Perhaps Capitalism’s Greatest Menace


Chapter 1

Introduction

Since the mid 1970's America has seen massive increases in the numbers of people who are taking long-term prescription medication

Specifically, we are interested in studying the increasing use of generic drugs. These drugs are being used as a panacea for problems such as Anxiety, Depression and learning and behavioral disorders

They include Prozac, AZT, Beta-Blockers, Cylert, Clonidine, Tofranil and Ritalin. Doctors generally prescribe these drugs to patients for at least six months and often indefinitely. While considerable research has been done on the short-term effects of many of these drugs, practically no studies are available to assess the longer-term consequences, both physiologically and socially, of using these medications

Adults have a relatively shorter life span to develop symptoms of the potentially harmful effects of these drugs (which might include liver disorders, premature dementia and Schedule 1 drug addiction)

However, children have plenty of time to develop drug-associated side effects and to witness any social changes that might occur because of the wide-scale use of them. In addition, while adults can usually make considered choices as to their medical treatment, children have very little say in the kinds of medications they take

Therefore, while we are concerned with the huge rise in generic drug use across the population age range, we are especially concerned about the millions of children who are now users of these drugs. It is a fact that over 2.3 million children are currently taking Ritalin everyday and more than a quarter of a million are taking Prozac. Across America (and almost exclusively in America as 90 % of world consumption of Ritalin occurs in the USA) the majority of these children are being prescribed Ritalin for Attention Deficit and Hyperactivity Disorder

Ritalin is a powerful amphetamine like drug classified as a schedule 2 controlled substance, along with other substances such as morphine

Valium for example is a schedule 4 drug (the higher the schedule the less the control on the manufacture and use of a drug). Currently, the manufacturers of Ritalin (Ciba-Geigy) are lobbying for Ritalin to be reclassified as a schedule 3 controlled substance. This would allow them to produce unlimited quantities of the drug for sale in America and worldwide export

These numbers and the strength of these generic drugs warrant careful medical and social oversight. We are concerned that this oversight is not sufficiently being done. We are concerned there is not enough information and research evaluating the causes and effects of the mass dispensation of these generic drugs. Specifically we are concerned that there is not enough oversight and far too little research evaluating the social and medical processes by which so many children are being diagnosed and administered these powerful drugs

As Ritalin is the single most prescribed drug of this kind, and children are its main users, with little say over its use and a whole future at stake, we chose to focus our research on Ritalin and ADHD in children under 18

We believe our research into this area will add to current oversight

Oversight is needed here to ensure that as a society we are not engaged in a process of shared ignorance. Oversight can test the validity of criticism from various, often contrasting theoretical perspectives. Such criticism might include the perception of physicians as conformists; simply prescribing drugs like Ritalin because it seems everyone is doing it. Or criticism might stem from the perception of our modern culture as being spellbound by generic 'wonder' drugs and the associated medicalization of society

Specifically, we hope this research will help clarify some of the main misconceptions and problems relating to ADHD and Ritalin and the current attitudes and treatments concerning them. In this way we hope our research will contribute to the understanding of underlying facts and issues that may have become obscured. This would allow patients, caregivers, medical professionals and policymakers to make more informed and objective decisions about the use of generic drugs, specifically Ritalin. We believe this kind of research will help such people make their decisions based on a more holistic understanding of the political, socio-economic as well as medical elements of this aspect of our modern culture

Our research focuses on answering questions such as these:

1) To what extent is there consensus and consistency in the diagnosis and treatment of ADHD in the medical community?

2) Are medical professionals in their evaluation giving children a thorough diagnosis for ADHD?

3) If they are not being given a thorough diagnosis, are children being improperly diagnosed and subsequently subjected to unwarranted medication?

4) If they are being improperly diagnosed what socio-cultural factors may be contributing to this improper diagnosis and process of unwarranted medication?

5) Are some children more at risk of improper diagnosis and unwarranted medication?

6) If so, then what socio-economic factors underlie the increase of this risk?

7) Can we confirm or reject Dr. Walker's contention (see Literature Review) that children are being misdiagnosed and subjected to unwarranted medication?

8) Are physician's following the DSM 4 criteria (see Literature Review) closely in their evaluation for ADHD?

9) Are physicians supplementing these criteria with a wider range of diagnostic/clinical criteria and tests? (And is their interpretation of the DSM criteria narrow or broad?)

