Attention-deficit hyperactivity disorder: Encyclopedia II - Attention-deficit hyperactivity disorder - Controversy

Attention-deficit hyperactivity disorder - Controversy

While ADD/ADHD is a known psychiatric condition, there are various theories about the cause and some controversy over the number of persons diagnosed and the cost of medications. Some denial in families may also relate to the negative perception of the condition as a hereditary brain disorder.

Attention-deficit hyperactivity disorder - Skepticism towards ADHD as a diagnosis

Critics have complained that the ADHD diagnostic criteria are sufficiently general or vague to allow virtually any child with persistent unwanted behaviors to be classified as having ADHD of one type or another.

A growing number of critics have wondered why the number of children diagnosed with ADHD in the U.S. and UK has grown so dramatically over a short period of time. However, doctors often claim that improving methods of diagnosis and greater awareness are probably in part, if not mostly the reason for this increase.

Dr. Mary Megson, however, in her presentation to the House Government Reform Committee on Autism and Vaccines (2000) claims the increase in ADHD, as well as autism, are a result of the increasing use of vaccines that deplete vitamin A stores, combined with a G-protein defect. This is especially likely in a family where at least one parent suffers night-blindness, she says.

It has often been suggested that the causes of the apparent ADHD epidemic lie in cultural patterns that variously encourage or sanction the use of drugs as a simple and expeditious cure for complex problems that may stem primarily from social and environmental triggers rather than any innate disorder. Some critics assert that many children are diagnosed with ADHD and put on drugs as a substitute for parental attention, whereas many parents of ADHD children assert that the associated demand for attention goes beyond what can be humanly provided, causing massive disruption to other individuals and relationships, as well as to environments with dysfunctionally structured relationships such as are manifest in many classrooms. This criticism also includes the use of prescription drugs as a substitute for parental duties such as communication and supervision.

Another source of skepticism towards making the diagnosis of "ADHD or not ADHD" may arise from the rising diagnosis of subclinical forms of ADHD. So called 'Shadow-syndromes' or 'sub-syndromes' stand for weaker forms of ADHD and are described in various degrees by John J. Ratey and Catherine Johnson on their book Shadow Syndromes: The Mild Forms of Major Mental Disorders That Sabotage Us.

Another explanation comes from a common misconception of the symptoms that leads to an incorrect diagnosis. For example, an employee of a school might think that a student has ADHD simply because the child cannot be controlled in the classroom. A teacher may think a student whom they cannot control has ADD, but in reality the problem may be a lack of discipline. The same teacher might not notice a child who forgets their papers, stares (entranced) at the carpet for long periods of time, or shows many of the recognized symptoms.

However, the results achieved in clinical tests with medication and anecdotal evidence of parents, teachers, and both child and adult sufferers has been taken as proof that there is both a condition and successful treatment options for most people who meet the criteria for a diagnosis. But critics point out that neurological differences exist among individuals just as with any human trait, such as eye color or height; and that stimulants have an effect on anyone, not just those diagnosed with ADHD.

Another problem lies in misdiagnosis; critics believe many of those being treated for ADHD do not suffer from the disorder to such a point that potentially mind-altering drugs should be prescribed.

A further problem is that ADD and ADHD are syndromes, associations of symptoms. There is no well established cause for the condition. This means that it may actually be a blanket term covering a multitude of conditions with a variety of causes. In fact, genome scans have identified several gene alleles which are prevalent among individuals diagnosed with ADHD, but no single allele can account for all cases, and not all cases have been explained genetically.

Confusion may also arise from the fact that ADD/ADHD symptoms vary with each individual, and some mimic those of other causes. A known fact is that, as the body (and brain) matures and grows, the symptoms and adaptability of the individual also change. Many individuals diagnosed with ADD/ADHD successfully develop coping skills, while others may never do so.

Another view is that while there does exist a phenotype that corresponds roughly to the ADHD diagnostic criteria, this phenotype should not necessarily be described as a pathology. There are many phenotypes considered normal-variant, which have liabilities, and perhaps some advantages as well, such as homosexuality and left-handedness. In other words, ADHD may be better seen as a form of neurodiversity.

Attention-deficit hyperactivity disorder - ADHD as pseudo-science and its falsifiability

Some experts have noted that the hypothesis "ADHD is a disorder" is unscientific, and point out that people generally assume that something is scientific just because it sounds scientific [6]. In other words, ADHD does not have good Popperian criteria for falsifiability. To be falsifiable, there would need to be a possible empirical observation which could show that the hypothesis is false. Given that the neurobiological basis is often brought up, one criteria could be the following:

However, this falsifiability criterion has a number of problems. For one, psychiatry doesn't define something as a disorder only if it has a neurobiological basis. But more importantly, human brains are not identical, so every single person could be said to have neuroanatomical differences compared to an average. For this criteria to be valid, there would need to be a clear distinction between which neuroanatomical differences constitute a disorder (e.g. a tumor) and which do not. Unless the specific neurobiological characteristics of ADHD are tautologically defined as a disorder, this task is clearly problematic, as behavior that is considered normal-variant (e.g. homosexuality, left-handedness, giftedness, being asleep, tired, etc.) likely has a neurochemical or neuroanatomical basis as well.

