I have been blogging and tweeting about ADHD a lot lately because I believe that change is in the air.
This is the worst of times for ADHD diagnosis because statistics show it is wildly overdiagnosed and overtreated. This is possibly the best of times for ADHD diagnosis because I think we have reached the tipping point and feel hopeful that the ADHD fad will soon begin to fade.
We humans are suggestible creatures comforted by the safety of the crowd and prone to groupthink. Most often going with the herd is the smart and safe bet, but follow-the-leader can cause big problems when the herd is running off the cliff.
The history of psychiatry is littered with the periodic recurrence of fad diagnoses that suddenly achieve prominence and then just as suddenly fade away. Human distress is always hard to explain and sometimes hard to tolerate. Diagnostic labels, even false ones, can gain great and undeserved popularity because they seem to explain the otherwise unexplainable and provide hope that describing a problem will lead to improving it. And once you have a diagnostic hammer, everything begins looking like a nail.
The tripling of ADHD rates and the skyrocketing use of stimulants in the last 20 years are sure signs of a fad. The forces promoting it are, and will continue to be, formidable:
- The drug companies will not give up their $10-billion-a-year stimulant cash cow without a fierce fight. They have the motive and the means to massively and misleadingly market ADHD and will try to expand its customer base by making it as ubiquitous in adults as it already is in kids. And Pharma is one of the most powerful lobbies in Washington: It has successfully bullied our government to allow direct-to-consumer drug advertising that is banned in almost all other countries.
- ADHD diagnosis occurs inappropriately in part because it is the ticket to the legal acquisition of stimulants, which can then be easily diverted for recreational use.
- ADHD provides a medically legitimized way to obtain stimulants that can be used for performance enhancement in perfectionistic adults and children who don't really have ADHD.
- Some of the influential experts who specialize in ADHD are blind to the risks posed by its overdiagnosis and overtreatment and (with heavy drug-company support) spread the false gospel that more diagnosis means better diagnosis.
- The largest patient-advocacy group related to ADHD receives one third of its funding from drug companies and parrots the party line.
- Teachers may also encourage the excessive diagnosis of ADHD, particularly when working in school systems that are chaotic (with classes that are too large, and insufficient gym periods for letting kids blow off steam).
Given this Goliath of support promoting the ADHD fad, why am I making the long-shot bet that it will now begin to fade?
- The percentage of kids being diagnosed (11 percent overall, and 20 percent of teenage boys) is so absurdly high that reasonable people can no longer accept that the label is being applied with anything approaching sufficient care and caution.
- The astounding rate of stimulant use (6 percent overall, and 10 percent in teenage boys) shocks us into the realization that we are creating a generation of drugged kids.
- Studies show that stimulants are much less effective than we originally thought in improving long-term school performance.
- Some of the leading experts who developed the concept of ADHD and did the best research are speaking out about their surprise and dismay at the way it is now being misused.
- The press is now on the case, with frequent exposés of careless ADHD diagnosis and stimulant misuse. Alan Schwarz of The New York Times deserves special mention (and a Pulitzer prize) for his vivid, in-depth reporting, but this story is now receiving extensive international coverage and has long legs.
Ultimately, though, my hopes rest mostly with parents. They have previously played a passive role in promoting the ADHD fad, going along with doctors' recommendations in an effort to help their kids. My bet is that parents will now play an active role in curtailing the ADHD fad, protecting their kids from unwarranted diagnosis and potentially harmful medication treatment.
No parent should give pills to a child after a diagnosis of ADHD that was made on a single visit of just a few minutes. Accurate diagnosis takes time in each session, and usually many sessions. Watchful waiting and environmental changes should precede the diagnosis and will often make it unnecessary. Stimulant drugs should not be used for performance enhancement because in the long run they don't enhance performance, and we don't know what harm they can do to the maturing brain.
The ADHD fad will fade because all dumb psychiatric fads eventually fade. As Abraham Lincoln is said to have put it, you can fool all the people some of the time, and some of the people all the time, but you can't fool all the people all the time.
There will soon be a tipping point when parental common sense, sobering research findings, and media exposure will overwhelm the marketing and political might of the unscrupulous drug companies and the careless prescribing habits of physicians. I am hoping and predicting that we are now just about there.
Allen Frances is a professor emeritus at Duke University and was the chairman of the DSM-IV task force.