Jane

Tharaphi

Kendra

Rachel

Christy

Chris

Pay Attention: The ADHD Controversy and the Media

Christy Dolph

Two years ago, a survey of 30,000 children in Virginia found that seventeen percent of fifth grade white boys were taking medications for Attention-Deficit/Hyperactivity Disorder (ADHD) (10). Over the past year, several lawsuits have been filed against Novartis, the manufacturers of Ritalin; CHADD, a support group for individuals with ADHD; and The American Psychiatric Association, claiming that the defendants have conspired together to create and promote the diagnosis of Attention Deficit Disorder(8). In Albany, New York, a family court recently ruled that a couple must put their seven-year-old son back on Ritalin after the public schools accused the parents of child abuse for taking him off the medication(7). As these examples illustrate, considerable controversy surrounds both the proper diagnosis and the treatment of the disorder known as ADHD, a controversy that has been highlighted in recent years by increased media coverage. Given the well-publicized nature of the debate, how do adults concerned that they or their children have ADHD make the difficult decision as to whether and how to treat it? One source of information for patients and their families is the Internet. Indeed, an Internet search for ADHD related websites produces an abundance of hits, including pages for parent support groups, alternative "natural" treatment options, and publications by the National Institute of Mental Health. However, the controversy surrounding the diagnosis and treatment of ADHD extends here as well. In this critique, I examine two Internet sites that each takes a somewhat different view towards ADHD. My evaluation is based upon the credibility of each site as well as the utility of each in helping an individual to make an appropriate treatment decision. Specifically, I will focus on the ways in which the two sites portray the use of stimulant medication as a means of treating ADHD, as this is one of the more controversial aspects surrounding the ADHD issue. First, however, I consider a brief history of ADHD, as the current controversy associated with the diagnosis and treatment of this disorder may be traced, at least in part, to a historical failure of the medical profession to understand its ultimate cause.

History of ADHD

Historically, most attempts to define the cause of ADHD have been biological in nature. In 1902, George Still produced the first clinical description of what we today refer to as ADHD(2). Through his clinical practice he observed children who seemed abnormally aggressive, poorly inhibited, highly emotional, resistant to discipline and easily distractible. Still conceptualized this disorder as the result of biological factors, including heredity and central nervous system damage(2). Widespread interest in children such as those described by Still did not arise until after World War II. At this time, scientists began to consider brain damage as the exclusive cause for restless and inattentive behavior, and they coined the term "minimal brain damage" to refer to this disorder in children(2). Doctors and scientists continued to accept neurological damage as the central causative explanation for this disorder until the 1970s, when a series of publications refuted the relationship between abnormally hyperactive, inattentive and impulsive behavior and brain damage. In 1980, the American Psychiatric Association relabeled the disorder "Attention Deficit Disorder (with our without Hyperactivity) and then again in 1987 as "Attention-Deficit/Hyperactivity Disorder. This most recent name places emphasis on the importance of hyperactivity as one of the central features of the disorder in addition to inattention and impulsiveness. Throughout the 1980s until the present day, doctors and scientists came to posit that the central deficiency in ADHD children was an inability to self-regulate behavior(2).

Today, a definitive cause of the disorder has still not been specified. Thus, doctors diagnose ADHD based upon the occurrence of certain symptomatic behavior, rather than on an understanding of the specific cause. The most common behaviors fall into three categories: inattention, hyperactivity, and impulsivity(1). ADHD individuals may experience difficulties with sustained attention to tasks, putting forth a constant effort, inhibiting their behavior, and impulsiveness(1). They also tend to be more active, restless, and fidgety than "normal" people of the same age and sex(1).

This brief account of ADHD's medical history highlights a point useful to the critique of the current ADHD debate. The historical tendency of medical professionals to attribute ADHD to biological factors, rather than social or environmental ones, has influenced the ways in which we currently understand and treat the disorder. If we believe, for example, that the disorder results predominantly from some misfiring of biochemical processes in the brain, we feel justified in treating the disorder with drugs that interfere with these biochemical processes. Alternatively, if we attribute ADHD-like symptoms not to some biological disorder but to the behavioral response of a healthy individual in an unhealthy environment, we are more likely to make environmental changes to treat this behavior, such as the initiation of personal counseling. Given that our understanding of ADHD has been grounded, from the beginning, on various biological explanations, we may more readily accept a medicinal approach to treatment of the disorder, whether this is the more legitimate approach or not. We should be conscious of this potential source of bias when we evaluate the pros and cons of medicinal treatment.

ADHD on the Web

The first website I have chosen to critique illustrates a pro-medication approach to the treatment of ADHD. This site is the homepage for Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD), a parent-based organization formed with a mission to "to improve the lives of people with attention-deficit/hyperactivity disorder through education, advocacy and support"(5).The CHADD website argues for a multimodal approach to the treatment of ADHD, which means intervention on medical, psychological, educational, and behavioral levels. The suggested interventions include changes in lifestyle such as educational modifications, behavioral management, individual and family counseling, parent training, and the use of medication. Although the organization does advocate this multi-faceted treatment process, their web pages emphasize the importance of medication in this treatment regimen. This emphasis is evident in the "Frequently Asked Questions" section, one of the major sources of information within the site. Here, the site's authors explain that "for most children and adults with AD/HD, medication is an integral part of treatment"(5). Moreover, the informative material repeatedly mentions the brand name Ritalin, a psychostimulant used to treat the disorder. To the question: "Are psychostimulants such as Ritalin safe?" the response is largely positive, emphasizing the lack of long-term side affects while noting a few relatively minor short-term effects.

