970s.[3][4][5] The controversy involves clinicians, 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 is genetic and physiological basis for the condition.[4]

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 are thought to have abuse potential; and 5) the rates of diagnosis and of treatment substantially differ across countries.[6]

Lack of clarity on exactly what qualifies as ADHD and changes in diagnostic criteria have caused confusion.[7] Ethical and legal issues with regard to treatment have been key areas of concern, particularly the use of psychostimulant medication and the promotion of stimulants to treat ADHD by groups and individuals who receive money from drug companies.[2]

Medical professionals and news sources have stated that the diagnosis and treatment of the disorder deserve greater scrutiny.[8]

Alternative theories to explain the symptoms of ADHD have been proposed.[9] These views include the Hunter vs. farmer theory, Neurodiversity, and the Social construct theory of ADHD.

Some individuals and groups reject the existence of ADHD entirely. They include Thomas Szasz and groups such as CCHR.[10] Most medical authorities and the US courts however support the legitimacy of the ADHD diagnosis. (See the Ritalin class action lawsuits.)

Status as a disorder

Concerns about methods of diagnosis

ADHD and stimulant use are 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. Most children who end up with a diagnosis of ADHD have normal behavior in the physician's office.[11]

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.[12]

Tools that are designed to analyze a person's behavior, such as the Brown scale or the Conners scale, for example, attempt to assist parents and providers in making a diagnosis by evaluating an individual on typical behaviors such as "Hums or makes other odd noises", "Daydreams" and "Acts 'smart'"; the scales rating the pervasiveness of these behaviors range from "never" to "very often". Connors states that, based on the scale, a valid diagnosis can be achieved; critics, however, counter Connors' proposition by pointing out the breadth with which these behaviors may be interpreted. This becomes especially relevant when family and cultural norms are taken into consideration; this premise leads to the assumption that a diagnosis based on such a scale may actually be more subjective than objective. (See cultural subjectivism.)

Some of the criticism does not reject the concept of ADHD as a valid disorder, but alleges that children with problematic behaviour are often diagnosed with ADHD when the the behaviour may result from other causes. They state that some children diagnosed with ADHD, or labeled ADHD by parents or teachers, are normal but do not behave in the way that responsible adults want them to behave. There is concern about teachers being used to assist in diagnosing students with ADHD.[13] Social critics[who?] make a connection between the extra funding some schools receive for children with ADHD and the increase in the diagnosis.[14]

ADHD is a subjective diagnosis with no definitive test. This leads to situations where one doctor would say a child needs psychotropic medication while another doctor could say the child is perfectly normal.[15] Concern exists that "elevated but still developmentally normal levels of motor activity, impulsiveness, or inattention" traits of childhood could be inappropriately interpreted as ADHD.[16][17]

Different views of ADHD outside North America

The view that ADHD is a problem requiring medical intervention has been far less prevalent outside of the United States and Canada. In Great Britain and France roughly one percent of children are diagnosed with hyperkinetic syndrome, the equivalent of ADHD in the International Classification of Diseases, the diagnostic system used by most medical professionals outside North America.

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."[18][19]

Anti-psychiatry movement

Members of the Anti-Psychiatry movement such as Fred Baughman and Peter Breggin[20][21][22][23] have extensively used the popular media to criticize ADHD and medications used for ADHD. Fred Baughman has also published articles about ADHD in peer reviewed journals.[24] They have testified at Congressional hearings on the use of Ritalin and supported legal challenges such as the Ritalin class action lawsuits. There is an antipsychiatry movement that often refers to their writings, but in contrast to Scientologists, they are not "anti-psychiatry," but critics of some of its practices.

Scientology

According to an article in the Los Angeles Times, "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 Scientologists in 1969, conducted a major campaign against Ritalin in the 1980s and lobbied Congress for an investigation of Ritalin.[25] 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".[25] Scientology states "the controversy over the many deaths and irreversible damage caused by psychiatric drugs prescribed for children labeled with... ADHD continues to grow".[26] The church states that mental disorders are a fraud,[27] "mental and behavioral problems are largely incorrect diagnoses that cover symptoms and don't handle the real problems, which may be physical or spiritual".[28] Specifically Scientology attributes all psychological disorders to the accumulation of psychic trauma retained from millions of years of human evolution and the interference of alien and human ghosts called thetans. [29]

Personality trait

Some believe that many of the traits of those diagnosed with ADHD are personality traits and not indicative of a disorder. Due to these traits being less desirable in modern society and increasing difficulty functioning in a society that does not label these conventions as the norm, they have been labeled as a disorder.[30]

Alternative theories concerning origins

Hunter vs. farmer theory of ADHD

The hunter vs. farmer theory is a hypothesis proposed by author Thom Hartmann about the origins of attention-deficit hyperactivity disorder (ADHD). He believes that these conditions may be a result of adaptive behavior of the species, his theory states that those with ADHD retained some of the older hunter characteristics.[31]

Neurodiversity

Proponents of this theory assert that atypical (neurodivergent) neurological development is a normal human difference that is to be tolerated and respected as any other human difference. They usually support treatment or therapy, but may or may not agree with the use of medication. Social critics argue that while biological factors may obviously play a large role in difficulties sitting still and/or concentrating on schoolwork in some children, for a variety of reasons they have failed to integrate into the social expectations that others have of them. [32]

