From the HuffPost Politics Blog
By Allen Frances, M.D.
Professor Emeritus, Duke University
March 28, 2016
"I now believe that ADHD is part of a normal continuum going from very mild restlessness and inattention to a severe form that requires treatment and skilled diagnostic assessment by well-trained clinicians.”
Keith Conners can rightly be called the “Father of ADHD”. He was there at the birth of the disorder and probably knows more about it than anyone else on the planet.
Fifty years ago, well before there was an ADHD diagnosis, Dr. Conners analyzed the data on the very first randomized trial of dextro-amphetamine (Dexedrine) - studying its efficacy in kids with severe restlessness and impulsivity. Soon after, he conducted the first trial of the then new drug, methylphenidate (Ritalin).
Dr. Conners developed the standard rating scales used for assessing children in research and clinical practice and for measuring the impact of treatment. His findings of positive medication effects on perception, impulsivity and attention provided the foundation for the whole field of child psychopharmacology.
Due in large measure to Dr. Conners’ efforts, what was once an obscure condition (then called Minimal Brain Dysfunction), became the widely accepted and DSM official diagnosis, Attention Deficit Hyperactivity Disorder.
Dr. Conners is a brilliant guy. He skipped high school and graduated from the University of Chicago at age 16; gained First Class Honors in Philosophy, Psychology, and Physiology as a Rhodes Scholar at Oxford; earned his Ph.D. in Clinical Psychology at Harvard; and has learned from, worked with, and taught the leading psychologists of the past half century.
If we want to understand the past history, current status, and future trajectory of ADHD, Dr. Conners is the man. He writes:
“I’ve always been fascinated by the classical reversible figures made popular by Gestalt psychologists. They illustrate a puzzling paradox in how the brain sometimes deals with perception. Take a good, long look at this picture.
Most of you will experience a sudden and surprising shift in the face - from beautiful woman to ugly witch, and then back and forth again. The very same visual information can be construed in radically different ways - same data, same observer, very different perceptions.
For many years I interpreted everything about ADHD in a positive light: the increased research funding and accumulating research findings; the increased clinical awareness; more kids being treated with stimulants; the interest of parents and teachers; legislation making ADHD kids candidates for Special Ed; even drug company support for medical education and parents’ groups like CHADD.
All seemed to be positive solutions to an important problem facing many families and school systems.
But then one day I was asked to give a talk on what is the true prevalence of ADHD, as shown by empirical data. I was already aware that in some circles, America is a laughingstock for its love affair with the idea of ADHD. Massive European birth registries show far lower rates than those being reported in the U.S.
And my wife, who is a school psychologist, was telling me that any misbehaving kid in school would be quickly labeled ADHD by teachers.
I was always suspicious that the high rates of “diagnosis” and prescription for ADHD came about because researchers based their figures on reports from parents, who in turn based their beliefs on teachers or doctors with no credible evidence.
However large a massive survey, the data are pretty much worthless for one simple reason: there is no thorough history taking and hands-on clinical diagnosis.
Large numbers of participants in a study guarantee sloppy diagnoses done via telephone interviews conducted by non-clinicians. Careful diagnosis by clinicians is simply too expensive. The reported rates are inaccurate and exaggerated, upper limits, not true prevalence.
There was one exception in the literature, a massive study in the Western counties of North Carolina by two epidemiologists at Duke University. The investigators, Adrian Angold and Jane Costello, interviewed thousands of parents AND THEIR CHILDREN, using the latest epidemiological methods. They devised a comprehensive interview schedule and trained dozens of interviewers with a thesaurus that made sure the same inquiry took place exactly the same way for each family.
For the first time, this highly praised, award-winning study had both large numbers and detailed clinical examination.
The results of this amazing project were startling. Only about 1-2% qualified as ADHD.
Moreover, many children not sick at all had been given a stimulant drug. Also there were some children who actually qualified for the diagnosis of ADHD who never were identified by a mental health professional; there was both over-diagnosis and under-diagnosis. The findings were replicated in successive rounds of follow-on studies.