Attention-deficit hyperactivity disorder - Hunter in a Farmer's Society theory

Proposed by Thom Hartmann, this evolutionary psychology theory holds that ADHD was an adaptive behavior for the "restless" hunter before agriculture became widespread. Scientific concern around Hartmann's theory revolves around the mismatch between the behaviours symptomatic of ADHD, and those he describes as being adaptive for hunters, which better fit a diagnosis of hypomania (Mota-Castillo, 2005). A positive feature of the theory is the idea that thinking in terms of attentional 'differences' rather than attentional 'disorders' may direct effort toward utilizing an affected individual's strengths and uniqueness. Conversely, it could also reinforce a person's denial and refusal to seek treatment.

A 2001 study published in Proceedings of the National Academy of Sciences [7] on the seven-repeat (7R) allele of the human dopamine receptor D4 (DRD4) gene (known to be linked to ADHD) has been cited as support for Hartmann's theory. The study concludes that "this allele originated as a rare mutational event that nevertheless increased to high frequency in human populations by positive selection." Some scientists point out that mutations may survive without conferring any benefit (see genetic drift) simply because the individuals mature and procreate. In other words, the gene causes no early mortality and does not reduce the fitness to procreate.

Attention-deficit hyperactivity disorder - ADHD as a social construct

Following from the Hunter-versus-farmer theory, as with many conditions in the field of psychiatry, ADHD can be explained as a social construct (Timimi, 2002) rather than an objective 'disorder'.

In this view, in societies where passivity and order are highly valued, those on the active end of the active-passive spectrum may be seen as 'problems'. Medically defining their behaviour (by giving a label such as ADHD) serves the purpose of removing blame from those 'causing the problem'.

Evidence presented against the social constructionist view comes from a number of studies that demonstrate significant differences between ADHD and typical individuals across a wide range of social, psychological, and neurological measures as well as those assessing various areas of functioning in major life activities. More recently, studies have been able to clearly differentiate ADHD from other psychiatric disorders in its symptoms, associated features, life course, comorbidity, and adult outcome adding further evidence to its view as a true disorder.

Invocation of this evidence is seen by proponents of the social construct theory as a misunderstanding, nonetheless. The theory does not state that individuals across a behavioral spectrum are identical neurologically and that their life outcomes are equivalent. It is not surprising for PET scan differences to be found in people at one end of any behavioral spectrum. The theory simply says that the boundary between normal and abnormal is arbitrary and subjective, and hence ADHD does not exist as an objective entity, but only as a 'construct'.

Nor does evidence of successful treatment persuade the social constructionist; for example the American National Institute on Drug Abuse [8] reports that Ritalin is abused by non-ADHD students partly for its ability to increase their attention. Evidence showing that ADHD is associated with certain liabilities does not appear to undermine this view either; normal-variant behavior could have certain liabilities as well, and a life outcome cannot be predicted with certainty for any given diagnosed individual.

Critics of the social constructionist view contend that it presents no evidence in support of its own position. Theories must present their details and mechanisms in as precise a manner as possible so that they are testable and falsifiable, and this theory is said to provide no such details. But proponents of the view disagree that criteria for falsifiability is lacking. One way, for example, is to show that there exists an objective characteristic posessed by virtually all diagnosed individuals which does not exist in any non-diagnosed individual. Current candidates for falsifiability include PET scans, genes, neuroanatomical differences, and life outcomes. However, none of these have been shown to be precise predictors of a diagnosis or lack thereof. (Such criteria is generally fulfilled by well-understood medical diseases).

Critics of this view also assert that it is not consistent with known findings. For instance, ADHD is as frequent in Japan and China as in the US, yet in such societies that favor child obedience and passivity one would expect higher rates of ADHD if this theory were correct. Timimi's view has been seriously citicized by Russell Barkley and numerous experts in Child and Family Psychology Review (2005).

Significant differences in the prevalence of ADHD across different countries have been reported, however (Dwivedi, 2005). Timimi himself cites a range of prevalence that goes from 0.5% to 26% as support for his theory.

Attention-deficit hyperactivity disorder - Concerns about the impact of labeling

Dr. Thomas Armstrong [9], a prominent critic of ADHD as an objective disorder, has said that the ADHD label is a "tragic decoy" which erodes away the potential to see the best in every child. 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 [10].

