Adhd Presentation

Proceeding with Caution: “Rethinking the ADHD Diagnosis”

Presented By: Luke Ibach and Josh Kakar

April 1, 2009Psychology 493

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Proponents of the ADHD Diagnosis

• Joseph Biederman - a Harvard child psychiatrist who believes that ADHD is real. Says 8-12% of all American children have the disease.

Proponents of the ADHD Diagnosis

• Russell Barkley - a research professor at SUNY Upstate Medical University in Syracuse. He reports that in a classroom with 30 students 1 in 3 will have ADHD.

Refuting their ideas • On the contrary, NIH reports that only about 3-

5 % of all American school children have been diagnosed with ADHD, which is considerably lower then Biederman’s 8-12% statistic.

• Biederman is also being investigated for failing to report almost 1.6 million dollars for consulting fees from drug makers.

• In one case Biederman falsely reported only receiving 3,500 dollars from Johnson & Johnson when he actually received over 58,000 dollars in grant money.

Critics of ADHD

• Thomas Armstrong - Argues that there is no definitive criteria to determine who has ADHD and who doesn’t. He also believes behaviors that test for ADHD are highly context dependent.

Critics of ADHD

• Peter Breggin – is a Harvard graduate who believes that stimulants are not the answer for ADHD. He claims that there is are no scientific studies that validate ADHD.

Growth of ADHD Epidemic

• 1970- 150,000 school children diagnosed• 1985- 500,00 • 1990- 1,000,000• 2000- 6,000,000

• Possible reasons for such a dramatic increase

ADHD Medicating Our Kids

• 8.3 million stimulant tablets prescribed in 1984.

• 38.4 million stimulant tablets prescribed in 2001.

• 56% of children that were diagnosed with ADHD were prescribed medication on the first Dr’s visit.

ADHD Statistics

• Boys are diagnosed with ADHD 3 times more often then girls.

• 1/3rd of children diagnosed with ADHD are also diagnosed with ODD.

• 1/4th of children with ADHD are diagnosed with CD.

• Overall about 1/3rd of children that have ADHD are also diagnosed with another disorder.

Introduction: What is ADHD?

DSM-IV Criteria: (A) Inattention or (B) Hyperactivity-Impulsivity• (A) Inattention: Six or more of the symptoms of inattention

have been present for at least 6 months to a point that is disruptive and inappropriate for developmental level:– Often does not give close attention to details or makes

careless mistakes in schoolwork, work, or other activities.– Often has trouble keeping attention on tasks or play

activities. – Often does not seem to listen when spoken to directly. – Often does not follow instructions and fails to finish

schoolwork, chores, or duties in the workplace.

Introduction: What is ADHD?(Continued)– Often has trouble organizing activities. – Often avoids, dislikes, or doesn't want to do things that

take a lot of mental effort for a long period of time.– Often loses things needed for tasks and activities (e.g. toys,

school assignments, pencils, books, or tools). – Is often easily distracted. – Is often forgetful in daily activities.

Introduction: What is ADHD?• (B)Hyperactivity-Impulsivity: Six or more of the following

symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for developmental level:– Often fidgets with hands or feet or squirms in seat.– Often gets up from seat when remaining in seat is

expected.– Often runs about or climbs when and where it is not

appropriate.– Often has trouble playing or enjoying leisure activities

quietly.– Is often "on the go" or often acts as if "driven by a motor".– Often talks excessively.

Introduction: What is ADHD?• (B)Impulsivity (Continued)– Often blurts out answers before questions have been

finished. – Often has trouble waiting one's turn.– Often interrupts or intrudes on others. – Some symptoms that cause impairment were present

before age 7.– Some impairment from the symptoms is present in two or

more settings (e.g. at school/work and at home). – Must be clear evidence of significant impairment in social,

school, or work functioning. – The symptoms are not better accounted for by another

mental disorder.

What is ADHD?

• ADHD, Combined Type: if both criteria 1A and 1B are met for the past 6 months

• ADHD, Predominantly Inattentive Type: if criterion 1A is met but criterion 1B is not met for the past six months

• ADHD, Predominantly Hyperactive-Impulsive Type: if Criterion 1B is met but Criterion 1A is not met for the past six months.

Criticisms of the ADHD Diagnosis: Reliability of Diagnosis

– Research shows low interater reliability of ADHD symptoms across countries, cultures, and even within cultures (Timimi et. al. , 2004)

– Specifically, rates vary by a factor of 10 from county to county within individual states in the U.S.

