The history of psychiatry is filled with fads. A diagnosis quickly gains momentum, is pushed by thought leaders, captures the imagination of clinicians, picks up widespread media attention, and soon attracts word of mouth buzz among potential patients. Rates escalate. New and exciting treatments are hyped. Miracle cures abound.
And then it all comes apart. The miracle cures turn out to be much less than miraculous. The casualties of the new treatments get negative word of mouth notoriety. The excitement wears off and a few years later there is an epidemic of a new fad diagnosis, which temporarily lights up the firmament- before in its turn also dimming.
Big Pharma is the 800 pound gorilla that separates modern fads from previous ones. It has the big bucks, marketing savvy, and political muscle to create something from nothing in a way never before experienced.
Adult Attention Deficit Disorder is the current fad-du-jour. It needs to be killed before it multiplies beyond easy taming. The best person to provide insight is Keith Conners, the man who did the first studies on ADHD -- even before there was an official DSM diagnosis called ADHD.
Keith writes:
"How many adults have ADHD? This question is even more problematic than determining the prevalence of ADHD in children. Studies always give inflated rates because they all use flawed methodology- most commonly relying only on telephone surveys based on a checklist of ADHD symptoms. One study reported that over 16% had "sub threshold ADHD" and 3% met full criteria. This is ridiculously inflated because there was no direct interview or history taking to confirm that symptoms were really sufficient to qualify as ADHD. But that didn't stop the researchers from claiming misleadingly that ADHD is very common in adults.
A meta-analysis reviewing the available literature gives an upper limit of 2.5% rate and also points out that there are vast differences in the quality and methods used across studies. The real rate is probably much lower. And a longitudinal study lasting several decades found that a large group of children once diagnosed as ADHD in early childhood showed entirely normal behavior as adults,while another group once diagnosed as normal is now diagnosed as adult ADHD. This proves that adult ADHD is being overdiagnosed- since by definition its onset must be in childhood.
A few years ago while I was studying and treating children with ADHD, I suddenly began getting a deluge of adults claiming they had ADHD. I was familiar with the concept of adult ADHD from very early years when my colleague Paul Wender published a book about it. I was also well aware that some of the parents of children I saw in my clinic complained of ADHD symptoms in themselves or their spouse.
But the pace of adult referrals really picked up when two psychiatrists published a book about themselves and their patients with ADHD. It sold over a million copies. The book contained the personal stories of these two busy psychiatrists, but was not based on any research studies of their own.
Naturally I was interested enough to check these authors out and I went to a workshop presented by one of them. He showed up late, then fumbled with the audio and visual setup for a half hour, and proceeded to give a very disorganized talk filled with not very relevent anecdotes. I surmised he was probably indeed in big trouble, but from what I dared not guess.
Soon adults or college students showed up in droves at our clinic, many carrying the book, claiming they had ADHD. But there really were no medical guidelines at the time or instruments to rely upon. We could only apply our extensive experience doing developmental histories with our younger patients. There was a lot of talk in the literature, but little data from actual studies.
So I met with two of my colleagues for a brainstorming session. We made up a rather long list of symptoms and impairments from what was being claimed as adult ADHD. Then we went through the painstaking process we always used, first doing a pilot study, then gathering a national sample of normal adults and another sample of clinically diagnosed adults. We used factor analytic and other statistical techniques to derive the empirical clusters which predicted a diagnosis compared to normal adults. This laborious process took several years, but finally we had a rating scale that met rigorous standards of reliability and validity, using standard criteria set out for test construction by professional organizations and researchers. We also made sure that there was a separate version for ratings by a "significant other," since a self rating by itself has little validity.
A few years later, I learned to my horror that a big pharmaceutical company had lured esteemed colleagues into a quick and dirty process to capture the adult ADHD market for their drug, at home and abroad. It began innocently enough with an invitation to attend a round table discussion of Adult ADHD. The other attendees included a dozen or more experienced clinicians of ADHD, some of whom I had taught, several others well known for their many years of research on ADHD. The leader of this conference was a famous epidemiologist from Harvard who presented some of his findings from a large World Health Organization survey of health impairments. This included six items that sounded like ADHD. He then published a paper based on our discussions at the conference, which included my name.
Shortly after, I was browsing through an Internet medical site when I was horrified to see those six items in a drug company advertisement, urging adults to see their doctor for ADHD treatment. The company of course was the same one that sponsored the conference, and they were marketing their new ADHD drug.
