Monday, May 26, 2014

The New York Times Criticizes the Medical Model of ADHD

The New York Times, the most prestigious and influential newspaper in the United States, has run a series of articles in the past year or two critical of the over-diagnosis and over-prescription of ADHD drugs (mainly stimulants) for children and adults. The Times doesn’t question that there is a disorder known as ADHD that can be effectively treated with stimulant drugs. What the newspaper criticizes is a biological interpretation of the rapidly increasing prevalence of ADHD, the increasing use of prescription drugs to treat this disorder, the excessive drugging of poor children on state assistance (Medicaid), and the refusal among many in the medical community to look at alternative treatments such as behavior and psychosocial therapy. For those who, like myself, want to see a reduction in the use of medication for ADHD, this is encouraging. Here are some examples of relevant articles:
  • Thousands of Toddlers Are Medicated for A.D.H.D., Report Finds, Raising Worries (May 16, 2014): More than 10,000 American children ages 2 or 3 are being medicated for ADHD, according to data from the CDC. Toddlers covered by Medicaid are especially vulnerable to being put on stimulant medication. Diagnosing ADHD and prescribing drugs in children so young is against established pediatric guidelines. “It’s absolutely shocking, and it shouldn’t be happening,” said Anita Zervigon-Hakes, a children’s mental health consultant.

     “People prescribing to 2-year-olds are just winging it,” according to Dr. Lawrence H. Diller, a behavioral pediatrician in Walnut Creek, CA. “It is outside the standard of care, and they should be subject to malpractice if something goes wrong with a kid.”

    The reason why pediatric guidelines don’t recommend diagnosing and treating ADHD in toddlers is that hyperactivity and impulsivity are developmentally appropriate at that age. Experts say that more time is needed to see if a disorder is truly present.

    The CDC data showed that about one in 225 Georgia toddlers covered by Medicaid is being prescribed drugs for ADHD. Extrapolating the Georgia data nationwide provides the 10,000 total number of toddlers being medicated for ADHD. An additional 4,000 toddlers covered by private insurance were also being prescribed stimulant drugs.

    Behavioral treatments, such as providing more structured environments for the children, are often ignored. “Some of these kids are having really legitimate problems,” Dr. Doris Greenberg, a behavioral pediatrician in Savannah, GA said. “But you also have overwhelmed parents who can’t cope and the doctor prescribes as a knee-jerk reaction. You have children with depression or anxiety who can present the same way, and these medications can just make those problems worse.”    

  • Exercising the Mind to Treat Attention Deficits (May 12, 2014). This article talks about treating ADHD by strengthening the patient’s “cognitive control,” the ability to maintain focus on something while ignoring other impulses. A number of research studies have shown that it is possible for children and adults to improve their cognitive control via exercises in “mindfulness”. Noting a “growing disenchantment with the first-line treatment for [ADHD]: drugs,” and the fact that the beneficial effects of the stimulant drugs usually wane by the third year, or sooner, researchers have been looking for treatment alternatives to drugs. According to James M. Swanson, a University of California, Irvine psychologist, “There are no long-term, lasting benefits from taking ADHD medications. But mindfulness seems to be training the same areas of the brain that have reduced activity in ADHD. That’s why mindfulness might be so important. It seems to get at the causes.”

    ADHD isn’t unique to Americans, but the belief that only medication can treat it is. As an example, a study showed that the incidence of ADHD among Finnish teenagers is the same as the incidence of ADHD among American teenagers. The big difference between the two countries is that although most Finnish teenagers weren’t taking medication, most American teenagers were.

    Some attributes included in the concept “cognitive control” are delayed gratification, impulse management, emotional regulation, self-control, and suppression of irrelevant thoughts. Cognitive control increases between the ages of 4 and 12, then plateaus during the early teenage years. After about age 16, cognitive control increases again until people achieve adult levels.

    To improve cognitive control, therapists teach people to dispassionately monitor their thoughts and feelings. This is known as “mindfulness training.” If their attention has wandered, they are taught to renew their concentration. According to a recent study, adults with ADD given mindfulness training combined with cognitive therapy had improved mental performance comparable to that achieved by adults given medication.

    One consequence of mindfulness training is that it gives you “the ability to self-regulate your internal distractions”, according to Dr. Adam Gazzaley of the University of California, San Francisco. Gazzaley uses video games to help older adults improve their cognitive control.

  • Report Says Medication Use Is Rising for Adults With Attention Disorder (March 12, 2014): An alternative title for this article that I came up with is: “Experts Fiddle While ADHD Drug Use Burns America.” The article refers to a study done by Express Scripts, the largest prescription drug manager in the U.S. The results of the study point to a disturbing and rapid increase in the number of prescriptions for ADHD, especially among young adults. The number of young American adults taking medication for ADHD nearly doubled between 2008 and 2012. In that same time period, the number of American adults of all ages taking ADHD medication rose 53%. Use of ADHD medication among American children rose 19%. In 2012, 7.8% of boys and 3.5% of girls between ages 4 and 18 were being prescribed ADHD medications. Almost 1 in 10 adolescent boys were taking ADHD medications.

    This explosion in ADHD drug use has occurred while experts fiddled, i.e. pretended that nothing was happening. The CDC last year did a telephone survey of 76,000 parents that reported a similar explosive increase in ADHD drug use. Experts dismissed the survey, similar to ones that were done every year since 2003, as lacking scientific rigor. The American Medical Association stated that these phone surveys “overestimated true prevalence” of ADHD diagnosis. Dr. Sanjay Gupta of CNN said that, “There’s not a lot of value in these studies.”

