HEALTH FEBRUARY 14, 2014
You might be saying to yourself, okay, ADHD is probably overdiagnosed. And yes, some people who are on a stimulant probably shouldn’t be, like the college student struggling to focus on a boring lecture or the kid who’s fidgeting a bit too much for his teacher’s liking. But how can it be that among the millions of people diagnosed—over 4 percent of adults and 11 percent of children in the U.S.—not one of them actually has ADHD? Because we’ve all encountered someone with severe attention or hyperactivity issues—the boy who is always daydreaming, the girl who gets out of her seat to run around the room while her classmates sit calmly, the woman who consistently asks questions that have just been answered. Surely at least some of these people have ADHD! Actually, not one of them does. Let me be clear: In my view, not a single individual—not even the person who finds it close to impossible to pay attention or sit still—is afflicted by the disorder called ADHD as we define it today.
Ever since 1937, when Dr. Charles Bradley reported that children who exhibited symptoms of distractibility responded well to stimulant medication, the core concept of ADHD has remained essentially unchanged. Imagine, despite decades of advancement in neuroscience, we’re still approaching this “disorder” the same way.
You may notice that there is something striking about the way we define this “illness”—that is, by its symptoms, rather than its cause. If we were to define a heart attack by chest pain, then the appropriate cure would be painkillers, rather than the revival and repair of the heart. Other examples are easy to find: Nasal congestion can be a symptom of a cold, allergy, or many other conditions, but a runny nose is not a diagnosis. In the same way, the symptom complex associated with the ADHD diagnosis is related to more than twenty medical diagnoses, (from those as mild as poor eyesight, sleep deprivation, and even boredom in the classroom, to more severe conditions like depression and bipolar disorder), that, when treated effectively, can result in the disappearance of the attention-deficit and hyperactivity symptoms. But before I make this case, allow me a brief digression into the mechanisms by which common medications for ADHD work.
The stimulants most often prescribed for ADHD represent several different types of agents that help control attention and behavior. These include methylphenidate (like Ritalin and Concerta) and mixed salt amphetamines (like Adderall and Vyvanse). Each of these has a specific effect on the body’s neurotransmitters, or the chemical compounds that help transmit signals within the nervous system. The exact mechanisms by which these chemicals interact are very complex, but essentially, if levels of these chemicals are too low or their activity is blocked, the transmission of messages within the nervous system decreases, corresponding to a state of inattention or impulsivity. Specific medications aimed at targeting attention-deficit and hyperactivity symptoms help increase levels of neurotransmitters and their activity. For example, methylphenidate-based medications like Ritalin increase the activity of the neurotransmitters dopamine and noradrenaline in the parts of the brain that help to control attention and behavior. Adderall also increases dopamine’s effects, but in a more gradual way than Ritalin and similar agents do.
So let’s back up a moment. If stimulants can increase one’s attention span and reduce impulsivity, why shouldn’t we use them? Furthermore, even if we’re masking another underlying condition, aren’t we at least solving the problems of inattention and impulsivity in the patient? The answer to both of these questions is a resounding NO. While stimulants can help people with a variety of symptoms in the short term, they have multiple damaging effects in the short- and long-term. The most common short-term side effects associated with stimulants involve overstimulation, such as loss of appetite and sleep disturbance, but perhaps more troubling are the longer-term effects of stimulant use, which include unhealthy weight loss, poor concentration and memory, and even reduced life expectancy in some cases. Long-term, patients also face the development of tolerance, which exacerbates these side-effects. After a while, the body adjusts its natural production of these same chemicals in the brain, and the temporary improvements in attention and behavior begin to disappear. This is why we see doctors prescribing higher and higher doses of the stimulant to achieve the same effect in the patient as time wears on—a dangerous pattern.
With over 50 years of experience, I’ve concluded that the only way to make long-term progress in eliminating a patient’s ADHD-related symptoms, is to find the cause of these symptoms. Such was the case for my patient William.
A blond boy with a big smile, William was the third of four siblings, and a student in sixth grade. His parents were deeply concerned about his behavior and had already been to four other doctors; the physicians’ consensus was ADHD, possibly accompanied by depression. Over the past year, William had been placed on six medications, including several stimulants and an antidepressant. The treatments had done little to improve the boy’s symptoms, which included significant learning challenges. His parents said that he generally performed well on standardized tests—above the 80th percentile for both math and verbal skills—but struggled to complete even the most basic homework assignments. His mother said, “Sometimes he forgets to bring his homework home from school, or he’ll bring it home but forget to take it out of his backpack until it’s too late.” It was clear that William’s poor organization skills and concentration were affecting his schoolwork; his grades were slipping fast. At home, he often failed to listen to his parents or siblings. “I’ll ask him to do a chore or come to dinner and he doesn’t even respond,” his father said. Both parents reported that they and their other children were frustrated by William’s short attention span and distractibility.
