Attention Deficit Hyperactivity Disorder: State of the Science. Best Practices
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jake inva...@invalid.com
Attention Deficit Hyperactivity Disorder: State of the Science. Best Practices In Jensen PS, Cooper JR (Eds); Kingston NJ, Civic Research Institute, 2002.
Chapter 3- Is ADHD a Valid Disorder?
by William B. Carey. M.D.
Overview The ADHD Diagnosis Increasingly Frequent Diagnosis Shortcomings of Diagnostic Criteria An Area of Consensus Major Diagnostic Problems ADHD Behaviors Not Clearly Distinguishable From Normal Temperament Variations Absence of Clear Evidence That ADHD Symptoms Are Related to Brain Malfunction Neglect of the Role of the Environment and Interactions With It as Factors in Etiology Diagnostic Questionnaires Now in Use Are Highly Subjective and Impressionistic Most Important Predisposing Factors May Be Low Adaptability and Cognitive Problems Lack of Evolutionary Perspective Small Practical Usefulness and Possible Harm From Label Widespread Misapplication of the Present ADHD Label Nonspecific Effects of Methylphenidate and Other Stimulants Conclusion OVERVIEW Despite the general agreement on the existence of a small group of "hyperkinetic" children (l-2 percent of the population), there is considerable uncertainty about the diagnostic terminology of attention deficit hyperactivity disorder (ADHD) used to describe another 5-10 percent of children, who are the chief concern of this chapter. The abnormal ADHD behaviors of activity, inattentiveness, and impulsiveness are not clearly distinguishable from normal temperament variations. The ***umption that the ADHD symptoms arise from cerebral malfunction has not been supported even after extensive investigations. The current diagnostic system ignores the probable contributory role of the environment; the problem is supposedly all in the child. The questionnaires most commonly used to diagnose ADHD are highly subjective and impressionistic. The current view of ADHD fails to achieve the evolutionary perspective that the behaviors regarded as troublesome in the modern cl***room may have had survival value in primitive times. The ADHD label, which is widely thought of as being beneficial, has little practical specificity and may become harmful.
In addition to problems with the diagnosis itself, there are concerns about the loose way it is being applied and the widespread misinformation about the specificity of the effects of methylphenidate.
ADHD fails to meet the criteria for a mental disorder according to the Diagnostic and Statistical Manual of Mental Disorders (DSM). What is apparently being described in most cases now is normal behavioral variations of inattention and activity that, accompanied by low adaptability and/or cognitive disabilities, sometimes lead to dysfunction through dissonant environmental interactions.
A DSM disorder should be defined in terms of the dysfunction itself, such as problems in social relationships or school achievement, rather than in terms of risk factors like activity. Brain malfunction should be diagnosed only when there is objective evidence of it. Problems in attention deserve a much more sophisticated analysis. This situation calls for a paradigm shift, a different way of looking at this area of children's problems.
THE ADHD DIAGNOSIS Increasingly Frequent Diagnosis The diagnosis of ADHD is being made with ever increasing frequency.
The label is confidently being attached to children by their parents, their child-care workers, over the telephone by professionals, and in a number of other alarming ways. Methylphenidate prescriptions have increased enormously. Although there is some dispute as to the exact figures (Safer, Zito, & Fine, 1996), there is no question that the usage of the drug in the United States has increased several fold in the last decade, making this country the world leader in its consumption by a wide margin (United Nations International Narcotics Control Board, 1995).
Medical, psychological, and educational professional organizations have expressed little concern about this epidemic. For example, the Council on Scientific Affairs of the American Medical ***ociation (AMA) concluded recently that "there is little evidence of widespread over-diagnosis or misdiagnosis of ADHD or of widespread over-prescription of methylphenidate by physicians" (Goldman, Genel, Bezman, & Slanetz, 1998, p. 1100) but this opinion was derived from a library review of papers already published without collecting any fresh, impartial, and more competent data.
The reasons for this great increase in diagnosis and treatment are undoubtedly complex and diverse, but a full exploration of these reasons would go beyond the scope of this chapter. The most comprehensive and reliable review of the problem is presented in the recently published book Running on Rita/in, by Lawrence Diller (1998). Certainly great social pressures by parents and teachers on physicians and psychologists have been a major factor in finding the fault within the child.