Now I understood why that company had undertaken a large validity study of my rating scale in Europe, and then later invited me to a large conference in Vienna on Adult ADHD. As much as I love Vienna, I turned it down.
Meanwhile, I was now outraged to see that a brand new rating scale with those six items as a core was being used by three colleagues from the conference and distributed widely with instructions that one could just use those six items as they were the most significant. Of course they cautioned that the actual diagnosis had to include a clinical history. Several new drug trials were now underway using this unvalidated UN-NORMED new scale.
I know many of the clinicians now touting the scale to be fine doctors with great skills and common sense in diagnosis and treatment of ADHD. But I worry that others are now doing quickie diagnoses, seeing their endorsement as a license to line their pockets in the new field of ADHD adults. I also worry that most research is Pharma financed.
Mediocre and potentially hazardous drugs are being heavily pushed by a worldwide marketing blitz to sell docs who have little experience with ADHD. I have no doubt that this new massive influx of ADHD adults is being diagnosed in a few brief minutes, without the careful history taking necessary to confirm the diagnosis. Even seniors in their 80s, as I saw recently in a proud report by a doc who runs a specialty mill for ADHD.
This madness must be stopped. Adults who suspect they have significant impairments from possible ADHD should make sure they get a detailed medical exam, have the report of significant others who know them well, and a detailed developmental history that includes their early years.
There are helpful behavioral methods to be considered before any drug therapy alone is undertaken. Remember that depression, anxiety, PTSD , dementia, and mild cognitive impairments can be misdiagnosed as ADHD.
Adult ADHD is real and of great life importance, but quite rare and easily over-diagnosed. Beware the charlatans and fringe practitioners making a new assault to capture the drug market. Also, remember that modern life is complicated. Perhaps you need to simplify your life before you decide you have ADHD."
Thanks so much, Keith. There are two reasons why ADHD is such a great, and such a dangerous, fad diagnosis.
First off, all of the various psychiatric diagnoses can in some people cause attention problems that can on superficial inquiry be mislabeled ADHD. This is great for generating a fad because concentration problems are so ubiquitous in psychiatric patients. It is dangerous because the real diagnosis is missed, the right treatment is not given, and the ADHD treatment is likely to be harmful for the real psychiatric problem. Most common example- mislabeled ADHD causes great problems when people with missed bipolar disorder receive stimulant ADHD drugs that make them manic.
Second, normal distractibility is part of human nature and most of us would like to concentrate better. Many people buy easily into the comforting idea that their problem is ADHD and that taking a pill can solve it. Almost always this is simply untrue. ADHD requires that there be an onset early in the person's childhood and that the symptoms be severe, pervasive, persistent, and cause significant impairment. Late onset ADHD simply does not exist.
A careful differential diagnosis will rule out ADHD in most adults receiving the label. Either they have normal distractibility or they have another more relevant psychiatric diagnosis.
The harmful consequences of the adult ADHD fad are considerable, both for the individual and society. Easy access to an ADHD diagnosis means easy access to legal 'speed'. This has created a large illegal secondary market of diverted pills. ADHD drugs have become the campus recreational drug of choice at parties and the performance enhancement drug of choice for all nighters during finals' week. At the other extreme of the life cycle, even seniors are not safe from really dumb ADHD diagnoses. Legal speed can cause many medical and psychiatric adverse effects and emergency room visits for complications are sky-rocketing.
The Drug Enforcement Agency is doing its best to contain the epidemic, but seems to be fighting a losing battle. ADHD is a Pharma driven fad that is now taking on a life of its own, pushed by 'thought leaders', careless clinicians, and patients looking for a quick fix. The fad will eventually die, but hopefully sooner rather than later and before its casualties build up.
Bottom line: Most of what looks like adult ADHD is not adult ADHD. Distractibility is ubiquitous. Most is normal; some is due to another psychiatric or medical problem. If you weren't diagnosed with ADHD as a kid, you almost surely don't have it now. And even if you were, a more careful history now may call the original diagnosis into question. Legal speed is not necessarily safe and doesn't solve all life's problems. ADHD drugs are useful when appropriately prescribed for the few, but harmful when carelessly prescribed for the many. It is past time to stop the adult ADHD fad before it gains even more traction.