Social construct theory of ADHD

Social critics question whether ADHD is wholly or even predominantly a biological illness. A minority of these critics maintain that ADHD was "invented and not discovered". They believe that no disorder exists and that the behaviour observed is not abnormal and can be better explained by environmental causes or just the personality of the "patient."[33]

Concerns about medication

The National Institute of Mental Health states that, "stimulant drugs, when used with medical supervision, are usually considered quite safe".[34]

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.[35] Neither safety nor efficacy of stimulants has been determined beyond two years.[36] 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.[37]

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.[38][39][40][41] Due to their non-specific activity, stimulants have been used by writers to increase productivity,[42] as well as by the United States Air Force to improve concentration in combat.[43] Some scientists recommend wide spread use by the population to increase brain power.[44]

Coercion

It is often not a child's decision to take medication. Ethical concerns regarding forced treatment or coercion of a minor arise. Some suspect that children are using stimulants as a cognitive enhancer at the request of their achievement oriented parents.[44]

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).[45]

Stimulant medications are commonly resold by patients as recreational drugs, and methylphenidate (Ritalin) is used as a study aid by some students without ADHD.[46]

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%.[47] 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.[48]

Advertising

Many pharmaceutical companies have received warning from the FDA regarding false advertising and inappropriate professional slide decks related to ADHD medication.[49] In Sept. of 2008 the FDA sent a notice to Novartis Pharmaceuticals regarding its advertising of Focalin XR in which they overstate its efficacy.[50] Similar warning were sent to Shire plc with respect to Adderall XR.[51]

Financial conflicts of interest

Russell Barkley, a well known ADHD researcher, admits to taking money from drug companies for speaking and consultancy fees. There are concerns that this may bias his publications.[52]

In 2008, it was revealed that Joseph Biederman of Harvard, who has played a significant role as a frequently cited ADHD expert, failed to report to Harvard that he had received 1.6 million dollars from drug companies between 2000 and 2007.[53] 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.”[53]

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.[54] This is viewed by some as a glaring conflict of interest.[55]

Concerns about the impact of labeling

Parents could be concerned that telling children they have a brain disorder could possibly harm their self-esteem. 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.[56] Furthermore studies also show that the education of the siblings and parents has at least a short term impact on the outcome of treatment. [57] 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. . . ."[56] Psychiatrist Harvey Parker, who founded CHAAD, 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 "b-a-d" kids, as brats, but as kids who have a problem that they can overcome".[58]

Social critics believe that this knowledge can effectively become a self-fulfilling prophecy mainly through self-doubt. Thomas Armstrong states that the ADHD label is a "tragic decoy" which severely erodes the potential to see the best in a child [59]. 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 [60]. Thom Hartmann has said that the brain disorder label is "a pretty wretched label for any child to have to bear."[61]

There is concern about the effects of an ADHD diagnosis on the mental state and self-esteem of patients.[62][63] There is disagreement over the cause of ADHD and there are questions about research methodologies [64], and skepticism toward its classification as a mental disorder.[62]

ADHD in politics and the media

The media have reported on many issues related to ADHD and has also reported on controversial opinions of individuals.

In 2001 PBS's Frontline ran a TV show entitled "Medicating kids".[65] The program included a selection of interviews with representatives of various points of view. In one segment, entitled backlash, retired neurologist Fred Baughman and Peter Breggin, founder of the 'International Center for the Study of Psychiatry and Psychology', who 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,"[66] 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.[67] Lawrence Diller was interviewed on the business of ADHD along with a representative from Shire Plc. The validity of the work of many of the ADHD "experts" (e.g. Dr. Biederman) Drug Companies & Doctors: A Story of Corruption has been called in to question by Marcia Angell,[68] former editor of The New England Journal of Medicine.

A number of notable individuals have given controversial opinions on ADHD. Scientologist Tom Cruise's interview with Matt Lauer was widely watched by the public. In this interview he spoke about postpartum depression and also referred to Ritalin and Adderall ( a mix of amphetamines) as being "street drugs" rather than as ADHD medication.[[69] In England Baroness Susan Greenfield, a leading neuroscientist,[70] wanted a wide-ranging inquiry in the House of Lords into the dramatic increase in the diagnosis of ADHD in the UK and possible causes.[71] This followed a 2007 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. In the UK medication use is increasing dramatically.[citation needed] Other notable individuals have made controversial statements about ADHD. Terence Kealey, a clinical biochemist, has stated his belief that ADHD medication is used to control unruly boys behaviour.[72] Newspaper columnists such as Benedict Carey have also written controversial articles on ADHD.[73][74]

Hearings were held in the US Congress. A series of lawsuits culminating with the failed Ritalin class action lawsuits were in the courts. Antipsychiatry critics such as Peter Breggin and Fred Baughman received a lot of press coverage including PBS's Frontline which ran a five-part TV series entitled "Medicating kids".[75] This timing also coincided with a dramatic increase in the use of stimulant medication which since has leveled off. Opinions regarding ADHD range from those who do not believe it exists to those who believe that there is genetic and physiological basis for the condition.[76]

See also

References

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