|Rethinking ADD and ADHD|
|Written by Roman Bystrianyk|
|Friday, 21 May 2010 00:03|
A recent news article reported by Reuters showed that children with break down products from organophosphate pesticides are almost twice as likely to develop ADHD as those with undetectable levels. This type of finding is hardly surprising because organophosphates are poisonous nerve agents that kill insects by disrupting their brains and nervous systems. Studies have linked these types of pesticides to toxic effects on the nervous system and the brain in people.
"Central nervous system toxic signs and symptoms include headache; nausea and vomiting; dizziness; respiratory depression; mental status changes, including coma; and seizures ... Organophosphates have been thought for many years to be associated with subtle, long-term neurologic effects years after acute and sub acute exposure. Individual case reports first documented patients with reported headaches, blurred vision, memory, depression, irritability, and problems with concentration." (Pediatric Clinics of North America)
"Organophosphate poisoning continues to be a relatively common occurrence, especially in rural areas of the United States. Insecticides fall into four classes: organophosphates, carbamates, organochlorines, and pyrethroids. All compounds can precipitate seizures except for carbamates, which have poor central nervous system (CNS) penetration." (Pediatric Emergency Care)
What really caught my attention was that in that article the researchers determined by interviewing children's mothers or caretakers that "about one in 10 met the criteria for ADHD, which jibes with estimates for the general population." That made me wonder how anyone could determine a mental condition simply from an interview. Did this in fact make sense?
So what exactly is ADD/ADHD?
Psychiatric diagnoses are categorized by the Diagnostic and Statistical Manual of Mental Disorders, 4th. Edition published by the American Psychiatric Association, better known as the DSM-IV. This document covers all mental health disorders for both children and adults.
According to the DSM-IV the following are the criteria for ADD & ADHD:
1. Six (or more) of the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:
a. Often fails to give close attention to details or makes mistakes in schoolwork, work, or other activities
b. Often has difficulty sustaining attention in tasks or play activities
c. Often does not seem to listen when spoken to directly
d. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)
e. Often has difficulty organizing tasks and activities
f. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)
g. Often loses things necessary to tasks or activities (e.g. toys, school assignments, pencils, books, or tools)
h. Is often easily distracted by extraneous stimuli
i. Is often forgetful in daily activities
2. Six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:
a. Often fidgets with hands or feet or squirms in seat
b. Often leaves seat in classroom or in other situations in which remaining seated is expected
c. Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)
d. Often has difficulty playing or engaging in leisure activities quietly
e. Is often "on the go" or often acts as if "driven by a motor"
f. Often talks excessively
g. Often blurts out answers before questions before questions have been completed
h. Often has difficulty awaiting turn
i. Often interrupts or intrudes on others (e.g. butts into conversations or games)
The first thing that stands out is the word "often" is used in every one of the 18 criteria. The word "often" is defined by Webster's Dictionary as many times or frequently. What does "often" mean in the context of the DSM-IV in diagnosing ADD/ADHD? Does "often" mean 10% of the time or 90% of the time? This subjective term could easily be interpreted in a wide range depending on the individual. For example if Bob is described as "often" laughing out loud to a person who loves to laugh this maybe much less frequent than to a person who is more reserved. Reasonable people would easily disagree on the interpretation of "often" in any given situation.
Second, both ADD and ADHD diagnosis require that at least 6 of 9 criteria must be met. Where did this requirement come from? Why not 7 or 8 or even 9 of 9? This is an apparently subjective condition. What if a person qualifies to "often" have 5 of 9 would they be considered borderline ADD or ADHD?
Third, each diagnosis require for a condition to last at least 6 or more months. Again, where does the number 6 come from? Why not 5 or 9 or some other period of time? The symptom time period for diagnosis appears to be arbitrary.
Since the criteria are so subjective studies that show a disagreement between teachers and parents are not surprising. A study in Behaviour Research and Therapy, examined 65 children (58 boys and 7 girls) that had been diagnosed with ADHD. The study was to examine the agreement of parents and teachers in ADHD symptoms and examine the association between parenting stress and depressed mood on these symptoms. The authors found that, "our analyses showed that, consistent with previous studies, parents and teachers do not fully agree. Especially for hyperactive/impulsive symptoms, agreement between parents and teachers was low."
The same study found that parental stress levels "to be systematically and significantly associated between agreement raters of inattentive, hyperactive/impulsive and oppositional behavior" and that "it is important to also assess the emotional well-being of the informant, as this significantly and systematically is related to their ratings."
A report titled Continuous Performance Tests (CPTs) for Diagnosis and Titration of Medication for Attention Deficit Hyperactivity Disorder (ADHD) clearly states that the diagnosis of ADD/ADHD is subjective.
