Well, read this piece here and begin the thinking process:
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Over the course of my career, I have found more than 20 conditions that can lead to symptoms of ADHD, each of which requires its own approach to treatment. Raising a generation of children—and now adults—who can't live without stimulants is no solution.
This Wednesday, an article in the New York Times reported that between 2008 and 2012 the number of adults taking medications for ADHD has increased by 53%, and that in the case of young American adults, it has nearly doubled. While this is a staggering statistic, and points to younger generations becoming frequently reliant on stimulants, frankly, I’m not too surprised. Over the course of my 50-year-long career in behavioral neurology and treating patients with ADHD, it has been in the past decade that I have seen these diagnoses truly skyrocket. Every day my colleagues and I see more and more people coming in claiming they have trouble paying attention at school and at work, and diagnosing themselves with “ADHD.”And why shouldn’t they?
If someone finds it difficult to pay attention or feels somewhat hyperactive, “Attention-deficit and Hyperactivity Disorder” has those symptoms right there in its name. It’s an easy, catch-all phrase, which saves time for doctors to boot. But can we really lump all these people together? What if there are other things causing people to feel distracted? I don’t deny that we, as a population, are more distracted today than we ever were before. And I don’t deny that some of these patients who are distracted and impulsive need help. But what I do deny is the generally accepted definition of ADHD, which is long overdue for an update. In short, I’ve come to believe based on decades of treating patients that ADHD — as currently defined by the DSM and as it exists in the public imagination — does not exist.
Allow me to explain what I mean.
Ever since 1937, when Dr. Charles Bradley discovered that children who displayed symptoms of attention-deficit hyperactivity responded well to Benzedrine, a stimulant, we have been thinking about this “disorder” in almost the same way. Soon after Bradley’s discovery the medical community began labeling children exhibiting these symptoms as having “minimal brain dysfunction,” or MBD, and treating them with the stimulants Ritalin and Cylert. In the intervening years, the Diagnostic and Statistical Manual of Mental Disorders, or DSM, changed the label numerous times, from “hyperkinetic reaction of childhood” (it wasn’t until 1980 that the DSM-III introduced a classification for adults with the condition), to the current label ADHD. But regardless of the label, we have been giving patients different variants of stimulant medication to cover up the symptoms. You’d think that after decades of advancements in neuroscience, we would shift our thinking.
Today, the fifth edition of the DSM only requires one to fulfill five of eighteen possible symptoms to qualify for an ADHD diagnosis. If you haven’t seen the list yet, look it up. It will probably bother you. How many of us can claim we have difficulty with organization, or a tendency to lose things; that we are frequently forgetful, distracted, or fail to pay close attention to details? Under this subjective criteria, the entire U.S. population could potentially qualify. We’ve all had these moments, and in moderate amounts, it’s a normal part of the human condition.
However, there are some instances in which attention symptoms are severe enough that patients truly need help. Over the course of my career, I have found more than 20 conditions that can lead to symptoms of ADHD, each of which requires its own approach to treatment. Among these are sleep disorders, undiagnosed vision and hearing problems, substance abuse (marijuana and alcohol in particular), iron deficiency, allergies (especially airborne and gluten intolerance), bipolar and major depressive disorder, obsessive compulsive disorder, and even learning disabilities like dyslexia, to name a few. Anyone with these issues will fit the ADHD criteria outlined by the DSM, but stimulants are not the way to treat them.
“What’s so bad about stimulants?” you might be wondering. They seem to help a lot of people, don’t they? The aforementioned article in the Times mentions that the “drugs can temper hallmark symptoms like severe inattention and hyperactivity but also carry risks like sleep deprivation, appetite suppression and, more rarely, addiction and hallucinations.” But this is only part of the picture.
Firstly, addiction to stimulant medication is not rare; it is common. The drugs’ addictive qualities are obvious. We only need to observe the many patients who are forced to periodically increase their dosage if they want to concentrate. This is because the body stops producing the appropriate levels of neurotransmitters that ADHD meds replace — a trademark of addictive substances. I worry that a generation of Americans won’t be able to concentrate without this medication; big pharma is understandably not as concerned.
Secondly, there are many side-effects to ADHD medication that most people are not aware of: increased anxiety, irritable or depressed mood, severe weight loss due to appetite suppression, and even potential for suicide. But there are consequences that are even less well-known. For example, many patients who are on stimulants report having erectile dysfunction when they are on the medication.
Thirdly, stimulants work for many people in the short-term, but in cases where there is an underlying condition causing them to feel distracted, the drugs serve as Band-Aids at best, masking and sometimes exacerbating the source of the problem.
In my view, there are two types of people who are diagnosed with ADHD: those who exhibit a normal level of distraction and impulsiveness, and those who have another condition or disorder that requires individual treatment.
For my patients who are the former, I recommend that they eat right, exercise more often, get eight hours of quality sleep a night, minimize caffeine intake in the afternoon, monitor their cellphone use while they’re working, and most importantly, do something they’re passionate about. As with many children who act out because they are not being challenged enough in the classroom, adults who have work or class subjects that are not personally fulfilling, or who don’t engage in a meaningful hobby, will understandably become bored, depressed, and distracted. Similarly, today’s standards are pressuring children and adults to perform better and longer at school and at work. I too often see patients who hope to excel on four hours of sleep a night with help from stimulants, but this is a dangerous, unhealthy and unsustainable way of living long-term.
For my second group of patients, who have severe attention issues, I make them undergo a full evaluation to find the source of the problem. Usually, once the original condition is found and treated, the ADHD symptoms go away.
It’s time to rethink our understanding of this condition, offer more thorough diagnostic work, and help people get the right treatment for attention deficit and hyperactivity.
Dr. Richard Saul is a Behavioral Neurologist practicing in the Chicago area. His book, ADHD Does Not Exist, is published by HarperCollins.
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