    It’s classic incompetence to dismiss reports of problems without doing anything. Couldn’t these “experts” have designed their own scientific studies to confirm or disprove the CDC data? According to Susanna Visser, the CDC’s lead epidemiologist for ADHD, the experts’ discrediting of the CDC survey data has been costly, not only in understanding the issue, but also coming up with solutions.

    One reason why the “experts” haven’t done anything is that many don’t think that increased drugging of adults for ADHD is a problem. According to Dr. Lenard A. Adler of NYU Langone Medical Center, “We still know that a majority of adults with ADHD are untreated.”

  • A.D.H.D. Experts Re-evaluate Study’s Zeal for Drugs (December 29, 2013): A discussion of how the results of the Multimodal Treatment Study of Children With ADHD, which argued strongly for the benefits of medication over behavioral therapy, are being re-interpreted today. This expensive, independent study of about 600 children, which began 20 years ago, is widely considered the most influential study on ADHD. The authors found that medication reduced symptoms in 56% of children, while behavioral therapy only reduced symptoms in 34% of children. Combination therapy (medication + behavioral therapy) reduced symptoms in 68% of children, which the authors felt was only a small increase over medication alone (56%). The conclusion was that medication was superior to behavioral treatment by a considerable margin.

    This sanction of approval by a major study not funded by them gave pharma a powerful weapon to use in their marketing materials and doctor-education classes. According to Laura Batstra, a psychologist at the University of Groningen in the Netherlands, “the only thing we heard was . . . that medication is the answer.”

    There were problems with the study design that led to the medication-being-superior conclusion. According to researchers involved with the study, it was structured to emphasize the reduction of impulsivity and inattention symptoms, with less emphasis placed on improving children’s longer-term academic and social skills. Medication mainly addresses the former, while behavior therapy addresses the latter by creating less distracting and more organized learning environments. In other words, the study was designed to make medications look good and behavior therapy bad.

    An additional $10 million in government funding extended the study, and followed the children into young adulthood, making it a true longitudinal study. Results called into serious question the value of medication. I have already blogged about the follow-up results. One highlight is that more than half of the children stopped taking medication after an 8 year follow up. Another highlight is that children who were no longer taking medication at the time of the follow up were functioning as well as children who were taking medication.

    Many experts interpreted these findings as showing that the efficacy of medications dissipated over time. Pharma apologists argued that children did worse because they went off the medications. A balanced interpretation is that treatment type cannot predict long-term functioning, i.e. we cannot conclude that medication is superior or inferior to behavior therapy.

    The warped initial findings of the study are examples of psychiatry’s obsession with symptoms as opposed to overall functioning. This is the philosophy behind the DSM, the psychiatrist treatment manual. Not all experts agree with this symptom-based approach. According to Stephen Hinshaw, a psychologist at the University of California, Berkeley (and one of the study researchers), “My belief based on the science is that symptom reduction is a good thing, but adding skill-building is a better thing.”

    According to another co-author, Dr. Lily Hechtman (McGill University), “I hope it didn’t do irreparable damage. The people who pay the price in the end is the kids. That’s the biggest tragedy in all of this.”

  • The Selling of Attention Deficit Disorder (December 14, 2013): I have already blogged about this article. It argues that pharmaceutical company marketing is a major culprit behind the explosion in ADHD diagnosis and treatment. The article also provides a detailed account of the various marketing tricks used to con doctors, parents, and patients into accepting the story that there are millions of undiagnosed children and adults with ADHD who would benefit from stimulant treatment.

  • The The Not-So-Hidden Cause Behind the A.D.H.D. Epidemic (October 15, 2013): This article argues for a sociological interpretation of the rapid rise in ADHD diagnosis and treatment. ADHD reached “epidemic” status at about the same time as some important policy changes that incentivized diagnosis. In 1991, ADHD was included in the Individuals with Disabilities Education Act. For students diagnosed with ADHD, this allowed access to tutors, and more time to take standardized tests. By the late 1990’s, as public awareness of ADHD increased, its prevalence also increased. Another important policy change was the legalization of pharma marketing of controlled substances to the public that occurred in 1997. This allowed pharma to market stimulant drugs directly to consumers via print and TV ads.

    Stephen Hinshaw of the University of California, Berkeley found that in 2007, 15.6% of children ages 4 to 17 in North Carolina had received an ADHD diagnosis, while only 6.2% of children in California had this diagnosis. The reason for this geographical disparity is likely due to effects of state educational policies. North Carolina was the first state to adopt a program linking school financing to standardized-test performance, while California was one of the last. Hinshaw found a correlation between state’s implementation of these laws and ADHD prevalence. The No Child Left Behind Act was a federal program punishing or rewarding schools for standardized test scores, signed into law by President George W. Bush. The rates of ADHD diagnosis nationwide increased by 22% in the first four years after the act was implemented.

    Parents and educators obsessed with standardized tests results will look favorably on any intervention that improves a child’s ability to perform on tests, and prevents him from being a distraction to others. An ADHD diagnosis with medication treatment is such an intervention that has obvious short-term benefits (with less clear long-term benefits). This provides enormous pressure for the parent to have her inattentive / hyperactive child be diagnosed and drugged.

    The ADHD diagnosis explosion is part of a broader American trend of medicalization of traits the previous generations handled in different ways, according to Joel Nigg of the Oregon Health and Science University. Instead of punishing children who misbehave, we diagnose them with ADHD and drug them.

  • A.D.H.D. Seen in 11% of U.S. Children as Diagnoses Rise (March 31, 2013): I have already blogged about this article. 19% of American high school boys have received an ADHD diagnosis. 11% of school-age children overall have received the diagnosis. There has been a 16% increase in children between ages 4 and 17 being diagnosed with ADHD since 2007, and a 41% increase in the last decade.