The whole ADHD field is quite controversial. Even the diagnosis has been called into question. Most of the research is distorted by the influence of drug industry money. It is a shocking fact that the number of Americans, both children and adults, given ADHD drugs doubled in just four years from 2000 to 2004. Now, an amazing 8% of all males between the ages of 10 and 19 are given ADHD medication! Even 1% of young and middle aged adults ages 20-44 are on stimulant ADHD drugs (M. Ellis, USA Today 11/15/05; 8D).
In my opinion, this is outrageous. The Bush FDA and the medical establishment have allowed the drugging of America, both with stimulants and a massive wave of opiate pain pills dispensed much more often than ever before. While many physicians are happy to have the business, the real money makers are the wealthy owners of the pharmaceutical industry. In our brave, new world, some pill can solve all of your problems.
Attention-Deficit/Hyperactivity Disorder is supposed to be present in 3-5% of grade school children according to the DSM-IV Diagnostic Task Force. However, other estimates range from 1% to 10% range. Children are diagnosed as Inattentive Type, Hyperactive-Impulsive Type, or Combined Type.
Officially, for the Inattentive Type, children must have six or more frequent symptoms for at least 6 months to a maladaptive degree: 1) poor attention to details or careless mistakes in school, etc., 2) difficulty sustaining attention in tasks or play, 3) not listening when spoken to, 4) not following through on directions and failing to finish work, 4) difficulty organizing activities, 5) reluctant to engage in sustained mental effort like schoolwork, 6) loses things necessary for activities, 7) easily distracted, 8) forgetful in daily activities.
For the Hyperactive-Impulsive Type, six or more frequent symptoms for at least 6 months to a maladaptive degree: 1) fidgets with hands or feet or squirms in chair, 2) often leaves seat in classroom, 3) runs about excessively, 4) difficulty playing quietly, 5) on the go excessively, 6) talks excessively, 7) blurts out answers before questions completed, 8) difficulty awaiting turn, 9) interrupts or intrudes on others. (When I was in 1st-3rd grade with 50 other children and one teacher, I can't remember anyone ever leaving his or her seat, running about, or talking without permission. It wasn't permitted. Hence, no one could have gotten this diagnosis.)
Some symptoms must be present before age 7, in at least two settings (school, work, home), and with a clinically significant impairment.
In fact, ADHD is not a disease. It is a bunch of symptoms artificially grouped together. It is an absolute certainty that all ADHD children do not have the same disease. They have dozens if not hundreds of different diseases and behavioral disorders that fit the ADHD diagnosis. Also, ADHD tests are vastly over-inclusive, labelling many as ADHD who don't even fit the required symptom grouping. Diseases which can look like ADHD include a wide variety of genetic diseases, lead toxicity, head trauma, in utero brain damage due to maternal substance abuse, bipolar disorder, mineral deficiencies, poor classroom management, learned aggression, poor diet, sleep apnea, and more, including calling normal child behavior ADHD. A careful evaluation is critical. The quick handing of a prescription for powerful stimulants is not the way to treat children, but it is extremely common by psychiatrists, pediatricians, and family doctors. It may result in the appearance of benefit, but do more harm than good. I was vigorously attacked by a couple psychiatrists in State College, PA, when I casually mentioned in a meeting that there was no double-blind research showing that stimulants improved long-term classroom academic performance. Psychiatrists have a vested interest. Stimulants help them make money.
There are many treatments for ADHD, both psychological and otherwise, that don't involve medications at all. Most "ADHD" children do not need any medication whatsoever. I prefer non-medical interventions first and non-stimulant interventions second. I am very reluctant to prescribe stimulants, but find that the demand for stimulants by schools, patients, and parents is sometimes intense.
