ADHD: A Modest Proposal

I’m reluctant to write a post about ADHD.  It just seems like treacherous ground.  Judging by comments I’ve read online and in magazines, and my own personal experience, expressing an opinion about this diagnosis—or just about anything in child psychiatry—will be met with criticism from one side or another.  But after reading L. Alan Sroufe’s article (“Ritalin Gone Wild”) in this weekend’s New York Times, I feel compelled to write.

If you have not read the article, I encourage you to do so.  Personally, I agree with every word (well, except for the comment about “children born into poverty therefore [being] more vulnerable to behavior problems”—I would remind Dr Sroufe that correlation does not equal causation).  In fact, I wish I had written it.  Unfortunately, it seems that only outsiders or retired psychiatrists can write such stuff about this profession. The rest of us might need to look for jobs someday.

Predictably, the article has attracted numerous online detractors.  For starters, check out this response from the NYT “Motherlode” blog, condemning Dr Sroufe for “blaming parents” for ADHD.  In my reading of the original article, Dr Sroufe did nothing of the sort.  Rather, he pointed out that ADHD symptoms may not entirely (or at all) arise from an inborn neurological defect (or “chemical imbalance”), but rather that environmental influences may be more important.  He also remarked that, yes, ADHD drugs do work; children (and adults, for that matter) do perform better on them, but those successes decline over time, possibly because a drug solution “does nothing to change [environmental] conditions … in the first place.”

I couldn’t agree more.  To be honest, I think this statement holds true for much of what we treat in psychiatry, but it’s particularly relevant in children and adolescents.  Children are exposed to an enormous number of influences as they try to navigate their way in the world, not to mention the fact that their brains—and bodies—continue to develop rapidly and are highly vulnerable.  “Environmental influences” are almost limitless.

I have a radical proposal which will probably never, ever, be implemented, but which might help resolve the problems raised by the NYT article.  Read on.

First of all, you’ll note that I referred to “ADHD symptoms” above, not “ADHD.”  This isn’t a typo.  In fact, this is a crucial distinction.  As with anything else in psychiatry, diagnosing ADHD relies on documentation of symptoms.  ADHD-like symptoms are extremely common, particularly in child-age populations.  (To review the official ADHD diagnostic criteria from the DSM-IV, click here.)  To be sure, a diagnosis of ADHD requires that these symptoms be “maladaptive and inconsistent with developmental level.”  Even so, I’ve often joked with my colleagues that I can diagnose just about any child with ADHD just by asking the right questions in the right way.  That’s not entirely a joke.  Try it yourself.  Look at the criteria, and then imagine you have a child in your office whose parent complains that he’s doing poorly in school, or gets in fights, or refuses to do homework, or daydreams a lot, etc.  When the ADHD criteria are on your mind—remember, you have to think like a psychiatrist here!—you’re likely to ask leading questions, and I guarantee you’ll get positive responses.

That’s a lousy way of making a diagnosis, of course, but it’s what happens in psychiatrists’ and pediatricians’ offices every day.  There are more “valid” ways to diagnose ADHD:  rating scales like the Connors or Vanderbilt surveys, extensive neuropsychiatric assessment, or (possibly) expensive imaging tests.  However, in practice, we often let subthreshold scores on those surveys “slide” and prescribe ADHD medications anyway (I’ve seen it plenty); neuropsychiatric assessments are often wishy-washy (“auditory processing score in the 60th percentile,” etc); and, as Dr Sroufe correctly points out, children with poor motivation or “an underdeveloped capacity to regulate their behavior” will most likely have “anomalous” brain scans.  That doesn’t necessarily mean they have a disorder.

So what’s my proposal?  My proposal is to get rid of the diagnosis of ADHD altogether.  Now, before you crucify me or accuse me of being unfit to practice medicine (as one reader—who’s also the author of a book on ADHD—did when I floated this idea on David Allen’s blog last week), allow me to elaborate.

First, if we eliminate the diagnosis of ADHD, we can still do what we’ve been doing.  We can still evaluate children with attention or concentration problems, or hyperactivity, and we can still use stimulant medications (of course, they’d be off-label now) to provide relief—as long as we’ve obtained the same informed consent that we’ve done all along.  We do this all the time in medicine.  If you complain of constant toe and ankle pain, I don’t immediately diagnose you with gout; instead, I might do a focused physical exam of the area and recommend a trial of NSAIDs.  If the pain returns, or doesn’t improve, or you have other features associated with gout, I may want to check uric acid levels, do a synovial fluid analysis, or prescribe allopurinol.

