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Doctor: ADHD Does Not Exist

Doctor: ADHD Does Not Exist

    Dr. Richard Saul
    March 14, 2014

Over the course of my career, I have found more than 20 conditions that can lead to symptoms of ADHD, each of which requires its own approach to treatment. Raising a generation of children—and now adults—who can't live without stimulants is no solution.

This Wednesday, an article in the New York Times reported that between 2008 and 2012 the number of adults taking medications for ADHD has increased by 53%, and that in the case of young American adults, it has nearly doubled. While this is a staggering statistic, and points to younger generations becoming frequently reliant on stimulants, frankly, I’m not too surprised. Over the course of my 50-year-long career in behavioral neurology and treating patients with ADHD, it has been in the past decade that I have seen these diagnoses truly skyrocket. Every day my colleagues and I see more and more people coming in claiming they have trouble paying attention at school and at work, and diagnosing themselves with “ADHD.”

And why shouldn’t they?

If someone finds it difficult to pay attention or feels somewhat hyperactive, “Attention-deficit and Hyperactivity Disorder” has those symptoms right there in its name. It’s an easy, catch-all phrase, which saves time for doctors to boot. But can we really lump all these people together? What if there are other things causing people to feel distracted? I don’t deny that we, as a population, are more distracted today than we ever were before. And I don’t deny that some of these patients who are distracted and impulsive need help. But what I do deny is the generally accepted definition of ADHD, which is long overdue for an update. In short, I’ve come to believe based on decades of treating patients that ADHD — as currently defined by the DSM and as it exists in the public imagination — does not exist.

Allow me to explain what I mean.

Ever since 1937, when Dr. Charles Bradley discovered that children who displayed symptoms of attention-deficit hyperactivity responded well to Benzedrine, a stimulant, we have been thinking about this “disorder” in almost the same way. Soon after Bradley’s discovery the medical community began labeling children exhibiting these symptoms as having “minimal brain dysfunction,” or MBD, and treating them with the stimulants Ritalin and Cylert. In the intervening years, the Diagnostic and Statistical Manual of Mental Disorders, or DSM, changed the label numerous times, from “hyperkinetic reaction of childhood” (it wasn’t until 1980 that the DSM-III introduced a classification for adults with the condition), to the current label ADHD. But regardless of the label, we have been giving patients different variants of stimulant medication to cover up the symptoms. You’d think that after decades of advancements in neuroscience, we would shift our thinking.

Today, the fifth edition of the DSM only requires one to fulfill five of eighteen possible symptoms to qualify for an ADHD diagnosis. If you haven’t seen the list yet, look it up. It will probably bother you. How many of us can claim we have difficulty with organization, or a tendency to lose things; that we are frequently forgetful, distracted, or fail to pay close attention to details? Under this subjective criteria, the entire U.S. population could potentially qualify. We’ve all had these moments, and in moderate amounts, it’s a normal part of the human condition.

However, there are some instances in which attention symptoms are severe enough that patients truly need help. Over the course of my career, I have found more than 20 conditions that can lead to symptoms of ADHD, each of which requires its own approach to treatment. Among these are sleep disorders, undiagnosed vision and hearing problems, substance abuse (marijuana and alcohol in particular), iron deficiency, allergies (especially airborne and gluten intolerance), bipolar and major depressive disorder, obsessive compulsive disorder, and even learning disabilities like dyslexia, to name a few. Anyone with these issues will fit the ADHD criteria outlined by the DSM, but stimulants are not the way to treat them.

“What’s so bad about stimulants?” you might be wondering. They seem to help a lot of people, don’t they? The aforementioned article in the Times mentions that the “drugs can temper hallmark symptoms like severe inattention and hyperactivity but also carry risks like sleep deprivation, appetite suppression and, more rarely, addiction and hallucinations.” But this is only part of the picture.

Firstly, addiction to stimulant medication is not rare; it is common. The drugs’ addictive qualities are obvious. We only need to observe the many patients who are forced to periodically increase their dosage if they want to concentrate. This is because the body stops producing the appropriate levels of neurotransmitters that ADHD meds replace — a trademark of addictive substances. I worry that a generation of Americans won’t be able to concentrate without this medication; big pharma is understandably not as concerned.

