ADHD: Is the Epidemic in the Kids, or Us?
[N]
I have heard speculation as to whether medical conditions like ADHD truly exist. When is it really medical neglect for a parent to refuse the "treatment" for their unruly child? Beyond the hopefully obvious risk or instances of physical protection, how much should we allow psychology and medicine to start to take the place of personal values, ethics and even religion?
[GLS]
The problem is that people with ADHD have real, honest-to-goodness neurochemical differences when compared to others. (This can be demonstrated at the research level; at present, there is unfortunately no clinical application of such tests.)
(See, for example, "ADHD patients have many more dopamine transporters than those without the condition." - JAMA, August 22-29, 2001--Vol 286, No 8, pp. 906 citing Lancet, 1999;354:2132 - 2133.)
It has also been demonstrated that people with ADHD who go untreated tend to, as adults: a) have more substance abuse, b) have more legal troubles, c) have more divorces, d) have lower educations, e) make less money
Thus, "doing nothing" may not be a 'benign' choice.
Anyone interested in the topic really needs to see:
http://www.healthyplace.com/Communities/add/nimh/treatment_study_children.htm
This is the NIH ADHD study. My residency site was one of the centres for this multi-centre double-blinded study. I saw people present the data a few times. The presenters were psychologists, and they had had a lot to do with driving the study. They were quite frank about the fact that they had pushed the study (which was huge, and still on-going) because they felt that medication was perhaps being overused, and that psychological techniques would fix these kids at least as well, with little or no need for meds. The patients were randomized into four groups:
1) intensive medication management: this was aggressive use of medication,with dose titration upward beyond that typically used in a primary care setting--usually called "optimized" medical management.
2) a psychosocial/behavioral component alone: they described this program, and it was INTENSE. It was something like 3 hours per day, 5 days a week, for two years with the children getting tutoring, homework help, and behavioral training. At least one parent had to attend each session with the children, and they got their own training and parenting classes as well.
3) combination (both 1 and 2 above).
4) Essentially the "placebo" or "control" group, this had support meetings for parents (to mimic the effects of coming for the group #2 stuff) but no real training or instruction. They also got "community" medication management (ie they were managed by their GP or pediatrician using standard medication dosing; the doses of medication used were up to the practitioner, but in the analysis were substantially lower than the group #1 dosing.)
What were the results? Well, no surprise that the control group did worst. And, no surprise that group #1 did much better. The intriguing thing, though, was that the combo therapy was not really any better for ADHD symptoms. (Though later work showed superior results for other behavioral issues.) Interestingly, the behavioral stuff alone was hardly better than placebo for the ADHD symptoms when medication wasn't involved.
Now, remember, this is psychologists doing a lot of the work. They present the data, run through all the stats, all the tables and graphs and then say rather ruefully, "Bottom line? Get them on medications, and titrate the doses UP!"
Take a look again at the behavioral treatment regimen. That's intense, and very expensive. How many families could do that sort of thing? How many have a parent free 3 hours per day, 5 days per week, for two years? Who could afford it?
This group was made up of what is probably the most functional and motivated cohort of parents (which are arguably not like a lot of the families you will see in the real world) and even then you HAD to have medication to get the best results. Think of the costs of such a program to society, and you're still not getting results as good as with medication.
Now, combo therapy has additional benefits (see the link), but there you're using meds AND doing the behavioral stuff.
This would seem to argue rather powerfully that there is a gen-you-ine, honest-to-goodness illness buried somewhere in there.
[N]
I have heard parents attest that they would not withhold psychotropic medication (like Ritalin) from their child with a behavior disorder any more than they would insulin from a diabetic child, or an inhaler from an asthmatic child. Is this a fair comparison?
[GLS] Probably in some cases. The difficulty is in dealing in generalities or anecdotes. One can always find a kid that was inappropriately diagnosed or treated. And, one can also always find kids that no amount of behavioral intervention is going to help without meds.
And, one can point to the fact that on a POPULATION basis, only 1 out of every 3 kids who meets the criteria for ADHD is diagnosed. So, I don't think overdiagnosis is the problem; MISdiagnosis may be, but there's a large pool of kids who never get noticed.
[N]
Do at least 3 out of my 9 Cub Scouts really have an illness? Is it truly a medical condition more than it is a human condition?
[GLS]
Well, define "illness." In most cases, the definition in psychiatry is something that causes a marked impairment of functioning in two spheres of life: school and home, for example.
