ADHD: turning a problem into a disease

‘That’s the trouble with you people – every time you see a problem you turn it into a disease.’

So stated mafia boss Tony Soprano, of the cult drama The Sopranos, on hearing his 13-year-old son diagnosed as a ‘borderline case’ of Attention Deficit Disorder (ADD) (1).

Also known as Attention Deficit Hyperactivity Disorder, or ADHD, this disorder has been one of the most controversial issues in American society over the past decade. October’s decision by the National Institute of Clinical Excellence (NICE) to approve the prescription of the amphetamine-type drug Methylphenidate (Ritalin) for the treatment of ADHD is likely to lead to an increase in the diagnosis and medical treatment of ADHD in Britain (2). But isn’t Tony Soprano’s pithy diagnosis the right one?

Soprano’s plight captures the confusion and controversy surrounding many diagnoses of ADHD. After being discovered drunk on stolen altar wine at his expensive private school, 13-year-old Anthony Junior is referred for ‘a complete battery of testing – psychological, behavioural and medical’. His tests completed, the earnest educational psychologist informs his parents that Anthony Junior manifests five of the nine symptoms required for a diagnosis of ADD (six are required to clinch the diagnosis). When Tony inquires further about these symptoms, he is told that, among other things, Anthony Junior fidgets. ‘That’s a sickness?’ comes the incredulous response, followed by a question that goes to the heart of the problem of diagnosis by ticking off checklists of symptoms – ‘what constitutes a fidget?’.

Tony sums up the diagnosis as ‘bullshit’. His wife, by contrast, seems relieved to hear that Anthony has a disease, ‘like polio’. ‘I knew it’, declares Carmella. ‘I always knew there was something wrong with that kid.’ Tony suggests that all he needs is ‘a whack up side the head’; she insists that ‘it’s an illness, right?’ – one that needs treatment not chastisement. Yet when Tony asks the psychologist, ‘What do we do as parents – nothing?’, he is informed that ‘Anthony has misbehaved and should be consequenced’. At a fraught family dinner, Carmella announces to her truculent son a string of restrictions and suspended privileges. But Tony is mystified – ‘If he’s got a disease, why do they tell me to punish him?’.

The Soprano family drama illustrates the depth of confusion surrounding Deficit Hyperactivity Disorder. Though ADHD was formally recognised as a distinct condition by the American Psychiatric Association in 1981, its rapid rise in popularity as a diagnosis followed the publication of a detailed checklist of symptoms over a decade later, in 1994 (3).

The British guidelines define different types of ADHD, according to the presence of particular combinations of the three key features: inattentiveness, impulsiveness and hyperactivity (4). Before ADHD can be diagnosed, these signs must have persisted for at least six months to a degree that causes developmental problems. The symptoms must be causing significant impairment of social or academic functioning, and they must be apparent both at home and at school.

Ritalin has been available for 40 years, but again, its use for the treatment of ADHD only took off in the mid-1990s. In some states in the USA, between three and five percent of primary school children have been diagnosed with ADHD; estimates of the number of American children on Ritalin vary between 1.7 million and 2.5 million. According to NICE, an estimated 366 000 children between six and 16 in England and Wales (around five percent of all schoolchildren) meet the diagnostic criteria for some form of ADHD. A core group of more than 73 000 (one percent) are believed to have severe ‘combined type’ ADHD, with all three features: this is the group for which it recommends treatment with Ritalin. At present, only around a quarter of this group are on medication. Treatment of children under the age of six is not recommended.

The guidance from NICE, which has been distributed to every General Practicioner (GP), paediatrician and psychiatrist in the country, has the force of government edict. It insists on diagnosis by a specialist psychiatrist or paediatrician, who are authorised to initiate drug treatment – which can then be continued, with appropriate safeguards, by a GP. The guidelines also recommend medication as part of a comprehensive treatment programme, involving parents and teachers, which could include specific psychological therapy.

Advocates of ADHD, who consider that it is ‘underdiagnosed and undertreated’ in Britain, have welcomed the NICE report as a vindication of their campaign for greater recognition of this disorder (5). They believe that ADHD is a ‘genetic, neurological’ condition and that evidence of brain dysfunction has been found in various cerebral imaging studies. These claims regarding ADHD – which have been made about a wide range of conditions from schizophrenia and manic depressive psychosis to alcoholism and homosexuality – remain controversial.

A consensus conference of independent scientists convened by the US National Institutes of Health in 1998 found no conclusive evidence for brain dysfunction and characterised all current theories about ADHD as ‘speculative’ (6). The conference noted that there was no simple and reliable diagnostic test and that most assessments were carried out by family doctors, with the result that there was no consistency in diagnosis, treatment or follow-up.

The symptoms attributed to ADHD are diverse, shading into more clearly defined psychiatric conditions on one side and into the range of normal experience on the other. In addition to the basic features, authorities claim that 60 to 70 percent of those diagnosed with ADHD have coexisting conditions such as ‘oppositional defiant disorder, conduct disorder, depression, anxiety and obsessive behaviour, specific learning difficulties, speech and language disorder’.

Many children with ADHD are also said to exhibit poor self-esteem and social skills, insatiability, excessive dogmatism, poor organisation and time management, relationship difficulties, lack of motivation, problems with rule-governed behaviour, over-sensitivity, vulnerability to stress. Harry Enfield’s ‘Kevin’ is immediately recognisable as a sufferer, but by these criteria, so are many, if not most, teenagers.

