Although the diagnosis has a high level of support from clinicians and most medical authorities, a number of alternative theories explaining the symptoms of ATTENTION-DEFICIT HYPERACTIVITY DISORDER have been proposed which range between describing ATTENTION-DEFICIT HYPERACTIVITY DISORDER as part of the normal spectrum of behavior instead of a disorder to rejecting its existence outright. These views include the Hunter vs. farmer theory, Neurodiversity, and the Social construct theory of ATTENTION-DEFICIT HYPERACTIVITY DISORDER. Additionally, a lack of clarity on exactly what qualifies as ATTENTION-DEFICIT HYPERACTIVITY DISORDER and changes over time in diagnostic criteria have caused confusion and concerns about misdiagnosis.[10]
The best course of ATTENTION-DEFICIT HYPERACTIVITY DISORDER management is also a source of debate. Stimulants are the most commonly prescribed medication for ATTENTION-DEFICIT HYPERACTIVITY DISORDER, and, according to the National Institute of Mental Health, "under medical supervision, stimulant medications are considered safe".[11] However, the use of stimulant medications for the treatment of ATTENTION-DEFICIT HYPERACTIVITY DISORDER has generated controversy because of undesirable side effects, uncertain long term effects, and social and ethical issues regarding their use and dispensation. Kids comprise the majority of ATTENTION-DEFICIT HYPERACTIVITY DISORDER diagnoses, but because they are unable to give informed consent due to their age, treatment decisions are ultimately determined by their legal guardians on their behalf. Ethical and legal issues also arise from the promotion of stimulants to treat ATTENTION-DEFICIT HYPERACTIVITY DISORDER by groups and individuals who receive money from drug companies.
Status as a disorder
The controversy surrounding ATTENTION-DEFICIT HYPERACTIVITY DISORDER involves clinicians, teachers, policymakers, moms & dads and the media with opinions regarding ATTENTION-DEFICIT HYPERACTIVITY DISORDER ranging from those who do not believe it exists to those who believe that there is genetic and physiological basis for the condition. Controversy continues to grow over the diagnosis, treatment and cause and etiology of ATTENTION-DEFICIT HYPERACTIVITY DISORDER, as well as concerns surrounding the long term effects of the stimulants used to treat ATTENTION-DEFICIT HYPERACTIVITY DISORDER.[12][13] Most healthcare providers accept that ATTENTION-DEFICIT HYPERACTIVITY DISORDER is a genuine disorder while significant controversy surrounds how it is diagnosed and treated.[13]
Researchers from McMaster University identified five features of ATTENTION-DEFICIT HYPERACTIVITY DISORDER that contribute to its controversial nature:
- Diagnostic criteria have changed frequently.
- It is a clinical diagnosis for which there is no laboratory or radiological confirmatory tests or specific physical features.
- The rates of diagnosis and of treatment substantially differ across countries.[14]
- Therapy often includes stimulant drugs that are thought to have abuse potential.
- There is no curative treatment, so long-term therapies are required.
[] Skepticism about the diagnosis
Skepticism about the validity of the diagnosis is a minority opinion in the general U.S. population. A 2002 survey found that of the 64% who had heard of ATTENTION-DEFICIT HYPERACTIVITY DISORDER, 78% believed it to be a "real disease".[15] In the United States, African-American moms & dads state that their friends and family are often unsure about the legitimacy of ATTENTION-DEFICIT HYPERACTIVITY DISORDER.[16] In a small study from 1999 of nine Australian health care professionals, three were skeptical of ATTENTION-DEFICIT HYPERACTIVITY DISORDER as a valid diagnosis.[17] In 1998 Fred Baughman stated "ATTENTION-DEFICIT HYPERACTIVITY DISORDER is total, 100% fraud" as a counter claim to Russell Barkley's 1995 comment that "ATTENTION-DEFICIT HYPERACTIVITY DISORDER is real".[18]
In 2002, Russell Barkley, a well-known proponent of drug treatments of ATTENTION-DEFICIT HYPERACTIVITY DISORDER, published The International Consensus Statement on Attention Deficit Hyperactivity Disorder (ATTENTION-DEFICIT HYPERACTIVITY DISORDER), signed by a group of 86 psychiatrists and psychologists, which asserts the existence of ATTENTION-DEFICIT HYPERACTIVITY DISORDER and denies the existence of controversy within the medical community.[19] Two critiques of their statements have since been published in the peer reviewed literature questioning the negative tone they have used to describe researchers with views differing from their own.
