Fix the Diagnosis, Not the Children

  1. Psychiatrist Paul Steinberg concedes: ‘Essentially, ADHD is a problem dealing with the menial work of daily life, the tedium involved in many school situtations and 9-to-5 jobs….In essence, attention-deficit disorder is context driven.  In many situtations of hands-on activities or activities that reward spontaneity, ADHD is NOT a disorder."

    "Ultimately, if studies show convincing evidence that children and adults have been harmed by medications for attention disorder, cardiologists will have every obligation to tell jus to halt their use."

    2. The Scottsman Evening News reported that Edinburgh University’s Dr Gwynedd Lloyd has said "decisions to hand out drugs are often made so that parents don’t feel guilty about their unruly children and that there is widespread abuse of  drugs such as Ritalin.  
    In fact, Attention Deficit Hyperactivity Disorder has been a source of contention ever since the term was first adopted by committee at the American Psychiatric Association back in 1987."

However, a debate in the British Journal of Psychiatry in 2004 observed: "Fundamental to the discussion are questions about whether the diagnosis of ADHD actually holds water and what it is that psychiatrists are trying to treat… there are no specific cognitive, metabolic or neurological markers and no medical tests for ADHD".

Dr. Lloyd observes: "As the multi-million-dollar ADHD industry has grown, so has the amount of literature describing fundamental flaws in logic and research and pointing out that claims of a neurobiological origin have never been substantiated."

  1. FDA comprehensive analysis of 4,582 patients in 24 drug trials was just published in the Archives of General Psychiatry.  The New York Times reports, "The analysis found that about four children and adolescents of every 100 who took the drugs reported suicidal thoughts or behavior, twice the number among those who took dummy pills"

    See also, power point review by FDA’s medical officer, Dr. Andrew Mosholder at: http://www.fda.gov/cder/present/DIA2005/Mosholder.pdf

    Dr. Mosholder first analyzed the pediatric SSRI data submitted to the FDA, but his report prepared for the FDA advisory committee meeting (Feb. 2, 2004) showing a twofold increased suicide risk was embargoed by FDA administrative officials.  His original findings were fully and repeatedly validated by numerous independent reviewers.   

    Since children prescribed ADHD drugs are often also prescribed antidepressants, the forcoming FDA advisory committee hearings on ADHD drugs need to address the full scope of the problem the drugs pose for children.
     
    Contact: Vera Hassner Sharav
    veracare@ahrp.org

    http://www.nytimes.com/2006/03/07/health/07essa.html
     March 7, 2006
    Essay
    THE NEW YORK TIMES
    Attention Surplus? Re-examining a Disorder
    By PAUL STEINBERG, M.D.

    The recent recommendation that Ritalin and other medications for attention-deficit disorder carry the most serious allowable warning will certainly slow the explosive growth in the use of those drugs.

    That was the intention of some members of the Food and Drug Administration advisory committee that called for the packaging alert, known as a black-box warning. But the recommendation and concerns about growth in the use of these drugs may force us to think about the disorder, known as A.D.H.D., in new and different ways, from an evolutionary and contextual standpoint.

    Every generation likes to believe that it is witnessing the most dramatic epoch in history. In the case of the current Western world, that belief may indeed be accurate, particularly in light of the striking changes of the last 30 years.
    As the business writer and consultant Peter Drucker pointed out, most people in the United States, Japan and parts of Europe are "knowledge workers." We live in an information age, in a knowledge-based economy.
    For those of us who have "attention-surplus disorder" — a term coined by Dr. Ned Hallowell, a psychiatrist in Boston who has A.D.H.D. — this knowledge-based economy has been a godsend. We thrive.
    But attention disorder cases, up to 5 to 15 percent of the population, are at a distinct disadvantage. What once conferred certain advantages in a hunter-gatherer era, in an agrarian age or even in an industrial age is now a potentially horrific character flaw, making people feel stupid or lazy and irresponsible, when in fact neither description is apt.

