Attention deficit disorder is a classic example of the medicalization of mental disorders, where virtually everyone “believes” it is some sort of biochemical or brain disorder and so medications are the appropriate (and wildly popular) treatment choice. Medications are the right and appropriate treatment choice for ADHD; not because it is a medical disease, but because the research base is pretty strong in showing that they are effective.
But if you can’t trust Consumer Reports to report accurately on this disorder (and other mental disorders), I’m not sure who you can trust anymore. A colleague recently referred me to the “Best Buy Drugs” section of Consumer Reports health website. So I took a look around and started at the beginning of the alphabet. Sadly, it didn’t take me more than 10 minutes to find the marketing influence of pharmaceutical messaging to psychiatrists and doctors in the first brochure I read.
The report in question is entitled “Evaluating Prescription Drugs Used to Treat: Attention Deficit Hyperactivity Disorder.” While I recommend the report for anyone who is starting medication for treatment of attention deficit disorder (ADHD), and generally agree with its lukewarm findings (some generics are preferred because they’re cheap and supposed to be just as effective), I found the introduction to the report written as though it came from a pharmaceutical brochure.
Here’s the most offensive paragraph:
What should lead you to suspect ADHD (which is a distinct biologically-based behavioral disorder now widely recognized by doctors) is this: a persistent pattern lasting at least six months of abnormally high levels of physical activity (hyperactivity), impulsivity, and/or lack of ability to pay attention and focus or complete tasks. (See the full list of symptoms on page 7.) The severity of symptoms and abnormal behavior patterns in children and teens with ADHD varies widely. Some children have only mild symptoms while others are severely affected. The range of symptoms among adults has not been well studied.
How many things are wrong with this paragraph?
1. ADHD, like all mental disorders, has only indirect, correlational evidence that suggests it is a “distinct biologically-based behavioral disorder.” The “biologically-based” phrase is one introduced by pharmaceutical companies as a subtle bias to suggest that such disorders are best medically treated (by their drugs, naturally). Mental disorders are complex bio-psycho-social conditions that have multiple and complex etiologies.
2. No mention is made of an important diagnostic component, and the reason ADHD is so often misdiagnosed and overdiagnosed — the hyperactivity or lack of paying attention has to occur in multiple settings. In other words, if you have trouble only paying attention at work or school, but not at home or with friends or family, technically you don’t qualify for an ADHD diagnosis. Why does this clause exist? Because almost everyone can lose attention at repetitive or boring tasks (e.g., work or school) from time to time.
Leave this component out of this brief symptom list (and its mentioned only in passing in the full symptom list), and you get overdiagnosis — great for the medicalization of childhood behavior!
3. The range of symptoms amongst adults has not been well-studied? Huh?? There are hundreds of studies that examine adult ADHD (I found 604 in PsycINFO), and a few validated psychometric objective measures that assess for it (like the Conners’ Adult ADHD Rating Scales). Not only has it been well-studied, but it’s pretty well-accepted and diagnosed amongst clinicians nowadays. Perhaps because most ADHD medications are targeted toward adolescents and children the emphasis is on that group rather than adults?
And of course this classic also made an appearance:
Doctors don’t know exactly what causes ADHD, but one prevailing theory is that it is due to abnormal levels of these chemical messengers and/or how they are used in the brain. Three neurotransmitters predominate, and the drugs used to treat ADHD alter the brain levels of one, two, or all three of those chemicals. Environment may also play a role — with children prone to ADHD having their symptoms triggered by factors in the home or at school.
We don’t know what causes it, and researchers have about a dozen different theories about its cause, but we’re going to pick the one that emphasizes biology. Well, it is, after all, a brochure about medications and its editing overseen only by psychiatrists and other medical doctors. We’ll also throw in a mention about the environment.
What about psychological factors? What about social factors? What about the other theories? They are given short-shrift, because, after all, they don’t really reinforce medication treatment.
The peer reviewers have a long laundry list of competing interests, which at least is disclosed (if you dig for it on the website; it appears nowhere on the actual report).
I commend Consumer Reports in its effort to help consumers make better-informed choices about their treatment options. But c’mon… Get some balance and reviewers in there who are not so well-schooled in the traditional “biologically-based” mental disorder nonsense and, if you’re going to talk about these disorders, talk about them with fairness and appreciation for their complexity (and completely not-understood causes).
