The great debate: does ADHD actually exist? - attention deficit hyperactivity disorder

Nutrition Health Review, Fall, 2002 by Julian Stuart Haber, Fred A. Baughman, Jr.

Yes, but it is overdiagnosed: Julian Stuart Haber, M.D., F.A.A.P.

Q. In your own words, define attention deficit with hyperactivity disorder (ADHD).

A. ADHD is a chronic disorder of the central nervous system that causes problems with attention spans, activity levels, and executive functions--which means organizational skills, sequential skills, self-monitoring, and social interaction. It must occur at least over more than one environment. By "more than one environment," we mean a young child at play, at home, in school, and in day care or an older child or a young adult in work. It has to have been present, by definition, by age 7 years. ADHD must be clinically significant; for example, if you have a list of symptoms and the child is making straight A's and B's, is doing well socially, is not having conduct problems at school, and is functioning well at home, that is not clinically significant. The condition must also cause problems beyond one's functional level. In other words, a child with a 95 IQ [intelligence score] who is making a lot of C's wouldn't be expected to make A's; therefore, this behavior shouldn't be called ADHD.

Q. Does ADHD actually exist?

A. Yes. There are many models. ADHD has been around for a long time--as far back as the 1930's or 1940's. Back then, it was called "minimal brain injury," which entailed poor coordination, learning disabilities, problems with attention span and impulsivity, and hyperactivity in executive function. In the 1960's, it was renamed "minimal cerebral dysfunction." All of these things were considered under one rubric at that time. In the 1970's, people started to break up ADHD into separate entities. Among these were learning disabilities, which were pulled off by the psychiatrists and the behavioral part of it called Attention Deficit Disorder initially, and then Attention Deficit Hyperactivity Disorder eventually, but we're still talking about the same clusters of kids. It occurs on two bases. ADHD itself is a bunch of symptoms that can occur with several different disorders, the attention span, the activity levels, and the impulsivity; for example, you can see that in depression, psychotic disorders, and other conditions. An entity that was called by these names before was the category labeled "neurogenic," a type that is passed on from family to family on what we call a "minor insult basis." For example, in groups of children who survive prematurity or in children with fetal alcohol effects or drug effects, you see this syndrome present in greater amounts. So yes, ADHD does exist; however, it is greatly overdiagnosed. Many children are labeled as having ADHD because the right diagnosis is not made, because the behavior might be a variant of normal, and because of overzealous professionals of all kinds.

Q. When was the ADHD diagnosis explosion?

A. The explosion occurred between the years 1990 and 2000, partly because corporations--not just drug companies but also nontraditional companies--were pushing it. Sometimes the literature, particularly the lay literature, spelled out the condition without really defining the parameters I explained earlier. Back in the 1980's, North Carolina, for example, indicated that, according to its Medicaid statistics, about 4.5 percent of children within the population had ADHD, or about 5,000 children. Of course, North Carolina grew in population, and in the next ten years it wound up with about 10 percent of its population [with ADHD]--about 20,000 children--but it was still roughly 10 percent of the overall population who had ADHD. So this rate had doubled. This is not terribly different than in 1990 to 1996; the amount of methylphenidate Ia central nervous system stimulant drug for ADHD] produced in the United States had increased six-fold.

Where did these newly diagnosed children come from? It might be parents who have had alcohol or drugs early on in their pregnancy. You have better medical technology. Years ago, when I was doing my training, if you had a 5-pound baby with respiratory distress, the child had a 50/50 chance of it making it; now it's a 100 percent chance. These surviving babies weigh 3 pounds and less, so that's another population. Leukemia was a death sentence years ago; now a lot of these young patients survive, but they have radiation to the brain, they receive chemotherapy to the spinal canal, and so forth. Thus, all these things have pushed us up on that "subtle insult" basis. On the other hand, many kids have other things wrong, and this may be called ADHD when actually the problem may be a variant of normal.

Q. Do you find that parents project ADHD behavior on to their children to get them medicated and docile?

A. Sometimes, yes. You might have teachers who don't want structure and do not do the things you need to do in a classroom. There a lot of very good teachers out there, please don't misunderstand, but you have some who take the easy way out. If a child has a learning problem, for some teachers it's a lot easier to say, "Let's put Billy on medication and see what happens," than to test the child to see whether the child has a learning problem or a learning disability in order to make an appropriate diagnosis and to give the child what he or she really needs, which is help in learning. Medicine may help for a short time, but if the child has difficulty learning, you're still going to have problems down the line. Part of the attention span problem is that the child doesn't understand what's going on; he or she is not being walked through it. The other thing we see now--a terrible problem--is the example I gave about the 95 IQ. We see parents who want their child, who really can't make A's, to make A's. The parents might put the child in high-powered schools with high achievers. The other children there are making good grades because they've got IQ's of 120 and they're learning two years ahead of themselves, whereas this poor kid can learn normally at an average level but is two years behind the other kids. These kids are tagged as having ADHD by the teachers at those schools, and the child gets tagged as having ADHD by the parents, and the parents then want you to put these children on medication. This is a terrible ethical issue.