– A U.S. study showed that teachers rated 49% of boys as restless, 43% having short attention span and 43% as inattentive during conversations.

Criticisms of the ADHD Diagnosis: Reliability of Diagnosis

– An England Epidemiological study diagnosed only two children out of 2,199 with hyperactivity(.09%) (Armstrong, 1996).

– In contrast, a study in Israel found that teachers rated 28% of students as hyperactive

– 80% of patients diagnosed do not show symptoms in the physician’s office(Armstrong, 1996).

– Prevalence Estimates range between 1 – 20%

Criticisms of the ADHD Diagnosis: Subjective Ratings of Behavior

– The most common assessment includes a checklist of behavior and scales for the frequency of the behavior exhibited.

Ex: Scale rating of 1 – 5 (1 = almost never) and (5 = almost always)Items: “Restless(squirms in seat)”, “Fidgety(hands

always busy)”, “Follow a sequence of instructions”

Iowa Connor’s Teacher Rating Scale


• Children are rated by teachers and parents who have subjective biases, standards and expectations about their behavior.

• These authority figures may have a proclivity towards the ADHD diagnoses in order to keep children compliant in either the home or school setting, as a result of medication or special education placement.


• These subjective measures of behavior are limited in scope considering they do not take into account the context or environment in which the child is currently in during time of assessment

• A child may be a 5(almost always) on fidgetiness in one situation ( i.e. during school work) but a 1 at during more stimulating activities (i.e. recess, play time)

• Therefore, assigning one number for all contexts and environments is not fully representative of a child’s true behavior.


• One study compared ratings of parents, teachers, and physicians for 5,000 elementary children.

• 5% were considered hyperactive by one of the groups but only 1% were rated hyperactive by all 3 groups of raters.

• Another study revealed that agreement between mothers and fathers on their child’s diagnosis of hyperactivity was only 32%

• The study also showed that rating agreement between parents and teachers was even lower, at 13%.


• What is considered normal behavior in children?• Many normal children have problems with

fidgetiness and attention. So where do we draw the line?

• What about children at the other end of the spectrum, who are too compliant, and too focused? This issue is rarely addressed.

• These evaluations are purely subjective, prone to error and bias, and not objective in their design.

Criticisms:Objective Ratings of Behavior

• (CPTs) – Continuous Performance Tasks – Measure patient’s selective attention to the presence or absence of stimuli during sets of distracters.

• Ex: (GDS) – Gordon Diagnostic System – Patients press a button after specific sets of ordered digits have been flashed up on a computer screen. The number of correct responses and incorrect responses are recorded as “hits” and “ misses” respectively.

Criticisms of the ADHD Diagnosis: Objective Ratings of Behavior

• These tests of vigilance were developed to select promising candidates for radar operations during World War II.

• Although CPTs intend to present an objective measure of children’s selective attention, they only tell how the child will perform on repetitive, mundane, and non-stimulating tasks irrelevant to what children encounter in their real lives.

• Therefore, the validity of their current use with children today should be questioned.

Criticisms of the ADHD Diagnosis:Temperament

– Symptoms do not significantly differ from children who have normal variations in temperament (Carey, 1998).

– This is especially true when children are given the chance to choose their own learning activities and perform at their own pace. (Armstrong, 1996).

– Children with ADHD behave normally when exposed to interesting, novel, or stimulating tasks.

– 70% of children diagnosed find ADHD symptoms disappear upon reaching adulthood.

– Temperament research shows only about 50% of most populations sampled are attentive with the other 50% displaying below average attentiveness.

Criticisms of the ADHD Diagnosis:Temperament

• Currently, there is no supporting evidence for arbitrary cut off scores for abnormal levels of high activity and attentiveness (Levy, Hay, Mcstephen, et. Al., 1997).

• Although children with difficult temperament (low adaptability , negative mood) and low task orientation (high energy, low persistence-attention span, high distractibility) experience more social problems and poor academic achievement respectively, these traits do not lead to dysfunction on their own, but only when other environmental problems occur as well.

Criticisms:Co-morbidity

• Co-existing conditions with ADHD include:– Problems with parent-child interaction– Family violence– Parental Psychopathology– Anxiety Disorder – (25-34%)– Bipolar disorder - (18-60%)– Depression – (18-60%)– Learning disabilities – (12-60%)– Conduct Disorder - (35-60%)– Oppositional Defiant Disorder – (35-60%)

Co-morbidity• According to Pliszka (2000) most children who meet

the criteria for conduct disorder or oppositional defiant disorder will also meet the criteria for ADHD.