In 2002, 8% of readers of the British Medical Journal who answered an online survey listed ATTENTION-DEFICIT HYPERACTIVITY DISORDER as one of the 10 top "non-diseases".[22]
Robins and Guze [23] criteria assert that the validity of any diagnosis must derive from empirical research and that some of this research must examine the neurobiological causes and correlates of disorders. The Robins and Guze criteria view the validity of diagnoses as arising from empirical studies demonstrating the following:
1) the diagnosis has well-defined clinical correlates
2) the diagnosis can be delimited from other diagnoses
3) the disorder has a characteristic course and outcome
4) the disorder shows evidence of heritability from family and genetic studies
5) data from laboratory studies demonstrate other neurobiological correlates of the disorder
6) the disorder shows a characteristic response to treatment.
A 2005 review recognizes the ongoing controversial nature of ATTENTION-DEFICIT HYPERACTIVITY DISORDER among both clinicians and the general public. It found that it fulfills the Robins and Guze criteria which support the idea that ATTENTION-DEFICIT HYPERACTIVITY DISORDER is a valid diagnostic category.[24] A 2008 review however came to the opposite conclusion and states that: "ATTENTION-DEFICIT HYPERACTIVITY DISORDER is unlikely to exist as an identifiable disease"[25]
[] Concerns about methods of diagnosis
ATTENTION-DEFICIT HYPERACTIVITY DISORDER is controversial in part because most kids are diagnosed and treated based on decisions made by their moms & dads and clinicians with teachers being the primary source of diagnostic information. Only a minority, about 20%, of kids who end up with a diagnosis of ATTENTION-DEFICIT HYPERACTIVITY DISORDER show hyperactive behavior in the physician's office.
The number of individuals diagnosed with ATTENTION-DEFICIT HYPERACTIVITY DISORDER in the U.S. and UK has grown dramatically over a short period of time. Critics of the diagnosis, such as Dan P. Hallahan and James M. Kauffman in their book Exceptional Learners: Introduction to Special Education, have argued that this increase is due to the ATTENTION-DEFICIT HYPERACTIVITY DISORDER diagnostic criteria being sufficiently general or vague to allow virtually anybody with persistent unwanted behaviors to be classified as having ATTENTION-DEFICIT HYPERACTIVITY DISORDER of one type or another, and that the symptoms are not supported by sufficient empirical data.[29]
Tools that are designed to analyze a person's behavior, such as the Brown scale or the Conners scale, for example, attempt to assist moms & dads and providers in making a diagnosis by evaluating an individual on typical behaviors such as "Hums or makes other odd noises", "Daydreams" and "Acts 'smart'"; the scales rating the pervasiveness of these behaviors range from "never" to "very often". Connors states that, based on the scale, a valid diagnosis can be achieved; critics, however, counter Connors' proposition by pointing out the breadth with which these behaviors may be interpreted.[] This becomes especially relevant when family and cultural norms are taken into consideration; this premise leads to the assumption that a diagnosis based on such a scale may actually be more subjective than objective.
Some of the criticism does not reject the concept of ATTENTION-DEFICIT HYPERACTIVITY DISORDER as a valid disorder, but alleges that kids with problematic behavior are often diagnosed with ATTENTION-DEFICIT HYPERACTIVITY DISORDER when the behavior may result from other causes. Critics state that some kids diagnosed with ATTENTION-DEFICIT HYPERACTIVITY DISORDER, or labeled ATTENTION-DEFICIT HYPERACTIVITY DISORDER by moms & dads or teachers, are normal but do not behave in the way that responsible adults want them to behave.[30] There is concern about teachers being used to assist in diagnosing students with ATTENTION-DEFICIT HYPERACTIVITY DISORDER. Dr. Thomas Armstrong states that teachers may have a deep, often subconscious, emotional investment in the diagnosis, because it could mean having a troublesome youngster out of the classroom. Social critics make a connection between the extra funding some schools receive for kids with ATTENTION-DEFICIT HYPERACTIVITY DISORDER and the increase in the diagnosis.
ATTENTION-DEFICIT HYPERACTIVITY DISORDER is a subjective diagnosis with no definitive clinical test.[33] This leads to situations where one doctor would say a youngster needs psychotropic medication while another doctor could say the youngster is perfectly normal.[34] Concern exists that "elevated but still developmentally normal levels of motor activity, impulsiveness, or inattention" traits of childhood could be inappropriately interpreted as ATTENTION-DEFICIT HYPERACTIVITY DISORDER.
