WK 8 SOCW 6443 Assignment: Addressing Ethical Implications in the Treatment of ADHD

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O R I G I N A L A R T I C L E

Is ADHD a ‘real’ disorder?

MICHAEL QUINN and ANDREA LYNCH

In many western countries, attention deficit hyperactivity disorder (ADHD) has achieved celebrity status, such that it probably no longer requires intro- duction. The disorder is a global phenomenon, spreading rapidly as result of the increasing dominance internationally of US psychiatric models, the need for new markets for major pharmaceutical companies, increasing use of the internet by parents and professionals and changing approaches to schooling. There is a broad consensus among international experts and organisations that ADHD is a genuine neurodevelopmental disorder based on empirical research. However, many critics have questioned the legitimacy of ADHD. This paper reviews the arguments for and against the ADHD construct. First, the review examines the literature and research endorsing ADHD as a ‘real’ disorder. Second, the criticisms levelled against the ADHD construct are examined.

Key words: ADHD, support, science, criticisms.

Introduction

According to the American Psychiatric Association (2013), ADHD is a neurode-

velopmental disorder characterised by a persistent pattern of inattention and

hyperactivity–impulsivity. Symptoms of this nature persist into adulthood and

can cause several impairments in social, academic and occupational functioning

(Gapin et al., 2011). Globally, the disorder affects 5.3% of children (Polanczyk et al., 2007). This figure was reported following a review of 102 prevalence

VC 2016 NASEN DOI: 10.1111/1467-9604.12114

studies from seven regions, including North America, South America, Europe,

Africa, the Middle East, Asia and Oceania. The disorder is more commonly

diagnosed in males than in females in the general population, with a ratio of 2:1

in children (American Psychiatric Association, 2013). In the United States, and

increasingly in Europe, psychostimulants are first-line treatments for ADHD

(Singh, 2008) and since the 1950s, medications for ADHD have been used

(Kewley, 2011).

In many western countries, ADHD has achieved celebrity status, such that it

probably no longer requires introduction (Graham, 2010). It is a global phenom-

enon, spreading rapidly as result of the increasing dominance internationally of

US psychiatric models, the need for new markets for major pharmaceutical com-

panies, increasing use of the internet by parents and professionals and changing

approaches to schooling (Stead et al., 2006). Campbell (2000) asserts it is safe to argue that we likely know more about ADHD than any other childhood con-

dition. Yet, despite the existing plethora of research and skyrocketing increases

in the number of persons diagnosed with ADHD, it is clear that this topic is

highly misunderstood (Kewley, 1999).

Support for ADHD

The symptoms of ADHD do not represent a new phenomenon (Goldstein and

Goldstein, 1998): the British physician George Still made reference to a disorder

we now recognise as ADHD in 1902 (Cooper and Bilton, 2002). Descriptions of

inattention, impulsive and hyperactive behaviour in childhood have appeared in

texts as old as the Bible (Goldstein and Goldstein, 1998). Many international

experts and organisations have endorsed ADHD as a valid medical disorder (e.g.

Barkley, 2013; DuPaul and Stoner, 2014; Mash and Wolfe, 2015; Tannock,

1998; Kewley, 2011; Goldstein and Goldstein, 1998; American Psychiatric

Association, 2013; National Institute of Mental Health, 2008; British Psycholog-

ical Society, 2000; National Institute of Clinical Excellence, 2013). Many of

these organisations, among others, have published comprehensive guidelines

that provide evidence-based recommendations for the diagnosis and treatment of

ADHD. In 2002, Professor Russell Barkley and a consortium of medical practi-

tioners and researchers published an International Consensus Statement on ADHD (Barkley et al., 2002). This document is significant in the context of the current article because it confirmed the status of the scientific findings

60 Support for Learning � Volume 31 � Number 1 � 2016 VC 2016 NASEN

concerning the validity of the disorder, and its adverse impact on the lives of

those living with ADHD.

