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ADHD: Backlash to the Backlash

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ADHD isn’t just “kids being kids.”

Attention Deficit–Hyperactivity Disorder (ADHD) had a star turn in the recent, high-profile murder trial of University of Virginia lacrosse star George Huguely. Lawyers for the defense aren’t using the condition to explain away their client’s presumed violent behavior; rather, they’re saying that the woman he’s accused of killing may have died from her own, personal battle with ADHD. Amidst their exculpatory evidence was the victim’s prescription for Adderall, and they offered that she could have died from a mix of the drug (which is prescribed to treat ADHD) and alcohol. The medical examiner has discounted that notion, calling the very low levels of Adderall in the victim’s blood “within therapeutic range.” The cause of her death rather seems to have been a blunt force trauma to the head.

The idea that ADHD drugs might be killing us—and in ways that resemble being bashed in the head—represents just one of several ominous storylines associated with the disorder. In recent years, we’ve also heard speculation about whether ADHD is real, and if it is real, whether it’s being grossly overdiagnosed. And then there are the drugs. A recent opinion piece in the New York Times by psychology professor L. Alan Sroufe argues at great length that attention-deficit drugs do more harm than good over the long term, a conclusion other professionals in his field dispute. The backlash against ADHD—which often targets the drugs used to treat it, the people who have it, and the therapists and parents who make treatment decisions—has again reached a fever pitch.

Mental disorders can accompany ADHD/ADHD

These backlashes against childhood developmental diagnoses seems to rise and fall every few years, but lately it's burgeoning. Part of the reason is a controversy over the DSM-5, a proposed update of the mental illness manual for health professionals. Professionals are publicly squabbling over the tome’s validity, and some of those who have been labeled under the existing criteria may suddenly be facing limbo. Overlooked in the noise is the fact that the symptoms underlying the still-current diagnosis of “ADHD” compose a real and often disabling disorder with limited but effective treatment options.

Probably the most persistent myth about ADHD is that it has become a catchall label for rowdy children, and one that’s a godsend for parents who are too lazy or incompetent to keep their kids under control. Yet there’s no reason to think that anyone with diagnosed ADHD merely has “ants in his pants,” as some have suggested. Rather, the label refers to a set of behavioral excesses that go beyond developmental norms. In the last 20 years, I’ve taught languages and science to thousands of people from kindergarten to college age, and those with ADHD shared a suite of behaviors and aptitudes that distinguished them from their peers in positive and negative ways, depending on the environment. The disorder often has the company of learning disabilities and mental health problems, too.

Ritalin

In fact, the science suggests that ADHD is not “systemically” overdiagnosed in the U.S. A 2007 review of ADHD prevalence studies found no “sufficient justification” for assertions that ADHD is overdiagnosed, but the authors noted that public perception and news media coverage often don’t reflect that. Furthermore, according to a 2012 publication from the U.S. Agency for Healthcare Research and Quality, the real prevalence of ADHD hasn’t changed since the 1980s, and changes in diagnostic rates are “consistent with changes in clinical guidelines.” In spite of all this, psychologists like Sroufe have sought to reduce ADHD to simple “problems in focusing” and “difficulty with concentration,” one that we’re too quick to use medications to address.

Sroufe asks, “Are these drugs really helping children?” Citing a 2009 study of the outcomes of using these drugs, Sroufe says that the medications have no benefits in the long term. But he’s off the mark. That study of 600 children ages 7 to 9 compared the safety and effectiveness of medication alone, behavioral treatment alone, the two in combination, and “routine community care,” which was essentially the placebo. Children using medication had reduced ADHD symptoms compared to behavioral treatment or placebo after 14 months, and combined medication and behavioral interventions resulted in even greater improvement. Responses to the different therapies varied, emphasizing how personal any therapeutic effectiveness can be.

Adderall

After 14 months, the children continued on for six years having whatever care their families chose for them, including no interventions at all. At eight years, the benefits the researchers found at 14 months had faded, but 64% of the children taking medications at 14 months weren’t taking them at 8 years. The authors also looked at safety of the drug and found that 4% of children discontinued for adverse effects such as loss of appetite and sleep problems but cited no more dire effects.

Sroufe points out that there aren’t any long-term randomized studies lasting longer than two years that examine the influence of ADHD meds on various outcomes such as academic performance. These studies randomize participants into either a real medication group or a placebo or “dummy pill” group, and the 2009 study Sroufe cites did randomize children for 14 months of the different interventions. Because these drugs are medically indicated for a diagnosis of ADHD and show benefits, however, an ethics committee is unlikely to approve a study that involves withholding them long-term. As child and adolescent psychiatrist Harold S. Koplewicz noted in the Huffington Post in a response to Sroufe, “you can’t put a child on a placebo for his entire adolescence for the purpose of a study.” Koplewicz also points out that many therapies, including insulin therapy for diabetes, haven’t gone through long-term randomized studies for the same reason.

Baby having a bath, by Georgios Jakobides.

As the parent of a child with ADHD, I want to point out something else. In his early schooling, our nine-year-old son experienced daily and persistent public humiliation for his ADHD-related behaviors. In one class in particular, his teacher embarrassed him several times a day by sending him to sit alone in the public hallway as a sort of “in the stocks” punishment for his behavior. Parents and teachers would walk by and stare, and other students would softly taunt him. His motor tics and compulsive behaviors of handwashing to the point of cracked, bleeding hands, nonstop “confessing” of every worrying thought, and expressed self-repulsion worsened throughout that school year and then decreased abruptly when the year ended. Only then did we learn the truth about his experiences.