And, ADHD (like most things in nature) is a continuum--mild to severe. And, parenting styles can doubtless impact where on that spectrum people appear.
Remember, too, that if you increase people's ability to pay attention with meds, they are likely going to be more responsive to the other things you're trying to teach them via behavioral stuff.
[N]
Few objective tests exist to prove the majority of the psychiatric diseases listed in the DSM.
[GLS]
But, there are objective CRITERIA, and those with experience can get quite good at separating out the wheat from the chaff. Like all things, there is fuzziness at the boundries, but (say) 90% of what you diagnose is pretty clear-cut.
These kids also have higher than normal co-morbidities, so you have things like childhood depression or learning disorders that muddy the picture as well. Lots of testing available for such things, though, which are fairly well validated (and usually performed by clinical psychology, not psychiatry).
[N]
There is likely no lab test, and often no defined list of signs and symptoms to be definitively checked-off that qualifies someone as having a clinical behavioral illness.
[GLS]
Not true. Look at DSM-IV--it is nothing if not a "check list" of symptoms.
And, those check lists correlate with what one sees biochemically--so the checklist really CAN choose out people that are physically, structurally, DIFFERENT than normal controls. That suggests this is more than merely arbitrary.
[N]
A child with asthma is told he can't help that there is something wrong with his lungs. A child with diabetes, her pancreas. Does the child on Ritalin have to accept that he is born with something similarly wrong with the way he thinks?
[GLS]
Not "thinks" so much as responds to stimuli for learning. Dopamine is vital in learning. Since ADHD patients have more dopamine transporters, they pull dopamine out of the synapse quicker than normal. So, the signal is not transduced as heavily. So, they require more stimuli to get the same "biochemical bang for their buck." This explains why they have trouble learning, since you need more dopamine to reinforce the learning pathways. It explains why they tend to risky behavior, since normal experiences are objectively less "stimulating"--they don't get the same Neurochemical reward for it. And, they also don't respond as well to discipline, since punishment just doesn't show as "severe" to them as to a normal person. So, ironically, they're probably "getting" less discipline than most kids, at the neurochemical level!
[N]
Cogito, ergo sum, "I think, therefore I am." If so, do we cause children to confuse their own identity with a disease?
Well, this is a risk with any chronic condition. We are always more than the sum of our diseases, tragedies, or weaknesses.
But, remember the alternative. Kids who aren't treated do worse in school, etc. So, then they tend to internalize messages like "I'm stupid" or "I'm a failure." When you see kids go from getting 40% while repeating grade 1 and being unable to read, to getting 80% with the addition of 20 mg of Ritalin, it's hard to argue that this is all just about parenting! :-) [GLS - How do you think it makes a kid feel to work twice as hard as everyone else, and still do worse?]
Do we make them wonder about what part of them is a "sickness", and what part of them is truly who they are? Do they start to believe their thoughts and actions are a result of being sick? Do we then rob them of important lessons in accountability, personal agency, and the consequences of ones own actions when lying, stealing, cheating; all is forgiven, inasmuch as they are "sick"?
[GLS]
One must always treat people as if they are responsible for their actions. Otherwise, one abdicates any hope of them controlling themselves. The drugs do not control them--they merely allow them to respond more effectively to the need for control. Likewise, the drugs don't teach them things--they just prepare the way for them to learn more effectively IF they exert the effort.
But, such things aren't all or nothing. It is a continuum. Are schizophrenics responsible? Yes, often--at least partly. But, not always, and not to the same extent in all cases. But, that is an issue for God and theologians; from a medical point of view, the question is "How can I help this child's life be better, and with what intervention(s)?"
[N]
As a Cub Scout leader, I think the psychotropic medication is great, and can't imagine being able to involve all nine of the boys in a productive activity without it. But there again, like the disease, maybe I'm a product of our culture as well.
How about the behaviorally challenged children of my generation who never had the option of having a mental illness and medication?
[GLS]
Some coped, some did not. Remember, though, the world is a different place than it was even 20-30 years ago. There was a time when you could graduate from high school, get a job, and stay there for 40 years. Now having a university education does not guarantee you a job, and people change jobs much more often. Things are more competitive academically.
I often see parents who are (in retrospect) clear examples of ADHD who coped relatively well, and have made out alright in their life. But, their kids have a much harder time, partly because what kids have to do today in terms of mental, cognitive activities, may well be more involved than what their Dad had to do.