• Although medication is claimed to successfully treat all 3 conditions, Children with Conduct Disorder require additional intervention when there is also family psychopathology present.

• This raises an obvious question if ADHD is an adequate diagnostic category to explain the child’s functioning in other domains in life.

Co-morbidity

• Learning disabilities can cause inattention and frustration and mask the presence of ADHD(Furman, 2006).

• Although stimulants have been shown to improve reading scores, it is believed that these improvements are related to performances requiring repetition and concentration and not genuine learning.

Co-morbidity

• Although stimulants are used primarily to treat ADHD, they can be extremely harmful in treating co-morbid conditions such as mood disorders

• Stimulants used to treat depression and bipolar disorder can cause dysphoria and harmful mood dysregulation. (Furman, 2006).

• Clinicians who use stimulants to treat these co-morbid conditions must exercise extreme caution.

Co-morbidity• According to evidence-based perspectives,

Cognitive-Behavioral Therapy is the best known treatment modality for children with anxiety and ADHD.

• In addition, children with ADHD and anxiety disorder do not respond as well to stimulant medication.

• Unfortunately, symptoms of anxiety disorder are overlooked by providers and not considered during the assessment process as ADHD symptoms are probably more salient (Furman, 2006).

Co-morbidity

• The large amount of overlap between ADHD and other co-ocurring psychopathology provides additional support for the argument that ADHD is not a separate psychological or neurological condition.

Criticisms:The Disease Model Of ADHD

• ADHD is believed to be a neurodevelopmental brain disorder with biological predispositions and distinct etiology.

• Potential causes include chemical abnormalities( serotonin, dopamine, norepinephrine), neurological damage, lead poisoning, thyroid dysfunction, prenatal exposure to harmful substances, and delayed transmission of nerve impulses.

• Mechanistic view of human capacity, where the mind functions much like a machine.

Criticisms:The Disease Model Of ADHD

• Despite an emphasis on biological brain causes, no clear biological markers have ever been discovered in patients diagnosed with ADHD.

• According to Carey(1998), children with brain damage show no clear pattern of hyperactivity or inattention and children diagnosed with ADHD show no consistent structural, functional or neurochemical abnormality.

• Carey(1998) even points out that brain differences are present in healthy children who display variations in normal temperament.

The Disease Model Of ADHD• Timimi(2002) also points out that there is no medical

test to detect the presence of ADHD.• Neuroimaging studies have shown no clinical

abnormalities between the brains of children diagnosed with ADHD and age matched-control groups (Hynd & Hooper, 1995) (Baumeister and Hawkins, 2001).

• A Federal Government report on ADHD concluded that: “…there was no compelling evidence to support the claim that ADHD was a biochemical brain disorder” (National Institutes of Health, 1998).

The Disease Model Of ADHD• However, many studies that claim to show biological

evidence of ADHD have omitted important additional research that contradicts original findings. This notion is also reinforced by inaccurate media coverage.

• For example, a study by Zametkin et. Al, 1990 at NIMH found a link between reduced metabolism of glucose and adult hyperactivity.

• They concluded that deficits in the premotor and superior prefrontal cortex accounted for this inhibited metabolism of glucose.

The Disease Model Of ADHD

• Despite positive attention by departments of psychiatry and the media, an additional study by Zametkin et. Al, in 1993 found no significant differences between the brains of normal and hyperactive adolescents.

• This contradictory finding to the study was not reported by the media or the ADHD community.

Criticisms:Medication for ADHD

• Methylphenidate, dextroamphetamine, and methamphetamine are the most popular psychostimulant treatments for ADHD.

• An estimated “10-12 percent of all boys between the ages of 6 and 14 in the United States have been diagnosed as having ADHD and are being treated with methylphenidate.”

• Breggin(1998) estimates that 4-5 million children receive psychostimulants in the U.S. each year.

Criticisms:Medication for ADHD

• However, these medications produce toxicity and general excitation of the Central Nervous System.

• Have effects on neurotransmitters such as dopamine, norepinephrine, and serotonin.

• Symptoms such as increased energy, hyperalertness, and hyperfocus are reported.

• Other symptoms include insomnia, OCD, agitation, hypomania, mania, seizures, fatigue, lethargy, social withdrawal, and depression, irritability, anxiety, and emotional sensitivity.