Secondly, there are many side-effects to ADHD medication that most people are not aware of: increased anxiety, irritable or depressed mood, severe weight loss due to appetite suppression, and even potential for suicide. But there are consequences that are even less well-known. For example, many patients who are on stimulants report having erectile dysfunction when they are on the medication.

Thirdly, stimulants work for many people in the short-term, but in cases where there is an underlying condition causing them to feel distracted, the drugs serve as Band-Aids at best, masking and sometimes exacerbating the source of the problem.

In my view, there are two types of people who are diagnosed with ADHD: those who exhibit a normal level of distraction and impulsiveness, and those who have another condition or disorder that requires individual treatment.

For my patients who are the former, I recommend that they eat right, exercise more often, get eight hours of quality sleep a night, minimize caffeine intake in the afternoon, monitor their cellphone use while they’re working, and most importantly, do something they’re passionate about. As with many children who act out because they are not being challenged enough in the classroom, adults who have work or class subjects that are not personally fulfilling, or who don’t engage in a meaningful hobby, will understandably become bored, depressed, and distracted. Similarly, today’s standards are pressuring children and adults to perform better and longer at school and at work. I too often see patients who hope to excel on four hours of sleep a night with help from stimulants, but this is a dangerous, unhealthy and unsustainable way of living long-term.

For my second group of patients, who have severe attention issues, I make them undergo a full evaluation to find the source of the problem. Usually, once the original condition is found and treated, the ADHD symptoms go away.

It’s time to rethink our understanding of this condition, offer more thorough diagnostic work, and help people get the right treatment for attention deficit and hyperactivity.

Dr. Richard Saul is a Behavioral Neurologist practicing in the Chicago area. His book, ADHD Does Not Exist, is published by HarperCollins.

23 Responses
Avatar universal
Not sure I can agree with this Dr fully but I do think it is being over diagnosed and medication given when it should not be given.
973741 tn?1342346373
Rather insulting to all the parents that are doing the best to help their child 'feel' better by making the difficult choice to go through an evaluation process, have their child diagnosed and then have chosen medication to help them.  I'm sure there are many that do 'jump' to this diagnosis to perhaps have an easier life caring for their kids but the reality of parenting a child with a neurological health issue is that it is exhausting and confusing and something that parents who don't have kids like this don't understand.  I feel for these parents and find it horrible that this doctor will add to a stigma that does exist regarding children with ADD/ADHD.  

What can help families is for doctors to be responsible.  To not cave to parents who have read online information and then diagnosed their child themselves or listened to teachers exclusively when they aren't seeing the symptoms themselves.  I do believe the guidelines for diagnosis should be stringent and for kids especially, based on school observations and testing.  And there is an educational component that is missing in an ADD/ADHD diagnosis.  That physical activity can slow and calm the nervous system is something that many parents don't realize or make the effort to work on.  Schools as well.  They take recess away from kids who have a tough time in school when running around on the playground is exactly what might help a student stay calm and focus better.  Kids need movement breaks and exercises to help with staying calm and focused but with all the screaming about curriculum and states tests, they don't have time.  All of this would help----  so feel education would greatly benefit those parents who feel their kids have add/adfhd/ schools dealing with kids they feel may have this and young adults who are having trouble in college and beyond.  

Doctors could do a much better job with that piece of the ADD/ADHD puzzle.  

Stimulant medication works on children with ADD/AdHD and makes a noticeable difference.  They focus and are calm.  When the meds wear off, not so much.  People without add/adhd are revved up when they take stimulants.  It's a noticeable difference in reaction and one this doctor doesn't touch on.  Really off the mark in my opinion to say that the disorder does not exist at all and I hope that the public ignores him as the last thing we need is to back track in intervention with our kids.  

I've been fortunate to never have to make that difficult decision to medicate my kids.  But I would do what is in their best interest if that were to arise.  And for some people, that is being diagnosed and taking medication.  