[N]
In the absence of organized evidence, I have an anecdote: I have a good friend who
is always willing to share her experiences of being a very troublesome child, and how she would act or do things often just because adults told her not to.
[GLS]
30% of ADHD people continue to have symptoms into adulthood. The other 70% don't. So, it is hardly surprising that many "troubled" children end up doing OK eventually, because their disease improves. But, when viewed as a group, these children DO NOT have "happy endings" to their stories--and, that's partly because once you fall behind educationally, or get into drugs or legal problems, those behavioral patterns are hard to overcome even if your primary ADHD improves.
[N]
I have one more parting anecdote to illustrate a danger of allowing a "science"-based argument to define all of what is normal or acceptable in our society:
In March, a former nuclear scientist and vocal public defender was forcibly taken from her home after police broke down her door and injected her with haloperidol. Marina Trutko was then subjected to daily injections for six weeks at psychiatric Hospital No. 14 in Dubna,Russia, to treat her for a "paranoid personality disorder."
All this really demonstrates is that not knowing all of a patient's history makes diagnosis dangerous. I'm guessing the admission into the hospital did not involve a review of her past educational or work history, a lengthy discussion with parents, spouse, or friends about her present and past behavior, a detailed screen of her urine for foreign substances, etc.
Psychiatry is a longitudinal discipline, and an abuse of that process means that you're going to be on dangerous diagnostic ground. If you ever sit through a psychiatric assessment, you'll see a lot (maybe the majority) of the interview focused on past history, family history, social history, educational history, substance abuse, problems with the law, etc.
[GLS]
But, with ADHD one often has the benefit of parents' reports, teachers' reports, and you can watch the kid tear your office apart. One can hardly complain that such kids are being treated in an information vacuum like those who use psychiatry for control of political prisoners. Indeed, what is often particularly dramatic about such cases is how some children were just "different" from all the other siblings from the get-go. Same parenting and environment, but one child will be completely out of control, resistant to discipline, doing horribly in school, etc.
Bottom line, I think one needs people that one can trust involved, and a willingness to examine all options. But, to claim that ADHD is merely a social construct or the like (which argument I don't think you're making) can't be sustained by the epidemiological, neurochemical, or RCT trial data.
Kind regards,
GLS (MD, CCFP)
I have heard speculation as to whether medical conditions like ADHD truly exist. When is it really medical neglect for a parent to refuse the "treatment" for their unruly child? Beyond the hopefully obvious risk or instances of physical protection, how much should we allow psychology and medicine to start to take the place of personal values, ethics and even religion?
[GLS]
The problem is that people with ADHD have real, honest-to-goodness neurochemical differences when compared to others. (This can be demonstrated at the research level; at present, there is unfortunately no clinical application of such tests.)
(See, for example, "ADHD patients have many more dopamine transporters than those without the condition." - JAMA, August 22-29, 2001--Vol 286, No 8, pp. 906 citing Lancet, 1999;354:2132 - 2133.)
It has also been demonstrated that people with ADHD who go untreated tend to, as adults: a) have more substance abuse, b) have more legal troubles, c) have more divorces, d) have lower educations, e) make less money
Thus, "doing nothing" may not be a 'benign' choice.
Anyone interested in the topic really needs to see:
http://www.healthyplace.com/Communities/add/nimh/treatment_study_children.htm
This is the NIH ADHD study. My residency site was one of the centres for this multi-centre double-blinded study. I saw people present the data a few times. The presenters were psychologists, and they had had a lot to do with driving the study. They were quite frank about the fact that they had pushed the study (which was huge, and still on-going) because they felt that medication was perhaps being overused, and that psychological techniques would fix these kids at least as well, with little or no need for meds. The patients were randomized into four groups:
1) intensive medication management: this was aggressive use of medication,with dose titration upward beyond that typically used in a primary care setting--usually called "optimized" medical management.
2) a psychosocial/behavioral component alone: they described this program, and it was INTENSE. It was something like 3 hours per day, 5 days a week, for two years with the children getting tutoring, homework help, and behavioral training. At least one parent had to attend each session with the children, and they got their own training and parenting classes as well.
3) combination (both 1 and 2 above).
4) Essentially the "placebo" or "control" group, this had support meetings for parents (to mimic the effects of coming for the group #2 stuff) but no real training or instruction. They also got "community" medication management (ie they were managed by their GP or pediatrician using standard medication dosing; the doses of medication used were up to the practitioner, but in the analysis were substantially lower than the group #1 dosing.)