Even more troubling for the boy’s family, teachers, and friends were his other symptoms. Since taking stimulants, he had become increasingly moody and irritable, especially when he had to do schoolwork. “Last week he threw his book across the room and ripped up his assignment,” his mother said. “He said he hated his homework and he was no good at it.” At other times, William acted “way too happy and goofy,” as described by his parents and teachers. The boy behaved impulsively, blurting out answers in school and poking his siblings at the dinner table. Many mornings, William had trouble getting out of bed for school. His parents said he had been asking to stay home because he felt sick or tired, but he had no specific symptoms (such as fever) other than appearing fatigued. When they forced him to go to school, he would often throw tantrums, crying for long periods. During these times, the boy also lost interest in activities he usually enjoyed, including soccer and guitar lessons. His parents reported that he asked to skip practices, games, or lessons, again because he felt tired or ill.
The medications recommended by William’s previous doctors had exacerbated some of his symptoms, including his fidgeting and poor concentration. His mother said, “They made him worse, not better.” His parents had even noticed that he was losing weight and not sleeping well. A generally gaunt appearance and dark circles under the boy’s eyes confirmed their concerns. “It seems like he’s mad, sad, or both—all the time,” his mother said. Both parents were deeply worried about their son, and frustrated that past treatments hadn’t helped at all.
In William’s case, we were quickly able to rule out several potentially contributing factors to his symptoms using a thorough history and medical tests. His hearing and vision were fine. He was normal on all physical tests and blood work, including screenings related to thyroid hormones, iron, and lead; abnormal amounts of those neurochemicals can result in attention-deficit symptoms. (I go into more detail on this in my book.) The much more relevant features in William’s case were his cognitive and behavioral symptoms: poor concentration, low energy, feelings of worthlessness, sleeplessness, difficulty getting out of bed, irritability, tantrums, impulsivity, pressured speech, and others. Together these form a picture of a likely mood disorder. But which one?
Overall, William fit criteria for a bipolar disorder diagnosis, and further inquiry confirmed this hypothesis. The preliminary diagnosis was confirmed strongly by William’s family history. Five relatives had been diagnosed with some form of mood disorder; four of the diagnoses had been bipolar disorder. When I suggested the diagnosis to William’s parents, his mother said, “I knew this ran in our family, but I didn’t think it could show up so early.” Moreover, the boy’s doctors and family had focused on ADHD as the most likely explanation for his symptoms, even when the medications hadn’t worked. Though at least one previous doctor had viewed the mood symptoms as severe enough to try an antidepressant (which hadn’t worked), no practitioner had thought to chart William’s mood or to consider the strong family history of bipolar disorder. They simply hadn’t asked, and the family hadn’t volunteered the information, given their focus on the attention symptoms and a prejudice toward an ADHD diagnosis.
Not surprisingly, attention-deficit symptoms will be likely in patients who meet criteria for depression, given the poor concentration and distractibility that depression involves. Both core elements of bipolar disorder drive attention deficits: depression and mania (or hypomania, which William displayed). Impulsivity is a hallmark symptom of mania; in children, this symptom can look like distractibility and disruptive behavior.
Researchers have pointed out the strong overlap between ADHD, depression, and bipolar, but these are usually seen as comorbid conditions (conditions that occur together). In my experience, major and manic-depressive disorders often explain the ADHD symptoms fully, and successful treatment of the former eliminates the attention-deficit/hyperactivity symptoms, with no need for stimulant medication and their consequent side-effects.
In William’s case, the family agreed to try medication first without psychotherapy, to see what kind of impact the pharmaceutical treatment could have. The first medication we tried, an anti-seizure drug commonly prescribed for bipolar disorder, reduced the boy’s mood and behavioral symptoms dramatically but resulted in side effects including upset stomach and dizziness. We started William on lithium, and within two months we found a dosage that worked well for him, reducing his symptoms to very mild levels, with no significant side effects. With regular use of the lithium, William’s functioning improved on every level. Instances of forgetting his homework at school or in his backpack became rare. Schoolwork-related tantrums subsided and his grades rose. His teachers noted a marked improvement in his classroom behavior, and his parents found him much more attentive at home. “It’s like a switch was flipped,” William’s father said. Though everyone was pleased with the outcome, I emphasized to William and his family that bipolar disorder is a chronic illness that for the vast majority of patients requires lifelong medication. Fortunately, the family already understood this, having seen their relatives manage the condition over time.
The symptoms of distractibility and impulsivity are all too real, but we’re using an outdated, invalid definition of ADHD, one that has been kept in place for decades by physicians and other practitioners, pharmaceutical companies, the media, and even patients themselves. The millions of false diagnoses result in a cascade of consequences including delayed or denied treatment, spiraling health-care costs, and significant health risks and frustration for patients and their families. There is no need for patients and their families to continue suffering, and for us as a society to bear the large, mounting costs of the ADHD-stimulant epidemic. It’s time to change our thinking about what really drives distractibility and impulsivity and help people get the right treatment.
Dr. Richard Saul is a Behavioral Neurologist practicing in the Chicago area. This is an extract from his book, ADHD Does Not Exist, published by HarperCollins this month.
Image via Shutterstock.