Science and ADHD

Findings from genetic and neurological studies have given weight to the argu-

ment that ADHD is a valid disorder. For example, Tannock (1998) reviewed

several studies and identified the following findings which support a genetic

basis for ADHD:

� Over the past 30 years, numerous family-genetic studies have reported a higher prevalence rate of psychopathology, particularly ADHD, in parents

and other relatives of children with ADHD.

� In twin and adoption studies, reports have consistently shown a much greater incidence of ADHD among identical monozygotic (MZ) twins than

among non-identical dizygotic (DZ) twins. Passmore (2014) also adds that

MZ twins share 100 per cent of their genes, whereas DZ twins only share

50 per cent of their genes: ‘Scientists have found that if one twin has

symptoms of ADHD, the risk that the other will have the disorder is as

high as 75-90%’ (Barkley, 2013).

� In the dopamine system, molecular genetic research has identified genetic abnormalities. Dopamine is one of many neurotransmitters found in the

brain and is essential for attention among other things (Ratey and Hager-

man, 2008).

There have also been suggestions that ADHD may have its roots in neurological

causes (Buckley et al., 2009; Barkley and Murphy, 2006; Jacobs and Wendel, 2010). Neurotransmitter chemicals such as dopamine, norepinephrine and sero-

tonin play a vital role in regulating human behaviour (Reynolds et al., 2012; Parker, 1998). These neurotransmitters carry messages between brain cells dur-

ing mental tasks – rather like workers moving around and putting things together

in a factory (Munden and Arcelus, 1999). Ratey and Hagerman (2008) explain

why these particular neurotransmitters are so important in the case of children

with ADHD. First, the neurotransmitter dopamine is essential for attention,

among other things. Second, norepinephrine affects arousal, alertness, attention

and mood. Third, serotonin regulates many functions, including mood, impulsiv-

ity, learning and self-esteem. Professionals maintain that children with ADHD

have a deficiency in these neurotransmitter chemicals (Barkley, 2013; Ratey and

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Hagerman, 2008; Reiff and Tippins, 2004). Studies have discovered particularly

low levels of activity in the neurotransmitters located in the frontal lobes of the

brain (Wheeler, 2007). Findings from various studies support the argument that

neurological factors are a key contributor to ADHD. Neuro-imaging studies

involving children with ADHD have shown a decreased size of the prefrontal

cortex (e.g. Mostofsky et al., 2002), resulting in expected deficits in certain pre- frontal executive functions, such as response inhibition and working memory

(Barkley, 1997; Tannock, 1998). In the United States, one study that deserves

particular attention was carried out at the National Institute of Mental Health by

Zametkin et al. (1990). This study has been described as a landmark piece of research (Ratey and Hagerman, 2008). Using a type of brain scan referred to as

Positron Emission Tomography (PET) scans, the study focused on the rate at

which the brain uses glucose, which is the brain’s main energy source. Results

illustrated that during an attention test, participants with ADHD displayed 10

per cent less brain activity than the control group. The largest deficit was within

the prefrontal cortex, an area of the brain which plays a crucial role in regulating

behaviour, and is also prone to positive reinforcement through physical activity

(Ratey and Hagerman, 2008).

Medicalising ‘annoying’ behaviour

Some critics of the ADHD construct question the possibility that ADHD is per-

haps nothing more than an example of the ‘medicalisation’ of behaviours in

children which are the most annoying and problematic for adults to control. As

Bromfield proclaims, the condition is implicated in ‘all sorts of abuses, hypoc-

risies, neglects, and other society ills that have nothing to do with ADHD’

(Bromfield, 1996, p. 3; cited in Conrad and Potter, 2000, p. 570). Indeed, those

who are critical of ADHD as a medicalised construct often cite ADHD as ‘a

means of labelling and controlling children who exhibit difficult behaviours’

(Mather, 2012, p. 19). Child neurologist Fred Baughman has been one of the

most outspoken critics of ADHD, calling it a ‘fraud’. As Baughman (2006)

argues:

‘Virtually all the symptoms of ADHD relate to classroom behaviour. Children

who don’t do homework, fidget, squirm, interrupt, and are forgetful and disor-

ganized are assumed to have a biochemical imbalance in their brain. These chil-

dren can be difficult to control in a classroom and in many cases are more

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compliant when drugged. However, there is absolutely no scientifically valid

evidence that compliant –drugged students learn faster.’ (2006, p. xiii)

He goes on to conclude: ‘ADHD is a disorder manufactured to match our times.

