The Hedgehog Review

The Hedgehog Review: Vol. 16 No. 2 (Summer 2014)

Losing Control of ADHD

Joseph E. Davis

Reprinted from The Hedgehog Review 16.2 (Summer 2014). This essay may not be resold, reprinted, or redistributed for compensation of any kind without prior written permission. Please contact The Hedgehog Review for further details.

The Hedgehog Review

The Hedgehog Review: Summer 2014

(Volume 16 | Issue 2)

It began inauspiciously enough, with a little niche market. In the late 1950s, drug manufacturers struggling to find new medical uses for their stimulant (amphetamine and amphetamine-related) medications, which they had been selling for narcolepsy, mild depression, weight loss, and lack of energy (e.g., “tired mother’s syndrome”), latched on to a set of behavior problems in children. These problems had attracted some research interest in the late 1940s and were given diagnostic names such as “hyperkinetic impulse disorder” and “minimal brain damage” and later, in the 1968 second edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), “Hyperkinetic Reaction of Childhood.” The essential feature of these problems was impulsiveness and excessive motor activity, and the syndrome was identified in a relatively small number of children, mostly boys. Though still an obscure diagnosis and considered rare in the 1960s, it attracted the attention of drug companies, who began to market their stimulant medications to both doctors and educators.

By 1970, there were signs of trouble. That year, the best guess (no national surveys existed) put the number of children being medicated, ostensibly for hyperactivity, at 150,000, sparking Congressional hearings. Thereafter, the number of cases would ascend an inexorable growth curve, with perhaps 500,000 cases by 1980, when psychiatrists in the third edition of the DSM linked a new problem, “attention deficits,” to the long recognized one, hyperactivity, in a hybrid diagnostic category. The new category, “attention deficit disorder, with or without hyperactivity” (later, attention deficit hyperactivity disorder) was redefined in terms of cognitive deficits in sustained attention and impulse control, precisely those deficits which stimulant medications were believed to reduce. This change, which made hyperactivity an optional symptom, dramatically enlarged the scope of the disorder and the number of cases along with it. Diagnosed cases reached nearly one million by 1990, with some 600,000 on stimulant medication, and then simply exploded after that. Along the way, it seems fair to say, psychiatry lost control of its category.

In the January 2014 issue of the Journal of the American Academy of Child and Adolescent Psychiatry, epidemiologists from the Centers for Disease Control and Prevention finally published the results of their 2011 National Survey of Children’s Health. The survey, whose results had first been publicized by The New York Times in March 2013, found that 11 percent of all children between the ages of 4 and 17 (6.4 million) had been diagnosed with ADHD at some time in their life, including nearly 20 percent of high school boys. The total represents a nearly 10 percent increase since the NSCH in 2007 and a 42 percent increase since the first survey in 2003. In the 2011 survey, parents reported that some 3.5 million kids were currently taking one of those amphetamine-related drugs. As these drugs were largely driven out of other areas of medicine over the years, the one-time niche market had become pretty much their only market, but one ringing up sales in the many billions of dollars.

The public reaction by physicians to these run-away numbers has gone in two directions. One reaction, exemplified most prominently by the heads of the task forces that oversaw the writing of the DSM-IV (1994), Allen Frances, and the DSM-5 (2013), David Kupfer, has been to acknowledge a false epidemic. They blame the diagnostic threshold levels in the DSM as well as societal factors, such as the intense pressure on doctors to diagnose children who are having problems at school. The second, and conventional position, is to employ the growing numbers within a scientific progress narrative. In this story, all the diagnosing and drugs are medically necessary.

An editorial, “Beyond Rising Rates,” published in the same January issue of the Journal of the American Academy, is devoted to spinning the progress story. The authors argue that “shock at the high and increasing rates” is misplaced. The real question is how close diagnostic rates are approaching the “true prevalence of a condition” and how many of those with the disorder are receiving “evidence-based treatment.” By these criteria, they argue, the CDC numbers on diagnostic rates are good news, while the “take-home message” on medication use is actually one of “undertreatment of ADHD, not of overtreatment, as commonly thought.”

The CDC numbers are not good news and asserting so is to conflate the results of epidemiological community studies, and two high-estimate ones at that, with the “true prevalence of a condition.” First, because psychiatric conditions lack objective markers, no one can measure the “true prevalence” of any such condition. What epidemiologists actually measure are “cases,” reports of behaviors or feelings, as given on structured questionnaires administered by nonprofessionals that meet the stipulated diagnostic thresholds described in the DSM. For ADHD, such behaviors include things like “often has trouble organizing tasks and activities,” “is often easily distracted,” “often talks excessively,” and so on.

Although constantly confused, an epidemiological case is not a diagnosis. Best practice guidelines for diagnosing ADHD in children, for instance, require conducting a clinical diagnostic evaluation, drawing upon information from parents, teachers, the child, and others across various settings, such as home and school, and evaluating the child for co-occurring or other conditions that might account for the problem behaviors. While clinicians themselves often fail to meet this minimum standard, epidemiologists, relying on interview instruments that lack professional judgment and contextual information, can never do so. An epidemiological case is a report of “symptoms”; it does not document the presence of a mental disorder.

Of course, the deeper presupposition of psychiatric epidemiology is that the DSM’s symptom-based approach is itself a valid indicator of mental disorder. There are many reasons to doubt this assumption, and even leading psychiatrists such as Thomas Insel, director of the National Institute of Mental Health, have described DSM categories as useful heuristics for clinical practice but lacking validity. The usefulness of ADHD, however, whose very definition is intertwined with the effects of stimulant drugs, extends to cultural troubles and tensions far beyond mental illness. Another space has emerged, fostered by the lifestyle promises of the pharmaceutical companies and incorporating a number of key cultural priorities, over which medicine’s jurisdiction is merely formal—and not even that in some contexts, such as university campuses, which are awash in extra pills. This loss of control is not a story of medical progress.

Joseph E. Davis

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