That’s what medicine is all about:  we see symptoms that suggest a diagnosis, and we provide an intervention to help alleviate the symptoms while paying attention to the natural course of the illness, refining the diagnosis over time, and continually modifying the therapy to treat the underlying diagnosis and/or eliminate risk factors.  With the ultimate goal, of course, of minimizing dangerous or expensive interventions and achieving some degree of meaningful recovery.

This is precisely what we don’t do in most cases of ADHD.  Or in most of psychiatry.  While exceptions definitely exist, often the diagnosis of ADHD—and the prescription of a drug that, in many cases, works surprisingly well—is the end of the story.  Child gets a diagnosis, child takes medication, child does better with peers or in school, parents are satisfied, everyone’s happy.  But what caused the symptoms in the first place?  Can (or should) that be fixed?  When can (or should) treatment be stopped?  How can we prevent long-term harm from the medication?

If, on the other hand, we don’t make a diagnosis of ADHD, but instead document that the child has “problems in focusing” or “inattention” or “hyperactivity” (i.e., we describe the specific symptoms), then it behooves us to continue looking for the causes of those symptoms.  For some children, it may be a chaotic home environment.  For others, it may be a history of neglect, or ongoing substance abuse.  For others, it may be a parenting style or interaction which is not ideal for that child’s social or biological makeup (I hesitate to write “poor parenting” because then I’ll really get hate mail!).  For still others, there may indeed be a biological abnormality—maybe a smaller dorsolateral prefrontal cortex (hey! the DLPFC!) or delayed brain maturation.

ADHD offers a unique platform upon which to try this open-minded, non-DSM-biased approach.  Dropping the diagnosis of “ADHD” would have a number of advantages.  It would encourage us to search more deeply for root causes; it would allow us to be more eclectic in our treatment; it would prevent patients, parents, doctors, teachers, and others from using it as a label or as an “excuse” for one’s behavior; and it would require us to provide truly individualized care.  Sure, there will be those who simply ask for the psychostimulants “because they work” for their symptoms of inattentiveness or distractibility (and those who deliberately fake ADHD symptoms because they want to abuse the stimulant or because they want to get into Harvard), but hey, that’s already happening now!  My proposal would create a glut of “false negative” ADHD diagnoses, but it would also reduce the above “false positives,” which, in my opinion, are more damaging to our field’s already tenuous nosology.

A strategy like this could—and probably should—be extended to other conditions in psychiatry, too.  I believe that some of what we call “ADHD” is truly a disorder—probably multiple disorders, as noted above; the same is probably true with “major depression,” ”bipolar disorder,” and just about everything else.  But when these labels start being used indiscriminately (and unfortunately DSM-5 doesn’t look to offer any improvement), the diagnoses become fixed labels and lock us into an approach that may, at best, completely miss the point, and at worst, cause significant harm.  Maybe we should rethink this.

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21 Responses to ADHD: A Modest Proposal

  1. Jay says:

    Bravo, again! This is still the best mental health blog I’ve stumbled upon yet. I did read the article, and I’ve been shaking my head all week at the posted reactions across a number of on-line venues.

    I agree strongly with your premise and will offer a highly condensed summation: in these days, diagnosis is nearly an end in itself. I applaud your bravery in this post. And yes, brace yourself for criticism from one side AND the other.

    One last thing I’ll toss out there in response to the highlighted point regarding “environmental factors”: our society is virtually demanding ADHD. The pace of life/work is truly hyperkinetic. The daily avalanche of information that must.be.received is fundamentally overwhelming. Who among us CAN cope without some sort of stimulant?

    • stevebMD says:

      Jay,

      Thanks. I’m glad you agree. I keep telling myself that I can’t be the only one who feels this way!

      Anyway, please note that my proposal is not a “real” one, it’s really more of a gedankenexperiment. I think it’s possible to continue to act responsibly under the status quo; we just need to be more thoughtful.

  2. Carol Levy says:

    I have often wondered about this Dx. It seems that so many kids are being labeled with it that other factors may be at work, such as ritalin’ing to make it easier on parents/teachers, for instance. (Again instead, as you say, of looking for the root cause of the behaviors in question.
    It occurs to me that there may be another reason so many kids behave ADHD. We have taken, recess and gym out of many schools. The kids no longer have a place and time where they can run off their extra, normal kid energy and it needs somewhere to go so instead, they act up in class.
    I think too that often it is a matter of drugs looking for an ailment.