Anyway, to me --  this sounds like a doctor trying to be controversial in a big way to sell books.  
Avatar universal
I really didn't see anything insulting to parents in the article. I do believe that the title of his book was chosen to create controversy and stimulate sales and I do think that was a poor choice. I don't know enough about ADHD to know whether his basic premise is sound but I think he does make an argument that ADHD may be an over-used and not well supported diagnosis.
973741 tn?1342346373
I'm not sure if 'insulting' is the right word if I said that.  I just think that parents with kids diagnosed with ADD/ADHD are under a lot of pressure.  Most are doing the best they can and may even be conflicted by the diagnosis.  And judgment from others for having a child diagnosed with this is rampant.  I've experienced people saying rude comments to me regarding my son and his behavior when he was younger that what he REALLY needed was a good spanking.  This minimizing of the challenges a child that has something like ADD/ADHD and their parents face is upsetting to me as a parent that has been there.  I feel for parents in that position.  I guess I'm lucky as my sons don't have that particular diagnosis and don't need any medication ----  but if they did, I would find this to be troubling that a doctor was making such a blanketed statement to the public.  One can argue that ADD/ADHD is over diagnosed but to say it doesn't exist?  That is irresponsible in my opinion and doesn't make the job of a parent with an ADD/ADHD kid any easier.  

But lots of things are over diagnosed.  Sinus infections are actually quite rare but doctors give antibiotics for it all the time to get patients who just paid a copay out of their office as an example.

I do think there is a subgroup of people that abuse the system as ADD/ADHD is covered under the disability act and families will have all their kids diagnosed with it after one has been in order to receive those disability checks.  I find that outrageous and awful.  

But the general parent that is trying to help their child----  I think it is a shame to have someone trying to belittle the diagnosis their child has been given.  I don't really know many who take diagnosing their kid lightly.  

I have a niece that was diagnosed with ADD as a freshman in high school.  ADD is much harder to spot because it doesn't have that hyperactivity component.  She's now a sophomore in college and doing well when she'd struggled all those years leading up to high school.  She believed she was dumb.  Her parents chose to give her medication and her whole world changed because FINALLY her nervous system wasn't derailing her.  That is such a success story in my mind.  And her parents struggled with it initially.  People like this doctor would have to explain why it is bad that this girl received a diagnosis, was treated and is now so much happier and excelling for me to give them any credibility.  

And that's the main thing.  His title of his book destroyed his credibility for the 'rest of his story' in my eyes.  
Avatar universal
I get it.
649848 tn?1534637300
"In short, I’ve come to believe based on decades of treating patients that ADHD — as currently defined by the DSM and as it exists in the public imagination — does not exist."  

I didn't understand him to say that ADHD doesn't exist at all, I understood him to say that it doesn't exist, as it's currently defined, and in that sense, I'd tend to agree with him.  

While I fully understand, and agree with, SM's contention and concern, that children who actually have ADHD definitely need to get the proper treatment for it, I've also known/read about children put on the medication for ADHD when they didn't need it.  Same goes for adults.  We've had people come to the thyroid forum and say they'd been diagnosed with ADHD and/or depression, when what they really needed was proper thyroid testing and adequate hormones.

My own son was quite hyper when he started school and he had a hard time paying attention and concentrating, in class.  ADHD wasn't a recognized condition, at that time, or he'd probably have been diagnosed with it; it was suggested that he be put on drugs for his hyperactivity and we declined.  His turned out to be a two-fold problem, with the first being that, unbeknownst to us, he was having trouble seeing clearly; once we got him glasses, he calmed down considerably, but not enough to suit the teachers.  He was diagnosed with diabetes at the age of 10, which made things that much worse, but had nothing to do with ADHD.

I think there needs to be more education about ADHD (maybe even change the name?), so that everyone will look for those root problems and eliminate them/rule them out, before tacking on an ADHD diagnosis.  I also think that with proper education, some of the "stigma" of such a diagnosis would disappear.  I used to work in a classroom with children who had, both, neurological and emotional disorders, so I'm well aware that there are many children out there who really do need the diagnosis and the meds.

I think with a better understanding and redefining the condition, the people who have it, will get the treatment they need and those who don't really have it would get the treatment for whatever their issues are, whether it be a thyroid condition, or other conditions that cause difficulty concentrating, hyperactivity, brain fog, etc.  
Avatar universal
Gender Identity Issues Linked to Autism, ADHD

Kathleen Louden
March 17, 2014

Children and teens with autism spectrum disorder (ASD) or attention-deficit/hyperactivity disorder (ADHD) are much more likely to express a wish to be the opposite sex compared with their typically developing peers, new research shows. But at least 1 expert is sceptical.