[] Over / under diagnosis
In 2005 82% of teachers in the United States consider ATTENTION-DEFICIT HYPERACTIVITY DISORDER to be over diagnosed while 3% consider it to be under diagnosed. In China 19% of teachers consider ATTENTION-DEFICIT HYPERACTIVITY DISORDER to be over diagnosed while 57% consider it to be under diagnosed.[37]
[] Changing diagnostic criteria
For over seventy years in the United States, symptoms of what is now called ATTENTION-DEFICIT HYPERACTIVITY DISORDER have had different labels.[38] The fact that the diagnostic criteria and the name used to describe the set of characteristics that make up ATTENTION-DEFICIT HYPERACTIVITY DISORDER have changed over time has lead to concerns.[39]
[] Views of ATTENTION-DEFICIT HYPERACTIVITY DISORDER outside North America
The view that ATTENTION-DEFICIT HYPERACTIVITY DISORDER is a problem requiring medical intervention is more prevalent in English-speaking North America than in the rest of the world. In Great Britain and France roughly one percent of kids are diagnosed with hyperkinetic syndrome, the equivalent of ATTENTION-DEFICIT HYPERACTIVITY DISORDER in the International Classification of Diseases, the diagnostic system used by most medical professionals outside North America.
The British Psychological Society said in a 1997 report that physicians and psychiatrists should not follow the American example of applying medical labels to such a wide variety of attention-related disorders: "The idea that kids who don’t attend or who don’t sit still in school have a mental disorder is not entertained by most British clinicians."
Norwegian National Broadcasting (NRK) sent a short television series in early 2005 on the extreme increase in the use of Ritalin and Concerta for kids. Sales were six times higher in 2004 than in 2002. The series included the announcement of a successful group therapy program for 127 unmedicated kids aged four to eight, some with ATTENTION-DEFICIT HYPERACTIVITY DISORDER and some with oppositional defiant disorder.[42]
[] Anti-psychiatry movement
Members of the Anti-Psychiatry movement such as Fred Baughman and Peter Breggin have extensively used the popular media to criticize ATTENTION-DEFICIT HYPERACTIVITY DISORDER and medications used for ATTENTION-DEFICIT HYPERACTIVITY DISORDER. Fred Baughman has also published articles about ATTENTION-DEFICIT HYPERACTIVITY DISORDER in peer reviewed journals.[47] They have testified at Congressional hearings on the use of Ritalin and supported legal challenges such as the Ritalin class action lawsuits. There is also a movement called critical psychiatry that often refers to their writings, but in contrast to Scientologists (see below), they are not "anti-psychiatry," but critics of some of its practices and offer alternative models and perspectives.
[] Scientology
Scientology has been vocal critics of ATTENTION-DEFICIT HYPERACTIVITY DISORDER and its treatments.[49] Scientology states that "the controversy over the many deaths and irreversible damage caused by psychiatric drugs prescribed for kids labeled with... ATTENTION-DEFICIT HYPERACTIVITY DISORDER continues to grow".[50] The church states that mental disorders are a fraud, [51] "mental and behavioral problems are largely incorrect diagnoses that cover symptoms and don't handle the real problems, which may be physical or spiritual".[52] Specifically Scientology attributes all psychological disorders to the accumulation of psychic trauma retained from millions of years of human evolution and the interference of alien and human ghosts called thetans.[53]
[] Personality trait
Some believe that many of the traits of those diagnosed with ATTENTION-DEFICIT HYPERACTIVITY DISORDER are personality traits and are not indicative of a disorder. These traits may be undesirable in modern society, leading to difficulty functioning in society, and thus have been labeled as a disorder.[54]
[] Questions concerning the cause
The pathophysiology of ATTENTION-DEFICIT HYPERACTIVITY DISORDER is unclear and there are a number of competing theories.[55]
[] ATTENTION-DEFICIT HYPERACTIVITY DISORDER as a biological illness
One of the most controversial issues regarding ATTENTION-DEFICIT HYPERACTIVITY DISORDER is whether it is wholly or even predominantly a biological illness leading to a chemical or structural defect in the brain. The current predominance of opinion in medicine is that ATTENTION-DEFICIT HYPERACTIVITY DISORDER is a mixture of genetics and the environment however the pathophysiology is unclear at this time.[56] Differences in the brain between ATTENTION-DEFICIT HYPERACTIVITY DISORDER and non-ATTENTION-DEFICIT HYPERACTIVITY DISORDER patients have been discovered,[57][58][59][60][61][62] but it is uncertain if or how these differences give rise to the symptoms of ATTENTION-DEFICIT HYPERACTIVITY DISORDER. Xavier Castellanos, the former head of ATTENTION-DEFICIT HYPERACTIVITY DISORDER research at the National Institute of Mental Health (NIMH), is "firmly convinced that ATTENTION-DEFICIT HYPERACTIVITY DISORDER is a biological illness", but he also noted, regarding our understanding ATTENTION-DEFICIT HYPERACTIVITY DISORDER and the brain, "We don't yet know what's going on in ATTENTION-DEFICIT HYPERACTIVITY DISORDER." [63]