Shortcomings of Diagnostic Criteria This chapter focuses on the shortcomings in the basic construction of the diagnostic criteria of the disorder of ADHD, which are probably the main source of the current confusion. Although the recently revised fourth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric ***ociation, 1994) has made the standards a bit clearer, the criteria still allow for the lumping together of a diverse collection of normal variations of temperament, problems in cognition, environmental dissonances, behavioral adjustment issues, and sometimes neurological immaturities under one vague, all-encomp***ing label. Substantial problems are evident in (1) the pathologization of normal temperament variations; (2) the continuing failure to demonstrate a neurological basis for the diagnosis; (3) the neglect of the participation of the environment in the clinical disorder; (4) the use of highly impressionistic and subjective questionnaires for diagnosis; (5) the likelihood that the most common predisposition in children now receiving this diagnosis is low adaptability, rather than inattention or high activity, and also problems in cognition; (6) the lack of an evolutionary perspective; and (7) the questionable value and possible harm of the label. Two additional troublesome problems are (8) the widespread failure to apply the diagnosis correctly at the practical level and (9) the common misperception of the specificity of methylphenidate for ADHD.
The diagnostic criteria for ADHD are officially set forth in DSM-IV.
The child must have six or more of the nine inattention symptoms or six or more of the nine hyperactivity/impulsivity symptoms present "for at least six months to a degree that is maladaptive and inconsistent with developmental level." Some of the symptoms must have been present in the child before the age of 7. Some impairment must be present in two or more settings, in social, academic, or occupational functioning. "The symptoms do not occur exclusively during the course of Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder and are not better accounted for by another mental disorder?‰" (American Psychiatric ***ociation, 1994, p. 78).
DSM-IV presents itself as purely descriptive without attempting to ***ign causes for the various conditions defined. (This may be regarded by some as a strength of the system, but it is probably also a great weakness.) For that reason, DSM-IV does not offer any explanation of where this set of ADHD behaviors comes from. Nevertheless, articles in journals and textbooks and reviews of the subject (Barkley, 1990; Cantwell, 1996; Tannock, 1998) have not hesitated to enlarge on this basic definition with several additional ***umptions. These suppositions include the notions that the ADHD behaviors are abnormal and clearly distinguishable from normal, the condition constitutes a neurodevelopmental disability, it is relatively uninfluenced by the environment, and yet it can be adequately diagnosed by brief questionnaires. All these postulates, and some others, must be challenged because of the weakness of the empirical support and the strength of the contrary evidence, as this chapter will indicate.
AN AREA OF CONSENSUS There does seem to be a general agreement on the existence of a small group of readily recognizable children with "hyperkinetic disorder," as defined more conservatively and rather briefly by the tenth edition of International Statistical Cl***ification of Diseases and Related Health Problems (lCD- 10; World Health Organization, 1992): A group of disorders characterized by an early onset (usually in the first five years of life), lack of persistence in activities that require cognitive involvement, and a tendency to move from one activity to another without completing one, together with disorganized, ill-regulated, and excessive activity. Several other abnormalities may be ***ociated ... often reckless and impulsive ... in disciplinary trouble because of unthinking breaches of rules unpopular with other children ....
Impairment of cognitive functions is common and specific delays in motor and language development are disproportionately frequent ?‰ (p. 378) Studies in the United Kingdom of children so defined have revealed a prevalence of l-2 percent of the primary school boys: The typical abnormalities found in school-age children are reduced verbal and performance IQ, immature articulation of speech, a history of language delay in earlier development, poor motor coordination in skilled tasks with marked overflow movements from one side of the body to the other, and impersistence in sustained acts. Such abnormalities have not generally been found in studies of children with ADHD. It is not yet possible to go further and ***ert that neurodevelopmental immaturity is the cause of hyperactive behavior. (Taylor, 1994, P.
294) In fact, it is not clear whether ...
"Jon Quixote" jpoisel_n_o_s_p_a...@starband.net
"Best Practices" for *what*?
<snip> That he doesn't believe ADHD is valid as currently diagnosed and cites the "nine traits" that are considered "normal" no matter which trait is high or low in comparison to the rest of the population as proof that he's correct.
It's apparently easier to believe in a pharmo/doctor conspiracy on a m***ive scale than in so many people reading/hearing the list of symptoms for the first time and nearly breaking their neck in agreement that the same thing happens with/to them *all the time*.
Not "sometimes". Not "occasionally".
CONSTANTLY.