10) Might physicians be engaged in 'lumping' of symptoms in order to prescribe generic drugs to conditions other than ADHD, for example AIDS, Depression and Anxiety?

11) What social implications might result?

12) How might this research shed light on our current understanding of concepts such as Deviance, Personal Responsibility and Disease

We worked with our local branch of CHADD (Children and Adults with Attention Deficit Disorder)

Our study is organized into five chapters: Introduction, Literature Review, Research Design, Analysis and Results and Conclusions. The Literature Review builds on the theoretical perspectives of the Introduction and the Research Design chapter focuses our study into specific hypothesis we tested. Our Concluding chapter hopes to offer actionable recommendations following on from our findings in the Analysis and Results chapter. You will find Appendices and a Bibliography at the end of the study

We must acknowledge up front the limitations of our study

Due to an early reduction of our research team to two people and significant financial and time constraints, we were only able to sample 50 people in the course of our primary data gathering activities. Therefore, this study that seeks to help people understand this complex and confusing area in a more holistic way, cannot claim to be comprehensive and must instead be seen as exploratory

We intend to forward our findings to the National Institutes of Health following their 'Lack of Consensus' statement and call for more research into this area

Chapter 2

The Literature Review We started our background search on line. We downloaded journals from databases including Lexis-Nexus and Ovid. Journals included the British Medical Journal, American Medical Journal, The Brown University Child and Adolescent Behavior Letter and the AORN Journal

Studies included the comparison of Ritalin and Cocaine in brain metabolism (Volkow 95), the relative likelihood of injury in ADHD children (DiScala 98), the Diagnosis and Treatment of ADHD (Goldman 98) and the comparative rise of Ritalin use in America in the 90's (Safer 96). These journals gave us a good grounding in the science and history of Ritalin (chemical name: methylphenidate hydrochloride). They also gave us an idea of the consensus and disagreements within the conventional medical community regarding Ritalin and ADHD. For example we found that the National Institutes of Health recently (November 1998) declared this issue a "major public health problem". A panel of medical experts supported by dozens of nationally recognized medical professionals, came together to make a call for more research and the development of consensus on this issue within the medical community. These are a few excerpts from their statement:

"Because of a lack of consistent improvement beyond the core symptoms (of ADHD) and the paucity of long term studies (beyond 14 months), there is a need for longer term studies and new research"

"There are wide variations in the use of psychostimulants across communities and physicians, suggesting no consensus regarding which ADHD patients should be treated with psychostimulants. These problems point to the need for improved assessment, treatment and follow-up of ADHD patients. A more consistent set of diagnostic procedures and practice guidelines is of utmost importance."

"After years of clinical research and experience with ADHD our knowledge about the cause or causes of ADHD remain largely speculative. Consequently, we have no documented strategies for the prevention of ADHD."

"The diverse and conflicting opinions about ADHD have resulted in confusion for families, care providers, educators and policymakers

The controversy raises questions concerning the literal existence of the disorder, whether it can be reliably diagnosed, and if treated, what interventions are the most effective."

"Psychostimulants, including Ritalin, are by far the most widely researched and commonly prescribed treatments for ADHD. Because psychostimulants are more readily available and are being prescribed more frequently, concerns have intensified over their potential overuse and abuse."

The journals also helped us understand how the process of diagnosis and prescription works. For example, we were surprised to find that there are no medical tests, physical examinations, office based psychological tests, or neuropsychological tests that are both sensitive and specific for ADHD (The Clinician's Practical Guide 99)

And while ADHD patients may show common disruption of brain processes in MRI's, (and contrary to popular belief) there is no specific brain disorder (congenital or acquired) linked to ADHD

For this reason, the diagnosis of ADHD requires best judgements by physicians and psychologists as to the degree of behavioral deviance associated with a child. Qualities of such deviance include degrees of inattention, hyperactivity and impulsivity. Because children often do not exhibit these symptoms in a physician's office, the physician frequently relies on the reports of others, such as teachers or parents in making his/her judgements

His/her final diagnosis is based on his/her overall examination of a patient and interpretation of the criteria for diagnosing ADHD as handed down by the American Psychiatric Association (see Data Appendix). These criteria are codified in the 800 plus page Diagnostic and Statistical Manual of Mental Disorders (currently edition 4). This has been dubbed the "Psychiatric Bible". These criteria can usually fit on less than a page and a half of most books and have changed through different editions. (Incidentally, this authoritative document is the same that classified homosexuality as a disease up until the mid 1970's)