In "Rethinking ATTENTION-DEFICIT HYPERACTIVITY DISORDER: International Perspectives" an alternative paradigm for ATTENTION-DEFICIT HYPERACTIVITY DISORDER argues that, while biological factors may obviously play a large role in difficulties sitting still and/or concentrating on schoolwork in some kids, the vast majority of kids manifesting this behavior do not have a biological deficit.[64] For a variety of reasons they have failed to integrate into their psychology the ability to work at chores that are expected of them. Their restlessness and daydreaming is similar to the behavior of other, normal kids when they are not engaged, and are bored and trapped by circumstances. Very frequently, kids with ATTENTION-DEFICIT HYPERACTIVITY DISORDER have no difficulty concentrating on activities that they find to be interesting. When they are taught by a charismatic entertaining teacher, they similarly can concentrate.[65]
Although ATTENTION-DEFICIT HYPERACTIVITY DISORDER is said to be highly heritable and twin studies suggest genetics are a factor in about 75% of ATTENTION-DEFICIT HYPERACTIVITY DISORDER cases, [66] some nevertheless question the genetic connection. Dr. Joseph Glenmullen states, "No claim of a gene for a psychiatric condition has stood the test of time, in spite of popular misinformation."Although many theories exist, there is no definitive biological, neurological, or genetic etiology for 'mental illness'."[67] His critics argue that ATTENTION-DEFICIT HYPERACTIVITY DISORDER is a heterogeneous disorder [68] caused by a complex interaction of genetic and environmental factors and thus cannot be modeled accurately using the single gene theory. Authors of a review of ATTENTION-DEFICIT HYPERACTIVITY DISORDER etiology have noted: "Although several genome-wide searches have identified chromosomal regions that are predicted to contain genes that contribute to ATTENTION-DEFICIT HYPERACTIVITY DISORDER susceptibility, to date no single gene with a major contribution to ATTENTION-DEFICIT HYPERACTIVITY DISORDER has been identified."[69]
[] Neuroimaging and ATTENTION-DEFICIT HYPERACTIVITY DISORDER
Various types of neuroimaging suggest there are differences in the brain, such as thinner regions of the cortex, between individuals with and without ATTENTION-DEFICIT HYPERACTIVITY DISORDER.[70] The methodology of some lobar volumetric studies used to evaluate cortex thinning in ATTENTION-DEFICIT HYPERACTIVITY DISORDER has been criticized as having "troubling reductionistic emphasis."[71] Critics contend that in some studies, the controls for stimulant medication usage were inadequate which makes it impossible to determine whether ATTENTION-DEFICIT HYPERACTIVITY DISORDER itself or psychotropic medication used to treat ATTENTION-DEFICIT HYPERACTIVITY DISORDER is responsible for decreased thickness observed in certain brain regions.[72][73] Jonathan Leo and David Cohen, who reject the characterization of ATTENTION-DEFICIT HYPERACTIVITY DISORDER as a disorder, believe many neuroimaging studies are oversimplified in both popular and scientific discourse and given undue weight despite deficiencies in experimental methodology.[74]
[] Hunter vs. farmer theory of ATTENTION-DEFICIT HYPERACTIVITY DISORDER
Main article: Hunter vs. farmer theory
The hunter vs. farmer theory is a hypothesis proposed by author Thom Hartmann about the origins of attention-deficit hyperactivity disorder (ATTENTION-DEFICIT HYPERACTIVITY DISORDER). He believes that these conditions may be a result of adaptive behavior of the species, his theory states that those with ATTENTION-DEFICIT HYPERACTIVITY DISORDER retain some of the older hunter characteristics.[75]
[] Neurodiversity
Proponents of this theory assert that atypical (neurodivergent) neurological development is a normal human difference that is to be tolerated and respected as any other human difference. They usually support treatment or therapy, but may or may not agree with the use of medication. Social critics argue that while biological factors may obviously play a large role in difficulties sitting still and/or concentrating on schoolwork in some kids, for a variety of reasons they have failed to integrate into the social expectations that others have of them. [76]
[] Social construct theory of ATTENTION-DEFICIT HYPERACTIVITY DISORDER
Social critics question whether ATTENTION-DEFICIT HYPERACTIVITY DISORDER is wholly or even predominantly a biological illness. A minority of these critics maintain that ATTENTION-DEFICIT HYPERACTIVITY DISORDER was "invented and not discovered". They believe that no disorder exists and that the behavior observed is not abnormal and can be better explained by environmental causes or just the personality of the "patient."[77]
[] Concerns about medication
The National Institute of Mental Health recommends stimulants for the treatment of ATTENTION-DEFICIT HYPERACTIVITY DISORDER, and states that, "under medical supervision, stimulant medications are considered safe".[11] A 2007 drug class review found no evidence of any differences in efficacy or side effects in the stimulants commonly prescribed.[78] However, the use of stimulant medications for the treatment of ATTENTION-DEFICIT HYPERACTIVITY DISORDER has generated controversy because of undesirable side effects, uncertain long term effects, and social and ethical issues regarding their use and dispensation.
