At the risk of stating the obvious, ADHD is not an illness. Rather, it is an unreliable and disempowering label for a loose collection of arbitrarily chosen and vaguely defined behaviors. ADHD has been avidly promoted as an illness by pharma-psychiatry for the purpose of selling stimulant drugs. In which endeavor, they have been phenomenally successful, but, as in other areas of psychiatry, the hoax is unraveling.
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In 2001, the American Academy of Pediatrics published Clinical Practice Guideline: Treatment of the School-Aged Child With Attention-Deficit/Hyperactivity Disorder. Here’s a quote:
“RECOMMENDATION 3: The clinician should recommend stimulant medication (strength of evidence: good) and/or behavior therapy (strength of evidence: fair), as appropriate, to improve target outcomes in children with ADHD (strength of recommendation: strong).
The clinician should develop a comprehensive management plan focused on the target outcomes. For most children, stimulant medication is highly effective in the management of the core symptoms of ADHD. For many children, behavioral interventions are valuable as primary treatment or as an adjunct in the management of ADHD, based on the nature of coexisting conditions, specific target outcomes, and family circumstances.”
Clearly, this recommendation is pushing the drugs (evidence good), and is downplaying the usefulness of behavioral interventions (evidence fair). The reference to behavioral interventions “…as an adjunct…” doesn’t inspire a great deal of confidence in their use as the primary intervention. And, indeed, this is how “treatment” of “ADHD” has developed in the intervening years: pills for all, and occasional behavioral programs, many of which were geared towards accepting one’s “illness” and promoting “medication compliance.”
And all of this in a context in which ADHD was being fraudulently promoted by psychiatry, and by its pharma partners, as a neurochemical imbalance which was corrected by stimulant drugs. Here’s what the eminent Harvard psychiatrist Timothy Wilens, MD, wrote on the matter in the article Paying Attention to ADHD in Family Circle magazine on November 20, 2011:
“ADHD often runs in families. Parents of ADHD youth often have ADHD themselves. The disorder is related to an inadequate supply of chemical messengers of the nerve cells in specific regions of the brain related to attention, activity, inhibitions, and mental operations.”
“Contrary to what most parents think, medication is one of the most important treatments for ADHD and is essential for long-term success of these kids.” (p 65)
The above quotes were clearly aimed at mothers, were designed to break down parental resistance to drug-taking, and are typical of what psychiatry generally has been saying on this subject for decades.
Dr. Wilens is an Associate Professor of Psychiatry at Harvard, and works as a psychiatrist at Massachusetts General Hospital. In 2014 he was named Chief of Staff in Child and Adolescent Psychiatry. So promoting the chemical imbalance hoax has certainly not harmed his career.
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In recent years, psychiatrists have been experiencing increased scrutiny and criticism from the media, the general public, and some legislators, for the “pill for every problem” approach. In this context, the American Academy of Pediatrics, in 2011, published an updated set of guidelines for ADHD under the title ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents In this revised document, their recommendations for treatment are divided into three parts: preschool children (4-5); elementary school children (6-11); and adolescents (12-18). Here is a quote from each section:
“Action statement 5a: For preschool-aged children (4–5 years of age), the primary care clinician should prescribe evidence-based parent and/or teacher-administered behavior therapy as the first line of treatment (quality of evidence A/strong recommendation) and may prescribe methylphenidate if the behavior interventions do not provide significant improvement and there is moderate-to-severe continuing disturbance in the child’s function.“
“Action statement 5b: For elementary school-aged children (6–11 years of age), the primary care clinician should prescribe FDA-approved medications for ADHD (quality of evidence A/strong recommendation) and/or evidence -based parent- and/or teacher-administered behavior therapy as treatment for ADHD, preferably both (quality of evidence B/strong recommendation).“
“Action statement 5c: For adolescents (12–18 years of age), the primary care clinician should prescribe FDA-approved medications for ADHD with the assent of the adolescent (quality of evidence A/strong recommendation) and may prescribe behavior therapy as treatment for ADHD (quality of evidence C/recommendation), preferably both.“
Note in particular that for preschool children, the recommended “first line treatment” is behavior therapy administered by the parent and/or teacher, and the pills are recommended only if the behavioral interventions are not effective, and the problem is moderate-to-severe. This is a sea-shift from the earlier guidelines.