The single-center study showed that compared with normally developing children, young people with ASD were nearly 8 times more likely to express a desire to be other than their biological sex — a phenomenon the authors describe as "gender variance." Those with a diagnosis of ADHD had more than 6 times the odds of communicating gender variance, according to parent-reported data.

"Doctors, whether general care or specialists in autism or gender identity, should be aware that a co-occurrence of these conditions is not uncommon," John Strang, PsyD, the study's lead author and a pediatric neuropsychologist at Children's National Medical Center in Washington, DC, told Medscape Medical News.

These findings, said Dr. Strang, confirm previous research suggesting that autism is overrepresented among children referred for management of gender identity disorder and gender dysphoria.

According to the investigators, the study is the first to compare the occurrence of gender identity issues in children with neurodevelopmental disorders against typically developing children and is the first report of a possible connection between ADHD and gender variance.

The research was published online March 12 in Archives of Sexual Behavior.

No Prevalence Difference in Males and Females

Through a chart review of patients in a hospital's pediatric neuropsychology program, the researchers tracked the parents' responses to the Child Behavior Checklist (CBCL) item "wishes to be the opposite sex."

Responses of "sometimes" or "often" were compared with responses of "never." The investigators excluded participants from the study if the hospital's gender identity clinic had referred the child.

Included in the study were 389 patients aged 6 to 18 years who had 1 of 4 neurodevelopmental disorders: ASD (n = 147), ADHD (n = 126), epilepsy (n = 62), or neurofibromatosis 1 (n = 54). The latter 2 conditions made up the medical neurodevelopmental disorder group. Each of these groups was compared with 165 control individuals from the local community who had no identified neurodevelopmental disorders and with normative data of 1605 nonreferred participants in the CBCL standardization sample.

Approximately 5% of the children with either an autism disorder or ADHD expressed gender variance to their parents. Significantly more patients with ASD (P = .003) or ADHD (P = .005) had parent-reported gender variance than local control individuals, whose parents reported no gender variance. Both groups also showed significant differences compared with the CBCL comparison group (0.7% gender variance).

Gender variance reportedly occurred equally in male and female patients after the investigators controlled for the high male-to-female ratios in the ASD and ADHD groups.

Dr. Strang said they were initially surprised to find an overrepresentation of gender variance among children with ADHD. However, they later realized that prior studies have shown increased levels of disruptive behavior and other behavioral problems among young people with gender variance.

Despite the overlap the investigators found with regard to gender variance and ADHD or autism, Dr. Strang cautioned that a child's expressing a desire to be the opposite sex does not imply a diagnosis of persistent gender dysphoria or gender identity disorder.

He did recommend, however, that healthcare professionals who treat children and adolescents with ASD or ADHD ask parents whether their child has expressed a wish to be the other sex, as part of the CPCL or another questionnaire.

"We want to help kids who struggle with both [gender variance and a neurodevelopmental disorder] get the help and support they need," Dr. Strang said.

The study findings underscore the need for more research into gender variance in neurodevelopmental disorders, including obtaining self-reports from children and adolescents, he added.

High Prevalence Disputed

Commenting on the study for Medscape Medical News, Eric Butter, PhD, a psychologist and associate director of the Child Development Center at Nationwide Children's Hospital in Columbus, Ohio, said, "I'm not ready to say that kids with autism spectrum disorder have a higher prevalence of gender variance. We don't know that from this research."

A study limitation was the use of parent-reported data, according to Dr. Butter, who was not involved with the research.

"Parents will respond to that question ["wishes to be the opposite sex"] from their own experience and their own cultural expectations of gender," he said. "Does a response of 'wishes to be the opposite sex' mean a little girl likes to play with trucks and a boy likes playing with dolls, or does it mean a child is uncomfortable with his or her gender and wants to be the opposite sex?"

That ambiguity may account for the high prevalence — 5.4% — of combined gender variance and ASD found in the study, Dr. Butter suggested.

"At our large regional clinic," he said, "some children presenting with ASD also present with gender variance, but it's a very small percentage, not anywhere near what the authors found."

On the basis of this single-center, chart-review study, Dr. Butter said he could not recommend acting clinically or changing practice at this time.

"This research is interesting and important because it opens a conversation about gender identity. We should make sure we are treating the whole child, no matter what the neurodevelopmental disorder is."