[] Frequency of stimulant use
In the 1990s the United States used 90% of the stimulants produced globally, in the 2000s this has decreased to 80% due to increased use in other areas of the world.[79] The UK uses one tenth while France and Italy use one twentieth the methyphenadate per capita as the USA.[79]
[] Concerns about side effects and long term effectiveness
Some moms & dads and professionals have raised questions about the side effects of drugs and their long term use.[80] Studies have shown that stimulants offer no benefits over behavioral management for periods over 3 years. Other side effects of concern include addiction, growth retardation, suicidal thoughts and effects on the heart. This has led to interest in non-drug treatments such as omega 3 oils which can help symptoms of ATTENTION-DEFICIT HYPERACTIVITY DISORDER.[83] On February 9, 2006, the U.S. Food and Drug Administration voted to recommend a "black-box" warning describing the cardiovascular risks of stimulant drugs used to treat ATTENTION-DEFICIT HYPERACTIVITY DISORDER.[84]
A 2008 review found that the use of stimulants improved teachers' and moms & dads' ratings of behavior; however, it did not improve academic achievement.[82] Stimulants neither increased nor decreased rates of delinquency or substance abuse at 3 years.[82] Intensive treatment for 14 months has no effect on long term outcomes 8 years later.[85] No significant differences between the various drugs in terms of efficacy or side effects have been found.[86][87] A meta analysis of clinical trials found that about 70% of kids improve after being treated with stimulants in the short term but found that this conclusion may be biased due to the high number of low quality clinical trials in the literature. There have been no randomized placebo controlled clinical trials investigating the long term effectiveness of methylphenidate (Ritalin) beyond 4 weeks. Thus the long term effectiveness of methylphenidate has not been scientifically demonstrated. Serious concerns of publication bias regarding the use of methylphenidate for ATTENTION-DEFICIT HYPERACTIVITY DISORDER has also been noted.[88]
Animal research on the neurotoxicity of amphetamines has found contradictatory results. For example in rats doses of amphetamines equivalent to those used therapeutically to treat ATTENTION-DEFICIT HYPERACTIVITY DISORDER were suggestive of benefits to the dopamine system, whereas in primates therapeutic equivalent doses were found to cause neurotoxicity.[89]
[] Long term effects
Methylphenidate, an amphetamine derivative and potent central nervous system stimulant, can also lead to a psychosis from chronic use. Although the safety profile of short-term methylphenidate therapy in clinical trials has been well established, repeated use of psycho stimulants such as methylphenidate is less clear. Long term effects of methylphenidate, such as drug addiction, withdrawal reactions and psychosis, have received very little research attention and thus are largely unknown.[92] Knowledge of the effects of chronic use of methylphenidate is poorly understood with regard to persisting behavioral and neuroadaptational effects.[93] Stimulants can cause delayed growth in kids for up to 3 years. Animal studies have led to concerns of the safety of long term use of stimulants in the developing brain of humans.[94] A study has shown persisting molecular changes to the dopamine system, specifically the reward system, when methylphenidate is given to adolescent rats.[95] Whether long term stimulants cause similar changes in the brain of kids leading to increased substance abuse is unclear.[96] There is limited data regarding long term use of stimulants which suggests that there may be modest benefits in correctly diagnosed kids with ATTENTION-DEFICIT HYPERACTIVITY DISORDER but there are also overall modest risks.[97] Effects resulting from long term use of methylphenidate most likely result from changes induced in the dopamine system.[98] Methylphenidate has an incidence 0.1 % of psychosis in short term clinical trials.[99] A small study of just under 100 kids which assessed long term outcome of stimulant use found that 6% of the kids became psychotic after months or years of stimulant therapy. Typically psychosis abates soon after stopping stimulant therapy. As the study size was small and was not standardized, larger studies have been recommended. The long term effects on the developing brain and on mental health disorders in later life of chronic use of methylphenidate is unknown. Despite this, between 0.51% to 1.23% of kids between the ages of 2 and 6 years take stimulants in the USA. Stimulants drugs are not approved for this age group.