Note also that for older children, pills and/or behavioral therapy are recommended, “preferably both.” Here again, behavioral interventions are being emphasized a good deal more than was the case in 2001.
Later in the guidelines document, the authors clarify what they mean by behavior therapy:
“Behavior therapy represents a broad set of specific interventions that have a common goal of modifying the physical and social environment to alter or change behavior. Behavior therapy usually is implemented by training parents in specific techniques that improve their abilities to modify and shape their child’s behavior and to improve the child’s ability to regulate his or her own behavior. The training involves techniques to more effectively provide rewards when their child demonstrates the desired behavior (eg, positive reinforcement), learn what behaviors can be reduced or eliminated by using planned ignoring as an active strategy (or using praising and ignoring in combination), or provide appropriate consequences or punishments when their child fails to meet the goals (eg, punishment). There is a need to consistently apply rewards and consequences as tasks are achieved and then to gradually increase the expectations for each task as they are mastered to shape behaviors. Although behavior therapy shares a set of principles, individual programs introduce different techniques and strategies to achieve the same ends.” [Emphasis added]
Note that what’s being recommended here is that the parents be trained in the ordinary, time-honored principles of effective parenting.
And remember, this was in 2011 – five years ago, but the shift in the pediatric guidelines has not resulted in a significant shift in practice.
In response to this inertia, on May 3, 2016, the Centers for Disease Control and Prevention (CDC) issued a press release titled More Young Children with ADHD Could Benefit from Behavior Therapy.
Obviously the CDC considers ADHD to be a disease, but if you can bear with the medicalization wording, here are some interesting quotes:
“The American Academy of Pediatrics recommends that before prescribing medicine to a young child, healthcare providers refer parents to training in behavior therapy. However, according to the Vital Signs report, about 75% of young children being treated for ADHD received medicine, and only about half received any form of psychological services, which might have included behavior therapy.” [Emphasis added]
Note that what’s being stressed here is the need to refer parents to behavioral training.
“Parents of young children with ADHD may need support, and behavior therapy is an important first step. It has been shown to be as effective as medicine, but without the risk of side effects. We are still learning about the potential unintended effects of long-term use of ADHD medicine on young children. Until we know more, the recommendation is to first refer parents of children under 6 years of age with ADHD for training in behavior therapy before prescribing medicine.” [Emphasis added]
“CDC is calling on doctors, nurses, and allied health professionals who treat young children with ADHD to support parents by explaining the benefits of behavior therapy and referring parents for training in behavior therapy.” [Emphasis added]
In addition to the press release, the CDC also provided a press telebriefing in which reporters were able to put questions to senior CDC officials. One of the questions was from Ariana Cha with the Washington Post. Her question was:
“Hi. I had a quick follow-up question about the — about insurance. And when you say that these should be covered, are you also talking about kind of the gold standard, which is A.B.A. [Applied Behavior Analysis] Therapy, which is incredibly expensive and usually used for autism but also to address a lot of the same behaviors that you see in ADHD?”
Two CDC officials responded. First was Anne Schuchat, MD, Principal Deputy Director for CDC:
“No, you know, the treatments are quite different. And I’d like Dr. Georgina Peacock to comment on that because we don’t believe the same interventions for autism should be used for children with ADHD.”
And then Georgina Peacock, MD, MPH, FAAP, Director, Division of Human Development and Disability:
“So we are talking about behavioral therapy, but this particular behavioral therapy is parent training. So parents learn skills that help promote positive behaviors in their children. There’s also a strengthening of the relationship between the parent and the child. And some of the other things, some of the examples of things that happen, is parents learn about limit setting. They learn about applying appropriate consequences for inappropriate behaviors and learn about how to improve communication between the parent and the families. That’s the type of behavioral therapy that we are talking about and the American Academy of Pediatrics recommends for families.” [Emphasis added]
It is clear from these responses that the CDC is not conceptualizing these recommendations as the provision of some kind of specialized treatment to the children, but rather as training the parents in the basic principles and practices of effective parenting.