  3. mara says:

    The problem I had on the David Allen blog was that you referred to ADHD treatment as “cosmetic.” And I don’t think ADHD is quite the same as removing cellulite or getting a more aquiline nose.

    But I do think you are correct that there needs to be better digging for root causes. Kids take a lot of time to manage and educate. And maybe people have just forgotten that. They need individualized attention. And I get why it is so hard to give that to them. It’s like Jay said, “our society is virtually demanding ADHD.” Teachers don’t have time to give individualized attention to kids who needs extra help learning to focus and sit still. And special education is expensive. Funding for that has to come from somewhere. Some schools just don’t have the money to really make a difference with these kids. Then there are the parents. Some of these parents don’t have time to spend with a special needs kid. That sounds terrible, but it is true. Sometimes both parents work, or it is a single parent situation. The same goes for psychiatry. Psychiatrists don’t spend much time with these kids either.

    I’m not sure what the answer is to fix all of that. The ADHD diagnosis could get thrown out, but is there anyone with enough time to work with these kids? The school psychologist I spoke to a while back mentioned that overcoming dyslexia requires daily help from the parents. They should be working with that kid every night in order to correct it. But some parents are at work when its homework time and don’t have enough hours to spend. Special education alone is not always enough to correct dyslexia.

    Even if we found the root causes, we would still need a society that gives these kids more time.

  4. ADD or just flaky? says:

    I cringe at the diagnosis. I’ve been diagnosed with ADHD along with the rest of America, and I admit I lean toward the skeptical. My therapist who I saw for a couple of years kept pushing me to see a psychiatrist and be evaluated for this. Honestly, I think I’m just kind of like the absent minded professor. I had a professor who was very forgetful and disorganized. She even came to class once not realizing her dress was wrong side out. She was book smart, but not real with it when it came to the day to day stuff.

    I finally went to a psychiatrist and he had me gave me a stack of paper and had me answer a bunch of questions. He said I’m a textbook case whatever that means. Not sure what my therapist told him. Anyway, I asked the psychiatrist, how do you know if this is really a disorder or just how I am? I still don’t know about the ADHD thing. Yes, I’m inattentive. Yes, I’m disorganized. Yes, I would lose my head if it werent’ attached. But, I’ve always been this way. Is it a disorder or just my screwy personality?

    I’ve been reluctant to take meds and refused for a long time. I’m now on an average dose of Vyvanse. I hate taking medication, but it does help with the flakiness and it makes me surprisingly more calm. Less frantic attempts to find my cell phone, my keys, where’s that paper, what did you say, and so on. I appear more together at work which helps. I don’t know if I’m doing the right thing by taking medication, or if I’m copping out. I worry about addiction and the doc have assured me he will keep an eye on it and take me off of it at the first hint of that kind of behavior. I hope so.

    I have a difficult time with the diagnosis. I find it embarrassing. When I see another physician I have a hard time admitting I’m on this drug. I feel myself rolling my eyes as I tell them. Most of the time I just say I take it to be less flaky. They seem to appreciate my honesty.

    • addBunny says:

      ADHD is a disorder, by definition. If someone’s life isn’t at least moderately fucked up then they might have an AD or ADH style or personality but not to the extent of disorder. If it’s beyond being waved off as “just my personality” then it’s something that needs to be addressed.

      As an adult, the diagnosis of ADHD, when you’ve finally got through all the barriers to getting it, leads to clear treatment options. Unlike children, we adults cannot mature neurologically any further to become unflaky or more competent. We can have therapy, learn skills, use technology (old and new) and other people to help us cope with the world but the underlying condition is with us. For that we need medication.

      That faulty aspect of brain function, which makes things harder, or *so much* harder, for us is with us just as a misshapen eye is with someone who cannot see clearly. For us it’s medication, for them it’s glasses.

      Dr Balt’s article is about childhood diagnosis and he makes good points. It’s a complex condition to diagnose and the various symptoms all occur for other reasons as well as being due to whatever the biological basis of ADHD is. But I would hope that he’d agree that ADHD in adults is less likely to be misdiagnosed than in childhood. Adults with ADH behaviours haven’t matured and outgrown it or become cured by a change in environmental factors. Some children do but the ADH-esque have taken it with them from childhood into adulthood and continue to suffer the consequences. For some, these are serious enough to be considered ADHD. And for them there are “corrective glasses”, as it were.