We were amazed that such an apparently puny set of criteria, and such a lack of consensus in diagnosis and treatment methods within the medical community, has been the basis for millions of children being diagnosed with a disorder that required serious and ongoing medication. These criteria it seemed, would allow for a massive range of interpretations by different physicians and psychologists when making their judgements about the ADHD of a child

This amazement sent us scurrying for books that would explore and explain in greater detail the history behind these criteria. We found works such as ADHD in Adolescents (Robin 98), The ADD Book (Sears 98), The Clinicians Practical Guide to ADHD (Power 99) and the Hyperactivity Hoax (Walker 98). The Hyperactivity Hoax was the most fascinating of these. It is written by a practicing neurologist and psychiatrist Dr. Sydney Walker, who trained in neurosurgery, physiology and pharmacology and after 3 decades of practise is currently a director of a Neuropsychiatric institute in California. His premise was most provocative. The premise of the book is that ADHD is not a disease at all. That is why there are no specific tests for it, the criteria are so vague and research into it has been so conflicting. According to Walker ADHD is simply a collection of symptoms. Generic drugs, that is 'one size fits all' drugs, such as Ritalin are used to deal with generic symptoms but they do not treat underlying causes of these symptoms. Therefore, children demonstrating symptoms such as hyperactivity, impulsivity and inattention (thus often suffering from learning difficulties or clashes with authority) are indeed experiencing real problems but not of the same source. As the FDA recently wrote to a physician "We acknowledge that as yet no distinct pathophysiology for the disorder has been delineated"

Walker argues that these children may be suffering form other diseases such as genetic disorders which run in the family, Hyperthyroidism, blood sugar imbalances such as pre-Diabetes, parasites, chronic infections, toxic poisoning such as by lead, caffeinism, mercury and pesticides or simply malnutrition. They may be suffering from a combination of these interacting with social stressors. These stressors might include family dysfunction and trauma, substance abuse amongst peers, our overly-stimulated culture laden with TV, rock music and Sega Mega- Drives, while at the same time children are under-exercised and poorly disciplined. All these factors can severely disrupt neuronal activity and physical well being, giving rise to mental and physical dysfunction and ultimately behavioral disorders says Walker

Walker goes onto suggest that in fact the epidemic of ADHD and Ritalin prescription is itself a symptom of social disorder and medical ineptitude. In effect children are being punished for the breakdown of aspects of the society in which they are trapped. HMO's push for financial efficiency, demanding doctors make superficial judgments in diagnosing children. Schools contain classes with up to 40 and 50 children each. Teachers are barely able to cope with the load, let alone unruly individuals disrupting class. They encourage parents to get these unruly children treated. Parents in turn are often divorced or at work when a child comes home and may have little energy left to investigate or dispute a teacher's recommendation

Further, Walker contends childhood itself is being treated as a disease

He compares the criteria for childhood and for ADHD and the differences are so minimal as to be almost laughable he says. This idea REALLY concerned us and solidified our conviction that further research and social oversight are necessary

In our reading of contrasting theories, we were obliged to ask ourselves why people would continue using Ritalin if it weren't treating their problem children? This is a valid question that physicians, who frequently prescribe Ritalin, often pose in journals and articles. The answers we turned up center on the fact that Ritalin can indeed control symptoms. This allows many students to be quieter, to focus better and to increase performance. But again Walker argues that this is not a real cure for the underlying problem (s). If the children stop taking the Ritalin they will usually experience symptoms again, possibly even worse following withdrawal

As children mature few simply outgrow their symptoms and can come off drugs altogether. Many continue with health, learning and behavior problems. These individuals are more likely to be involved in auto accidents or get into trouble with the law. In addition, they are more likely to switch to other generic drugs such as Prozac in adult life. In this perspective Ritalin is only a temporary and risky fix to an ongoing and largely invisible set of problems

Ritalin is an amphetamine drug. It is much like "speed". Chemically it also resembles cocaine, another drug that helps users increase performance and focus better. These drugs do this by altering Dopamine levels in the brain, a chemical mood enhancer. In short, Ritalin produces an artificial high, "not a real treatment"(Walker)