Call it what you will, discover a different cause of it as you will, the symptoms are all too familiar to those who are afflicted with it. The drugs may not be completely safe, and I can even concede a remote possibility that our positive reactions to them may incorporate a certain psychosomatic component to it, but: Show me the new rascals before trying to throw the old rascals out.
Disagreeing that it exists without providing alternate hypothesis that fits AND TREATS the same symptoms gains you and nobody else anything.
He provides no alternate hypothesis, and essentially ducks the question of what to do other than broaden testing even further. Just as ADHD covers a gamut of problematic behavior, so, too, could his "nine traits" be stretched to cover virtually anything ... except now it would be considered "normal variant" behavior and NOT treated.
His most solidly fallacious ***umption is that we supposed "self-selected" sufferers are, without exception, glomming onto ADHD as an excuse to avoid taking responsibility for ourselves - which neatly ducks why I, at least, am being extremely diligent in trying to learn how to TAKE responsibility for my problems.
I'm forty years old, dude. Why should a diagnosis of ADHD suddenly make me change my set, irresponsible ways? He doesn't define "environmental factors" to my satisfaction - I've been in many different environments, physically and interpersonally, and my behavior is normed across all environments.
And he casts doubt on his entire treatise by acknowledging that so-called "1 to 2% of population that are hyperkinetic" and apparently implying they are likely the "true" ADHD sufferers - except he doesn't take into account the varying levels of affliction. If he can claim a "rating scale" of traits and say they are all normal variations, he will have to deal with varying levels of ADHD affliction as well.
In essence this is nothing but a verbose bash on the current diagnostic criteria regarding ADHD without redeeming value - unless one counts the bashing in and of itself as valuable in stirring controversy, which I concede when done in this manner. At least it was a well-thought-out bash, which takes it out of troll-bait category for me.
--
Jon Quixote What is axiomatic frequently isn't.
jake inva...@invalid.com
On Wed, 29 Oct 2003 21:20:18 GMT, "Jon Quixote" I would hope so ..seeing as Dr Carey is a leading national and international authority in the field of Paediatrics..
"To these measures I add for your special consideration today the need for national legislation to prevent educational and governmental officials at any level from requiring parents to accept the diagnosis and use drug treatment for fear of the legal actions of exclusion from school or child protective agency intervention.
My reasons are simple: The definition of ADHD is extremely vague, the application of it in American medical practice is inadequately disciplined, and the current treatment is nonspecific and noncurative.
For parents to be penalized in any way for skepticism and noncompliance would be medically unsound and ethically unsupportable" http://edworkforce.house.gov/hearings/108th/edr/childmedsafety050603/... Testimony of Dr. William Carey ???Protecting Children: The Use of Medication in Our Nation??™s Schools and H.R. 1170, Child Medication Safety Act of 2003???
Hearing before the Subcommittee on Education Reform Committee on Education and the Workforce United States House of Representatives May 6, 200 In the last two decades the United States has experienced a great increase in the diagnosis of Attention Deficit Hyperactivity Disorder (ADHD) and its treatment with stimulants. Not only child health professionals but now also a wide variety of unqualified persons, such as preschool teachers and acquaintances, are freely offering the diagnosis and confidently urging parents to accept their judgment and obtain drug treatment, such as methylphenidate (Ritalin), for the child. If a physician formally applies the label, educational and governmental authorities sometimes attempt to coerce parents into accepting the verdict and giving the medication or face the possibility of exclusion of the child from school or being judged unfit parents. This chaotic situation urgently requires intervention at several levels, including the Federal government.
One should acknowledge at the outset that virtually all well informed professional observers agree that about 1-2 % of the child population are so pervasively overactive or inattentive that they are very difficult for anyone to manage. Although the cause of their problems is often not clear, they are likely to perform better with medication as a part of their management. But why are up to 17% or more of children being given this label? Why is 80% of the world??™s methylphenidate being fed to American children?
1) The diagnosis of ADHD is very impressionistic and highly subjective, making it easy to include a broad variety of children: a) The component symptoms, such as "often talks excessively," are not clearly different from normal.
b) There is no confirmatory laboratory test, and no proof that the behaviors are due to brain malfunction.
c) The diagnosis is usually made with vaguely worded, brief questionnaires.
2) Even if one accepts the current definition, there is abundant evidence that it is not being applied rigorously at the practical level. Two large surveys of medical practice in the leading psychiatric and pediatric journals have established that about 60% of the time medical practitioners are not using the established diagnostic criteria.