Don’t say, “We don’t know what causes them” and then proceed to spit out a pharmaceutical marketing message cloaked in science double-talk. We expect more from Consumer Reports — and so should you.
The full report is here: valuating Prescription Drugs Used to Treat: Attention Deficit Hyperactivity Disorder (PDF)
20 comments
These are the comments I hear only from those who are fully niave to any understanding or training in psychology, diagnostics, the brain or scientific methodology in general. There is no more “medicalization” of ADHD than there is of Alzheimers or Asthma. And “no, I do not have any interests, financial or otherwise in medications.” (My training is in psychology, more of the “psycho-social than the bio-areas.”) I do have interest in honesty, scientific integrety. Shame on him for suggesting to the public that ADHD is caused by their social or emotional problems, or evil spirits perhaps.
There is so much wrong with this article. My main concern is that it discounts the serious nature of ADHD. These out dated arguments undermine individuals and families determination to seek diagnosis and treatment. This is of special concern when you consider the life experiences and life out comes of people with ADHD. If you’re interested look at how many adults with ADHD are in prison compared to the general population. We don’t discus serious issues like that. Instead we spend time on conspiratorial rhetoric that does a disservice to a population that struggles and suffers every day. I expect more from Psych Central.
AB: “[The article is] suggesting to the public that ADHD is caused by their social or emotional problems, or evil spirits perhaps.”
DSB: “[The article] discounts the serious nature of ADHD.”
What are you talking about? The complaint is not that people with ADHD don’t have a serious medical disorder; it’s that the kind of writing found in Consumer Reports is going to encourage people who *don’t* have it to think that they do.
If you’re worried about trivializing a serious disorder, shouldn’t you then be concerned about making sure it’s appropriately diagnosed? Doesn’t misdiagnosis do more harm than good to your cause?
And I thought that ADHD is known for a problem with Executive Function, which in turn involves one particular part of the brain. May be I fell into that “medicalization” trap, too. Continuing using lay terms, I thought that the Executive Function part of the brain some times cannot keep up with the rest and therefore needs stimulants to work better. Is there a better explanation for why stimulants work and other methods don’t?
Just my own 2 cents’ worth.
One of the subtexts of this discussion is the notion that psychogenic symptoms do not have biological correlates and vice versa. For example, “ADHD, like all mental disorders, has only indirect, correlational evidence that suggests it is a ‘distinct biologically-based behavioral disorder.'” This notion, particularly in the light recent research, is untenable. Every mental function, including those called “mental disorders,” has neural underpinnings. We can track these neural correlates down, often to the chemical level. This is not to say that there are no psychogenic disorders. In many cases, circumstances of a person’s past or present may “cause” abnormal behavior, and, in many cases, a psychological intervention can mitigate the problem. However, in every case something going on in the person’s brain is responsible for his or her behavior, and it’s therefore worth considering biological as well as psychological approaches, even when the disorder is psychogenic. In the case of ADHD, for example, it could be that children deprived of rough and tumble play (a psychological cause), develop the disorder. However the effect of this deprivation may be on incomplete or abnormal development of frontal cortex, that ADHD is mediated biologically.
I agree thaqt it is problematic to characterize difficulties as being purly biological, psychological, or social. Most “disorders” are best treated with a combination of approaches (even asthma and diabetes have emotional and social aspects to consider.) Further, we have lost sight of the fact that Normal is a distribution, and that much of what is distressing about being on the edges of the curve, is that society has been built to accomodate those with characteristics close to the norm (average.)
For example, schools and offices operate with the expectation that everyone can function with an attention span that is only found in about 68% of the popualtion. What is realy devistating about attention differences is the expectations of others. Nobody refers to the kid with ADD as the multi-tasking genious of the family.
We even diagnose Mental Retardation with intellegance test scores that are a certain distance from average. Clients with disabilities often wish they were just “normal”. I tell them that average dows not always mean better, or even healthy (the average American is significantly overweight).
You wrote: “Medications are the right and appropriate treatment choice for ADHD; not because it is a medical disease, but because the research base is pretty strong in showing that they are effective.”