Better living through chemistry? We see this long term (and potentially dangerous) drug dependance as giving rise to many important social and medical issues. For example: Is the same kind of diagnostic 'lumping' happening with AIDS and AZT or tranquilizers and anxiety trends? Are children being conditioned to see drugs as the best solutions to their problems? What are the ethical considerations for undermining traditional conceptions of self-responsibility and accountability? Are we encouraging drug companies to exploit us? We believe these provocative and unresolved questions confirmed that we were on the right track in seeking to engage in a valid and important piece of research

Chapter 3

Research Design To narrow the focus of our study, we settled on the development of a questionnaire to gather primary evidence for our research (see Data Appendix). It constitutes a series of questions that we asked of individuals who were diagnosed (or who were present during the diagnosis) with ADHD. We also posited these questions to people who were suspected of having ADHD but who after examination, were not labelled ADHD or who were prescribed some other treatment for another disorder relating to their symptoms. This was our control group

We stressed that we did not seek to know details of an individual's medical condition. We were only hoping to find out about the details of the diagnostic procedures they encountered in their physician's care. In this way we hoped to avoid the Hawthorne effect and refusal of people to talk to us based on embarrassment, legal or privacy grounds

The aim of the questionnaire was to find out if the physician diagnosing ADHD performed a thorough assessment of both social and physical conditions in a child's situation before diagnosing ADHD (or not) and then prescribing Ritalin (or not). It was also designed to assess the consistency of diagnostic procedures between physicians and psychologists. We would then be able to test a number of hypotheses relating to these objectives. In general, we suspected that there would be inconsistency in diagnostic procedures. We also suspected that the fewer the medical and social aspects outlined on the questionnaire considered by the physician, the greater the chance for a diagnosis of ADHD and a prescription of Ritalin. Ultimately, this might mean that there are many physicians who are conducting insufficient diagnostic procedures. In attempting to gather data on this to test, we would be helping to confirm or reject aspects of the controversial arguments presented by experts such as Dr.Walker

The hypotheses initially included are as follows:

1) The fewer the categories checked on our Questionnaire, the greater the chance that a physician prescribed Ritalin

2) The higher the frequency of HMO physicians conducting the diagnosis of ADHD, the higher the probability the child is diagnosed as ADHD and medicated

3) The fewer the categories checked on the Questionnaire, the higher the probability that the initial ADHD suggestion came from a teacher

4) The higher the income level of a respondent ('s parents) the less likely the diagnosis was made by an HMO physician

5) The 'lower' the socio-economic background of the school a child attends the higher the rate of ADHD diagnosis and Ritalin prescription

6) The fewer the visits to the physician during the diagnostic phase, the higher the frequency of an ADHD diagnosis and the subsequent prescription of Ritalin

7) The higher the rate of ADHD (as opposed to ADD) diagnosis, the higher the rate of Ritalin medication

8) The more a child was prescribed other treatments for any other disease, the less likely the child was prescribed Ritalin, or the shorter the time for which the prescription was made

9) The more categories checked on the Questionnaire the more likely the diagnosis of other or additional disorders/diseases to be treated by means other than Ritalin

10) The more a Psychologist asks about cognitive development and tests for it, the less a Physician will

11) The more a Physician conducts physical tests the less a Psychologist will

12) The less a Physician or Psychologist conducts a 24 hour schedule test the less they will ask about nutritional intake

13) The more a Psychologist asks about social development, the more a Physician asks about possible toxic exposure

To administer this questionnaire we worked with CHADD branches in Ft

Myers and throughout Florida. They were able to help us find participants for our survey and we also utilized their information services in collecting reliable secondary data for comparative statistical studies

CHADD representatives pointed out that the people they could connect us with, would be informed and eager participants. We did not want a large number of 'don't knows' on our questionnaires. They also suggested they had contact numbers for people in different states of a variety of socio-ethnic backgrounds

In addition to the contact numbers we got though CHADD, we asked everyone we knew if they or someone they knew had been through an ADHD (or related) diagnosis. We were surprised at the number of willing responses

Subsequently, we divided these contact numbers into two groups. The first was the group we got from CHADD, the second group we got from our own asking around. We took the numbers from CHADD and divided them into groups by state. We randomly chose ten states and from each state randomly picked five numbers. From these fifty numbers we called people and stopped at twenty-five responses. From the other group we randomly picked thirty numbers. From these contact numbers we stopped at twenty-five responses also. This gave us a sample of fifty people who responded to our questionnaires