Dr. Strang and Dr. Butter have reported no relevant financial relationships.


Also see abstract of article:

Avatar universal
Stimulants Likely Behind ADHD-Obesity Link

Megan Brooks
March 17, 2014

Treating attention-deficit/hyperactivity disorder (ADHD) with stimulants changes growth trajectories in childhood and is likely to be behind the reported association between ADHD and obesity, a new study suggests.

The study showed that children with untreated ADHD or ADHD treated without stimulants had a faster increase in body mass index (BMI) than those without ADHD. Conversely, children with ADHD treated with stimulants demonstrated slower BMI growth early in childhood, but they rebounded later in adolescence with higher BMIs ― higher than in children without a history of ADHD or stimulant use.

"Given the rapid increases in both ADHD diagnosis and stimulant treatment over the past decades, our findings might suggest to clinicians that long-term impacts on childhood and adolescent BMI growth trajectories, and perhaps continuing into adulthood, may result from stimulant use in childhood," Brian S. Schwartz, MD, from Johns Hopkins University Bloomberg School of Public Health in Baltimore, Maryland, and the Geisinger Center for Health Research in Danville, Pennsylvania, told Medscape Medical News.

The study was published online March 17 in Pediatrics.

Strong, Consistent Link

There is substantial evidence linking stimulant use to growth deficits, and there is some evidence of growth delays in ADHD. However, "increasingly, and paradoxically," concerns have been raised about a possible link between ADHD and obesity, the investigators note. They add that this is the first longitudinal study to examine associations between ADHD and stimulant use on BMI growth trajectories.
Dr. Brian Schwartz

Dr. Schwartz and colleagues examined electronic health record data from the Geisinger Health System on 163,820 children aged 3 to 18 years. They used random effects linear regression models to determine BMI trajectories in relation to ADHD diagnosis, age at first use of stimulant medication, and duration of stimulant use, while controlling for confounding variables.

They found that children with unmedicated ADHD had faster rates of BMI growth after about age 10 years compared with control individuals with neither a history of ADHD nor stimulant use. Children with ADHD treated with stimulants had reduced rates of BMI growth in early to mid childhood, but they experienced a rebound in BMI in late childhood and an acceleration in BMI growth after that, leading to BMIs in late adolescence that were higher than those in the control individuals.

The data are "quite consistent and strong in implicating stimulant use for ADHD in changing childhood BMI growth trajectories," Dr. Schwartz told Medscape Medical News. "We found that the earlier in childhood that stimulants were started and the longer they were used, the stronger were the effects in producing both delayed BMI growth in early childhood and rebound BMI growth in late adolescence," he said.

"These kind of 'dose-response' relations are very important in causal inference and quite persuasive to epidemiologists. This BMI growth rebound has not, to my knowledge, been previously reported, so requires replication," Dr. Schwartz added.

In the study, the investigators note that their findings "should motivate greater attention to the possibility that longer-term stimulant use plays a role in the development of obesity in children."

Metabolic Stressor

Commenting on the study for Medscape Medical News, L. Eugene Arnold, MD, professor emeritus of psychiatry, Ohio State University in Columbus, said that it is "interesting and fits" the developmental origins of health and disease (DOHaD) hypothesis.

This hypothesis holds that an "unfavorable uterine environment (eg, gestational smoke exposure) both predisposes to ADHD and also tricks an epigenetic transformation to thrifty phenotype in anticipation of an unfavorable postnatal environment. The calorie-saving metabolic changes then lead to large size after encountering a more favorable environment postnatally than the genes 'expected,' " he explained.

"By showing that stimulant treatment makes this worse, the article extends the DOHaD hypothesis to a postnatal metabolic stressor, the appetite suppression of stimulants, with a similar rebound after that appetite suppression is taken away," Dr. Arnold said. However, it is important to remember that this is a hypothesis and is not proven, he added.

163305 tn?1333672171
Nowadays my son would be called ADHD. He had a hard time sitting still as a kid however that didn't stop him from going to Cornell and doing quite well for himself as a young man.