It seems obvious to me that the steady increases over time In the apparent high prevalence of ADHD is due to doctor practices fueled by the shoddy science and allure of the big numbers, without the only meaningful ingredient--a comprehensive clinical history.
Doctors on the front line who only have 20 minutes to get a story from a parent or to follow with medication checks or alternative therapies, are under pressure that guarantee mistakes with a complex disorder like ADHD.
My review suddenly flipped my perception. I felt and announced to stunned colleagues that the over-diagnosis of ADHD was “an epidemic of tragic proportions.” Tragic because many kids get the wrong diagnosis and really have a different problem that needs a different treatment: or they are normal youngsters given a treatment they don’t need; or the drugs prescribed for them are given away or sold to other students wanting a quick fix for studying or partying—a reason why schools and colleges now have huge numbers of students using stimulant drugs, and why emergency rooms are increasingly overwhelmed with overdosing youngsters.
Alan Schwartz of the New York Times exposed how disease-mongering and ruthless advertising by Big Pharma had fed an eager medical system with false data, also capitalizing on the cooperation of unscrupulous “thought leaders” in child psychiatry. Doctors of course bear a lot of the responsibility - prescriptions for stimulant drugs can only come from doctors.
Most hard-working primary care or general pediatric practitioners mean well but have too little time to really get to know their patients and too little expertise to be skeptical of misleading Pharma propaganda.
I am alarmed to see how even some of my most respected colleagues deny the facts and bury their head in the sand. I recently talked to one of these highly published senior professors who has a “Distinguished Chair of Psychiatry and Genetics” and many publications on ADHD. I asked him what he thought about the New York Times revelations on the role of pharmaceutical companies in promoting over-diagnosis. He said, ‘I really don’t know that much about the numbers; I’m not an expert in epidemiology.’
Well, neither am I, but I know how to tell the difference between studies relying on telephone interviews of parents and those doing an actual meaningful clinical assessment. In today’s ADHD world the detailed family and developmental history has been replaced by word of mouth from parents and teachers and quickie interviews, largely by untrained primary care or general pediatric practitioners.
I now believe that ADHD is part of a normal continuum going from very mild restlessness and Inattention to a severe form that requires treatment and skilled diagnostic assessment by well-trained clinicians.”
Thanks, Dr. Conners.
It is disheartening to see diagnoses that are useful for the few become harmful when misapplied for the many. ADHD is a good example, but there are many others - Autism, Depression, Bipolar Disorder, PTSD, Generalized Anxiety Disorder, Binge Eating Disorder, and on and on.
The history of psychiatry has always been a history of fads. As you point out with your Gestalt picture, human distress can be interpreted in so many different ways that come into and then soon fall out of fashion.
What is new now is the massive commercialization of psychiatric disorders in the service of Pharma profit- selling the ill through non-stop disease mongering in order to peddle the pill. Harried doctors and worried patients have bought into the medicalization of every day life, turning distress and difference into mental disorder.
The diagnosis of ADHD should be a last resort, not an automatic reflex or an attempt at a quick fix. The symptoms must be classic, severe, persistent over time, pervasive across situations, early in onset, and cause considerable distress and impairment. Information should come from careful direct observation and from a wide array of well informed informants. Evaluation should stretch over weeks or months, because kids can change so much from visit to visit. Diagnosis should be preceded by watchful waiting, advice, parent training, environmental changes, stress reduction, and/or psychotherapy.
We are currently spending more than $10 billion dollars a year for ADHD drugs - a fifty-fold increase in just 20 years. Much of this is wasted, medicating children who have been mislabeled. Studies in many countries show that the youngest kid in a class is twice as likely as the oldest to get an ADHD diagnosis.
We have turned normal immaturity into a mental disorder. It would be much smarter to spend most of this money on smaller class sizes and more gym periods.
Keith Conners has done us a great service. His alert to the over-diagnosis and over-treatment of ADHD will hopefully mark an important turning point toward ending the fad. At current rates of diagnosis, 15% of kids in the US will get the ADHD label by the time they are 18 years old.
Clinicians, parents, and teachers must resist the pressure and ensure that diagnosis and treatment are restricted to those few who really need and can benefit from them.