Three Recent Major Reviews of ADHD and Its Treatment

"Problems in the Management of Attention-Deficit-Hyperactivity Disorder," AJ Zemetkin and M Ernst, New England Journal of Medicine, vol. 340 (1999), pp. 40-46.

"Treatment of Attention-Deficit-Hyperactivity Disorder," J. Elia, PJ Ambronsini and JL Rapoport, New England Journal of Medicine, vol. 340 (1999), pp. 780-788.

"Problems in Diagnosing Attention and Activity," WB Carey, Pediatrics, vol. 103, pp. 664-667.

Whew! When it rains it pours.

The continuing power and interest in ADD and Ritalin is revealed in these reviews appearing in these prestigious journals. It is virtually unheard of that two reviews on the same subject appear in the New England Journal of Medicine within two months of one another. They cover very similar ground and since they are reviews basically coming from the same source, the Child Psychiatry Branch of the National Institutes of Mental Health, one shouldn't be surprised that they promote a primarily biological view of ADD behavior and emphasize medication interventions.

Both briefly mention the great rise in the diagnosis of this uniquely American phenomenon but do not see this as troubling. Zametkin acknowledges that the possibility of over diagnosis remains a concern. The Carey piece, on the other hand, is a tour-de-force concise summary of the construct and practical problems associated with the DSM-IV ADHD diagnosis. Carey, the nation's leading researcher on child temperament, raises the provocative question whether impulsivity and activity should be seen as the main problem for ADHD kids. He suggests that cognitive disablities and the quality of low adaptability are the true causes of problems for children with high activity and low persistence.

Reviewed 4/17/99

The Undiscovered Mind

The Undiscovered Mind: How the Human Brain Defies Replication, Medication and Explanation, John Horgan, The Free Press (New York), 1999.

John Horgan, who achieved fame and notoriety with his previous book, The End of Science, now challenges the "decade of the brain" and other theories of the mind in this new and provocative book.

Horgan addresses both psychological and biological theories of the brain, emotions, consciousness, and mental disorders and finds all of them wanting in intellectual rigor and proof. He notices that every theory has their adherents and critics and sides with the critics in that no theoretical framework (Freudian, biological, medication, artificial intelligence) stands up to the physical sciences as science. He challenges the successes of medication (noting that most of the effects are equivalent to controls when placebo is counted). Evolutionary psychology seems to be a competition of who can tell the best story. His attack on genes and heredity seems the weakest to me but all one needs to do is turn to the chapter called "Blaming the Brain" in Running on Ritalin for a more trenchant analysis of the genetic theories of ADHD as a paradigm for the field in general.

Horganís notion of a good theorist (and I couldn't agree more) is someone like Oliver Sacks, who writes case histories from a literary narrative perspective. Sacks is always attempting to demonstrate the humanistic universality of pathological behavior. Of course, case histories are somewhat limited when it comes to generalizations about other individuals. This book is a welcome companion to the previously reviewed Pseudoscience In Biological Psychiatry: Blaming the Brain.

The American Medical Association article on ADD

"Diagnosis and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents," Larry S. Goldman, et al, Journal of the American Medical Association, vol. 279 (April 8, 1998), pp. 1100-1107.

This much ballyhooed article is in effect the American Medical Association's statement on the diagnosis of ADHD and its treatment today.

The authors, none of whom are connected with any particular ADHD/Ritalin camp, reviewed 22 years worth of citations in the literature about this subject. Given their methods, it is not surprising that the researchers concluded Although some children are being diagnosed as having ADHD with insufficient evaluation and in some cases stimulant medication is prescribed when treatment alternatives exist, there is little evidence of widespread overdiagnosis or misdiagnosis of ADHD or of widespread overprescription of methylphenidate by physicians. The findings were trumpeted both by CHADD and Novartis, the maker of Ritalin (who sent the article with a cover letter to most pediatricians), as organized medicineís support for their position that ADHD is a medical disorder and that Ritalin is the most effective treatment and is not overprescribed.

I have several criticisms of the report. Mark Wolraichís study of the practices of pediatricians from two mid-western towns is mentioned in the report (they incorrectly described it as a national study). They noted that only 3/4's of those children diagnosed by their doctor met criteria for diagnosis. Only half used teacher reports as part of their diagnostic evaluation. Michael Reiffís survey of 600 pediatricianís and child behavior specialists showed that while 90% of the physicians felt they used a regular set of diagnostic criteria for ADHD, researchers found that only 8% of the doctors surveyed used methods that could be replicated. Unfortunately in the real world of medical practice, ADHD remains a diagnosis very much in the eye of the beholder (see Chapter Three of Running on Ritalin for a much more detailed critique).

The AMA researchers acknowledge that published prevalence rates of ADHD vary widely (1.6% to 16%) . Relying primarily on Daniel Saferís data which follows trends in Baltimore County only, the researchers report that national rates of Ritalin use have not risen especially dramatically during the 1990s (despite a 700% increase in production) nor are they overly high given the prevalence of ADHD. They overlook the tremendous variation in Ritalin usage throughout the country and within individual states. Relying on ARCOS data from the DEA there is a six-fold difference between the highest (currently New Hampshire) and the lowest (perennially Hawaii) states in per capita use of Ritalin. There are twenty-fold variations within states with the most white, most affluent areas having the highest rates of Ritalin use and the most African American, poorest areas having the lowest rates. District-wide, 17 % of fifth grade boys in Virginia Beach, Virginia were found to be prescribed Ritalin in 1995-1996. Clearly there are areas of over prescription of Ritalin and areas, especially where there are minorities, where Ritalin is rarely prescribed.

The AMA report will be used to justify current diagnostic practices and treatment. Steady as she goes. No rocks ahead. Even in accepting Ritalinís short term effectiveness it still is not the moral equivalent to addressing the social, economic and political factors involved in the generation of childrenís behavior and performance problems.

Reviewed 8/15/1998