Questionnaires were administered largely over the phone, although a few were handed out and returned later. We did this to help explain complex questions to respondents, to ensure a swift rate of return in our data gathering and to be open to wider comments and other information people cared to share with us. To ensure reliability in this process Sabrina and I practiced the questionnaires on each other. This we believed would reduce the chances of unintentionally skewing our separate responses. We stressed asking the same questions in the same way even to the point of the inflection of voice. We stressed the need to give the same descriptions and clarifications to potential questions that might arise during the study. We reminded each other not to lead respondents or prompt answers

We conducted a process of random sampling with a degree of stratification by state, in order to 'cast our net far and wide' but with as little selective bias as possible. We were limited in the number of people we could survey as our group of researchers shrank form four to two and each questionnaire took about ten to twelve minutes to administer. The process of selecting randomly was done by cutting lists of numbers into individual strips of paper, or writing them onto strips of paper, shaking them together in a plastic jar and pulling out strips blindly until we had enough. This was practical and easy and somewhat fun.

We faced a problem with our control group however. We could not find a significant number of people who had seen a medical professional in relation to ADHD-like symptoms that hadn't been diagnosed with ADHD and subsequently prescribed Ritalin or another drug. In fact, for all our searching we could only find five people who had gone to a Physician or Psychologist with symptoms of inattention, anger, hyperactivity and so on, and come out with a diagnosis and treatment for problems other than ADHD. This small control group we believed was a major limitation in our study. We could not afford to select randomly from this group for example. Yet, we also believe this might illustrate the frequency with which medical professionals are diagnosing people with ADHD and prescribing drugs as treatment.

In our gathering of secondary evidence we utilized statistical information and graphs from journals, the inter-net, books and databases such as OVID. This helped us develop our overview and provided corroborative and comparative sources for use in analyzing the data results from our questionnaire

Chapter 4

Analysis and Results Having gathered our data from the questionnaire, we developed a spreadsheet summarizing our findings using SPSS. From this spreadsheet, frequencies, correlations and crosstabs were run and from these, bar graphs were constructed. In doing this we hoped to reveal patterns in the data that could help us answer some of the questions we had posed for this study (see Data Appendix)

We must note that because we had such a small control group we wanted to include those few adults we sampled randomly who had gone through an ADD/ADHD diagnosis as adults. This would give us an added dimension to our sample for comparison

We must also note that in addition to our control group being small, we found limited ethnic diversity. Therefore we had insufficient data to test some of our early hypotheses. For example, we could not validly test if different ethnic groups were being diagnosed at different rates or in different ways

Findings It was found that there was a great variation of questions/tests administered by medical professionals, at different rates across and within fields of medicine

Of those who had been through an ADD/ADHD related diagnosis:

~ Nearly 80% was male ~ 65% were aged 5-10 ~ 90% were Caucasian ~ 75% attended public school ~ 44% were initially identified by a teacher ~ 38% were initially identified by a parent ~ 73% of visits were paid by insurance (largely HMO) ~ 65% were diagnosed only after a series of visits ~ 30% were diagnosed after one or two visits ~ 40% were diagnosed with ADD ~ 54% were diagnosed with ADHD ~ 73% were prescribed Ritalin ~ 39% were prescribed another drug instead of/in addition to Ritalin

The bar graphs in the data section illustrate the level of consistency in diagnosis. They show that there are a few questions and tests that most medical professionals administered as part of their diagnostic procedures. There are a few that most did not. There are many more that were administered by about half the medical population and left out by the rest

Most frequently administered tests/questions:

~ IQ test (77%) ~ Problems associated with depression (77%) ~ Mobility tests (77%) ~ Adverse physical reactions to medications (75%) ~ Problems associated with divorce (75%) ~ Problems associated with death (73%) ~ Standard ear, nose and throat exam (71%) ~ Coordination disorders test (71%)

Most infrequently administered tests/questions:

~ Test diet prior to diagnosis (90%) ~ Exposure to parasites (79%) ~ Use of pesticides at home (77%) ~ Proximity to farmland/industry (77%) ~ Gerstmann test (73%) ~ Cardiac test (73%) ~ Substance abuse (65%)

Tests/questions administered approximately half the time:

~ Bullying at school (50%) ~ Prior physical injuries (50%) ~ Family history (52%) ~ Post-natal breast feeding (52%) ~ Glucose Tolerance test (48%) ~ Parenting stress index (54%) ~ Trouble with parents (54%) ~ Hours of parent-child interaction (54%) ~ Walking age (46%)