Good grief Dr. Grohol. The research is effective at what? Look at the criteria for ADHD! The criteria is too subjective. The drugs do not help the children. It helps the adults! ADHD drugs are the equivalent to electroshock treatments. These special needs kids need love and nurture…hugs, adults who listen and are patient, non-judgmental, etc. Too bad our society no longer has time to nurture our kids. We prefer the drive-thru…magic pill….but it doesn’t exist for parenting and geniune love and safe affection. We are too busy. Drug the kids and we can make them learn and behave!
I know I haven’t written a very persuasive argument. But what I write and how I write it doesn’t make it untrue. Intuition is also important, especially when dealing with kids. I hope more parents begin to listen to their hearts and less to these drug dealers.
For a more eloquent response to this ADHD issue…check out the Dr. John Breeding videos available on YouTube.
http://www.youtube.com/watch?v=eAJmuDnQh9w
http://www.youtube.com/watch?v=mbwNgIdYQN8
http://www.youtube.com/watch?v=TBVxjpnWO9c
(This report has recently been re-released with a new lede and splashed all over the internet thanks to PR Newswire and ostensible “news” sites that simply run press releases. Reader, beware….)
I agree with your points, John, but I’m afraid you missed the much larger, and more egregious. ones. Primarily, the idea that these fast-start/fast-stop decades-old medications are better than the newer formulations and delivery systems. And the notion that generics are just fine when it comes to ADHD, which requires very careful titration? Outrageous!
You see pharma’s hand here. I don’t. I see the penny-pinching state-sponsored health program bean counters. That’s John Santa’s background, as far as I can see (he’s the medical director behind such reports at CR).
And if these clueless wonks with calculators have their way, this type of bone-headedness will infiltrate our healthcare “reform” efforts. That means the progress that has been enjoyed by so many people with ADHD in finding medications that work for them (as opposed to the MPH and AMP IRs that largely do NOT) will be dashed. That would be a tragedy.
This “report” is reckless and in no way reflects the opinion of experts in the field (nor the vast majority of people who take these medications).
Consumer Reports should stick to vacuum cleaners and not meddle in psychopharmacology, for which they are eminently not qualified. I explain the reasons why in a recent blog post: http://tinyurl.com/nmulcl
Gina Pera, journalist-author
Is It You, Me, or Adult A.D.D.?
Winner – 2008 Psychology Book of the Year – ForeWord Magazine
P.S. I should say that I agree with SOME of your points. And other posters have nicely addressed those that are problematic. 😉
Ah, once again the push for meds, eh, Ms Pera.
Attack an organization that has the sole purpose to be a watchdog for citizens, which by the way does have a health care branch, as I subscribed to their Health Newsletter for 2 years and found it moreso helpful and educational than sensational and absurd. But, that is my purpose too, to watch out for people, not my wallet.
What is your rebuttal to the July/Aug Scientific American Mind piece, pages 38-43, that does not paint a very positive picture about meds. I think the last paragraph of the article puts the matter of medicating perfectly in perspective: “without these (behavioral modification, mental exercises, lowest dose prescribed) or similar measures, large numbers of people who regularly take stimulants may ultimately struggle with a new set of problems spawned by the treatments themselves.”
Still no disclaimer you are not a recipient of some type of pharmaceutical monies. Silence is deafening, ma’am.
Responsible rebuttal, or your usual insults and deflections from the topic at hand?
Skillsnotpills, board certified psychiatrist
While I do understand in small part, your issues about the over-prescribing of any medication, it’s apparent that you personally, are not afflicted with ADHD. Your remarks about possible future “issuesâ€, or any suffering related to possible repercussions of taking a stimulant medication, does not in fact, cause someone who may have a mild to a more severe level of ADHD, or the related symptoms, would realize that stimulants do not act the same way in those who actually have ADHD. Although it may at times appear to cause stimulation, such drugs only work to help us stay more focused, & task oriented, far better than without treatment. We do not have the stimulation or hyper-vigilant behaviors that a “normal†person taking such medications, will have & display.
5 days later, no rebuttal, attack the issue at Dan Carlat’s site over his Acre post on July 23, and no disclaimer you have no gain to push for new ADD meds so blatantly. Seems like an agenda.