Thom Hartmann became interested in ADHD when his son was diagnosed; Hartmann has said that the brain disorder label is "a pretty wretched label for any child to have to bear" [11].

Others have expressed concern that the brain disorder label can negatively impact the self-esteem of a child and effectively become a self-fulfilling prophecy mainly through self-doubt.

Attention-deficit hyperactivity disorder - Concerns about medication

Many parents and professionals have raised questions about the safety of drugs used to treat ADHD, particularly methylphenidate (Ritalin). Despite belief to the contrary, no significant effects have been observed on stature or the emergence of tics [12]. Deaths attributed to methylphenidate are believed to be caused by interactions with other drugs, and are extremely rare. Medical Examiner Ljubisa Dragovic does not agree, however, and in the case of the death of 14-year-old Matthew Smith he said, "There is an ocean-sized problem out there that needs to be looked at very carefully by multidisciplinary teams for careful reassessment of the use of this drug." He discussed the type of disorder called "small vessel disease" which is caused only by stimulant drugs - including Ritalin - and the likelihood that diabetic children were at higher risk for cardiac problems. The web page Stimulant medication and heart disease lists a number of relevant studies. In particular, Brown (1989) showed that African-Americans are more prone to increase in blood pressure and should be monitored closely.

A new concern, raised by a small scale 2005 study, is that methylphenidate might cause chromosome aberrations [13], and suggested that further research is warranted considering the established link between chromosome aberrations and cancer and considering that all the children in this study showed suspicious DNA changes within a very short time. A team from the Food and Drug Administration (FDA), the National Institutes of Health (NIH) and the Environmental Protection Agency (EPA) went to Texas on May 23, 2005 to evaluate the methodology of the study. Dr. David Jacobson-Kram of the FDA said that the study had flaws in its methods but that its results could not be dismissed. Flaws cited are (1) that the study did not include a control group on placebo, and (2) that it is too small. Several research teams will attempt to replicate the study on a larger scale.

Studies on rats have suggested there could be plastic changes in personality and brain functioning after chronic use into adulthood, including changes in sensitivity to reward [14] [15]. But, again, studies in humans are lacking and so such results cannot be automatically extrapolated to humans.

Attention-deficit hyperactivity disorder - ADD/ADHD a hoax?

There are some claims that ADD/ADHD is simply a hoax. Some of these charges are that there has been a conspiracy between medical and counseling professionals and the pharmaceutical companies, or that the former have been misled by the latter, which have profited greatly from the sale of medication such as Ritalin and Adderall, and have advertised their products extensively. Since medications became available, there has been an increased number of persons diagnosed. This might be explained by increased awareness or easy solution for doctors.

A major proponent of this theory, although not the only one, is the Church of Scientology, which is opposed to the field of psychiatry in general, citing ADHD as one example in which psychiatrists "harm" patients. Scientology maintains several satellite organizations like the Citizens Commission on Human Rights which have been outspoken critics of the biological basis of ADHD and medications used to treat it.[16] There may exist a conflict of interest as Scientology advocates and sells an alternative and expensive non-pharmacological treatment known as Dianetics. To complicate matters, The Church of Scientology is associated with other organizations, many of which do not openly declare themselves to be connected in any way. This makes the work of other opponents of the ADHD diagnosis difficult, because they are under false suspicion of being undeclared Scientology agents.

Nevertheless, evidence for any such grand conspiracy theory is lacking. Moreover, many studies show numerous differences/deficits between those with ADHD and the general population that contradict this view that ADHD is simply a fiction or hoax. The Church also has a conflict of interest in their position given that organized psychiatry and psychology are their competitors against their own therapies and course work through their Church.

Attention-deficit hyperactivity disorder - famous people and ADHD

Many professional counselors find it useful to emphasize to persons diagnosed with ADHD and their families the perspective that the condition does not necessarily block, and may even facilitate, great accomplishments. Most frequently cited as potentially useful is the mental state of hyperfocus. A number of lists of famous persons either diagnosed with ADHD, it predecessor ADD, or suspected (but not necessarily known to have had ADHD) are numerous.

Among the individuals often listed is comedian Robin Williams, whose spontaneous humor, hyperactive manner, and other noted behavior (not all constructive) have combined to earn the him the label "Poster child for ADD (orADHD)." Notwithstanding inspirational value, cited by critics is the fact that Williams' personal medical records are not public information, so including him and many others found on such lists falls below reasonable criteria for validity. List of famous peoples with ADD or ADHD http://adhd-famous.ca.cx/

Adapted from the Wikipedia article "Controversy", under the G.N U Free Docmentation License. Please also see http://en.wikipedia.org/wiki