Concerns have been raised that long-term therapy might cause paranoia, schizophrenia and behavioral sensitization, similar to other stimulants.[103] Psychotic symptoms from methylphenidate can include hearing voices, visual hallucinations, urges to harm oneself, severe anxiety, euphoria, grandiosity, paranoid delusions, confusion, increased aggression and irritability. It is unpredictable in whom methylphenidate psychosis will occur. Family history of mental illness does not predict the incidence of stimulant toxicosis in ATTENTION-DEFICIT HYPERACTIVITY DISORDER kids. High rates of childhood stimulant use have been noted in patients with a diagnosis of schizophrenia and bipolar disorder independent of ATTENTION-DEFICIT HYPERACTIVITY DISORDER. Individuals with a diagnosis of bipolar or schizophrenia who were prescribed stimulants during childhood typically have a significantly earlier onset of the psychotic disorder and suffer a more severe clinical course of psychotic disorder in kids who are vulnerable to psychotic disorders.
Young ATTENTION-DEFICIT HYPERACTIVITY DISORDER patients taking stimulant medication may have a reduced rate of height and weight gain during adolescence, but stimulant medication has little effect on the ultimate weight and height of the medicated patient.[107] It is unclear whether the delay in growth is due to stimulant medication or ATTENTION-DEFICIT HYPERACTIVITY DISORDER itself; ethical problems in giving stimulant medication to kids without ATTENTION-DEFICIT HYPERACTIVITY DISORDER as experimental controls makes such studies problematic. Some patients will take a period of time off of medication, called a "drug holiday," in hopes of allowing the normal rate of height and weight attainment to resume. Stimulant medication may also inhibit cartilage growth, liver development and central nervous system growth factors.[108] Periodic CBC, differential, and platelet counts are recommended during prolonged use of methylphenidate.[12]
[] Coercion
It is often not a youngster's decision to take medication, especially those under the age of six, a group that is seeing a dramatic increase in the prescription of psychiatric medications. Some schools have attempted to require treatment with medications before allowing a youngster to attend school.[109] The United States has passed a bill against this practice.[109] Thus ethical concerns regarding forced treatment or coercion of a minor arise. Some suspect that kids are using stimulants as a cognitive enhancer at the request of their achievement oriented moms & dads.[110]
[] Non specific nature
Stimulants are often seen as cognitive enhancers or smart drugs. Their effects are non-specific with similar results seen in kids and adults with and without ATTENTION-DEFICIT HYPERACTIVITY DISORDER. One finds improved concentration and behavior in all.[111][112][113][114] Due to their non-specific activity, stimulants have been used by writers to increase productivity,[115] as well as by the United States Air Force to improve concentration in combat.[116] A small number of scientists recommend wide spread use by the population to increase brain power.[110]
[] Stimulant misuse
Stimulants are controlled psychotropic substances. They are classified as Schedule II substances (Schedule II: Potential for abuse; potential for psychological or physical addiction; currently accepted medical use).[117]
Controversy has surrounded whether methylphenidate is as commonly abused as other stimulants with many believing that its rate of abuse is much lower than other stimulants. However, the majority of studies assessing its abuse potential scores have determined that it has an abuse potential similar to that of cocaine and d-amphetamine.[118]
Both kids with and without ATTENTION-DEFICIT HYPERACTIVITY DISORDER abuse stimulants, with ATTENTION-DEFICIT HYPERACTIVITY DISORDER individuals being at the highest risk of abusing or diverting their stimulant prescriptions. Between 16 and 29 percent of students who are prescribed stimulants report diverting their prescriptions. Between 5 and 9 percent of grade/primary and high school kids and between 5 and 35 percent of college students have used non-prescribed stimulants. Most often their motivation is to concentrate, improve alertness, "get high," or to experiment.[119]
Stimulant medications may be resold by patients as recreational drugs, and methylphenidate (Ritalin) is used as a study aid by some students without ATTENTION-DEFICIT HYPERACTIVITY DISORDER.[120]
Non-medical prescription stimulant use is high. A 2003 study found that non prescription use within the last year by college students in the US was 4.1%.A 2008 meta analysis found even higher rates of non prescribed stimulant use. It found 5% to 9% of grade school and high school kids and 5% to 35% of college students used a non-prescribed stimulant in the last year.[122]
[] Substance use disorders
There has been controversy surrounding whether ATTENTION-DEFICIT HYPERACTIVITY DISORDER is associated with increased rates of problematic substance misuse. The available evidence suggests that there is no increased risk of substance use disorders in ATTENTION-DEFICIT HYPERACTIVITY DISORDER kids unless there is a co-existing conduct disorder.[123] Studies investigating whether stimulant medication can lead to drug abuse later in life found that despite the higher rate of substance abuse among ATTENTION-DEFICIT HYPERACTIVITY DISORDER patients as a whole, stimulant medication use in childhood did not affect or lowered, the risk for substance of abuse in adulthood compared to un-medicated individuals with ATTENTION-DEFICIT HYPERACTIVITY DISORDER.[124]
A study found that those who had received stimulants during childhood showed the highest number of cocaine abusers in adulthood - twice that of the other groups - thus suggesting that stimulant use during childhood was associated with sensitizing or predisposing kids to cocaine abuse later in life. Smoking tobacco also appeared to increase the risk of cocaine abuse in this population but even after controlling for tobacco exposure cocaine abuse was still significantly higher in adults who had been medicated with stimulants as kids. This risk was still present 15 years after stimulant medication exposure.