      I would say that the cringing, shame and embarrassment is an extra – and unnecessary – burden that you’re suffering. Having those beliefs and feelings doesn’t invalidate your diagnosis nor provide any rationale for being sceptical about it. It’s a form of denial, a filter on reality, not the experience of reality. It’s like someone trying to tell you that they don’t really need glasses because they find it embarrassing, even if they do have to admit that they see better with them.

      I hope that you can begin to consider losing the embarrassment, especially if its origin is in ignorant and insensitive things that others in your life have said. There should be no more shame in having ADHD than in having short sight or a congenital limp.

      That’s the ideal, of course, and there will always be people who judge. But we really are better off if we don’t join them in that negativity towards ourselves, our diagnoses and the acceptance of treatment and assistance, whether that’s medication or any of the other things that ease an ADHDer’s life.

      Wishing you all the best,
      addBunny

  5. Dr. D says:

    So much to say about this topic, so pardon the long post. I’ll try to organize my thoughts a bit, as follows:

    1. Your proposal is very interesting. I think it is worth noting that the DC:0-3, which is a classification system devised for infants and toddlers because the DSM is so inadequate for that age group, does not have an ADHD diagnosis, but rather has various categories of regulatory disorders, such as Type I: Hypersensitive, Type II: Underreactive, and Type III: Motorically Disorganized, Impulsive. It’s interesting that ADHD is co-morbid with anxiety, depression, disruptive behaviors/conduct disorder, and substance abuse, all of which may be thought of as disorders in regulating internal states.

    2. The NYT article seemed to me to be misleading at best, and quite ignorant at worst. The psychologist wrote:

    But in 2009, findings were published from a well-controlled study that had been going on for more than a decade, and the results were very clear. The study randomly assigned almost 600 children with attention problems to four treatment conditions. Some received medication alone, some cognitive-behavior therapy alone, some medication plus therapy, and some were in a community-care control group that received no systematic treatment. At first this study suggested that medication, or medication plus therapy, produced the best results. However, after three years, these effects had faded, and by eight years there was no evidence that medication produced any academic or behavioral benefits.

    He was talking about the MTA study, which, according to the NIMH:

    The MTA treatment lasted for 14 months only, after which the children were referred back to their community providers. Some of them continued treatment. Others discontinued their treatment or changed it, based on their individual situation. All participants, regardless of the treatment they received, were invited to return to the MTA clinics every one to two years for an assessment of their ADHD symptoms and level of functioning.

    Because their treatment after the end of the study was not controlled, it is not possible to draw accurate conclusions about the effectiveness of interventions beyond 14 months, or determine if treatment improves long-term functioning.

    The fact that this study lasted 14 months and showed benefit at 14 months, is, I think, remarkable. And it argues against the writer’s quote later on in the article: “If drugs, which studies show work for four to eight weeks, are not the answer, what is?” Given that randomized treatment ended after 14 months and was followed by naturalistic observation (during which many participants stopped taking meds), and given that ADHD is a chronic condition, why would anyone be surprised that the effects were not long lasting?

    3. The NYT article also tries to emphasize the fact that social factors and “experience” contribute to ADHD, making false the claim that ADHD is more “biological.” While this is totally true, that doesn’t necessarily mean that treatment for ADHD shouldn’t be based on meds. It’s like saying because we know schizophrenia has a strong environmental basis, we shouldn’t use meds so much to treat people with schizophrenia (an extreme analogy, I know).

    4. I suspect the unfortunate thing with ADHD is that the diagnosis and use of meds is rising not because of psychiatrists, but because our culture in general has failed to teach children self-regulatory skills (due to lack of parenting, poverty, television, and who knows what else). And once a child reaches a certain age and does not have those self-regulatory skills, it’s very hard to teach it to them, short of a full-time therapeutic environment. Thus, meds end up being used because earlier interventions were not done. Again, this does not argue against the use of meds for ADHD or their effectiveness. I hope we can all agree that there should be more focus on how we as a society can help young children develop those important self-regulatory skills so they would not need so many meds.

  6. Claudia Gold says:

    Hi Steve

    I’m all for eliminating the ADHD diagnosis. Bruce Perry, who I reference in the above piece, also advocates for this approach. I agree that this is a highly emotionally charged subject, and Sroufe unfortunately presented a very important perspective in a way that would inevitably make people respond defensively.

  7. ADHD or just flaky? says:

    Dr. Steve writes, “ADHD drugs do work; children (and adults, for that matter) do perform better on them, but those successes decline over time, possibly because a drug solution “does nothing to change [environmental] conditions … in the first place.”

    One thing I’ve wondered about is if people build up a tolerance to these drugs over time. Does anyone know?