    The term attention-deficit disorder turns out to be a misnomer. Most people who have it actually have remarkably good attention spans as long as they are doing activities that they enjoy or find stimulating. As Martha B. Denckla of the Kennedy Krieger Institute in Baltimore has noted, we should probably be calling the condition something like "intention-inhibition disorder," because it is a condition in which one’s best intentions — say, reading 50 pages in a dense textbook or writing a 10-page paper in a timely fashion — go awry.

    Essentially, A.D.H.D. is a problem dealing with the menial work of daily life, the tedium involved in many school situations and 9-to-5 jobs.
    Another hallmark, impulsivity, or its more positive variant, spontaneity, appears to be a vestige from lower animals forced to survive in the wild. Wild animals cannot survive without an extraordinary ability to react. If predators lurk, they need to act quickly.
    This vestige underscores the fact that human genetic variability, the fact that we are not all simply clones of one another, has allowed us to survive as a species for 150,000 years in a variety of contexts and environments.

    In essence, attention-deficit disorder is context driven. In many situations of hands-on activities or activities that reward spontaneity, A.D.H.D. is not a disorder. 
    Ultimately, if studies show convincing evidence that children and adults have been harmed by medications for attention disorder, cardiologists will have every obligation to tell us to halt their use.

    But a more fundamental societal accommodation would be highly beneficial — to recognize that each child and adult learns and performs better in certain contexts than others.  As Arthur Levine, president of the Teachers College at Columbia University, has noted, future teachers will be able to individualize and customize the education of students.  Some children and young adults with attention disorder may need more hands-on learning. Some may perform more effectively using computers and games rather than books. Some may do better with field work and wilderness programs.
    If it is indeed a context-driven disorder, let’s change the contexts in schools to accommodate the needs of children who have it, not just support and accommodate the needs of children with attention-surplus disorder.

    For those with attention disorder who wish to be full participants in a knowledge-based world, medications equalize their opportunities. The drugs should and can be used only as needed in the context of dealing with the tedium of school or the drab paperwork of some jobs.

    Cardiologists, biostatisticians and consumer advocates may clamor, appropriately or inappropriately, to reduce the use of the medications. But unless we go back to the caveman world, some people will find the drugs increasingly necessary to succeed as knowledge workers in a drastically transformed modern world.

    Paul Steinberg is a psychiatrist and writer in Washington.

    Copyright 2006The New York Times Company

    http://news.scotsman.com/opinion.cfm?id=274972006
    THE SCOTSMAN
    Fix the diagnosis not the children
    JANICE HILL

    THE news that an Edinburgh academic believes Scottish youngsters are handed out "mind-altering" drugs for hyperactivity when in fact their bad behaviour is nothing more than a natural part of growing up will, I’m sure, have alarmed the thousands of parents whose children are currently taking medication such as Ritalin.

    Edinburgh University’s Dr Gwynedd Lloyd has said decisions to hand out drugs are often made so that parents don’t feel guilty about their unruly children and that there is widespread abuse of drugs such as Ritalin.  In fact, Attention Deficit Hyperactivity Disorder has been a source of contention ever since the term was first adopted by committee at the American Psychiatric Association back in 1987.

    As the multi-million-dollar ADHD industry has grown, so has the amount of literature describing fundamental flaws in logic and research and pointing out that claims of a neurobiological origin have never been substantiated.  For example, a debate in the British Journal of Psychiatry in 2004 observed: "Fundamental to the discussion are questions about whether the diagnosis of ADHD actually holds water and what it is that psychiatrists are trying to treat… there are no specific cognitive, metabolic or neurological markers and no medical tests for ADHD".

    Ritalin is in fact a Class B drug which has the same pharmacology as cocaine and one can safely assume any parent would have deep concerns about their child taking it – if they are aware of all the facts. But parents are not informed of the continuing division of medical opinion surrounding ADHD and its validity as a diagnostic concept and the nature of the drugs prescribed.

