ADHD – probing the controversy

A bit of a background…

So I was diagnosed with ADHD as a child, and then again in high school. By diagnosed, I mean I took a trip to the big apple (Brisbane, Qld) for aptitude tests, interviews and an electroencephalography; the works. I was prescribed Ritalin (methylphenidate) in high school.

After about a year or two I stopped taking the drugs (without telling anyone). I discovered that I was experiencing side effects, which I now know are well known and common side effects of these medications. I stopped taking them immediately and have never taken them since. The side effects weren’t particularly severe, I just didn’t like them.

I also, to the best of my memory, experienced no withdrawal symptoms whatsoever.

I flaked my way through the rest of high school, then became a blue-collar worker for the first half of my twenties.

Fast forward to today and I have since earned two degrees, and completed an honours year in a field which, in retrospect, I was not trained for. Now I’m at the very beginning of a PhD studying the genetics of ADHD… all without medication.

I’m learning that it’s quite normal for the start of a PhD to kick off rather slowly, so I’ve had plenty of time to read up.

Apparently there is some pretty heated discussion surrounding the general phenomenon of child hyperactivity and inattention. So far as I can tell the vast majority of the scientific and medical establishment accepts ADHD as a perfectly legitimate medical condition/disorder/diagnoses. There are also however some very highly qualified (and some less highly qualified) skeptics, some of whom have been medical practitioners working with children for many years.

The purpose of this post will be to try to disentangle some of the controversy and highlight what I see are some of the main issues surrounding the heated pop culture debate.

What is ADHD?

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According to the DSM-V, currently the most up to date version of the ‘Diagnostic and Statistical Manual of mental disorders’, Attention Deficit Hyperactivity Disorder, or ADHD, is:

“A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development, as characterized by (1) [inattention] and/or (2) [hyperactivity/impulsivity]”

There are 9 symptoms associated with both 1 and 2, making 18 in total.

I won’t list them, they’re easy enough to find, but are summarized thus:

Inattentiveness: distractibility, carelessness, short attention span, absent-mindedness, forgetfulness.

Hyperactivity: restlessness, impulsivity, loudness, being hyperactive (shocking)

In theory these behaviours only lead to a diagnosis when exhibited collectively, when they’re beyond what is ‘normal’ for a given age/level of development, when they have persisted for at least six months, and when they are specifically negatively affecting an individual’s life in at least two of these three categories:

  • school/work/learning
  • family life
  • social life

Again in theory, diagnoses should also rule out a better explanation such as another mental disorder, or defiance/boredom etc.

The method of diagnoses forms a portion of the controversy.

Prevalence differs from place to place also, but in general it’s estimated to be anywhere between 2 – 5% of youth with approximately 50 – 60% persisting with symptoms into adulthood.

What is the controversy?

Based on my currently very non-academic skim of the controversy, the skeptics concerns appear to fall into two broad categories:

  1. Whether ADHD is a legitimate disorder, or simply a set of normal behavioural characteristics which are expressed to varying degrees in all children (and adults)

  2. The legitimacy/safety/necessity/ethics of the medications that are typically used as a treatment for ADHD

The rest of this post will summarize these two main points and try to bring a little clarity to the very emotional hype.

1. Is ADHD legit?

The question of what, if anything, ADHD represents is an interesting one.

No one denies that children everywhere exhibit large variation in their abilities to pay attention, sit still, and listen quietly, etc.

So far as I can tell, no one denies that these behaviours can be quite extreme in some kids.

No one denies that these behaviours can pose some tough challenges for the child and their parents, teachers, guardians etc.

What is the subject of debate is:

  • The proportion and distribution of these behaviours in the general population
  • The underlying explanation for these behaviours
  • Whether these behaviours represent some underlying disorder, or are simply kids being normal
  • Whether these behaviours require treatment, and what kind of treatment that should be

so let’s have a bit of a look at these.

The proportion and distribution of these behaviours in the general population

To what extent are these behaviours seen in children? How prevalent are they?

Complaints include the apparent vagueness and ambiguity in the terminology and the language used to define ADHD. Skeptics argue that anyone could be forgiven for thinking they have ADHD.

However, if it’s true that the criteria are so vague that they apply to anyone, then why don’t they? If all kids exhibit these behaviours to some extent, then why are only 5% or less diagnosed?

The underlying explanation for these behaviours

This is where the discussion gets really personal. People are quick to blame parenting, individuality, GMO, genes, standardized testing, anything.

‘These children are just poorly disciplined’

‘My child is uncontrollable, there’s nothing I can do about it’

‘There’s too much sugar in their diet’

‘The kids are not the ones with the problem, the education system is’

Every explanation under the sun is given.

It seems almost axiomatically true that children’s personalities are partially influenced by their genes, but how much?