3) Contrary to the popular notion, the stimulants being prescribed today are not specific for ADHD. Improved behavior when taking them is not proof of the diagnosis. Ritalin would make any of us function better.
I am one of a group of pediatric moderates who say that both the radical critics and the American Psychiatric ***ociation??™s diagnostic system are wrong, because we believe that these children do have real problems but that the diagnosis and management is not so simple as is presently being proposed by the ***ociation??™s official manual.
There is no easy answer to this chaotic situation. The main elements in a solution could be: 1) a better diagnostic system, 2) better research, 3) better education of professionals and the public, 4) better individualized evaluations of children, 5) better treatment with greater reliance on psychosocial and educational interventions, 6) better monitoring of aggressive advertising by the drug companies, 7) better reimbursement schemes for physicians so that they are allowed to take the time necessary to do adequate evaluations. The appropriate professional groups must solve the first five of these steps. The last two lie within the proper range of the Federal government.
To these measures I add for your special consideration today the need for national legislation to prevent educational and governmental officials at any level from requiring parents to accept the diagnosis and use drug treatment for fear of the legal actions of exclusion from school or child protective agency intervention.
My reasons are simple: The definition of ADHD is extremely vague, the application of it in American medical practice is inadequately disciplined, and the current treatment is nonspecific and noncurative.
For parents to be penalized in any way for skepticism and noncompliance would be medically unsound and ethically unsupportable
Joe Parsons a...@yankeemedia.n3t
On Wed, 29 Oct 2003 21:20:18 GMT, "Jon Quixote" What this fellow seems to neglect to mention in his criticism of the DSM-IV criteria for ADHD is the sine qua non: that "the symptoms...have persisted for at least six months to a degree that is maladaptive and inconsistent with developmental level." It's interesting how those little words in the criteria, so often omitted by critics, deal with the "kids are *all* like that" argument, isn't it?
Joe Parsons
Mark D Morin mdmp...@nospsmgwi.net
http://www.medscape.com/viewarticle/407851 http://www.medscape.com/viewarticle/407257 http://www.medscape.com/viewarticle/423499 http://www.medscape.com/viewarticle/446416 Just how representative of the professional community are Jensen and Cooper?
==================================================== Ruby stepped toward him. "Edward," she said softly.
"Learn this from me. Holding anger is a poison. It eats you from inside. We think that hating is a weapon that attacks the person who harmed us. But hatred is a curved blade. And the harm we do, we do to ourselves.
"Forgive, Edward, Forgive. Do you remember the lightness you felt when you first arrived in heaven?...
No one is born with anger. And when we die, the soul is freed of it. But now, here, in order to move on, you must understand WHY you felt what you did, and WHY you no longer need to feel it.
"Yo need to forgive your father." Mitch Albom, "the five people you meet in heaven" http://home.gwi.net/~mdmpsyd/index.htm
"Jon Quixote" jpoisel_n_o_s_p_a...@starband.net
I'm not sure which part you are agreeing to - I ***ume you're agreeing with the last sentence's sentiment of his treatise being well-thought-out and that it is, in fact, essentially just a bash.
I'm sure you realize that being an "authority" in anything doesn't immunize the person from using his/her authority as a bully pulpit to get his personal viewpoints validated more than they may otherwise be on their merits alone.
Foolishness. Not the sentiment per se, but the logic therein - if there is no ADD, just varying levels of "normal" traits, there is no need to worry about exclusion from services that aren't required.
It's rabble-rousing, an attempt to heighten a perception of "danger" requiring legislation to save us all from ourselves - if his concerns about ADHD are valid, then the legislation should be directed against the diagnosis of ADHD and the (apparently) mistaken practitioners who make this "dangerous" diagnosis, not against the agencies and organizations that attempt to follow what accepted medical practice says should be done, as interpreted and enforced by various government bodies and laws.
"Vague" in his estimation. IANAD, but so far the DSM definition of the symptoms seem pretty clear to me.
That, I concede, could well be a possibility - but it doesn't invalidate the affliction nor current "best practices" in it's treatment.
Uh? Not specific enough to deal with the varying levels and subtypes of affliction yet, perhaps - but noncurative? Who's he trying to kid? NONE of the credible (to me) literature I've read even ATTEMPTS to imply that ADHD is "curable" or even "slightly healable". The manifestions can often be worked around, but AFAIK, if you got it, it's here to stay for the foreseeable future.