It was found that visits paid for privately tended to involve fewer questions/tests. Visits paid for by insurance, including HMO based, experienced a slightly broader range of questions/tests

There were no big differences in numbers of questions and tests performed and the income level of respondents. However, there was a significant positive correlation between income levels and Glucose Tolerance test, suggesting those in the top income level were more likely to be given a Glucose Tolerance Test. (Note: this can be quite a pricey and time-consuming test)

Correlations suggested that the younger the person (not including 5 years and below) the more likely he/she would be prescribed Ritalin and only Ritalin. Adults were prescribed Ritalin at a lower rate or prescribed other drug combinations such as Adderall, Wellbutrin, Prozac, Zoloft and Dexedrine

Males and females were prescribed Ritalin at similar rates

General Practitioners and specialists administered physiologically based questions and tests at a higher rate than psychologists and psychiatrists. For example, only one psychologist asked about the use of pesticides in the home and only one had a cardiac test performed

Psychologists tended to administer more psychological based and behavioral centered tests and questions. These would include Dyslexia tests, academic problems, Parent Stress Indexes and IQ tests

School psychologists tended to administer the smallest range of questions and tests. They focused on finding out about situational problems at home and at school such as issues relating to divorce, depression and death. They performed physical (invasive) tests most infrequently

Psychiatrists consistently explored relationships of divorce and depression with patients. General Practitioners did the same at a significantly lower rate

Many of the medical professionals labeled 'specialist' were Pediatricians. However, it must be noted that Pediatricians are essentially General Practitioners who concentrate on treating children

The Glucose Tolerance Test was performed at similar rates between professions. But in each profession, the rate at which this test was performed was approximately half the time

Those who were not diagnosed with ADHD or prescribed Ritalin volunteered to explain their diagnosis. One for example, was told that the child was just 'full of energy and extremely gifted' and needed strict structure and opportunities for release of this energy (through sport and extra tutoring). Another was told that some counseling would help for problems associated with 'oppositional defiance'. Another was told that the child had pinworms and that the child's inability to sit still in class would be remedied by eradication of the worms

General Observations

From conversations and feedback we got from interviews, we were able to make some general observations. For example:

There are new studies suggesting children with ADHD will always have ADHD associated problems and that life-long medication should be considered in many cases. We could not find the American Medical Association publications that apparently suggested this in time for this report. But there did seem to be consensus that many children would continue to need medical treatment past childhood and adolescence

A good number of respondents shared information about their treatment history. Many had been diagnosed as ADD as children and having been on Ritalin at first had subsequently tried many different medications and combinations of medications. Adderall, Clonidine and Dexedrine were popular alternatives. A number of people said that after years of Ritalin they now found Prozac, Zoloft and other anti- depressants an important part of their treatment regime

ADD was the major diagnosis in the 70's and 80's. ADHD has been the diagnosis of the 90's

Once an individual had been prescribed Ritalin he/she was told to return for review in a matter of weeks. The longer the period with which an individual had subsequently been on medication, the longer the period of time between reviews. These intervals were often three to six months

Parents, who have had children on medication for more than six months indicated that their doctors during reviews, largely followed their recommendations for increases or decreases in dosage according to their observations of the child's progress

It seemed that when a child in a family was diagnosed as having ADHD, other members of the family were diagnosed ADHD soon after. This follows from the belief that ADHD is an inherited disorder. One parent described the 'mists lifting', after she tried her son's Ritalin for a few days (without a prescription) in order to see the world through his eyes when he was on medication. She was diagnosed as ADHD soon after. Another respondent said her whole family was on medication for ADHD

Many people said they had to fight hard for any learning disability allowances for themselves or their children. Some said it wasn't worth the effort to claim it or they just didn't know enough about it

A number of the parents who said they were the initial identifiers of their child's ADHD were schoolteachers and nurses

One man who was diagnosed twenty years ago said, "At that time you had to fight your doctor to get diagnosed, they just didn't believe in the disorder to the extent they do today". He said that "In those days ADD was the diagnosis but they were still diagnosing many of us as 'Retards'. To me it meant the difference between being labeled a retard and a gifted person with a learning disability. Today everyone seems to be getting diagnosed. It's just being used as an excuse"

Many of the CHADD members said they saw a lot of undiagnosed children who could be helped by medication