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In other words, as we “mental illness deniers” have been saying for years, the problem does not reside in the child in the form of some hypothesized brain dysfunction. Rather, the problem is the direct result of ineffective discipline, training, and correction on the part of caregivers. And the truly ironic thing is that older people, with no particular training in psychology, psychiatry, social work, counseling, etc., have been saying this for decades, shaking their heads in sadness and disbelief as they watch their children and grandchildren accept pharma-psychiatry’s hoax, and feed the serotonin-disruptive drugs to their children in ever-increasing numbers. Grandparents – nature’s own trainers in parenting skills – have been effectively silenced by pharma-psychiatry’s spurious, self-serving insistence that these kinds of misbehaviors constitute a brain illness which needs the attention of medically-trained experts. These unsubstantiated assertions undermine parental confidence, open “uncooperative” parents to accusations of child neglect, and create an environment in which the levels of mastery and self discipline that were the norm for children fifty years ago, are rapidly becoming the exception.
Even CHADD, not noted for challenging the ideology of their pharma benefactors, makes some concessions in this direction. Here’s a quote from their About ADHD document:
“Problems in parenting or parenting styles may make ADHD better or worse, but these do not cause the disorder. ADHD is clearly a brain-based disorder. Currently research is underway to better define the areas and pathways that are involved.”
This, incidentally, is a truly delightful example of typical psychiatric mental gymnastics. Let’s take a closer look.
“Problems in parenting or parenting styles may make ADHD better or worse…”
Now, as is well known, ADHD is defined by the presence of six or more habitual behaviors from either or both of two checklists of nine items each. So if it is being conceded that “problems in parenting” can make ADHD worse, this can only be in terms of a deterioration on one or more of the criterion items. But since all the criterion items are continuous variables, this inevitably entails a recognition that problems in parenting can push a child past whatever threshold of severity or frequency is required to constitute a “hit.” Which in turn entails the fact that problems in parenting can produce the six or more hits required to make the “diagnosis.” In other words, problems in parenting, by CHADD’s own admission, can cause ADHD. Obviously the drafters of the document realized that they had opened this door, and immediately tried to slam it shut by countering even their own logic with their customary mantra-like assertion: “ADHD is clearly a brain-based disorder,” the proof of which will be forthcoming any decade now!
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And incidentally, the American Academy of Pediatrics guidelines includes a section on the adverse effects of stimulant drugs. Here’s a quote:
“An uncommon additional significant adverse effect of stimulants is the occurrence of hallucinations and other psychotic symptoms.”
In 2009, Mosholder et al conducted a study on the incidence of these kinds of events and found:
“A total of 11 psychosis/mania adverse events occurred during 743 person-years of double-blind treatment with these drugs, and no comparable adverse events occurred in a total of 420 person-years of placebo exposure in the same trials. The rate per 100 person-years in the pooled active drug group was 1.48. The analysis of spontaneous postmarketing reports yielded >800 reports of adverse events related to psychosis or mania. In approximately 90% of the cases, there was no reported history of a similar psychiatric condition.”
Eleven cases in 743 person-years (i.e. one in 68 person-years) sounds like a small effect. But in any given year, about 3.5 million American children take a stimulant drug for ADHD. And if we assume that each of these children takes the pills for an average of six months (almost certainly an under-estimate), this amounts to approximately 25,700 drug-induced psychosis/mania incidents each year in the US alone. To the best of my knowledge, no large-scale, systematic study of the outcome of these incidents has been undertaken.
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The 2011 pediatric guidelines, reinforced as they were by the CDC’s recent press release and telebriefing, represent a formidable broadside against psychiatry’s promotion of ADHD as a brain illness residing within the child. If this “illness” can be “cured” by improved discipline/correction on the parents’ part, isn’t it eminently reasonable to conclude that ineffective discipline was the precipitating cause of the problem in the first place? We can be sure that pharma-psychiatry are already working on counter-measures to neutralize the impact of these documents, and we should not expect the bastions of bio-bio-bio psychiatry to crumble overnight. But as Andrew Lloyd Webber and Tim Rice put it so lyrically back in 1968:
“But if my analysis of the position is right,
At the end of the tunnel there’s a glimmer of light”
(Joseph and the Amazing Technicolor Dreamcoat)
On all sides the hoax is unraveling, and psychiatry has no response other than the repetition of the same unsubstantiated assertions, laced generously with PR, obfuscation, and the assignment of blame to others for their own errors and deceptions.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.