Is it his contention that a mental disorder, regardless of origin, must *always* be amenable to "curative" treatment - treatment that produces objectively noticable improvement every time - before it can even be cl***ified as a disorder?
I don't think so.
Sounds like he is giving a blanket "OK" to those sects who object to medical treatment over God's will. And when their kids die of it or otherwise come to harm from it, we hold them accountable in the courts.
For parents to be persuaded against the majority of evidence both anectodal and scientific supporting the existence of ADD because one doctor doesn't support the majority is also medically unsound and ethically unsupportable.
Best practice is to use the diagnosis that most closely fits the symptoms and the treatments as recommended. If one disagrees with the medical majority, a doctor can only ethically withdraw himself from treating the patient so diagnosed.
He can protest all he wishes, but to become an activist to abolish a diagnosis and treatment *without proposing an alternative acceptable to the medical community at large* does NOBODY any good, saves NO ONE from harm and leaves these people that are suffering from SOMETHING still floundering and causing harm to themselves and to others in many aspects of their lives.
<nip> ^ Wow, this guy has been in the field for a VERY long time, huh?
;-) <nip> Again, that is a complaint that has nothing to do with the validity of the diagnosis or it's treatment. That he keeps including such fluff in an attempt to pad his arguments make his premise suspect, "reknowned pediatric authority" or no.
Really? Then why do I read so many times that the speed-based stuff acts like, well, *speed*, for so many people who aren't afflicted? That it happens so consistently that those who simply begin to act "normally" USED to be a definitive proof that they were afflicted?
And that last sentence is a whole-cloth lie - regardless of their other benefits or dangers, none of the drugs listed are guaranteed or are even more than around - at best - 85% likely to "make any of us function better." Ok, ok, ok, wait a minute - first these "self-elected" non-sufferers are "only" manifesting varying levels of "normal" traits inappropriately within a given environment - yet now he's saying "these children" DO have real problems?
Which "children" is he referring to: the 1-2% of so-called hyperkinetics, the rest, or both?
And that, I can certainly agree with.
That more research and more education needs to occur I can't disagree with -
but again, it *doesn't solve anything right now*. His "solution" involves elements that can rightfully be applied to all branches of medicine, not just ADHD.
That he disagrees with current symptoms, diagnosis and treatment is his right - but to go so far as to agitate for legislative intervention against the treatment of it *when it is currently the accepted treatment of a generally accepted diagnosis* without providing alternative is irresponsible at best and suspect at worst.
Penicillin would kill me if I had to take it - yet would it make sense to advocate against using it with others when so many people DO get better using it?
My point is: So far as I can tell, the literature I've read regarding ADD reaffirms the consistently neurobiological basis of it, the exacerbating internal and external factors, the (pre)cautionary approach that seeks to identify and/or eliminate co-morbid elements and treat them separately from the ADHD, the duration of symptoms, the affect of the symptoms on the patient's three main areas of life - in short, and in a surprise twist, this whole thing looks more like an attempt of a particular doctor to excuse some doctor's inability to read and follow directions conscientiously (whether for valid or invalid reasons) under the pretext of condemning it.
There is no proposed alternative, only that there must be alternative in his estimation.
With so many anectodal and clinical recitals of the benefits achieved under the current system, even *if* (note this) even *if* the "benefits" should turn out to be mostly psychosomatic, it's still *better than being left the way we are without that diagnosis and treatment*, at least until something *scientifically* better comes along.
That last doesn't require me to cite any figures or facts, I am notably a changed man *for the better*, and commented upon as such by all who know me.
Such is the "power of the revelation" [praise Jes... oops, overdone analogy, sorry], such is the power of the treatment *and/or* the possible psychosomatic impetus - until something else comes along, I'm personally ecstatic with the current rascal and refuse to throw him in jail before the next one shows up and proves himself as endearing, and you're not going to convince me, or others like me, otherwise.
Especially when you can usually only produce "negative proof" and no alternative.
Face it, what's the best result you can hope to achieve? To prove that we're living a lie, that we either don't have a problem at all - leaving us where we were before our diagnosis and much unhappier in the process - or that our problems are not currently addressable - leaving us the way we were and much unhappier in the process.
My pack of ...
jake inva...@invalid.com
On Thu, 30 Oct 2003 03:26:01 GMT, "Jon Quixote" about half a century..in fact..rather than thirteen centuries :>)
jake inva...@invalid.com
LOL..rather than 18 centuries that is..
I am turning in..I am clearly too tired for this :>)
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