The silence is stifling, ma’am!
SNP, seriously, you have a problem.
Why don’t you see a specialist. You can’t be a happy person. Your rants are irrational, my answers are never enough for you, and your venom pours through every post. That can’t be good for you. And it’s certainly not good for the discourse (as if that’s possible on the Internet anymore).
It is ironic that I see this as i finish 2008 taxes. Yes, I filed for an extension because I had surgery in January, after spending five years steadily working on my book.
My total profit-loss, if you must know (not that it would stop your aggressive harassment of me, but for the record) was NEGATIVE $36,000. Out of my pocket. With no pharma investment. Just little old me and the money I’ve saved my entire life. I could have gone on a nice, long cruise, or lived a little higher on the hog. Or thought about retiring. But I did this instead. Because this has been an important book and important work.
What have you done with your life that makes you proud? Anything? Or, do you tell yourself you are valiant for attacking me? Me, someone who has given my money and my time, with no ulterior motive.
And that’s the part you just can’t understand, can you, because it’s not in your emotional make up. You are a conspiracy theorist, pure and simple. And you are bitter, bitter man.
You only hurt yourself and your tangled neural pathways with these tirades.
Not to stress, Ms Pera, (although I doubt that you’d feel the need, given the content & context that your aggressive “stalker†is trying to malign you about)! You know what they say, about certain body parts, “everybody has one�!
What an idiotic piece of work this jack-wad is…
No ulterior motive?? Did YOUR meds stop working again??
Ha Ha!
What a joke. Gina, you need to read some articles about personalized medicine. Even the drug companies agree tailoring treatments to the individual makes sense.
You are a liar and a very disturbed person. You are the one who needs medication.
THANK YOU MS PERA FOR ACTUALLY RESPONDING TO MY REQUEST, even though I have absolutely no interest in the specifics of your finances. And, as usual, your attacks and deflections show you are not up to responsible and respectful debate to at least agree to disagree. But now, you have gone on record, I sincerely thank you for your response, and hope you make a difference to those who genuinely would benefit from your perspectives.
By the way, an opinion on the Sci Amer piece I mentioned in the post back on July 22?
Just so you have it in print, I will not ask you again about any disclaimers hereon.
Also, by the way, what have I done with my life to be proud? Be transparent, honest, direct, and not put up with bullshit and selfishness. It has cost me jobs and at one point my home in a community, as the evil, greedy scumbags that Carlats and Dawdys go after run the show, and they use pharma as a main source of income to do the evil they do.
So, to put it back at you, ma’am, I sleep well over what I do professionally, I have a family who supports me, and in the end, if there is an afterlife that judges us on our choices and actions, if the big man/woman upstairs will care to listen to my opening statement, it will be why do bad people get away with so much and good, honest people who are guided by their conscience and responsible needs get screwed.
We’ll see if 2012 is going to be a bitch year!
I am sure CHADD does not reimburse you for your efforts. Altrusim is certainly your calling.
As far as harassment, what about the tirade you laid on Miss Weiss. That was pathetic. I read how CHADD members shame parents on the Internet. You need to quit pressing so hard.
Try balance and some emotional healing.
You idiot, Rolling on the floor/MIchael Elder/Rolling on the Floor/Don Potochny. Gina VOLUNTEERS for CHADD, like hundreds of others. And CHADD has the support of its members, of which I am one. Get a life, Don. I know as a child you lived, as you say, to harass the police department. I also read where you got so angry at an employer that instead of washing the pots and pans, as was your job, you put them in the dumpster and walked out. What a prince of a guy. And now apparently you’ve grown up to have anti-social personality disorder. Maybe skillsnospills can help you, especially with your multiple-personality poster disorder! hahahahaha Watch out for that swine flu. What will you hyperfocus on next? Aliens that are coming to drug your non-existent children?
Wow. Must have hit as nerve. The government and pharmaceutical industry cannot be sued for any defects in the swine flu vaccine. If they are not confident enough, why should I be. Feel free to take your shot. I refuse to take mine.
Name calling is so beneath me. I believe in the Fruits of the Spirit.
You do provide a nice chuckle. Now I must move on. Have a nice day.