MYTHOLOGY 401


ADHD MYTHOLOGY 2011

LESSON 401 – CONTROVERSIES

 

I will do my best in this Lesson to identify and discuss many of the most persistent and distressing controversial issues about diagnosis and treatment of ADHD.  I will try to use “laypeople friendly” terms, which is sometimes hard for me. 

 

POPULAR MYTH 1:  ADHD is Overdiagnosed.  This is simply not true.  Hundreds of careful studies by many hundreds of psychologists and psychiatrists published in the leading journals and books in this field have addressed this controversy over and over again for 10 – 20 years.  There is substantially more published literature now about ADHD than any other condition affecting children; Asthma is a distant second. 

 

This controversy is relatively recent, since it has been known for many years ADHD was very infrequently diagnosed in children and hardly ever in adults until the early 80's.  Although the English pediatrician Sir George Frederick Still very clearly described and authored papers about ADHD as long ago as 1902, his work was ignored until 1937, when the amphetamine medication Benzedrine was found to be very helpful for hyperactive children.  This discovery was overwhelmingly rejected by psychologists and psychiatrists then because we were collectively in the era where all child or adolescent behavioral problems were assumed to occur due to ineffective parenting (by the mother, of course).  Until the late 60's, treatment was almost always psychoanalysis for the mother and play therapy for the child. 

 

Modern research in this field did not begin until the 70's, and then slowly began to be addressed more frequently until the publication of twin studies in the early 80's suddenly alerted academic specialists to something most Grandparents knew all along:  “The apple does not fall far from the tree.”  Inherited genes were recognized as the primary cause of ADHD, and a tremendous change occurred in our research and treatment of this condition.  We went from “underdiagnosis” to concern about “overdiagnosis” in the ensuing years. 

 

There is now essentially an international consensus ADHD affects 7-9% of all children, more boys than girls until ages18-20, does not suddenly go away during or soon after puberty, and usually persists into adult years just like almost all other serious Neurobiological conditions.  Children typically do become less hyperactive between the ages of 13-16, but problems with tasks requiring sustained attention persist and often become more distressing during the growing and aging years. 

 

Careful studies of the prevalence of ADHD in the general population by numerous experts and the national CDC (Center for Disease Control) have consistently found  only about 25-50% of all children who clearly have ADHD have ever been evaluated for and diagnosed with this condition.  Two studies discoveredpockets” in small regions of the country where as many as 15-18% of all 10-12 year old children had been diagnosed as having ADHD.  There did appear to be reasonable concern about overdiagnosis in these towns and counties.  Dozens of other studies of much larger regions and populations, as mentioned above, have consistently discovered a pattern of underdiagnosis, even in regions where there is a widespread assumption by teachers and parents ADHD is overdiagnosed. 

 

POPULAR MYTH 2:  Medications are Overprescribed.  There has been a very rapid increase in the quantity of stimulant medications prescribed in the U.S. in the past 30 years.  Canada, United Kingdom, Australia, and New Zealand were slower to pick up this pace, but are now essentially equivalent to the U.S.  Europeans persisted in a remarkably resistant belief that ADHD is a result of poor parenting skills until the past decade, and are just recently approaching our rate and quantity of medication prescribing.  Most European countries have amazingly restrictive national health care programs which artificially reduce the selection of “approved medications” as well as the severity of the symptoms which can be treated, e.g. in many European nations only the most severely impaired children and adolescents who have ADHD can receive any medication treatment.  It is obvious these policies are used there simply to reduce national health care costs, even in countries as advanced in medical and psychiatric expertise as the U.S., e.g. Germany and Israel.  We have 16 medications approved for the treatment of ADHD here in the U.S.; there are only 2 in Israel:  Ritalin and Cylert (which has been banned for use in the U.S. for many years due to liver toxicity). 

 

All recent (past 10 years) careful studies of medication prescribing in the U.S. have consistently revealed much less than half of all children who have ADHD are being treated with ANY medications.  Several very large multi-state, multi-communities studies led by eminent academic authorities such as Dr. Peter Jensen, then at the National Institute for Mental Health (NIMH), and others, found fewer than 25% of children diagnosed as having ADHD were being treated with any medication during the year prior to assessment, and yet worse, most of the children who were being treated received less than half the prescriptions needed, and were being seen very infrequently by the prescribing physician. 