Pure ADHD Uncommon: A Swedish study of 409 children age 7 with follow-up 2-4 years later found 87% of the 15 children with ADHD had at least one comorbid diagnosis and 67% had two or more. The most common were oppositional defiant disorder and developmental coordination disorder. Children with subthreshold ADHD (N = 42) also had very high rates of comorbid diagnoses (71% and 36%), whereas those without ADHD (N = 352) had much lower rates (17% and 3%). The rate of associated school adjustment, learning, and behavior problems at follow-up was very high in the ADHD groups. The authors concluded that pure ADHD is uncommon even in a general population sample. Thus, studies reporting on ADHD cases without comorbidity probably refer to highly atypical samples which cannot inform rational clinical decisions. The comorbidity of ADHD in the general population of Swedish school-age children. Kadesjo B, Gillberg C. J Child Psychol Psychiatry. 2001 May;42(4):487-92
ADHD Youth Often Grow Up Developing Many Problems: In a case-control, 10-year prospective study of 140 ADHD youth vs. 120 without ADHD, many psychiatric disorders were more common in the grown up ADHD youth: Major Psychopathology (mood disorders and psychosis) up 510%, Anxiety Disorders 120%, Antisocial Disorders (conduct, oppositional-defiant, and antisocial personality disorder) 490%, Developmental Disorders (elimination, language, and tics disorder) 150%, and Substance Dependence Disorders (alcohol, drug, and nicotine dependence) 100%, as measured by blinded structured diagnostic interview. Young adult outcome of attention deficit hyperactivity disorder: a controlled 10-year follow-up study. Biederman J, et al. Massachusetts General Hospital, Boston. Psychol Med 2006 Feb;36(2):167-79.
6.5% ADHD, 6% Dyslexic Prevalence in Thailand School: All 433 students of 1st to 6th grade studied. 11 boys and 12 girls ADHD by DSM-IV with school and parent Connors. ADHD students lower in math. p<.006. Prevalence and clinical characteristics of attention deficit hyperactivity disorder among primary school students in Bangkok. Benjasuwantep B, Ruangdaraganon N, Visudhiphan P. J Med Assoc Thai 2002 Nov;85 Suppl 4:S1232-40; Dyslexia in same study 6% and probable dyslexia 12%. Males 3.4:1. Verbal IQ dyslexics 76. 8.7% dyslexics comorbid for ADHD. Prevalence and clinical characteristics of dyslexia in primary school students. Roongpraiwan R, Ruangdaraganon N, Visudhiphan P, Santikul K. J Med Assoc Thai 2002 Nov;85 Suppl 4:S1097-103
35% Epileptics Kids Diagnosed ADHD, Primarily Inattentive Type: On Child Symptom Inventory-4 (CSI) or Adolescent Symptom Inventory-4 (ASI), 20 of 175 children met DSM-IV criteria for ADHD combined type; 42 of 175 had ADHD predominantly inattentive type; and 4 of 175 met criteria for ADHD predominantly hyperactive-impulsive type. Sex ration even. Indiana U, ADHD and epilepsy in childhood. Dunn DW, Austin JK, Harezlak J, Ambrosius WT. Dev Med Child Neurol 2003 Jan;45(1):50-4
23% ADHD Kids Have Adult Psychiatric Admission: Children aged 4-15 years, referred for hyperactivity/inattention and treated with stimulants were included (n=208). Follow-up data on psychiatric admissions in adulthood until a mean age of 31 years found a total of 47 cases (22.6%) had a psychiatric admission in adulthood. Conduct problems in childhood were predictive of 130% more hospitalizations (hazard ratio HR=2.3). Girls had a higher risk compared with boys (HR=2.4). Denmark. Conduct problems, gender and adult psychiatric outcome of children with attention-deficit hyperactivity disorder. Dalsgaard S, Mortensen PB, Frydenberg M, Thomsen PH. Br J Psychiatry 2002 Nov;181:416-21.
ADHD Higher in Ethiopian Cities: A study of 1447 children found ADHD 184% higher in larger urban areas and ADHD and disruptive behavior each were over 300% higher in the 10-14 age group vs. the 6-10 age group. Socio-demographic correlates of mental and behavioural disorders of children in southern Ethiopia. Ashenafi Y, Kebede D, Desta M, Alem A. East Afr Med J. 2000 Oct;77(10):565-9.