In their most recent publication, GD Kewley and PA Latham claim that ADHD is a progressive condition, which, if left untreated in young children, leads to grave consequences in teenage years (7). This – unsubstantiated – claim is illustrated with a diagram indicating ‘the likely progression of untreated ADHD’. This shows ‘ADHD only’ at the age of six progressing through various stages to reach ‘criminal behaviour, school exclusion, substance abuse, conduct disorder, lack of motivation, complex learning difficulties’ at the ages of 14 to 16.

The attraction of Ritalin, a drug which ‘normalises brain function and stabilises the situation’, is obvious. It not only offers to improve children’s behaviour, it also promises to solve the social problems of the nation. According to Kewley and Latham, up to 90 percent of children show ‘very significant improvement’ on Ritalin and only 5 to 10 percent experience side effects, which are usually mild, dose-related and transient. Pass the tablets, then?

Not so fast. The dramatic expansion in the number of children diagnosed with ADHD and treated with Ritalin in the USA in the 1990s has provoked criticism from a number of different quarters. Psychotherapists question the reliability of the diagnostic criteria, the neglect of wider social and emotional factors which may cause behavioural disturbance in children and the emphasis on medication at the expense of psychological and social therapies.

Pharmacologists and psychologists have expressed alarm at the widespread use in children of a class of drugs which is considered potentially dangerous and addictive among adults (8). Since their widespread abuse, in the form of ‘speed’ in the 1950s and 1960s, amphetamines have been strictly controlled. The paradox that drugs which have a stimulant effect in adults appear to have a calming effect on hyperactive children is little understood, though there are theories about their effects on neurotransmitters such as serotonin and dopamine.

Arguments rage about the incidence and seriousness of the side effects of Ritalin among children taking it for ADHD. The drug is well known to cause loss of appetite, disturbance of sleep, mood and behaviour, headaches and tics; its more severe critics believe it can cause more severe toxicity, growth retardation and addiction. Enthusiasts for the drug treatment of ADHD deny these more severe side effects and claim that the minor ones are uncommon, dose-related and short-lived.

In the USA, Ritalin and ADHD are at the centre of a series of battles involving rival groups of parents, psychiatrists and paediatricians, lawyers, politicians and drug companies. One group has recently launched a class-action lawsuit against the drug company Novartis and the American Psychiatric Association, claiming that they ‘planned, conspired and colluded to create, develop and promote the diagnosis of ADD/ADHD in a highly successful effort to increase the market’ for Ritalin (9). Another group is suing Novartis for the alleged adverse effects of Ritalin on their children. Yet another parents’ group is actively promoting the wider use of Ritalin: opponents allege that it receives financial support from the drug companies.

The key problem underlying the ADHD controversy – accurately identified by Tony Soprano – is the trend for defining a wider and wider range of experience and behaviour in psychiatric terms, ‘turning a problem into a disease’. The tendency to medicalise social problems is encouraged by the availability of treatments – either tablets or talking cures – which offer a ready solution to difficulties experienced by individuals, families and communities.

Over the past decade there has been an explosion of labels such as post-traumatic stress disorder, chronic fatigue syndrome (‘ME’), addictions to everything from heroin, alcohol and tobacco to sex, food and toxic relationships. It seems that in a society that appears to have lost any sense of purpose or direction, individuals feel intensely vulnerable and fragile. It is not surprising that the consequences of this pervasive insecurity are experienced most acutely in the sphere where adult confidence is most critical – in bringing up children. When Tony Soprano vents his family problems with his senior mafia confidantes, one sagely observes that ‘it’s hard to raise kids in the information age’.

Tony later confesses to his own psychiatrist his worries that Anthony’s problems have been passed down to him from his own father (‘the belt was his favourite child development tool’). He believes that the problem is in the blood, in the genes – ‘my son is doomed’. The psychiatrist challenges Tony’s fatalistic view that ‘you are what you are’, insisting that ‘a genetic predisposition is not a destiny’, that behaviour is not ‘preordained’. ‘You have a choice’, she tells him. ‘You have free will. This is America.’

But the choice cannot be reduced to that between drugs and psychotherapy, biological determinism and therapeutic voluntarism. The real choice is to refuse the diagnosis of ADHD: the difficulties of family life in the modern world cannot be understood – or resolved – at the levels of biology or psychology.

Dr Michael Fitzpatrick is the author of MMR and Autism, Routledge, 2004 (buy this book from Amazon (UK) or Amazon (USA)); and The Tyranny of Health: Doctors and the Regulation of Lifestyle, Routledge, 2000 (buy this book from Amazon UK or Amazon USA). He is also a contributor to Alternative Medicine: Should We Swallow It? Hodder Murray, 2002 (buy this book from Amazon (UK) or Amazon (USA)).

(1) The Sopranos, series one, episode seven, ‘Down Neck’, written by Mitchell Burgess and Robin Green, directed by Lorraine Senna. See The Sopranos
(2) See the National Institute of Clinical Excellence website
(3) A detailed checklist of ADHD symptoms was published in 1994, in the Diagnostic and Statistical Manual of Mental Disorders, APA, Washington DC
(4) Guidance for the use of Methylphenidate (Ritalin, Equasym) for Attention Deficit Hyperactivity Disorder (ADHD) in childhood was produced by the National Institute of Clinical Excellence in October 2000
(5) See the arguments put forward by Geoffrey Kewley in the British Medical Journal, 23 May 1998. See also GD Kewley, PA Latham in Update, 19 October 2000
(6) See the British Medical Journal, 5 December 1998
(7) ‘ADHD – underdiagnosed and undertreated?’, GD Kewley and PA Latham, Update, 19 October 2000
(8) See the article ‘Strong medicine’ by Steve Baldwin on netdoctor
(9) See the British Medical Journal, 23 September 2000