It is a quick catch-all diagnosis with a magic bullet treatment’ (2006, p. xiii).

Other critics view ADHD as a social construct which is the result of our

performance-driven cultures and societies, citing the prolific increase of Ritalin

and other stimulants to ‘treat’ ADHD as nothing more than a method of perform-

ance enhancement. According to Lawrence Diller (1998), the ADHD label is ‘sal-

vation’ for some, allowing them to avoid feelings of ‘failure’ as they blame their

behaviour and related issues on brain functioning or genetics, rather than accepting

personal responsibility for their problems. The same author contends that the

increased numbers of those diagnosed with ADHD has led to the development of

supportive communities which provide a sense of belonging to people whose

behaviour has otherwise made them outsiders in the dominant culture.

Disagreement on how to ‘define’ ADHD

A review of literature shows there is no consensus on an agreed definition for the

disorder. For the example, in the Diagnostic and Statistical Manual of Mental Dis- orders, Fifth Edition (DSM-5) published by the American Psychiatric Association (2013), ADHD is defined as a ‘neurodevelopmental disorder’, and the Interna- tional Classification of Diseases and Related Health Problems refers to it as a ‘hyperkinetic disorder’ (World Health Organization, 1992). ADHD is also defined

in a wide variety of ways within the research literature, and each definition can

give some insight into the author’s philosophical position concerning the nature of

ADHD. It is not uncommon to see ADHD defined as a neurobiologic condition (Quinn, 2008), a neurodevelopmental disorder (Mrug et al., 2012), a mental disor- der (Benkert et al., 2010) and a heterogeneous condition (Newcorn et al., 2001; Faraone and Biederman, 1998). In addition, the following terms have also been

historically applied to ADHD: ‘attention deficit disorder (ADD), hyperkinetic dis-

order (HKD), hyperkinesis, minimal brain dysfunction, minimal brain damage

(MBD), and disorder of attention, motor control, and perception (DAMP)’ (Carr,

2006, p. 421). Regardless of the kind of term used, children with ADHD continue

to present with severe and pervasive symptoms of inattention, hyperactivity and

impulsivity.

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Lack of a biological marker and unknown etiology

Despite copious amounts of medical and psychological research, science has yet

to discover a biological marker or characteristic for ADHD. Unlike other medi-

cal conditions which have clear and identifiable markers that indicate the pres-

ence of disorder, in the case of ADHD, ‘No biological marker is diagnostic’

(American Psychiatric Association, 2013, p. 61). Also, there are no objective

medical ‘tests’ which can detect the presence of ADHD (Timimi and Taylor,

2004). Science remains unable to identify the exact causes or etiology of

ADHD, and prominent researchers like Faraone and Biederman admit that we

have yet to achieve this goal (Faraone et al., 1995). The inability to conclusively identify causes of ADHD calls into serious question the legitimacy of ADHD as

a medical disorder (Visser and Jehan, 2009). Not surprisingly, several theories

exist concerning the causes of ADHD in the individual.

The biological theory of impaired brain functioning is perhaps the most widely

accepted of all theories (Tidefors and Strand, 2012), as it suggests that ADHD is

the result of malfunction in brain processes and/or structures (Qiu et al., 2011; Castellanos et al., 2002; Taylor, 1999). Genetic factors have also been strongly linked to ADHD causation (Tannock, 1998; Hawi et al., 2013; Park et al., 2010; Thapar et al., 2007; Faraone and Biederman, 1998), as have ‘deficits’ in the individual, such as deficits in executive functioning (Shoemaker et al., 2012), in executive inhibition (Nigg, 2001) and in behavioural inhibition (Barkley, 1997).