It also seems reasonable that different parenting styles would have vastly different effects on different personality types in children. It’s also basically a given that children learn a great deal merely by the example that their parents set for them.

All this and more must be taken into account. Again, in theory it should be taken into account in the diagnoses.

Whether these behaviours are normal, or the expression of some underlying disorder

This is one of the key controversies.

Is there really anything ‘wrong’ with these kids?

Isn’t it likely by pure chance that at least some subset of the population will harbor a collection of these behaviours to some extent?

I’ll say that even if it’s true that these behaviours are quite rare, that doesn’t mean that the kids who exhibit them are automatically ‘bad’ or have a ‘disorder’. A diagnosis is made based on whether the behaviours significantly disadvantage the child.

That being said, one criticism is that the diagnostic criteria are vague. This means that they lie on a spectrum with no clear cut-off point. The behaviours are not a matter of ‘yes’ or ‘no’, it’s more of a ‘on a scale of 1-10’ kind of matter.

However, it’s also true that just because these behaviours lie on a spectrum, that does not invalidate a diagnoses. Many human traits and disorders, particularly psychiatric disorders lie on a spectrum.

BMI is a good example. Obesity is a very real problem, but it definitely lies on a vague spectrum. Nonetheless at some point clinicians have to draw the line between healthy and unhealthy. The same can, in principle, be said of ADHD symptoms.

Whether these behaviours require treatment, and what kind of treatment that should be

Now this is the real crux of the issue.

After everything else we’re left with the question ‘what do we do about it?’

If the behaviours of these children are ‘normal’ or at least not due to some biologically real disorder, then how does the real world deal with them?

Even if these behaviours are perfectly normal and simply a part of the unique qualities of some individual children, that doesn’t mean they do not have some potentially negative effects on the child and those around them. In the least the children need to be encouraged and educated to be socially and educationally well-adjusted humans.

We can argue that it’s just bad parenting, or the education system is failing some personality types, or whatever we want, but none of these ‘explanations’ do anything to appease the concerns of tired worn out parents, or children who are struggling to make it through each day. I don’t think anyone disagrees with this.

The real question is do these children need medication? Which brings me to the next major circle of controversy…

2. To med, or not to med…

The second major branch of controversy and debate centers around the drugs used to ‘treat’ the symptoms of ADHD.

Do they work and how?

Are they safe?

Are the necessary?

Ask anyone who supports the use of these drugs and they will emphatically assure you that they are perfectly safe and helpful, and there is a wealth of research to back them up and without them some parents would be lost.

Ask any skeptic and they will emphatically assure you that this is all a total scam set up by big pharma in a diabolical conspiracy to dupe flaky, apathetic parents seeking to avoid the responsibility of parenthood into buying their drugs in order to make evil pharmaceutical companies millions upon millions of dollars.

They will say that the wealth of research is completely flawed for various (often quite valid) reasons. They will say big pharma doesn’t actually care about the consequences of children taking the medication, and they are exploiting the apathetic parent’s sensitivities to make them think their kids need the drugs.

Some say the drugs are almost completely unnecessary and a healthy dose of good living is what most of these kids need. Everything from proper nutrition, adequate sleep, physical activity and good parenting will solve the majority of problems. Frankly I’m inclined to agree, at least for a significant portion, but time and research will tell.

But there are many who swear by the medications, at least for some cases.

What’s certain is that the drugs do something. They definitely have an effect of some kind. Children who are hyperactive take these drugs and it changes their behaviour.

Skeptics claim that the changes are bad, that it messes with their brain chemistry. They claim that these drugs are highly addictive, that they have no long-term benefit, but rather have severe long term side effects.

Answers to these questions form a significant portion of the ongoing debate.

Where to from here?

Proponents are quick to point out that ADHD has been ‘known’ to exist for over a century, and that there are – like seriously – 30,000 research articles documenting this.

I honestly haven’t read the apparently 30,000 odd articles written about ADHD so far; I doubt anyone has read them all. But over the course of my PhD, I will read as many as I can, and I will attempt to explore this issue further both in terms of what’s relevant to my research, and what will simply improve the public perception in general. I will read more articles and learn more, and then I will write about it.

Finally, whether you’re a skeptic or not, it’s important to understand that researchers, doctors and psychiatrists are not stupid. They’re not emotionless automaton’s that treat children like test subjects and call every little thing a ‘disorder’.

The whole point of understanding ADHD is to help people. If ADHD isn’t a ‘disorder’, but merely a quirky subset of the population, that doesn’t change much from a research perspective. If their quirky characteristics make it extremely difficult for these children (or adults) to learn, or socialize, then it’s important to understand what we can do to help. Maybe that means better parenting, maybe it’s their diet, maybe it’s just fostering good time management skills, or maybe it’s cocaine.

Answering these kinds of questions is one of the goals of medical science.

It’s not always about putting people into a box and giving them a label.

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