CHADD's advocacy of medication-based treatments is less than credible, given that in 1999-2000, CHADD received $315,000 from pharmaceutical companies that produce such treatments, an amount equal to about 13% of the organization's budget. Indeed, Novartis (formerly Ciba-Geigy), the producer of Ritalin, has given almost 1 million dollars to CHADD since 1988(5). The financial relationship between CHADD and the pharmaceutical industry clearly affects the information presented to viewers, as evidenced by the multiple references to Ritalin and other brand name drugs throughout the informative pages. CHADD's acknowledgment of this financial relationship is a one-sentence blurb buried in the annual report section of the web page. The organization's failure to make this relationship more obvious could potentially mislead the reader as to the objectivity of the material presented.

Despite CHADD's assertion to the contrary, some medical professionals have argued that important adverse effects are indeed associated with commonly used stimulant drugs. As Dr. Peter Breggin notes, the Drug Enforcement Administration classifies drugs used to treat ADHD, such as methylphenidate (Ritalin) and amphetamine (Dexedrine and Adderrall), in the same Schedule II category as methamphentamine, cocaine, and the most potent opiates and barbituates(9). Schedule II includes only those drugs that are highly addictive and therefore easily abused. Studies have indicated that prescribed stimulant use in childhood can predispose an individual to drug abuse in adulthood, produce brain cell death and permanent changes in brain chemistry, and endanger the cardiovascular system(9). Clearly, the potential positive and negative aspects of these drugs are highly contested, suggesting that the patient should exercise caution when deciding whether or not to take stimulant medication for his or her condition. Any possibility that pharmaceutical drugs may have serious negative side effects makes imperative the representation of these ideas on the CHADD website, if it aspires to be a truly objective source of information for the concerned reader.

Offering a different perspective on the treatment of ADHD-like behavior is a site entitled "Born to Explore! The OTHER Side of ADD"(3). The author, Teresea Gallagher, is not a medical professional. Rather, she is essentially a layperson who has independently acquired a great deal of information about ADHD and synthesized it into her own coherent web page. An ADHD patient herself, Gallagher describes "Born to Explore" as a "non-commercial site devoted entirely to exploring positive and alternative views of attention deficit disorder in children and adults"(3). Like the CHADD website, "Born to Explore!" advocates a multi-modal approach to treating ADHD. Unlike the CHADD website, however, this site offers little information or praise regarding a pharmaceutically medicated treatment program. Although Gallagher states that she is not "anti-meds", and merely cautious about medications, her website lacks detailed information regarding the use or potential benefits of prescribed drugs for the treatment of ADHD. Instead, she devotes an entire page to "alternative treatments", including nutritional supplements, meditation, and exercise. She does not recognize that even alternative methods of treatment can be potentially dangerous if used incorrectly, especially in the case of nutritional supplements, which are often not reviewed for safety and efficacy by the Food and Drug Administration(4).

Gallagher's de-emphasis of medication as a treatment option stems from her view of ADHD as one of many personality types, rather than as a medical disorder. Indeed, Gallagher explicitly makes the connection between ADHD individuals and certain personality types as defined by the Meyers-Briggs Type Indicator. Just as with any other personality type, she argues that ADHD individuals have certain strengths and weaknesses that other people may not have, including creativity and inventiveness. The author is concerned that individuals who medicate their ADHD condition may be depriving themselves of valuable mental potential, which, while perhaps not perfectly suited to leading a "normal" life, nevertheless confers important intellectual strengths. Although Gallagher's credibility is limited somewhat by her lack of medical expertise, her suggestion that we re-evaluate our view of ADHD as a harmful condition requiring medication is a valid one. Given that we lack understanding of the causes of ADHD, and therefore of the precise ways in which psycho stimulants act to alleviate ADHD-like behaviors, ADHD patients should look to alternative ways of dealing with the disorder before resorting to psycho stimulant use. In this way, patients can keep the risk that they may unknowingly compromising their personality, or inflict permanent biochemical damage upon themselves, to an absolute minimum.

The controversy surrounding the diagnosis and treatment of ADHD will likely remain unresolved in the near future. Unlike the sites described here, which urge children and adults with ADHD to one side or the other of this debate, web sites would benefit ADHD patients most highly by objectively presenting the positive and negative aspects associated with the various treatment options for this disorder. Armed with this information, people can decide to treat themselves or their children in a way that most appropriately fits their individualized needs.

References

1. Attention Deficit Hyperactivity Disorder. National Institute of Mental Health. http://www.nimh.nih.gov/publicat/adhd.cfm

2. Barkley, Russell A. 1998. Attention-Deficit/Hyperactivity Disorder. In Mash, Eric J. and Russell A. Barkley, eds. Treatment of Childhood Disorders, 2nd edition. The Guilford Press, New York.

3. Born to Explore! The OTHER side of ADD by Teresa Gallagher. http://borntoexplore.org.

4. Council for Responsible Nutrition. www.crnusa.org/shellscireg000003.html

5. CHADD. Children and Adults with Attention-Deficit/Hyperactivity Disorder. http://www.chadd.org

6. Merrow, John. http://adhdfraud.org/follow_the_money_trail.htm

7. Parents Pressured to Put Kids on Ritalin by Thomas, Karen. From USA TODAY, August 8, 2000. http://www.usatoday.com/life/health/child/lhchi193.htm

8. Recent Lawsuits and Ritalin by Bailey, Eileen. http://add.about.com/library/weekly/aa051001a.htm

9. Testimony September 29, 2000 before the Subcommittee on Education and the Workforce U.S. House of Representatives by Breggin, Peter R., M.D. http://www.breggin.com/congress.html

10. Zito, J.M., Safer, D.J., dosReis, S., Gardner, J.F., Boles, M., Lynch, F. 2000. Trends in the prescribing of psychotropic medications to preschoolers. Journal of the American Medical Association 283 (8).