    I’m all for doing away with the diagnosis. I don’t care either way. Whether it’s called ADHD or not, it’s not going to make me any more or less the way I am. I think the name itself is stigmatizing. People just roll their eyes when they hear it, and I can’t really blame them. I don’t advertise the diagnosis. I would never tell anyone at work, even though a few have mentioned it in a teasing way. I think anyone who is really disorganized and takes those diagnostic tests is going to come out as ADHD, and I don’t know that that’s really all that helpful.

  8. jksnydern says:

    It seems like most of these articles are against stimulant meds, what about the other meds prescribed for ADHD? It is almost like you consider the diagnosis lazy by the parents. I took my child to her pediatrician and the first thing they do is prescribe stimulants, why not change to mandatory testing to cut down on over diagnosis? I would gladly take my child to have an MRI if it meant a definitive diagnosis. If I could find a doctor to help my child without medication I would, but it seems like none of the doctors we have seen have any better solutions.

  9. pheski says:

    Nice post, and very pertinent to my practice and to one of my long standing concerns.

    I’ve made a brief comment and linked to this on my blog:

    http://bit.ly/yeovAh

  10. Santa Diego, MD says:

    I think ADHD in children is a valid diagnosis with excellent somatic and psychological treatment methods available. In my experience it is often over diagnosed. I think diagnosis of ADHD in adults is especially problematic, and essentially boils down using what the patient says he has to make your dx. The symptoms of ADHD are universal when considered in isolation–who can truly claim that they don’t ever have trouble concentrating on a boring task? It is easy to look up the symptoms of ADHD and report them to the doctor. ADHD is an ‘acceptable’ diagnosis in psychiatry, and many of these patients have mood disorders, but don’t like to hear that depression might cause poor concentration. An additional problem with adult ADHD is the relatively high rate of symptom fabrication. There are some interesting articles in the neuropsychology literature about effort tests. College students claiming ADHD fail these tests at a significant rate. I find neuropsychological evaluations to be quite helpful. Since ADHD is thought to be the result of executive functioning problems, I want to see some evidence of these deficits before agreeing to start treatment.

  11. I am very concerned that all the focus is placed on medication for dealing with ADHD. As a specialist in working with this I know that medication alone is not effective. Those with ADHD need help in learning how to deal with organization problems, problems in time management,dealing with short term memory problems and planning and prioritizing. The stress of these problems make the symptoms worse. These people have also been given labels or irresponsible, lazy, uncooperative and underachievers.

    Medication can be helpful, but helping these people with strategies to compensate in the areas mentioned above is a necessity. The medication does help them focus and stay on task so that they can learn these strategies. These are life skills that they must learn in the way they learn best, which is visual and tactile.

    Currently, most schools do not know how to work with these students. When professionals truly understand the approaches that really work for helping people with ADHD there will be less need for medication and many who are failing throughout their lives would be managing their lives successfully

  12. Hawkeye says:

    Make the diagnosis, but don’t treat it—much. I got it into my head by reading something a long time ago that the symptoms of ADHD are useful to hunter-gathers. That’s where they may have come from and that means something.
    Dr. Steve may disagree with this, but ADHD like symptoms can be(can be!!!) a sign of bipolar. Giving stimulants to people who are diagnosed with bipolar II is maybe not a good idea, even if the disease is fake.
    Got to run for more coffee.

  13. [...] mode, he or she often asks those questions that confirm the initial “Type 1″ hunch, or our questions are nonspecific in nature.  As a result, we end up finding we expect to [...]

  14. [...] But in some cases the critics are right.  Sometimes clinicians do get answers from the book, or from some senseless protocol (usually written by a non-clinician).  One caller to the NPR program said she was handed an antidepressant prescription upon her discharge from the hospital after miscarrying her 8-month old fetus.  Was she grieving?  Absolutely.  Did she need the antidepressant?  No one even bothered to figure that out.  It’s like the clinicians who see “bipolar” in everyone who has anger problems; “PTSD” in everyone who was raised in a turbulent household; or “ADHD” in every child who does poorly in school. [...]

  15. [...] for an extra “edge,” regardless of whether they actually have ADHD.  In this blog, I’ve written about ADHD.  It’s a real condition—and medications can help tremendously—but the diagnostic [...]

  16. [...] colleges, use stimulants for an extra “edge,” regardless of whether they actually have ADHD. I’ve written about ADHD.  It’s a real condition—and medications can help tremendously—but the diagnostic criteria [...]

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