What were the results? Well, no surprise that the control group did worst. And, no surprise that group #1 did much better. The intriguing thing, though, was that the combo therapy was not really any better for ADHD symptoms. (Though later work showed superior results for other behavioral issues.) Interestingly, the behavioral stuff alone was hardly better than placebo for the ADHD symptoms when medication wasn't involved.
Now, remember, this is psychologists doing a lot of the work. They present the data, run through all the stats, all the tables and graphs and then say rather ruefully, "Bottom line? Get them on medications, and titrate the doses UP!"
Take a look again at the behavioral treatment regimen. That's intense, and very expensive. How many families could do that sort of thing? How many have a parent free 3 hours per day, 5 days per week, for two years? Who could afford it?
This group was made up of what is probably the most functional and motivated cohort of parents (which are arguably not like a lot of the families you will see in the real world) and even then you HAD to have medication to get the best results. Think of the costs of such a program to society, and you're still not getting results as good as with medication.
Now, combo therapy has additional benefits (see the link), but there you're using meds AND doing the behavioral stuff.
This would seem to argue rather powerfully that there is a gen-you-ine, honest-to-goodness illness buried somewhere in there.
[N]
I have heard parents attest that they would not withhold psychotropic medication (like Ritalin) from their child with a behavior disorder any more than they would insulin from a diabetic child, or an inhaler from an asthmatic child. Is this a fair comparison?
[GLS] Probably in some cases. The difficulty is in dealing in generalities or anecdotes. One can always find a kid that was inappropriately diagnosed or treated. And, one can also always find kids that no amount of behavioral intervention is going to help without meds.
And, one can point to the fact that on a POPULATION basis, only 1 out of every 3 kids who meets the criteria for ADHD is diagnosed. So, I don't think overdiagnosis is the problem; MISdiagnosis may be, but there's a large pool of kids who never get noticed.
[N]
Do at least 3 out of my 9 Cub Scouts really have an illness? Is it truly a medical condition more than it is a human condition?
[GLS]
Well, define "illness." In most cases, the definition in psychiatry is something that causes a marked impairment of functioning in two spheres of life: school and home, for example.
And, ADHD (like most things in nature) is a continuum--mild to severe. And, parenting styles can doubtless impact where on that spectrum people appear.
Remember, too, that if you increase people's ability to pay attention with meds, they are likely going to be more responsive to the other things you're trying to teach them via behavioral stuff.
[N]
Few objective tests exist to prove the majority of the psychiatric diseases listed in the DSM.
[GLS]
But, there are objective CRITERIA, and those with experience can get quite good at separating out the wheat from the chaff. Like all things, there is fuzziness at the boundries, but (say) 90% of what you diagnose is pretty clear-cut.
These kids also have higher than normal co-morbidities, so you have things like childhood depression or learning disorders that muddy the picture as well. Lots of testing available for such things, though, which are fairly well validated (and usually performed by clinical psychology, not psychiatry).
[N]
There is likely no lab test, and often no defined list of signs and symptoms to be definitively checked-off that qualifies someone as having a clinical behavioral illness.
[GLS]
Not true. Look at DSM-IV--it is nothing if not a "check list" of symptoms.
And, those check lists correlate with what one sees biochemically--so the checklist really CAN choose out people that are physically, structurally, DIFFERENT than normal controls. That suggests this is more than merely arbitrary.
[N]
A child with asthma is told he can't help that there is something wrong with his lungs. A child with diabetes, her pancreas. Does the child on Ritalin have to accept that he is born with something similarly wrong with the way he thinks?
[GLS]
Not "thinks" so much as responds to stimuli for learning. Dopamine is vital in learning. Since ADHD patients have more dopamine transporters, they pull dopamine out of the synapse quicker than normal. So, the signal is not transduced as heavily. So, they require more stimuli to get the same "biochemical bang for their buck." This explains why they have trouble learning, since you need more dopamine to reinforce the learning pathways. It explains why they tend to risky behavior, since normal experiences are objectively less "stimulating"--they don't get the same Neurochemical reward for it. And, they also don't respond as well to discipline, since punishment just doesn't show as "severe" to them as to a normal person. So, ironically, they're probably "getting" less discipline than most kids, at the neurochemical level!
[N]
Cogito, ergo sum, "I think, therefore I am." If so, do we cause children to confuse their own identity with a disease?