Adult Psychiatric Illness Common in ADHD Children, But Not for Adult ADHD: A surprising follow-up study of 147 hyperactive 7-8 year old children found that 13 years later they had a higher rate of mental illness diagnoses than 71 control children. The Hyperactive group had a significantly higher risk for any nondrug psychiatric disorders than the control group (59% vs. 36%). More of the Hyperactive group in adulthood met criteria for ADHD (5%); major depressive disorder (26%); and histrionic (12%), antisocial (21%), passive-aggressive (18%), and borderline personality disorders (14%). University of Wisconsin, Milwaukee. Young adult follow-up of hyperactive children: self-reported psychiatric disorders, comorbidity, and the role of childhood conduct problems and teen CD. Fischer M, Barkley RA, Smallish L, Fletcher K. J Abnorm Child Psychol. 2002 Oct;30(5):463-75
Inattentive vs. Hyperactive-Impulsive Sensible Division: All 18 factors of the ADHD diagnostic criteria were studied. School teachers rated 21,161 children in 4 locations: Spain, Germany, urban US, and suburban US. Factor analysis suggested that the 2-factor model (inattention, hyperactivity/impulsivity) fit best. A third factor, impulsivity, was too slight to stand-alone. Children with academic performance problems were distinguished by inattention, but children with behavior problems typically had elevations in inattention, hyperactivity, and impulsivity. Teachers' screening for attention deficit/hyperactivity disorder: comparing multinational samples on teacher ratings of ADHD. Wolraich ML, Lambert EW, Baumgaertel A, Garcia-Tornel S, Feurer ID, Bickman L, Doffing MA. J Abnorm Child Psychol. 2003 Aug;31(4):445-55
Depression: Small Increase in ADHD in Children with Bipolar or Unipolar Depression: A small Canadian study of 44 bipolar children, 30 unipolar depressed children, and 45 controls found 6% of bipolar, 10% unipolar, and 0% of normals with ADHD. No evidence of attentional deficits in stabilized bipolar youth relative to unipolar and control comparators. Robertson HA, Kutcher SP, Lagace DC. Bipolar Disord. 2003 Oct;5(5):330-9. Ed: This report is the direct opposite of the one below.
Irritability: Three Different Types Identified in ADHD Children: 274 ADHD children, 30 with co-morbid bipolar and 100 with co-morbid unipolar depression, were administered the Kiddie Schedule for Affective Disorders and Schizophrenia (Epidemiologic Version) structured diagnostic interview. Three measures of irritability were identified: oppositional defiant disorder (ODD)-type irritability, mad/cranky irritability, and super-angry/grouchy/cranky irritability. Oppositional defiant disorder-type irritability was very common in all ADHD subjects, was the least impairing, and did not increase the risk of mood disorder. Mad/cranky irritability was common in only ADHD children with a mood disorder, was more impairing than the ODD-type irritability, and was predictive of unipolar depression. Super-angry/grouchy/cranky irritability was common only in ADHD children with bipolar disorder, was the most impairing, and was predictive of both unipolar depression and bipolar disorder. Two percent of the subjects with ODD-type irritability only, 6% of subjects with mad/cranky irritability, and 46% of subjects with super-angry/grouchy/cranky irritability were diagnosed with bipolar disorder. Heterogeneity of Irritability in Attention-Deficit/Hyperactivity Disorder Subjects With and Without Mood Disorders. Mick E, et al. MGH-Harvard. Biol Psychiatry. 2005 Aug 5
Mood Disorders in ADHD Said Very Common: 60% of 104 children ages 5-11 who were referred for ADHD were found to also have a mood disorder. They were 3.3 times more likely to have a family history of affective disorder and 18 times more likely to have a family history of bipolar disorder. 32% of the children with mood disorders were found to have psychotic features. Children meeting the standard criteria for mania, but who did not have grandiosity or psychotic features were much less likely to have a family history of mood disorder (70% vs. 8%). UCSD. Dilsaver SC, Henderson-Fuller S, Akiskal HS. Occult mood disorders in 104 consecutively presenting children referred for the treatment of attention-deficit/hyperactivity disorder in a community mental health clinic. J Clin Psychiatry 10/2003;64:1170-6. Ed: This study seems evidence that bipolar disorder often manifests itself in childhood and has ADHD type symptoms as well as mood disorder symptoms. Since stimulants are poor treatments for mood disorder and several anti-depressants with low switch rates and lithium help ADHD, these might be better treatments for ADHD with depression and ADHD with manic symptoms. Perhaps, children with ADHD-type symptoms and mania with grandiosity or psychotic features shouldn’t be considered to have ADHD but to have Bipolar Disorder.