A number of respondents when questioned about whether their doctor had asked about eating habits and nutritional intake, said their doctors 'didn't believe in that kind of stuff'

Many parents suggested that ADHD is still not well understood and that 'follow- up' on children with ADHD, including the monitoring of their medication is 'very poor'

It must also be noted that many respondents who returned a 'don't know' on the questionnaire did so because they felt sure such questions would have been asked, or assumed the doctor took them into consideration but they couldn't remember exactly. This was because a diagnosis of ADHD had not been carried out 'cold'. Often these respondents had been seeing their doctor for a number of years and thus they assumed he/she would have known or asked such questions at some point in the past

Chapter 5

Conclusions, Policy Implications and the Future Based on our findings, we believe the National Institutes of Health acted correctly in declaring a 'lack of consensus' regarding the diagnosis and treatment of ADD and ADHD. We also believe the NIH was correct to label this situation "a major public health problem"

It seems that inconsistency of ADD/ADHD diagnostic procedure is a feature of the medical profession as a whole, as it is a feature within different fields of practice. This inconsistency points to confusion at various levels about the nature and best treatment of ADD/ADHD. Again, we agree with the NIH in their opinion that such confusion may result in the frequent misdiagnosis of children with ADHD and the unnecessary prescription of medication

The NIH concluded, "The absence of a simple, consistent diagnostic test for the disorder continues to pose validity problems". We suspect that the reason such a test has not been developed after two decades of experience with ADD/ADHD is that such a test may not exist. It is more likely that ADD/ADHD is not a single testable disease. Rather it is a collection of symptoms that vary in intensity and scope which, for want of a better explanation, are lumped together under the catchall diagnosis of ADD/ADHD

Instead, we agree with Dr. Walker in seeing these real, debilitating symptoms as caused by many different underlying physical and psychological dysfunctions. Thus for every child who is properly discovered to have contracted pinworms, causing irritability and the inability to sit still in class, others may be wrongly diagnosed with ADHD and prescribed Ritalin

For every child today that is being helped by Ritalin or another medication, there may be an adult tomorrow who will remain dependent on stimulant medication, in conjunction with anti- depressant medication. These patients may then have lived a life on schedule 2 medications without truly knowing what has been causing their condition. It is worth repeating that as yet there are "no medical tests, physical examinations, office based psychological tests, or neuropsychological tests that are both sensitive and specific for ADHD" (The Clinician's Practical Guide 99). This is because as yet there has been no distinct pathophysiological delineation for the disorder

However, we disagree with Dr. Walker's contention that many doctors are conducting cursory diagnoses and that HMO's are encouraging this superficial diagnostic trend. We found that most people were diagnosed only after a number of visits, involving a high number of questions/tests

Indeed, it was insurance paid visits, including HMO's that tended to result in a more lengthy and wide-ranging diagnostic experience. (It seems it would not be to an insurance company's advantage to force doctors into diagnoses that resulted in extended, expensive albeit shared, drug expenditures.)

Yet, in a culture where people are so frequently exposed to pollutants, we were surprised to find that few doctors merited testing for or asking about exposure to pesticides or toxins such as lead based products. Exposure to such toxins has been consistently linked to delinquency, aggressive behavior and attention- defect

Likewise, we were surprised to find so few doctors merited asking about family history and the incidence of genetic disorders running in the family. ADD/ADHD symptoms can be symptoms of any number of disorders that run in the family. They are often subtle and initially are indicated by hyperactivity, attention disorders and learning disabilities. This would explain why so many families experience similar behaviors across the generations. It does not have to mean ADD/ADHD is itself a genetic disease

In addition, in a culture renowned for its 'junk food' eating habits, we were surprised to see so few doctors exploring the effects of sugar, caffeine, nutritional supplements and allergies on a particular child's behavior or conducting Glucose Tolerance testing

It is known that children today consume enormous quantities of sugar and caffeine in the form of Cola drinks and candy. These substances, in their refined forms, offer no vitamins, minerals, fiber or nutritional benefit of any kind. They are literally considered by many nutritionists to be poisons, which can over time cause physical and mental dysfunction. To illustrate the extent of nutritional deficiency in America's children the national Cancer Institute revealed that only one percent of all children between the ages two and nineteen were meeting experts recommendations for intake of grains, vegetables, fruits, meats and dairy. Sixteen percent didn't meet any at all. Forty percent of these children's calories came from fats and sugars added to foods