 

POPULAR MYTH 3:  Mediction Diversion.  The term “diversion” means kids who are being properly treated for ADHD are sneakily giving some of their medication to other kids who do not have ADHD, or who do have ADHD but have run out of their medication.  Several large studies have shown 5-9% of adolescents have at least once taken stimulants given to them by other teens without parent or physician authorization.  There are actually no reports of any harm done in these cases.  Kids in Middle and High School give other kids all manner of other substances far more often:  alcohol, marijuana, “downers” like Xanax or Valium, and all manner of pain medications.  Girls very often provide each other with Midol or Aleve or Tylenol to relieve menstrual cramps. 

 

College students are sometimes more prone to provide each other with stimulant medications given their perception stimulants help them study for and pass tests more effectively, and help them stay up late to complete procrastinated essays or other assignments.  Rates of medication diversion in colleges range all the way from as little as 5% to one reported college where an amazing 35% of students admitted to receiving illicit medication from other students.  This is a preposterous amount and is almost certainly erroneous.  There is no question some college students who are being treated for ADHD occasionally sneakily share some of their medication with roommates or friends who are preparing for or taking difficult tests or staying up too late to complete assignments.  Again, however, there are no published reports of any college students suffering from adverse effects of these occasionally taken illicit medications.  Most current college students know a great deal more about all manner of medications than their parents, and sometimes more than prescribing physicians!  They have easy access to extensive Internet information about all manner of drugs and routinely share their knowledge and experiences with each other.

 

I always warn ADHD students going away to college to keep their stimulant medication in a private, secure place, in a bottle which is labeled something like Vitamin D or Zyrtec, and to keep their use of stimulants confidential.  I believe as many as 25% of all 18 year olds going away to college probably follow these directions!  I also prescribe as precisely as possible the exact quantity needed to “cover” the time they will be gone, e.g. from mid-August to Thanksgiving, etc., so their parents and I can be pretty darned sure – in some cases – when they run out of medication too soon there may be something sneaky going on.  Naturally, the kids then just tell their parents and me they didn't use the standard amount of medication on weekends and look perfectly innocent while lying to us.  If occasional diversion were really a serious matter and might endanger some other students, we would have to use more Draconian measures to monitor these kids, but it isn't a serious issue at all, and going away to college is realistically supposed to be an important social as well as academic learning experience.          

 

POPULAR MYTH 4:  Use of Prescribed Stimulants Creates Dependency and Increases the Risk of Future Substance Abuse.  This is not true.  In fact, children who begin properly monitored stimulant medication treatment during Elementary School years, and who are seen regularly by a capable / concerned / knowledgeable / friendly / compassionate / wise / experienced prescribing physician who has a good sense of humor and engaging professional manner, who develops and maintains a good relationship with the kid and his/her family, and who is a physician the child – adolescent likes and respects, have a remarkably reduced risk of future substance abuse vs medication untreated ADHD children.  One study by Harvard professors suggested as much as an 85% lower rate of substance abuse compared to medication untreated ADHD children, but it did not follow these children long enough into young adult years to be convincing.  However, a much better designed German research study came to an even more positive conclusion tracking the development of medication treated vs untreated ADHD children over the course of 10 years, from age 12 to age 22. 

 

Most experts in this field now strongly advocate using behavioral treatment interventions for very young ADHD children who have mild problems, but virtually all now agree even very young ADHD children who have moderate to severe symptoms should be treated with one of the many useful medications as soon as their problems become truly developmentally impairing.  This term means parents are frazzled and angry almost every day with the child's symptoms; baby sitters and even day care centers don't want to try to cope with the child again; Grandparents are more and more reluctant to assist with the child's care; neighbors don't want their children playing with the child anymore; taking the child to a store or almost anywhere away from home leads to nasty and embarrassing confrontation; and when the child starts Kindergarten the child is considered “immature.” 

 

Modern research has clearly documented even very young ADHD children with these impairing features benefit from some medication treatment as well as intensive behavioral interventions, and most child psychologists and child psychiatrists now agree early medication treatment intervention is almost always essential for severely affected children. 

 

Further, current research now strongly suggests the earlier effective treatment is initiated the better the outcome.  Stimulant treatment has been found to “normalize” the quantity of so-called “white matter” in the ADHD child's developing brain.  “White matter” refers to important sub-cortical connective neurons. 

 

There are some well-known problems found in ADHD children and families which clearly increase the risk of adult substance abuse:  starting treatment late in adolescence; multiple doctors who cannot see the teenager often enough to develop a positive relationship; conduct disorder or oppositional defiant disorder symptoms; early onset (before 15) of cigarette smoking; bipolar disorder; family history of at least one parent exhibiting antisocial features; and some other issues.