Manic Bipolar vs. ADHD Children: Five symptoms (i.e., elation, grandiosity, flight of ideas/racing thoughts, decreased need for sleep, and hypersexuality) provided the best discrimination of Prepubertal and Early Adolescent-Bipolar (PEA-BP) subjects (93) from ADHD (81) and normal community controls (92). These five symptoms are also mania-specific in DSM-IV (i.e., they do not overlap with DSM-IV symptoms for ADHD). Irritability, hyperactivity, accelerated speech, and distractibility were very frequent in both PEA-BP and ADHD groups and therefore were not useful for differential diagnosis. Concurrent elation and irritability occurred in 87.1% of subjects with PEA-BP. Data on suicidality, psychosis, mixed mania, and continuous rapid cycling are also provided. Washington Univ. DSM-IV mania symptoms in a prepubertal and early adolescent bipolar disorder phenotype compared to attention-deficit hyperactive and normal controls. Geller B, Zimerman B, Williams M, Delbello MP, Bolhofner K, Craney JL, Frazier J, Beringer L, Nickelsburg MJ. J Child Adolesc Psychopharmacol. 2002 Spring;12(1):11-25
Neurofibromatosis Type 1 Have 50% ADHD: A German study of 93 children with neurofibromatosis found a very high rate of ADHD. These children had lower IQs than ADHD or other NF patients. Methylphenidate was reported helpful though only an open study. Treatment of ADHD in neurofibromatosis type 1. Mautner VF, Kluwe L, Thakker SD, Leark RA. Dev Med Child Neurol. 2002 Mar;44(3):164-70
Obese Said Often ADHD: A Portland, Oregon, study reported an incredibly high rate of adult ADHD in 210 obese patients in obesity treatment. The rate was even higher for the markedly obese: 42.6% for BMI >= 40. Mean weight loss among obese patients with ADHD (OB+ADHD) was 2.6 BMI (kg/m2) vs. 4.0 for non-ADHD (NAD) (p < 0.002). Prevalence of attention deficit/hyperactivity disorder among adults in obesity treatment. Altfas JR. BMC Psychiatry. 2002 Sep 13;2(1):9 (Ed: For a disease that didn't even exist in the minds of most people 10 years ago, calling 27% of obese ADHD seems hard to believe.)
Parents Report Much More Young Adult ADHD Persistence: A study of 147 ADHD children and 71 controls grown to young adults found only 5% and 0% of young adults report symptoms of ADHD. However, based on parent reports, young adult ADHD rates were 46% for former ADHD children and 1% for controls. The persistence of attention-deficit/hyperactivity disorder into young adulthood as a function of reporting source and definition of disorder. Barkley RA, Fischer M, Smallish L, Fletcher K. J Abnorm Psychol. 2002 May;111(2):279-89
Prescribing Practices Vary Dramatically: A study in Northern Israel found only 0.2% of children in Israeli Arab cities vs. 6.6% of Israeli Jewish children on kibbutzim were on methylphenidate for ADHD. 77% were boys. Prevalence of and change in the prescription of methylphenidate in Israel over a 2-year period. Fogelman Y, Vinker S, Guy N, Kahan E. CNS Drugs. 2003;17(12):915-9
Prisons: ADHD Very Common; Mental Illness the Norm: In a study of 129 German prison inmates, average age 19 and 54 healthy males for the presence of adult ADHD using the Wender Utah Rating Scale (WURS), the Eysenck Impulsivity Questionnaire (EIQ), the diagnostic criteria for ADHD according to DSM-IV and ICD-10-research criteria and the Utah criteria for adult ADHD, 45% of prisons had ADHD based on DSM-IV. 64% suffered from at least 2 disorders. Only 8.5% had no psychiatric diagnoses. Rosler M, Retz W, et al. Universitatskliniken des Saarlandes, Germany. Eur Arch Psychiatry Clin Neurosci. 2004 Dec;254(6):365-71. Ed: Like many psychiatrists who has worked in prisons, I don't think that stimulants are appropriate treatment. However, many alternatives are available.