ADHD has also been linked to a host of sources outside of the individual, such

as conditions before, during and after gestation, psychosocial influences and

environmental factors (Thapar et al., 2013; Taylor and Sonuga-Barke, 2008). The existing body of research is not without its critics. Researchers such as

Ongel (2006) take a more sceptical view of such studies, warning us that associ- ation between variables (such as abnormal behaviour and brain abnormalities) does not automatically signify causation.

Diagnosis of ADHD: subjectivity and checklists

The subjective nature of the ADHD diagnosis is another cause for criticism.

Senior (2009) argues that ADHD is so contested precisely because of the subjec- tive nature of the diagnostic process. ADHD diagnosis is based largely on the

characteristic criteria established in the DSM-5 (American Psychiatric Associa- tion, 2013) and the International Classification of Diseases and Related Health

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Problems (World Health Organization, 1992), and is subjectively identified by medical professionals through use of behavioural checklists and rating scales

(Stead et al., 2006). There is no one standardised checklist in use for ADHD diagnosis; rather, there are at least two dozen, if not more (Cohen, 2006). Often,

whether a person obtains a diagnosis of ADHD can be a matter of degree and

personal opinion.

Over-diagnosis and use of psychotropic drugs in children

Critics of the ADHD construct also question the ever increasing diagnosis of

ADHD along with skyrocketing rates of psychostimulant drug usage in children.

It is estimated that in the UK during the ten-year period from 1994 to 2004, the

prescription of methylphenidate increased by an astonishing 7,600% (Cohen,

2006). As Cormier (2008) explains, we should be extremely concerned regard-

ing the ever increasing numbers of pre-schoolers who are diagnosed with

ADHD, as well as the ‘sevenfold’ increase in the prescription and use of stimu-

lant medications in children. Statistics such as this raise questions regarding the

possibility of the ‘over-diagnosis’ of ADHD. In their research, Bruchmuller

et al. (2012, p.128) determined that therapists commonly fail to diagnose in strict accordance with manuals and that ‘overdiagnosis of ADHD occurs in the

clinical routine’. However, others argue against the concept of overdiagnosis,

claiming this is a misperception which has simply taken hold in public percep-

tion and media coverage (Sciutto and Eisenberg, 2007).

Questions have also been raised regarding the influence and motives of the phar-

maceutical industry in the race to ADHD diagnosis (Conrad and Bergey, 2014;

Ongel, 2006). While much of the research literature strongly asserts the efficacy

of psychostimulant drugs in treating and controlling symptoms associated with

ADHD (Benkert et al., 2010; Forness et al., 1999), questions must be raised regarding the potential for bias, especially in cases where pharmaceutical com-

panies are backing research into the efficacy of pharmacological treatments for

ADHD. One example of such research is the Survey of ADHD in Irish Children (Fitzgerald, 2007) which was directly supported by the pharmaceutical company

Eli Lilly and Co. (Ireland) Ltd. Interestingly, many of the questions in this ‘sur-

vey’ of parents of children with ADHD highlight strongly positive outcomes

reported by parents when their children were on medication, as opposed to

when they were not.

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Conclusion

The authors of this paper reviewed the literature and research supporting ADHD

as a valid disorder. They also explored the many criticisms levelled against the

ADHD construct. Research literature on both sides of the ADHD argument

presents clear and compelling evidence for their theories and positions and it is

clear that the debate surrounding the legitimacy of ADHD as a medical condi-

tion is far from over. Although the ADHD construct has been scientifically

explored, it has gathered limited medical support, and admittedly, serious gaps

in knowledge remain unanswered. This highlights the need for further research

and exploration of this controversial and contested condition, with which many

of our children and students continue to be diagnosed and labelled in the present

day.

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Correspondence Michael Quinn

School of Education

University College Dublin (UCD)

Ireland

Email: [email protected]

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