[] Advertising
In 2008 five pharmaceutical companies received warning from the FDA regarding false advertising and inappropriate professional slide decks related to ATTENTION-DEFICIT HYPERACTIVITY DISORDER medication.[127] In Sept. of 2008 the FDA sent a notice to Novartis Pharmaceuticals regarding its advertising of Focalin XR in which they overstate its efficacy.[128] Similar warnings were sent to Shire plc with respect to Adderall XR.[129]
[] Financial conflicts of interest
Russell Barkley, a well known ATTENTION-DEFICIT HYPERACTIVITY DISORDER researcher, admits to taking money from drug companies for speaking and consultancy fees. There are concerns that this may bias his publications.[130]
In 2008, it was revealed that Joseph Biederman of Harvard, a frequently cited ATTENTION-DEFICIT HYPERACTIVITY DISORDER expert, failed to report to Harvard that he had received 1.6 million dollars from drug companies between 2000 and 2007.[131] E. Fuller Torrey, executive director of the Stanley Medical Research Institute which finances psychiatric studies, said “In the area of youngster psychiatry in particular, we know much less than we should, and we desperately need research that is not influenced by industry money.”[131]
Kids and Adults with Attention-Deficit/Hyperactivity Disorder, CHADD, and an ATTENTION-DEFICIT HYPERACTIVITY DISORDER advocacy group based in Landover, MD received a total of $1,169,000 in 2007 from pharmaceutical companies. These donations made up 26 percent of their budget. This is viewed by some as a major conflict of interest.[133]
[] Concerns about the impact of labeling
Moms & dads could be concerned that telling kids they have a brain disorder could possibly harm their self-esteem. Barkley believes labeling is a double-edged sword; there are many pitfalls to labeling but by using a precise label, services can be accessed. He also believes that labeling can help the individual understand and make an informed decision how best to deal with the disorder using evidence based knowledge.[134] Furthermore studies also show that the education of the siblings and moms & dads has at least a short term impact on the outcome of treatment.[135] Barkley states this about ATTENTION-DEFICIT HYPERACTIVITY DISORDER rights: "because of various legislation that has been passed to protect them."There are special education laws with the Americans with Disabilities Act, for example, mentioning ATTENTION-DEFICIT HYPERACTIVITY DISORDER as an eligible condition. If you change the label, and again refer to it as just some variation in normal temperament, these individuals will lose access to these services, and will lose these hard-won protections that keep them from being discriminated against. . . ."[134] Psychiatrist Harvey Parker, who founded CHAAD, states, "we should be celebrating the fact that school districts across the country are beginning to understand and recognize kids with ATTENTION-DEFICIT HYPERACTIVITY DISORDER, and are finding ways of treating them. We should celebrate the fact that the general public doesn't look at ATTENTION-DEFICIT HYPERACTIVITY DISORDER kids as "bad" kids, as brats, but as kids who have a problem that they can overcome".[136]
Social critics believe that this knowledge can effectively become a self-fulfilling prophecy mainly through self-doubt. Thomas Armstrong states that the ATTENTION-DEFICIT HYPERACTIVITY DISORDER label is a "tragic decoy" which severely erodes the potential to see the best in a youngster.[137] Armstrong has adopted the term neurodiversity (first used by autistic rights activists) as an alternative, less damaging, label.[138] Thom Hartmann has said that the brain disorder label is "a pretty wretched label for any youngster to have to bear."[139]
Kids may be ridiculed at school by their peers for using psychiatric medications including those for ATTENTION-DEFICIT HYPERACTIVITY DISORDER.[140]
[] ATTENTION-DEFICIT HYPERACTIVITY DISORDER in politics and the media
The media have reported on many issues related to ATTENTION-DEFICIT HYPERACTIVITY DISORDER and have also reported on controversial opinions of individuals.