Medication for ADHD• Firestone et. al (1998), found preschool children

ADHD who were treated with methylphenidate experienced greater social dampening effects when compared to a placebo group.

• Such sideffects included: – “Talks less with others” - increased from 21% to 50%– “Uninterested in others” – increased from 31% to 75%– “Sad/Unhappy” – increased 47% to 84%

– These findings are also consistent with those of Schleifer et. al. (1975) who also found “less social behavior and interaction, and increased solitary play” in ADHD children treated with methylphenidate.

Medication for ADHD• A study by Mayes and colleagues (1994) found that

children treated with methylphenidate were reported as “withdrawn, listless, depressed, dopey, dazed, subdued, and inactive”.

• This study also found that children suffered from somatic complaints including insomnia(13%), nausea or vomiting(11%), loss of appetite(20%), and headache(4%).

• Schachar et. al. (1997) concluded that affective symptoms develop in later stages of drug treatment are often missed in most short term drug studies.

Medication for ADHD• Firestone et al. (1998) also found increases in

nervous movements (“tics”) in children treated with stimulant medication, with an increase from 3% (placebo) to 12% in children on methylphenidate.

• Barkely et. al (1990) reported a 10% increase in abnormal movements in children treated with higher doses of methylphenidate.

• Borcherding et. al. found 58% of their medicated children demonstrated abnormal nervous movements, with one permanent case of “tics”.

Medication for ADHD

• Breggin, 1998b; Kessler, 1993; Leber, 1992 highlight 2,821 reports of adverse reactions to methylphenidate in the Spontaneous Reporting System:– 1. More than 150 reports of liver abnormalities– 2. Sixty Nine reports of convulsions, 18 specifically grand

mal.– 3. Eighty-seven reports of drug dependency, addiction– 4. Thirty reports of drug withdrawal– 5. Two hundred fifty reports of hair loss– 6.Fifty reports of leukopenia (low white blood cell count)

Medication for ADHD• According to Karch (1996) several studies now show

direct evidence that methylphenidate has cardiotoxic effects.

• Specifically, Henderson & Fischer (1994) studied the effects on mice and discovered toxic effects within 3 weeks after using only minimum doses

• Ishiguro & Morgan (1997) found that methylphenidate adminstered to ferrets at levels equal to clinical usage produced contraction problems in the heart muscles.

• FDAs Spontaneous Reporting System found 121 reports of cardiovascular problems, with 9 cardiac arrests and 4 hearts failures (Elinwood & Tong, 1996).

Medication for ADHD• According to the American Psychiatric Association

(1994), methylphenidate: “In clinical studies…produces behavioral, psychological, subjective, and reinforcing effects similar to d-amphetamine and cocaine.”

• “7% of Indiana high school students have used Ritalin non-medically at least once, and that about 2.5% of high school students use it on a monthly or more frequent basis” (Indiana Prevention Resource Center, 1998).

• Breggin (1998a) believes that over medicating children teaches them to exert less control over their actions and behavior.

Medication Research

• Much medication research has been questionable in it’s design.

• For example, the (MTA) NIMH Multimodal Treatment Study for ADHD had an abundance of errors in methodology yet claimed that stimulant treatment was superior to behavioral and community treatment.

• Peter Breggin offers a critical analysis of this study and points out many of it’s limitations

Medication Research• 1. The MTA was not a placebo controlled, double

blind clinical trial.– Investigators relied on ratings made by teachers and

parents who were not blind to the treatment - “Open label studies” which are often discredited.

• 2. The study used no control group of untreated children.– The study only compared 3 drug conditions to behavioral

treatments

• 3. Thirty-two percent of the Medication Management group was already taking medication before hand.– Created unequal participants for the study due to history

Medication Research

• 4. Blind classroom raters observed no difference between treatment groups– Although medication did not demonstrate any

superior benefits behavioral treatments, this finding was withheld from the studies’ conclusions

• 5. Drug treatments exceeded behavioral treatments in length of duration.– This bias could appear to make medication a more

effective treatment then behavioral treatments

Medication Research• 6. Children in the drug treatment group did not

rate themselves as feeling improved.– This important finding was also omitted from the

study’s conclusions as well• 7. All of the principal investigators were well

known drug advocates– Received funding from Richwood, Bristol-Myers,

Solvay, Wyeth-Ayerst, Glaxo, and Eli Lilly • 8. Parents and teachers were exposed to drug

propaganda. – Parents were told their children would be treated with

“safe effective doses of medication”

Overlooked Factors:Nutrition

• A nutrition approach takes longer to show results. “With dietary supplements you can see improvement in behavior in a week or two,” says Zimmerman. “A food approach is more of a long-term thing—a 30-day plan, for example.”