Because we couldn’t magically change his behavior, we decided to home-school him, opting to change his environment instead of medicating him. His neurologist told us that most ADHD medications would exacerbate his tics, and we were already home-schooling his brother. For us, this choice was preferable to leaving him that environment and attempting medications that might worsen his tics and OCD.

Baby crying in bath. This does not cause ADHD.

Not every family has that luxury, and not every child with ADHD has tics and OCD that may preclude medication. Because of impulsive and inattentive behaviors, people with ADHD usually find themselves absorbing incessant blows to their self esteem and personal achievement as our son did. Medications can reduce the behaviors that bring on these blows, and thus improve a child’s life. They may also help in other ways. According to the 2009 study that Sroufe cites, ADHD symptoms may interfere with a child’s ability to learn social skills, and the study results suggested that medication can reduce the symptoms sufficiently to allow children to acquire these skills.

Do meds “cure” ADHD? No. They ease symptoms only when a person is taking them and, as noted, may allow for deeper improvements in behavior. And in environments that require a specific behavioral conformity, they also may offer some real protection. As the study Sroufe cites noted, children experienced a benefit from the medications at 14 months, months that can translate into a break from constant negative inputs. One thing Sroufe glosses over in mentioning that study is that behavioral therapy combined with medication produced even greater benefits. The research doesn’t support not using medications, but it does support combination therapies as providing the best outcome.

Some experts, like psychiatrist Peter Breggin, also writing in the New York Times, drive the current backlash by accusing parents of using these drugs for children who are just badly or lazily parented, whose parents have “parent attention disorder.” This idea that parents of children with ADHD turn willy nilly to drugs ignores the real complex and painful calculation of costs and benefits parents do--and the outcome is often not to choose medications. According to the U.S. Centers for Disease Control and Prevention, at least one-third of children diagnosed with ADHD are not on any medication at all (and that number could be closer to one-half).

Parents may be reluctant to turn to medications because of what they’ve heard about the related risks and the seeming impossibility of teasing out what the risks really are. ADHD medications do carry risks, as all medical interventions do. A recent controversy about one ADHD medication, Focalin, associates it with suicidal thoughts in four children, even though the Food and Drug Administration says clinical trials don’t support a link. Strattera, another ADHD medication, has been associated with a risk of suicidal thinking in the first months of therapy in an average of every 4 children of 1000 taking it. But at least one study has found that early treatment can reduce the risk of suicide attempts among teenagers with ADHD. Other research finds that that drug therapy for children can help to stave off substance abuse down the road. Again, as with any therapy, effects vary from individual to individual, one probable reason these risks and benefits are so hard to pin down.

Adderall

The FDA also warns that people with pre-existing heart problems could be at risk taking Focalin. A 2011 study, however, identified no increased risk of cardiac-related deaths among children and young adults taking various ADHD medications. A just-released study in adults found that increasing drug dose of methylphenidate (e.g., Ritalin) was actually associated with decreasing risk of cardiovascular events, such as stroke or death. Finally, while it’s true that these medications may stunt growth for the first year that a child is taking them, patients appear to catch up with growth curves a few years later. As with any intervention, considerations of the risks of the medication must be balanced against consideration of the benefits of using it.

In his piece, Sroufe also encompasses parents in blame, saying that parents may be responsible for ADHD and that drugs get everyone, including parents, “off the hook.” He has a point: Research indicates that drugs combined with behavioral therapy may be the best route for ADHD treatment. But Sroufe asserts that early childhood environment is the real cause of ADHD. In addition to stressors like domestic violence, lack of social support, and frequent moves, he cites “parental intrusiveness”—and gives the improbable-seeming examples of a parent who ridicules her three-year-old for poor problem-solving or suddenly grabs an infant for a plunge into a bath.

Psychiatrist Breggin also writes that “the idea that American children are somehow genetically or even culturally predisposed has no scientific or common sense basis.” Yet, as seven board members of the American Professional Society of ADHD and Related Disorders noted in response to Sroufe’s commentary, research indicates that ADHD is “highly heritable” (about 60 to 80% inheritable [PDF]) and environment is thus only part of the equation. Indeed, thanks to the identification of gene variants and chemical signaling differences related to ADHD, researchers have developed mice that either lack an identified gene or carry mutations of it. These mice show behaviors that look like the rodent version of ADHD, without any history of “parental intrusiveness.”

This latest backlash against ADHD relies on recycled “diagnosis du jour” tropes of subpar parenting and doped-up, misbehaving kids, but it makes no mention of the abundant science showing what really underlies and helps with this disorder. Worse, the perpetuation of myths about ADHD encourages the perception that children like mine, with their very real disabilities, might be diagnostic frauds. That’s a potential harm that deserves a backlash of its own.

Images:

Adderall, by Twirligig; More adderall, by Patrick Mallahan III; Ritalin, by Sponge; Baby crying in bath - This does not cause ADHD, by Kyle Flood; Baby having a bath, by Georgios Jakobides; Baby vs. Bathwater, by Richfife; Mental disorders can accompany ADHD/ADHD, by Ezagren; ADHD isn’t just “kids being kids.”, by Bjoertvedt.

The views expressed are those of the author and are not necessarily those of Scientific American.

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