• The selling of ADHD

    Attention Deficit Hyperactivity Disorder is a serious problem in kids. I’ve been funded in the past, and published on the results, for a trial to improve physician diagnosis and management of the condition. So I hope I don’t have to convince you that I agree that it’s real, and that it warrants attention.

    That said, the NYT had a longform piece yesterday on how it’s being oversold these days:

    After more than 50 years leading the fight to legitimize attention deficit hyperactivity disorder, Keith Conners could be celebrating.

    Severely hyperactive and impulsive children, once shunned as bad seeds, are now recognized as having a real neurological problem. Doctors and parents have largely accepted drugs like Adderall and Concerta to temper the traits of classic A.D.H.D., helping youngsters succeed in school and beyond.

    But Dr. Conners did not feel triumphant this fall as he addressed a group of fellow A.D.H.D. specialists in Washington. He noted that recent data from the Centers for Disease Control and Prevention show that the diagnosis had been made in 15 percent of high school-age children, and that the number of children on medication for the disorder had soared to 3.5 million from 600,000 in 1990. He questioned the rising rates of diagnosis and called them “a national disaster of dangerous proportions.”

    “The numbers make it look like an epidemic. Well, it’s not. It’s preposterous,” Dr. Conners, a psychologist and professor emeritus at Duke University, said in a subsequent interview. “This is a concoction to justify the giving out of medication at unprecedented and unjustifiable levels.”

    I can’t do the thing justice here, as there are far too many important points. Read it. And watch this NYT video. But I can’t resist a few excerpts. Here’s Roger Griggs, who introduced Adderall:

    “There’s no way in God’s green earth we would ever promote” a controlled substance like Adderall directly to consumers, Mr. Griggs said as he was shown several advertisements. “You’re talking about a product that’s having a major impact on brain chemistry. Parents are very susceptible to this type of stuff.”

    Or get a load of this:

    Many of the scientific studies cited by drug company speakers involved Dr. Joseph Biederman, a prominent child psychiatrist at Harvard University and Massachusetts General Hospital. In 2008, a Senate investigation revealed that Dr. Biederman’s research on many psychiatric conditions had been substantially financed by drug companies, including Shire. Those companies also paid him $1.6 million in speaking and consulting fees. He has denied that the payments influenced his research.

    Seriously? There’s a reason drug companies give out marketing materials like pens. They work. But Biederman thinks he’s not influenced by $1.6 million?!?!?!?

    And this:

    “The fastest-growing segment of the market now is the new adults who were never diagnosed,” Angus Russell told Bloomberg TV in 2011 when he was Shire’s chief executive. Nearly 16 million prescriptions for A.D.H.D. medications were written for people ages 20 to 39 in 2012, close to triple the 5.6 million just five years before, according to IMS Health. No data show how many patients those prescriptions represent, but some experts have estimated two million.

    Foreseeing the market back in 2004, Shire sponsored a booklet that according to its cover would “help clinicians recognize and diagnose adults with A.D.H.D.” Its author was Dr. Dodson, who had delivered the presentation at the Adderall XR launch two years before. Rather than citing the widely accepted estimate of 3 to 5 percent, the booklet offered a much higher figure.

    “About 10 percent of adults have A.D.H.D., which means you’re probably already treating patients with A.D.H.D. even though you don’t know it,” the first paragraph ended. But the two studies cited for that 10 percent figure, from 1995and 1996, involved only children; no credible national study before or since has estimated an adult prevalence as high as 10 percent.

    I have to stop. Just do me a favor and go read it.

    @aaronecarroll

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    • Marcia Angell in the NY Review of Books talked about the problems with psychiatry being that diagnosis is all on subjective symptoms, not objective clinical signs. When all you got was talk therapy, it probably didn’t matter if the kid’s problem was brain chemistry, bad parenting or boredom.

      One of the problems with the American system of medicine is that the “market” comes with so much marketing influence.

    • I know Dr. Carroll dislikes anecdotes, but I have to comment. My Godson has been diagnosed ADHD. For those without the personal experience, I must emphasize that it’s far more than an annoyance, it’s tragic. It affects everything and everybody around him. He is a natural athlete, a potential baseball star. I know because I was his coach. I say was because his inability to focus, the uncertainty whether he would be on or off, was so discouraging to him that he finally quit. You might say that baseball is just sports. But it’s the same with whatever he does, including school, where his inability to focus frustrates him and his teachers, and tags him with the label of the disruptive student. What about medication? Yes, what about giving him a narcotic. Does a good parent give her child a narcotic? That is the dilemma faced by parents. For those with a child who might suffer from ADHD, I recommend Buzz: An ADHD Mother’s Search for Understanding, by Katherine Ellison. No, it’s not a technical book on the subject, or even a manual for parents with an ADHD child. But it helps knowing that my Godson is like many other children and my experiences are like those of many other parents. Dr. Carroll is correct, ADHD is a serious problem in kids. It’s tragic.

      • I absolutely, positively believe ADHD exists. I’ve done research to improve its care and management. Read the first two sentences again.

        That doesn’t mean the rest of the article is wrong.

        • On a related note, I’m aware that Wellbutrin can also be used to treat ADHD: it’s an antidepressant with stimulant effects, and I believe it is less addicting and has fewer side effects than Adderall and other amphetamines. You do not have to have depression to use Wellbutrin.

          Can any clinicians comment? It certainly reduces the dilemma parents face.

          • The issue isn’t just pushing amphetamines on kids, it’s overdiagnosis.

            My son was in trouble in school and his teachers and the school psychologist pushed getting him diagnosed and I was told medication can work wonders and make him into a successful kid, rather than one on the road to juvenile delinquency. My son had trouble paying attention, he had trouble doing his homework, he fidgeted, etc. A large number of ADHD symptoms.

            When he moved into Middle School, this improved when the curriculum got harder, which was, according to everyone in Elementary school, going to be too much. He’s in Advanced Math getting As, doing the curriculum for the one grade above his grade. And guess what? He’s not bored, fidgety and distracted in math class any more. He no longer complains about math homework being boring. In fact, he does his math homework first.

            I dodged the whole diagnosis thing and got away with it because the school psychologist and principal left. A friend did go through with diagnosis and their son, who is, IMHO, no different from mine, was put on medication. I haven’t seen much change in the kid’s behavior as a result of this supposed correction of a brain chemistry imbalance.

    • Anyone, please correct my ignorance. As of this moment, I know of no reasonably planned study of ADHD use in adults as having a meaningful duration, i.e., three years or more. I suspect that there are no credible long-term studies published because there is no long term benefit, as in stable employment, fewer accidents, no suicide gestures, no DUIs. and no divorce. I suspect the rising use of stimulants would parallel the rising use of narcotics.