An article is making its way around Facebook newsfeeds that reports Leon Eisenberg, "the scientific father of ADHD" made the startling deathbed confession that "“ADHD is a prime example of a fictitious disease.” It goes on to reinforce the idea that ADHD is a disease made up and propagated by pharmaceutical companies and physicians in the pockets of pharmaceutical companies, all with the end goal of making lots of money. Of course when I read this article, I knew I would be writing a blog about it.
I get to talk about this issue from both personal and professional perspectives. Let's tackle professional first. I'm a physician. My specialties are psychiatry and addiction medicine. My position on all illnesses/diseases/disorders is that ideal management is psychological and social, with the risk of medication taken only when the benefits of that medication supersede the risk. I should clarify that by all illnesses, I mean mental and physical. If your high blood pressure can be managed with diet, exercise and stress reduction, I would recommend trying that first, before reaching for a pill. Likewise, if your depression can be managed with therapy, healthy nutrition, exercise and stress reduction, let's try that before prescribing an antidepressant. The bar for starting medications is in a different place depending on the severity of symptoms and the impact on functioning. Even if you've never tried diet and exercise, if you come in with a blood pressure that is sky high and complaint of chest pain, I'm reaching for medication immediately. The same is true for depression. If you have suicidal ideations and a feeling that you are close to making an attempt -- of course, we need to look at psychosocial factors, but medication is going to be at the top of my list of interventions as well.
Because child and adolescent brains are still in critical developmental periods, my professional stance is that the bar for starting medications is higher. Yes, this flies in the face of research that recommends stimulant medications as a first line treatment, but my stance is that ideally, for a child with ADHD or any other illness physical or mental, you try environmental interventions first -- calm and structure the environment at home, behavioral therapy , family therapy, biofeedback, join forces with the teachers at school, make the school environment more accomodating, change the diet, increase physical activity, introduce mindfulness, evaluate and manage other emotional reactivity etc. etc. etc. (and even more etc). However, the fact is that many families don't have the resources to make those changes. They don't have the resources of time, money and access. Taking it a step further, many don't have the cognitive or emotional resources necessary to make the types of changes that would be effective. And so, do we leave them with nothing? Or in the absence of the ability to control symptoms with psychosocial interventions, do we offer a medication? I think you know what my answer is.
Yes, ADHD is over diagnosed. But that does not change the fact that undiagnosed ADHD is associated with increased physical injuries, drug addiction, early and lingering involvement with the legal system, early drop out from the educational system and possibly even an increased risk for premature death. It boils my blood when I see inflammatory articles like this one. Without question, the chaotic, poorly nutritional, crowded school environment that many of our children living in poorer communities experience is inflating the frequency of behavioral symptoms and causally -- the diagnosis of ADHD. Without question, our inability to tolerate boisterous children inflates it as well. Without question, pharmaceutical companies have made LOTS of money. And without question, there are physicians in the pockets of pharmaceutical companies -- acting more in the role of marketing consultants than stewards of good health. But to say ADHD doesn't exist, and to make medication the villain is a blatant refusal to look at the entire system.
I said I get to speak from two angles, and the second is that I'm a mother. My oldest son irrefutably has ADHD. Luckily, I was a psychiatrist and noticed that his behavior was not because he was a bad kid, but that there was likely something going on at the brain level. Luckily, we had the resources to pull him out of traditional school, put him in Montessori school and get a full psychological evaluation. Luckily, my husband and I had the cognitive and emotional resources to make the changes in our home environment that the psychologist recommended. Luckily, my son had teachers who are fully on board and understand his behavior rather than blame him. Luckily, he goes to a school that offers yoga and meditation. Luckily, our income allows us to afford soccer, track, swimming, drums, in-home internet for access to yoga videos and a treadmill in the house for those times when he urgently needs to burn off some energy. Luckily, we had the time, money, access, time, money, access, time, access and more time, money, and access. I believe directly as a result of that time, money and access, we are not on medications. But trust me, we are lucky that we can mitigate the risk of ADHD with all the other resources we have. If we didn't have those resources, the risk of his ADHD being untreated would far outweigh the risk of a medication and we would be taking a pill every day. In fact, he is 9 now, and we are not yet out of the woods. If at any point we are unable to continue to manage his ADHD and it begins interfering with his functioning, trust me, we will be getting a prescription -- STAT.
So yes, over diagnosis of ADHD is a problem. It's dangerous and it disproportionately affects children who live in poorer communities. And yes, there is definitely a system that is profiting off this diagnosis. However, to say that ADHD is a fictional diagnosis is just as, if not more dangerous than over diagnosing it. By creating this stigma, it removes responsibility to fix the system (disproportionate access to time, money and resources) and pushes more young people and families into a sinkhole where the help they need is inaccessible.