Sleep-Disordered Breathing Children More ADHD Symptoms: A Massachusetts study of 3019 5-year-old by Boston University found 25% of parents reported symptoms of SDB (frequent or loud snoring, loud and noisy breathing, trouble breathing, or witnessed sleep apnea). These children had parent-reported daytime sleepiness 120% more often and problem behaviors (10%), including hyperactivity 150% more often (19%), inattention 110% more often (18%), and aggressiveness 110% more often (12%). Symptoms of sleep-disordered breathing in 5-year-old children are associated with sleepiness and problem behaviors. Gottlieb DJ, Vezina RM, Chase C, Lesko SM, Heeren TC, Weese-Mayer DE, Auerbach SH, Corwin MJ. Pediatrics. 2003 Oct;112(4):870-7.
Sleep Problems Not Increased by Stimulants According to Small Study: A study of 53 ADHD children on stimulants vs. 34 ADHD without meds vs. 51 controls found both ADHD groups with considerably more sleep problems but no difference between the two ADHD groups. Univ Louisville. The effect of stimulants on sleep characteristics in children with attention deficit/hyperactivity disorder. O'Brien LM, Ivanenko A, Crabtree VM, Holbrook CR, Bruner JL, Klaus CJ, Gozal D. Sleep Med. 2003 Jul;4(4):309-16
Smoking Common in Inattentive ADHD: In a study of 1066 U.S. 10th graders, 31% were current smokers. Current smoking was also associated with peer smoking (OR = 2.99) and clinically significant ADHD inattention symptoms (OR = 2.80). Association of attention-deficit/hyperactivity disorder symptoms with levels of cigarette smoking in a community sample of adolescents. Tercyak KP, Lerman C, Audrain J. J Am Acad Child Adolesc Psychiatry. 2002 Jul;41(7):799-805
Substance Abuse: Slight Decrease in Adult Substance Abuse in ADHD Treated Children: Six studies--2 with follow-up in adolescence and 4 in young adulthood comprised 674 medicated subjects and 360 unmedicated subjects who were followed at least 4 years. The pooled estimate of the odds ratio indicated a 1.9-fold reduction in risk for SUD in youths who were treated with stimulants compared with youths who did not receive pharmacotherapy for ADHD. We found similar reductions in risk for later drug and alcohol use disorders. Studies that reported follow-up into adolescence showed a greater protective effect on the development of SUD (OR: 5.8) than studies that followed subjects into adulthood (OR: 1.4). Harvard, Does stimulant therapy of attention-deficit/hyperactivity disorder beget later substance abuse? A meta-analytic review of the literature. Wilens TE, Faraone SV, Biederman J, Gunawardene S. Pediatrics 2003 Jan;111(1):179-85
Substance Abuse: ADHD and Conduct Disorder Common in Teen Substance Abusers: 600 teens ages 12-18 admitted to four different out-patient programs for marijuana problems: 50% dependence and 46% abuse diagnosis. Only 20% thought they needed any help for substance abuse. 30% were comorbid for ADHD and conduct disorder. U S. Florida, Characteristics and problems of 600 adolescent cannabis abusers in outpatient treatment. Tims FM, Dennis ML, Hamilton N, J Buchan B, Diamond G, Funk R, Brantley LB. Addiction 2002 Dec;97 Suppl 1:46-57
Substance Abuse: No Evidence Adult Substance Abuse Due to ADHD Treatment: In a 13 year follow-up of 146 ADHD children, stimulants did not significantly increase drug abuse. Does the treatment of attention-deficit/hyperactivity disorder with stimulants contribute to drug use/abuse. Says 11 previous studies find similar results. U Mass, A 13-year prospective study. Barkley RA, Fischer M, Smallish L, Fletcher K. Pediatrics 2003 Jan;111(1):97-109
Thomas E. Radecki, M.D., J.D.