    Although many children have been "medically diagnosed" with ADHD, very few if any have been subject to basic procedures and medical tests to establish a correct differential diagnosis – ie finding out what causes the symptoms.  Clearly, many factors influence children’s behaviour: poverty, divorce, overcrowded classrooms, nutritional problems and more. It is also true that many factors influence prescription rates for drugs used to influence children’s behaviour. The rise in prescriptions rates – last year in Scotland prescriptions were up 11 per cent – reflects an increase of publicity for ADHD as a condition afflicting children, and the number of children so categorised.

    ADHD has generated huge profits for the pharmaceutical industry but I would argue this is against a background of poor-quality research, publication bias and payments to some of the top academics in this field. Thus the mainstream dogma on ADHD is contaminated and misleading.
    This division of medical opinion is reflected in a wide variation in prescription rates in different localities in Scotland – from 0.5 per cent to 26 per cent – indicating variations in the acceptance of this as a diagnosis by different practitioners or clinics.

    The largest meta-analysis study, the results of which were published in September last year by the Oregon Drug Effectiveness Review Project, analysed 2287 pieces of research – virtually every investigation ever done on ADHD drugs – to reach its conclusions: it found no evidence to support the claims about these drugs’ safety or the legitimacy of the ADHD diagnosis.

    A parent who is not aware of these points cannot be considered sufficiently informed to give legally meaningful informed consent to treatment proposed for their child. And in fact, the GMC requires as a standard of practice that UK medical practitioners obtain informed consent before treatment. To continue to medicate children as young as two years old with powerful mind-altering drugs is a public health scandal.
    To give such drugs to toddlers still in nappies who have not yet attended nursery school and whose brains and central nervous systems are still developing, is nothing more than a form of social control and fascism. Few of us would like to see the word "junkie" attached to any of our children in the illicit sense, yet we are happy to give them mind-altering drugs, whose long-term consequences have yet to be determined.

    Is self-control, self-monitoring, self-regulation and good diet, a thing of the past? Will our kids remain the shiny happy people we had hoped for with such medical intervention? Only time will tell but there are those who would prefer to see the psychiatrists and drug companies drugged and institutionalised as a better cure-all than the drugging of children for profit.

    • Janice Hill runs Overload Network, a support group for parents with hyperactive children

     Last updated: 22-Feb-06 11:18 GMT

    http://www.nytimes.com/2006/03/07/health/07depress.html?ex=1142398800&en=e3b143b5b01dcd67&ei=5070&emc=eta1

    Study Details Link of Drugs and Thoughts of Suicide
    By BENEDICT CAREY
    Published: March 7, 2006

    Antidepressant drugs raise the small risk of suicidal thoughts and behavior in depressed children and adolescents, scientists at the Food and Drug Administration are reporting today in a detailed published account of findings they reached in 2004.

    The study, an analysis of 4,582 patients in 24 drug trials, is the first widely published evaluation of data that the agency reviewed that year. The analysis found that about four children and adolescents of every 100 who took the drugs reported suicidal thoughts or behavior, twice the number among those who took dummy pills.

    The publication of the study is not likely to alter the debate about the relative risks and benefits of antidepressant treatment, experts said. No one in the trials committed suicide, and the suicide rate among adolescents has dropped significantly since doctors began prescribing the drugs to minors in the early 1990’s.

    But some experts said publication of the report, in today’s issue of The Archives of General Psychiatry, may make it harder to deny that antidepressants like Prozac, Zoloft and Effexor cause a worsening in a small number of children and adolescents with depression, stirring in them thoughts of suicide they would not otherwise have had. The findings so impressed F.D.A. officials in 2004 that they voted then to require a suicide warning on the drug’s labels, "and we felt and still feel that was the right thing to do," said Dr. Thomas Laughren, director of the agency’s Division of Psychiatry Products, who was a co-author of the study.

    Still, a spokesman for the American Psychiatric Association, Dr. David G. Fassler, a child and adolescent psychiatrist in Burlington, Vt., said the study had yet to clarify the relationship between suicidal thinking and behavior.

    "It shows that kids taking the medications are twice as likely to tell the clinician about suicidal thinking," Dr. Fassler said, not whether there is a significant difference in the incidence of suicide attempts.

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