‘While ADHD is defined by the DSM-IV criteria, the symptom complex is diagnosed by a clinician. In the absence of a gold standard, the "reference standard" is the clinician's judgment. Ideally, this decision would be based on information gathered from a number of sources (e.g., parent, teacher, observations of the child), and would be reached by consensus. That is, a number of qualified clinicians would confer in making the appropriate diagnosis. Nevertheless, the clinician's decision is ultimately a subjective one, and this introduces a level of variability that is difficult to control for in evaluating any tool used for diagnosing ADHD. Moreover, the DSM has undergone several iterations over the past two decades, suggesting that ADHD is indeed a "symptom complex" characterized by behaviors that are difficult to agree upon.'
It's a wonder that this "difficult to agree upon" and "subjective" condition has become so pervasively and commonly used today. People have even incorporated the term into their everyday language sometimes commenting on how they have ADHD when they have trouble concentrating.
In a recent article in the Independent education expert Dr Gwynedd Lloyd from the University of Edinburgh declined to even recognize that ADD is even a condition.
"You can't do a blood test to check whether you've got ADHD - it's diagnosed through a behavioural checklist," says Lloyd. "Getting out of your seat and running about is an example -half the kids in a school could qualify under that criterion. I know a lot of children have genuine difficulties, and some of these are biological, but most are social and cultural."
Let's take a hypothetical example of an 11-year old child named Kevin. Kevin does well in Mrs. Hijack's math class, paying attention because he's interested in the subject and he likes Mrs. Hijack. He's struggling a bit in Mrs. Hatch's boring English class and fidgets and looks out the window especially on nice days. He doesn't always pay attention and when called on he doesn't always respond well. While Mrs. Hijack doesn't have an issue with Kevin, Mrs. Hatch has brought up the issue of attention problems in her class.
Kevin's mother is a highly stressed person with a high stress job. Being a very uptight person she expects perfection in others and looks for Kevin to be perfect. Her high stress attitude results in repeat conflicts with Kevin and at times he tunes her out when she begins yelling and pushing him. She is convinced he has ADHD even if she doesn't know any of the criteria for ADHD. On the other hand, Kevin's father is more relaxed and centered and knows that when given a positive environment with a healthy diet Kevin does well and pays attention to the things he is interested in. Kevin even spent two hours one day spontaneously and creatively making a complete suit of armor out of paper and staples with a complete focus on what he was doing. Kevin's father doesn't see any type of problem.
So does Kevin have a mental condition called ADD or ADHD or is Kevin just a normal boy with interaction with the real world and real people simply growing up? Does Mrs. Hatch need some training to make her class more interesting? Does Kevin's mother need some therapy to deal with her stress levels and her issues with perfectionism?
Let's take another example of two children: Doug and Larry.
Doug is a very high energy child that often is on the go and fidgeting and talking in class. He's always looking out the window wishing he was playing outside. He loves to talk to the other kids even during class. He's enthusiastic and often blurts out the answer without raising his hand or waiting his turn. He joins in other kids' games without asking because he's very outgoing. He loves to laugh and play rough. Doug does alright in school, but is more interested in playing than always doing school work.
Larry is very quiet and only answers questions when he is called on. He would never yell out an answer. He sits very still and is quiet and always pays attention to the teacher. He never looks out of the window and always plays quietly. He doesn't engage with other children and never intrudes on someone else's activities. Larry is the model student that the teacher's love because he is so well behaved and never causes a problem.
According to the criteria in the DSM-IV Doug isn't a normal child because he has all the symptoms of hyperactivity - impulsivity and would be classified with a psychiatric disorder. But does Doug really have a psychiatric problem or is he just a normal kid?
Again the DSM-IV notes that children with a hyperactivity disorder are different from normal children by
"Fidgetiness or squirming in one's seat ... talking excessively ... being constantly on the go and into everything; they dart back and forth, are ‘out of the door before their coat is on,' jump or climb on furniture, run through the house, and have difficulty participating in sedentary group activities in preschool (e.g., listening to a story)"
This seems to describe just about every healthy and normal child. It's amazing that a group of people actually believe that leaving for somewhere before your coat is on or running through a house are signs of possible mental disorder.
The DSM-IV does state that the DSM-IV should "not be applied mechanically by untrained individuals" and that diagnostic criteria are "not meant to be used in a cookbook fashion", noting that even if someone falls short of meeting the full criteria that "clinical judgment" may be exercised to still render a mental diagnosis. There is no mention that a "clinical judgment" that derives its paradigm from the very document that is to be used as a guide would be inherently biased in favor of using these criteria.