Well, this is a risk with any chronic condition. We are always more than the sum of our diseases, tragedies, or weaknesses.
But, remember the alternative. Kids who aren't treated do worse in school, etc. So, then they tend to internalize messages like "I'm stupid" or "I'm a failure." When you see kids go from getting 40% while repeating grade 1 and being unable to read, to getting 80% with the addition of 20 mg of Ritalin, it's hard to argue that this is all just about parenting! :-) [GLS - How do you think it makes a kid feel to work twice as hard as everyone else, and still do worse?]
Do we make them wonder about what part of them is a "sickness", and what part of them is truly who they are? Do they start to believe their thoughts and actions are a result of being sick? Do we then rob them of important lessons in accountability, personal agency, and the consequences of ones own actions when lying, stealing, cheating; all is forgiven, inasmuch as they are "sick"?
[GLS]
One must always treat people as if they are responsible for their actions. Otherwise, one abdicates any hope of them controlling themselves. The drugs do not control them--they merely allow them to respond more effectively to the need for control. Likewise, the drugs don't teach them things--they just prepare the way for them to learn more effectively IF they exert the effort.
But, such things aren't all or nothing. It is a continuum. Are schizophrenics responsible? Yes, often--at least partly. But, not always, and not to the same extent in all cases. But, that is an issue for God and theologians; from a medical point of view, the question is "How can I help this child's life be better, and with what intervention(s)?"
[N]
As a Cub Scout leader, I think the psychotropic medication is great, and can't imagine being able to involve all nine of the boys in a productive activity without it. But there again, like the disease, maybe I'm a product of our culture as well.
How about the behaviorally challenged children of my generation who never had the option of having a mental illness and medication?
[GLS]
Some coped, some did not. Remember, though, the world is a different place than it was even 20-30 years ago. There was a time when you could graduate from high school, get a job, and stay there for 40 years. Now having a university education does not guarantee you a job, and people change jobs much more often. Things are more competitive academically.
I often see parents who are (in retrospect) clear examples of ADHD who coped relatively well, and have made out alright in their life. But, their kids have a much harder time, partly because what kids have to do today in terms of mental, cognitive activities, may well be more involved than what their Dad had to do.
[N]
In the absence of organized evidence, I have an anecdote: I have a good friend who
is always willing to share her experiences of being a very troublesome child, and how she would act or do things often just because adults told her not to.
[GLS]
30% of ADHD people continue to have symptoms into adulthood. The other 70% don't. So, it is hardly surprising that many "troubled" children end up doing OK eventually, because their disease improves. But, when viewed as a group, these children DO NOT have "happy endings" to their stories--and, that's partly because once you fall behind educationally, or get into drugs or legal problems, those behavioral patterns are hard to overcome even if your primary ADHD improves.
[N]
I have one more parting anecdote to illustrate a danger of allowing a "science"-based argument to define all of what is normal or acceptable in our society:
In March, a former nuclear scientist and vocal public defender was forcibly taken from her home after police broke down her door and injected her with haloperidol. Marina Trutko was then subjected to daily injections for six weeks at psychiatric Hospital No. 14 in Dubna,Russia, to treat her for a "paranoid personality disorder."
All this really demonstrates is that not knowing all of a patient's history makes diagnosis dangerous. I'm guessing the admission into the hospital did not involve a review of her past educational or work history, a lengthy discussion with parents, spouse, or friends about her present and past behavior, a detailed screen of her urine for foreign substances, etc.
Psychiatry is a longitudinal discipline, and an abuse of that process means that you're going to be on dangerous diagnostic ground. If you ever sit through a psychiatric assessment, you'll see a lot (maybe the majority) of the interview focused on past history, family history, social history, educational history, substance abuse, problems with the law, etc.
[GLS]
But, with ADHD one often has the benefit of parents' reports, teachers' reports, and you can watch the kid tear your office apart. One can hardly complain that such kids are being treated in an information vacuum like those who use psychiatry for control of political prisoners. Indeed, what is often particularly dramatic about such cases is how some children were just "different" from all the other siblings from the get-go. Same parenting and environment, but one child will be completely out of control, resistant to discipline, doing horribly in school, etc.
Bottom line, I think one needs people that one can trust involved, and a willingness to examine all options. But, to claim that ADHD is merely a social construct or the like (which argument I don't think you're making) can't be sustained by the epidemiological, neurochemical, or RCT trial data.
Kind regards,
GLS (MD, CCFP)
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