George Washington University

• A study by George Washington University found that hyperactive children who ate a meal high in protein did equally well or sometimes even better in school then non hyperactive kids

Fatty acids

• What are they?

What are some examples?

Where do you get them from?

Oxford University

• Oxford University found that the ADHD symptoms in children receiving essential fatty acids improved over children in a control group receiving a placebo


• Researchers further documented the essential fatty acid deficiency tie to Attention Deficit Disorder in a 1987 study. Then, a 1995 study comparing essential fatty acid levels in ADHD boys against a control group of boys without ADHD found significantly lower levels of Omega-3 fatty acids.


• In 1996 Purdue University researchers have found that boys with low blood levels of Omega-3 fatty acids have a greater frequency of Attention Deficit Disorder ADHD.

Food Coloring

• Study done by South Hampton University in UK

• EFSA’s advice given to ADHD parents

• Types of food coloring used

Overlooked Factors:American Culture

• Change in the cultural expectations of children– Children now are expected to behave in ways that

are not always developmentally appropriate– Many view these high expectations as an end to

childhood innocence, coupled with the fact that children are constantly exposed to adult information via media and television (Postman 1983).

– Children are now seen as a danger to society and need to be controlled, reshaped and changed.

Overlooked Factors:American Culture

• With more anxiety in place regarding childrearing, but also fear of state intervention in domestic affairs, ADHD offers a shift away from social dilemmas and onto the child. (Timimi, 2002).

• Parents feel economic pressures to work long hours leaving medication the most convenient “quick fix” treatment for ADHD and less time for family therapy approaches involving parent-child interaction (Furman, 2006).

Overlooked Factors:American Schools

• Public school system curriculums are tailored mainly towards academics such as reading, writing, arithmetic, and standardized testing, and leave less emphasis on creative and engaging activities.

• Thus, students who do no excel in these areas but in others such as the arts, physical activities, or hands-on kinesthetic learning are not in an environment that is conducive to their style of learning

Overlooked Factors:American Schools

• Therefore these students fall through the cracks and receive less assistance for their special needs of learning and are viewed as having a biological brain disorder.

Overlooked Factors:Alternative Treatment

• According to Breggin (2000), ADHD can be treated through means other than medication such as individualized family counseling and educational approaches to empower children, parents teachers and others.


• Applied behavior analysis is an overlooked yet effective method for improving behavior in school.

• According to Packard (1970), classroom attention can be achieved and maintained in students when teacher instruction is coupled with group contingencies.

• For example, in Packard’s (1970) study, the instructor turned on a red light-timer device whenever a student was not paying attention.


• When all students showed proper attention, the teacher turned off the device.

• Classrooms were rewarded with play activities upon maintenance of attention and teachers gave verbal feedback as to what percentage of the class paid attention. All students achieved 90-100% levels of classroom attention.

• Therefore, Packard (1970) concluded that it is possible to motivate students to pay attention when an appropriate and appealing reward system is implemented.

Improving the ADHD Epidemic(Carey) 2005

• 1. Improved diagnostic system - Distinctions must be made between hyperkinetic children, who are truly pervasively overactive or inattentive, and those primarily having other problems

• 2. Better research - Much is still unknown about the origin of ADHD and additional research is needed to adequately conceptualize and treat what appears not to be a biologically based psychological disorder.


• 3. More education of professionals and public – People need more information about important matters such as normal variations in temperament and the non-specificity and harmful side effects of stimulant medications.

• 4. Better evaluations – Children should undergo educational testing to rule out learning disabilities as the main cause of their behavior and also examine the child’s temperament and adjustment.


• 5. Improved treatment – Greater reliance on psychosocial and educational interventions. Treatments should also be geared to build on the child’s strengths and remediate their weaknesses.

• 6. Close monitoring of drug company advertising and promotion

• 7. Regulation of both medical diagnosis and teacher insistence on medication.

Conclusion

• ADHD should be questioned until more sound scientific evidence becomes available to consider it a distinct neurological condition.

• Parents and practitioners should remain skeptical of the disorder and be cautioned against a quick assignment to the ADHD diagnosis.

• The risks of medication and stigmatization are too harmful to unique children who hold so much potential.

The End Thank you for watching.

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