So how was the condition and diagnosis of ADD/ADHD created as it appears in the DSM-IV?
According to the DSM-IV it was the product of 13 Work Groups each with the primary responsibility of different parts the manual. The Work Groups would reflect the available evidence and "opinion" and not just the views of the members of the individual work groups. "It must be noted that DMS-IV reflects a consensus about the classification and diagnosis of mental disorders derived at the time of its initial publication." So at least in part a diagnosis was based on a consensus of opinions and not necessarily hard science.
The "Disorders Usually First Diagnosed During Infancy, Childhood, or Adolescence Work Group" was composed of 16 members. These members are listed as David Schaffer MD, Magda Campbell MD, Susan J. Bradley MD, Dennis P. Cantwell MD, Gabrielle A. Carlson MD, Donald Jay Cohen MD, Barry Garfinkel MD, Rachel Klein PhD, Benjamin Lahey PhD, Rolf Loeber PhD, Jeffery Newcorn MD, Rhea Paul, PhD, Judity H. L. Rapoprt MD, Sir Michael Rutter MD, Fred Volkmar MD, and John S. Werry MD.
Very disturbingly a 2006 study by Sheldon Krimsky, PhD found 95 of the 170 DSM-IV panel members had one or more financial link to the pharmaceutical industry.
"Of the panel members who had financial links with the pharmaceutical industry 76% had research funding, 40% had consulting income, 29% served on a speaker bureau, and 25% receive honoraria other than from serving on a speaker bureau ... If financial COI (Conflicts-Of-Interest) among medical researchers can bias the outcome of a study (as recent research shows), there is as much reason to believe it can also bias the recommendations made by members of advisory panels."
The study also noted that "pharmaceutical advertising in APA (American Psychiatric Association) journals, totaling USD 7.5 million in 2003, increased 22% in 1 year", also according to Reuters "millions of people take ADHD drugs including Novartis AG's Ritalin, known generically as methylphenidate, and Shire Plc's Adderall and Vyvanse. Annual U.S. sales totaled about $4.8 billion in 2008, according to data from IMS Health."
So it appears clear that there is a huge financial motivation in the creation and diagnosis of these mental conditions including ADD/ADHD. It's extremely hard to believe that finances did not in some way bias the DSM-IV working groups in the creation of these opinion based conditions that are then used by other people with their own biases and opinions to diagnose patients.
In the 1800s people believed that a mysterious miasma was the cause of infectious diseases such as cholera, the Black Death, and other diseases of the time. A miasma, which was a strongly held theory at that time, held that a poisonous vapor or mist filled with decomposed matter caused these illnesses. We now know that these plagues were the result of poor hygiene, sanitation, and nutrition, as well the various bacteria and viruses as well as a number of other factors and not some mysterious mist.
Today we know that many toxins can affect brain function including lead, pesticides, mercury, thimerosal, aluminum, and various other environmental toxins. We also know proper nutrition, omega-3 fatty acids, vitamin E, B Vitamins, and others can also make a positive impact on the brain. In fact there are a whole host of environmental influences that can affect a person's brain in positive and negative ways. Perhaps one day people will examine all the influences on the brain replacing a highly biased, financially influenced, and opinion based diagnosis that so many have been labeled with.
Pesticides tied to ADHD in children in U.S. study, Reuters, http://www.reuters.com/article/idUSTRE64G41R20100517
Pesticides in Children, J. Routt Reigart MD and James R. Roberts MD, MPH, Pediatric Clinics of North America, October 2001, Vol. 48, No. 5, pp. 1-17
Toxic seizures in children: Case scenarios and treatment strategies, Michael Shannon MD, Erica Anderson McElroy DO, Erica L. Liebelt MD, Pediatric Emergency Care, June 2003, Vol. 19, No. 3, pp. 206-210
Diagnostic and Statistical Manual, DSM-IV
The association between parenting stress, depressed mood and informant agreement in ADHD and ODD, Behaviour Research and Therapy, November 2006
Continuous Performance Tests (CPTs) for Diagnosis and Titration of Medication for Attention Deficit Hyperactivity Disorder (ADHD), November 2000, http://ablechild.org/right%20to%20refuse/continuous_performance_tests.htm
Are drugs the solution to the problem of ADHD among young people? The Guardian, May 11, 2010, http://www.guardian.co.uk/education/2010/may/11/ritalin-adhd-drugs
Financial Ties between the DSM-IV Panel Members and the Pharmaceutical Industry, Psychotherapy and Psychosomatics, 2006
Attention drug emergencies soar for U.S. kids: report, Reuters, Aug 23 2009 http://www.reuters.com/article/idUSTRE57N0LB20090824
|Last Updated on Friday, 21 May 2010 00:33|