Further, the AMA has linked sugar to Obesity and Diabetes and the Centers for Disease Control estimate that more than five million people are undiagnosed sufferers of Type 2 Diabetes and half of all children in America are overweight. Of these, hundreds of thousands are children with pre-Diabetes or undiagnosed Diabetes. Symptoms of early-stage Diabetes include depression, aggression, mental confusion, attention problems and anxiety. Being overweight can also cause physical and psychological problems. All of these symptoms are closely associated with behavior that the DSM 4 criteria consider indicative of ADD/ADHD

Therefore, we believe that while many doctors are administering extensive tests and questions, they are missing out in key areas

Those key areas may vary according to the doctor and the field in which he/she is a medical professional. This is not surprising considering the focuses medical professionals are required to take

The process of specializing that is so familiar to our modern culture inevitably detracts from the ability to view a problem or sets of problems holistically. Thus, a Psychologist trained to administer psychological tests and ask behavior related questions would tend to see problems in psychological terms

In contrast, a Pediatrician or even a General Practitioner will tend to approach the problem form a more physiological perspective. Thus, they might conduct a cardiac test or ear, nose and throat exam but fail to take into account the insidious psychological effects of bullying or divorce in the family, possibly linked to aggressive behavior or withdrawn and uncooperative attitude at school. To this end many doctors may be conforming to each other, to the extent they believe it is appropriate to conform within their field of expertise

Overall, it seems most medical professionals are conducting proper diagnosis according to the DSM 4 guidelines and in accordance with their own best interpretations of the associated causes, as they understand them through their own training. Such a complex and mysterious disorder as ADD/ADHD demands a lot of those who diagnose it. However, we believe it is the failure of a medical and social culture to approach such problems holistically that is contributing to much of the confusion outlined in the NIH declaration

We believe that this study indicates another way in which our modern culture tends to fight its complex, related problems with specialized 'magic bullets'. The ever widening use of generic 'wonder drugs' such as Ritalin or Prozac based on the 'lumping' of symptoms, seems to support the validity of this view. This is a trend that cuts across all socio-economic barriers to one extent or another. It is our conclusion that this is a potentially damaging trend, particularly to those who are in no position to challenge it. Many of these people are children currently being diagnosed with ADD/ADHD and starting on a long, sometimes lifelong course of powerful medication

For this reason, we believe that the confusion and lack of consensus in the diagnosis of ADD/ADHD and therefore the potential for widespread misdiagnosis warrants considerable oversight. We recommend that review of medical criteria such as those given in DSM 4 be extensive and inclusive. We recommend that corporations such as Ciba- Geigy should be closely monitored in their efforts to lobby for a re- classification of Ritalin to a drug schedule permitting limitless production. We recommend that psychologists and physicians should be encouraged to adopt a more restrained approach to Ritalin (and other drug) treatments. We recommend that a more holistic approach be taken to the diagnosis and treatment of such disorders. This may involve the alteration of some aspects of medical training, encouraging more interdisciplinary and cross-disciplinary evaluation

Policy that would be affected by discussion of such recommendations includes policy toward medical training and drug production, but also in regard to ethical and legal issues. For example, if such recommendations were to be rejected and psychopharmacology, involving the use of drugs such as Ritalin and Prozac, continues to expand then our culture and our legal system will be forced to reassess our concepts of personal responsibility and deviance. For example, if a child is diagnosed with ADHD but its family is uninsured and cannot afford to pay for medication, what fault is it of the child who commits aggressive or deviant acts? Who should pay for the damage to society? Who should pick up the tab to keep a child from committing unfortunate acts for which he/she cannot be held accountable?

If such recommendations should be widely accepted, policy must be shaped to decide how best to achieve a balance between holism and specialism. How do we protect children from misdiagnosis and unwarranted medication and preserve their ability to approach life's problems drug free? At the same time, how do we do this while preserving children's rights to proper and appropriate medication? How do we educate and legislate to ensure such protections? These are questions that require ongoing consideration and as always further research

It is our opinion that these questions will be more widely and rigorously discussed in the near future. The interest of parents, the dedication of doctors and the coming of age of drug dependent millions will make sure of it. We hope this ongoing discussion will expose those elements of shared ignorance and build on those elements of collective wisdom. We hope this study contributes in some small way to the development of this discussion, and we believe each one of us, whether policymaker, parent, patient or practitioner has a vested interest in continuing to take part.


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