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The ADHD Controversy

Attention Deficit Hyperactivity Disorder (ADHD) is a behavioural syndrome characterised by dysfunctional levels of inattention and/or impulsivity/hyperactivity.  Despite concerns about the validity of the diagnosis and the long term safety of the drugs used to treat it, ADHD is the most commonly diagnosed and medicated childhood and adolescent psychiatric disorder in the world.[1][2] 

 

Although the cause or causes are unknown there is widespread recognition that biological and social factors can contribute to a child exhibiting ADHD type behaviours.  There is also little argument that psychostimulants, the most commonly used treatment, when taken in low oral doses will often reduce the external presentation of these behaviours. 

Despite this limited agreement there is significant controversy around numerous aspects of ADHD, including the:

  1. Validity and reliability of the diagnosis. - Are the diagnostic criteria of ADHD (e.g. fidgeting, losing things, disliking homework, playing loudly, interrupting and being disorganised) valid and sufficient evidence to diagnose a childhood psychiatric disorder?

  2. Safety and long term efficacy of ADHD medications. - Is it good for the developing brains and bodies of distracted/hyperactive children, for them to have a daily low dose amphetamine habit?

  3. Cause/s of ADHD type behaviours. - Are ADHD type behaviours the product of defective genes and biochemical brain imbalances, and/or are they a product of a multitude of social, family, environmental, and other factors?

  4. Relationship between ADHD and drug misuse. - Does a daily low dose of amphetamines, administered to children diagnosed with ADHD, promote, or prevent, future drug misuse?

  5. Do non-drug ADHD treatments work? - What are the non-drug treatments for ADHD and do they work?

  6. Role of Genetics and Parenting in ADHD. - Nature versus Nurture - what does the evidence say?

  7. History of ADHD. - How the boundaries of ADHD have been progressively broadened so that more children are 'disordered' and fewer are 'normal'.

There is a spectrum of views ranging from, proponents who contend ADHD is a serious medical condition that is massively under-diagnosed and under-treated globally, through to critics who contend it is a harmful false epidemic and marketing triumph supported by pseudoscience.

Proponents contend that ADHD is a common neurodevelopmental condition, with at least in part a genetic/biological cause. They assert that ADHD is frequently comorbid with other psychiatric conditions but can be treated safely and effectively with medications and psychosocial interventions.  They claim that skilled clinicians can reliably distinguish ADHD from other potential causes of dysfunctional behaviour and from normal childhood inattention and exuberance. They argue that if it goes undiagnosed and untreated ADHD children and adolescents will disproportionately suffer significant avoidable social, educational, economic and employment disadvantage and frequently self-medicate with alcohol and illicit drugs later in life. Proponents proffer a biomedicalized explanation for growing ADHD prescribing rates.  Specifically they argue that improvements in diagnostic processes and greater access to appropriate pharmaceutical treatments and increased awareness, accounts for the global increase in ADHD prescribing rates. Many proponents contend it remains significantly under-diagnosed and under-treated.

Critics believe that ADHD is not a valid psychiatric disorder, and the drugs used to treat it are unsafe and ineffective in the long term.[3] Many critics contend that the psychostimulants are addictive and frequently abused or diverted for illicit use and claim inappropriate medicalization accounts for increased global ADHD prescribing rates. They point to the lack of objective physical tests and the broadening of diagnostic criteria as evidence of unjustified industry-driven pharmaceuticalization. They assert ADHD is at best a loose description of behavioural patterns that is often mistakenly regarded as a biological cause, resulting in circular claims that the behaviours called ADHD, are caused by ADHD.[4]  They argue that elevating a ‘description’ to a ‘diagnosis’ stops doctors, parents and teachers from identifying and responding to the cause of some children and adolescents’ problematic behaviour. 

There is also a centrist group that believes ADHD is a real but frequently over-diagnosed and over-medicated condition.[5] The situation is further complicated by a subset of critics of 'medication' use' who believe that ADHD is a legitimate psychiatric disorder, and promote the use of a single alternative treatment as being the appropriate universal response to ADHD.  The different perspectives on ADHD are outlined in further detail on the other ADHD related pages. 

Editors Comment - I (Dr Martin Whitely) acknowledge that I am a prominent ADHD critic. However, I have tried to fairly reflect the diversity of views, and identify the relevant robust evidence, on this, and the other, ADHD related pages. While I and many other critics believe that ADHD is not a useful diagnostic label, we agree that some children diagnosed with ADHD have significant problems and need support. We contend that for each child the obligation is on teachers, doctors, parents and other adults to identify what is causing any problematic childhood behaviours and respond to each child's individual circumstances.  We also contend that it the obligation is on proponents of ADHD diagnosis and prescribing to prove their claims that ADHD is a brain disorder, and that the drugs used to treat it are safe and effective for developing brains and bodies.  So far proponents have failed to meet any of these obligations. 

References

[1]  Inyang Takon (2011), ‘Clinical use of a modified release methylphenidate in the treatment of childhood attention deficit hyperactivity disorder’, Annals of General Psychiatry, 10:25. Available at http://www.annals-general-psychiatry.com/content/10/1/25  (accessed 30 March 2019).

[2]  Storebo et al. 2015 Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD) http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009885.pub2/abstract  (accessed 30 March 2019)

[3]  Psychologist and Professor Emeritus at California State University, David Keirsey, criticises the circularity of the argument stating, ‘It’s preposterous to say that the symptoms of attention deficit cause the deficit of attention.’ David Keirsey, ‘The Great A.D.D. Hoax’ at Keirsey.com, n.d., http://www.keirsey.com/add_hoax.aspx (accessed 30 March 2019).

[4]  Schwarz, A. (2013, December 15). The selling of attention deficit disorder. New York Times, pp. A1. https://www.nytimes.com/2013/12/15/health/the-selling-of-attention-deficit-disorder.html  (accessed 30 March 2019)

[5]  Frances A, Keith Connors, Father of ADHD, Regrets Its Current Misuse Setting things straight on the ADHD diagnosis Posted Mar 28, 2016 https://www.psychologytoday.com/blog/saving-normal/201603/keith-connors-father-adhd-regrets-its-current-misuse (accessed 30 March 2019)