In 2001 PBS's Frontline ran a TV show entitled "Medicating kids". The program included a selection of interviews with representatives of various points of view. In one segment, entitled backlash, retired neurologist Fred Baughman and Peter Breggin, founder of the 'International Center for the Study of Psychiatry and Psychology', whom PBS described as "outspoken critics who insist [ATTENTION-DEFICIT HYPERACTIVITY DISORDER] is a fraud perpetrated by the psychiatric and pharmaceutical industries on families anxious to understand their kid’s behavior,"[142] were interviewed on the legitimacy of the disorder. Russell Barkley and Xavier Castellanos, then head of ATTENTION-DEFICIT HYPERACTIVITY DISORDER research at the National Institute of Mental Health (NIMH), defended the viability of the disorder, although Castellanos stated that little is scientifically understood.[143] Lawrence Diller was interviewed on the business of ATTENTION-DEFICIT HYPERACTIVITY DISORDER along with a representative from Shire Plc. The validity of the work of many of the ATTENTION-DEFICIT HYPERACTIVITY DISORDER "experts" (e.g. Dr. Biederman), Drug Companies & Doctors: A Story of Corruption, has been called in to question by Marcia Angell, former or of The New England Journal of Medicine.
A number of notable individuals have given controversial opinions on ATTENTION-DEFICIT HYPERACTIVITY DISORDER. Scientologist Tom Cruise's interview with Matt Lauer was widely watched by the public. In this interview he spoke about postpartum depression and also referred to Ritalin and Adderall (a mix of amphetamines) as being "street drugs" rather than as ATTENTION-DEFICIT HYPERACTIVITY DISORDER medication. This has some basis in fact, as the sale of stimulants on campuses is not uncommon; they are used by non ATTENTION-DEFICIT HYPERACTIVITY DISORDER students to tackle drudgery.[145] In England Baroness Susan Greenfield, a leading neuroscientist,[146] wanted a wide-ranging inquiry in the House of Lords into the dramatic increase in the diagnosis of ATTENTION-DEFICIT HYPERACTIVITY DISORDER in the UK and possible causes.[147] This followed a 2007 BBC Panorama program which highlighted US research (The Multimodal Treatment Study of Kids with ATTENTION-DEFICIT HYPERACTIVITY DISORDER by the University of Buffalo showing treatment results of 600) suggesting drugs are no better than therapy for ATTENTION-DEFICIT HYPERACTIVITY DISORDER in the long-term. In the UK medication use is increasing dramatically.[] Other notable individuals have made controversial statements about ATTENTION-DEFICIT HYPERACTIVITY DISORDER. Terence Kealey, a clinical biochemist, has stated his belief that ATTENTION-DEFICIT HYPERACTIVITY DISORDER medication is used to control unruly boy’s behavior.[148] Newspaper columnists such as Benedict Carey have also written controversial articles on ATTENTION-DEFICIT HYPERACTIVITY DISORDER.
Hearings were held in the US Congress. A series of lawsuits culminating with the failed Ritalin class action lawsuits were in the courts. Antipsychiatry critics such as Peter Breggin and Fred Baughman received a lot of press coverage including PBS's "Medicating kids" which featured interviewees whose opinions regarding ATTENTION-DEFICIT HYPERACTIVITY DISORDER ranged from doubting its existence to support of the notion of genetic and physiological basis for the condition. This timing also coincided with a dramatic increase in the use of stimulant medication which since has leveled off.[152]
According to an article in the Los Angeles Times, "the uproar over Ritalin was triggered almost single-handedly by the Scientology movement."[153] The Citizens Commission on Human Rights, an anti-psychiatry group formed by Scientologists in 1969, conducted a major campaign against Ritalin in the 1980s and lobbied Congress for an investigation of Ritalin.[153] Scientology publications identified the "real target of the campaign" as "the psychiatric profession itself" and said that the campaign "brought wide acceptance of the fact that (the commission) [sic] and the Scientologists are the ones effectively doing something about [...] psychiatric drugging".[153] Scientology states "the controversy over the many deaths and irreversible damage caused by psychiatric drugs prescribed for kids labeled with... ATTENTION-DEFICIT HYPERACTIVITY DISORDER continues to grow".[154]
[] History
The controversies around ATTENTION-DEFICIT HYPERACTIVITY DISORDER have been on-going at least since the 1970s. Questioning of the safety of stimulants began in the 1990s among the general population when anti-Ritalin advocates denounced it as "kiddie cocaine".[26]
External links
- ScienceDaily: ADD and ADHD News
- Simon Sobo, MD, "ADHD and Other Sins of Our Children"
- The New England Skeptical Society: Defending ADHD
- http://www.icspp.org International Center for the Study of Psychiatry and Psychology
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