I do think labeling people can be problematic. No doubt some kids are labels ADHD when they are simply energetic and don't like sitting still at a desk in school. That doesn't mean there aren't kids who genuinely have problems that need to be treated.
973741 tn?1342346373
Labeling my child allowed was one of the best things if not THE best thing I ever did for my son.  His label isn't on his head---  it's a diagnosis that came with a good plan on how he could overcome his challenges or at least learn to cope.  

I think that those that see this as something they can 'kind' of relate to probably had kids that were lively, energetic and strong willed.  That is much different than meeting the criteria for a developmental delay or neurological issue.

My son is pretty successful at this point (only 10) but I attribute it to all the help he was given early on.  

What really drove me into action to getting to the root of what was going on with my son was when he was 4 years old and I went to preschool to observe things for myself.  He WAS different.  And alone.  Kids with ADHD and Sensory Integration Disorder (my son's delay) very often have significant social issues with peers.  When I was talking to my son after school --  he said something that has never left me.  At four, he said "I want to be one of the guys".  I never pursued labeling/diagnosing my son to please anyone such as a teacher, school director, or myself . . .  I did it because he was sad feeling different.  The tools and things we learned in our journey have helped him fulfill his goal of being 'one of the guys' and not feeling so different from the other kids.  

That label is worth a million dollars to me.  AND, he has done well enough that he hasn't needed much intervention at all in elementary school but I meet with every teacher before the school year explaining his diagnosis, explaining what she/he might see and what they need to know about my son's developmental delay.  I'm not ashamed of it and personally think that information regarding my kid is power.

Anyway, clearly a subject I care greatly about and have seen it from the personal side of caring for my own son as well as prior to having kids . . .  all my preconceived notions about it.  

Sadly, everyone uses ADHD like a cliché these days . . .  why did I forget to mail that bill . .. oh, must have been my ADHD again.  So sad for those that really do have this disorder.

So, my wish is that all kids get what they need to succeed or have a happy life being 'one of the guys' or gals . . .   even if that means they needed a diagnosis to do it (like my son).  
973741 tn?1342346373
Interesting read on the gender identity issue.  Hadn't seen anything on this.  I wonder if some of the responses had more to do with a general displeasure with who these kids were in general as a common thread with many ADHD kids and those with developmental issues is a poor sense of self.  Anxiety and depression are very common overlapping conditions.  And children have a difficult time verbalizing this.  Always feeling like you wanted to be someone else when growing up can certainly take a toll.  

I think the end of the article generally states that this information would have to be much more widely seen for it to have any place in diagnosing/working with those either on the spectrum or with adhd.  

I also thought that pointing out the ambiguity of the questions was important.  I had a son who played with a ballerina Barbie when 2 as she twirled around and he would spin in circles to self sooth.  Guess he could relate.  At 2, he might have told you he wanted to be a ballerina Barbie when he grew up.  At 10, he'd tell you girls have cooties and he wouldn't be caught dead in pink.   Time will tell what the final verdict was although I have a really good idea.  

Anyway, interesting read and we'll have to see where this kind of research goes.  
973741 tn?1342346373
Ran across this today and thought I'd add it to the mix of information given here.



WEDNESDAY, Oct. 24 (HealthDay News) -- A few minutes of exercise a day can help children with attention-deficit/hyperactivity disorder (ADHD) do better at school, according to a small new study.

The findings suggest that exercise could provide an alternative to drug treatment. While drugs have proven largely effective in treating children with ADHD, many parents and doctors are concerned about the medications' side effects and costs.

The study included 20 children with ADHD and 20 children without the disorder, ages 8 to 10, who for 20 minutes either walked briskly on a treadmill or sat and read. The children then completed a short reading comprehension and math test, and also played a computer game that assessed their ability to ignore distractions and focus on their goal.

All of the children performed better on both tests after exercising, according to the study published Oct. 16 in the Journal of Pediatrics.

This study shows that a single session of exercise can help children with ADHD ignore distractions and focus on a task. This type of "inhibitory control" is one of the main challenges faced by people with ADHD.

"This provides some very early evidence that exercise might be a tool in our nonpharmaceutical treatment of ADHD," study leader Matthew Pontifex, an assistant professor of kinesiology at Michigan State University, said in a university news release. "Maybe our first course of action that we would recommend to developmental psychologists would be to increase children's physical activity."

The findings support calls for schools to provide students with more physical activity during the school day, Pontifex added.

-- Robert Preidt



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