Dramatic Rise In ADHD

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    S C H O O L I S S U E S A R T I C L E

    Dramatic Rise in ADHD Sparks Controversy
    Concerns about the rise in childhood ADHD and its treatment with psychotropic
    medication go beyond worried parents and questioning educators. Some say ADHD
    is a myth -- not a brain-based disorder, but a reflection of what's wrong with
    our society and education. Others worry about the financial relationships
    between drug companies and academic researchers who study treatments. Today,
    Education World looks at some controversial issues surrounding ADHD. Included:
    Comments from leading researchers and experts!
    Almost a century after the symptoms of attention deficit hyperactivity disorder
    first were recognized, its diagnosis, treatment -- and very existence --
    continue to be debated.

    The debate focuses on the dramatic rise in the number of children diagnosed
    with ADHD over the past ten years along with the significant increase in the
    number of children, including preschool-aged children, being prescribed
    psychotropic medication to treat the disorder. Some say that this explosion of
    childhood ADHD is indicative of what's wrong with our society and education
    system; they blame parents and educators for choosing quick fixes for what they
    say is a behavioral problem, not a brain-based disorder.

    Education World Explores ADHD in a Five-Part Series
    Attention deficit hyperactivity disorder has been the subject of countless
    investigations, seminars, and individual education plans (IEPs). This week,
    Education World offers a five-part series that explores ADHD, research and
    treatments, and the controversy that surrounds it.

    * Monday:
    ADHD: What Is It?

    * Tuesday:
    Statistics Confirm Rise in Childhood ADHD and Medication Use

    * Wednesday:
    Is Medication the Best ADHD Treatment?

    * Thursday:
    How Can Teachers Help Students With ADHD?

    * Today: Dramatic Rise in ADHD Sparks Controversy

    Regardless that most research supports the belief that ADHD is a brain-based
    disorder, concerns about the dramatic rise in its diagnosis is widespread.
    Those concerns go beyond worried parents and questioning educators. During the
    past few years, agencies and branches of government, including the Surgeon
    General's Office, the General Accounting Office, the White House, the Drug
    Enforcement Agency, Congress, and the National Institute of Mental Health, have
    conducted investigations into the rise of ADHD. All those agencies separately
    convened national experts in an effort to study the dramatic rise in ADHD and
    stimulant medication treatment.

    Along with those government investigations, Waters and Kraus, a Texas law firm
    known for litigating cases involving asbestos and tobacco-related lung cancers,
    has filed three ADHD-related class action lawsuits during the past year. The
    most recent suit claims Novartis Pharmaceutical Corporation and its
    predecessor, Ciba-Gigy Corporation, "planned, conspired and colluded to create,
    develop and promote the diagnosis of Deficit Disorder to increase the market
    for its product Ritalin." Ritalin, the brand name for methylphenidate, is the
    most commonly prescribed psychotropic stimulant medication for treating ADHD.

    The lawsuit also contends that Children and Adults With Attention
    Deficit/Hyperactivity Disorder, a nonprofit organization comprising primarily
    parents of children with ADHD, conspired with the drug company. The
    organization accepted nearly $750,000 from Ciba-Gigy between 1991 and 1994,
    according to the lawsuit. The suit claims that Novartis and Ciba-Gigy worked
    with the American Psychiatric Association to broaden the symptoms of ADHD to
    create a large market for Ritalin.

    Those accused all deny the conspiracy claims made by Waters and Kraus.

    Although the lawsuit raises the issue of financial conflicts of interest
    between drug companies and nonprofit organizations, specifically regarding
    ADHD, the growing role of drug companies in medical pharmaceutical research in
    all areas is also troubling to many people, including Marcia Angell, a senior
    lecturer at the division of medical ethics at Harvard School of Medicine.
    Angell is a former editor-in-chief of The New England Journal of Medicine.

    This summer at the Health and Human Services Conference on Financial Conflicts
    of Interest, Angell called for new, stricter rules and restrictions regarding
    financial conflicts of interest that could threaten the safety of research
    subjects or the objectivity of the research itself. Any financial association
    that would cause an investigator to prefer one outcome of his research
    constitutes a financial conflict of interest, she stated at the conference.
    "Thus, there is nothing potential about a conflict of interest. Either it
    exists or it doesn't."

    The relationship between drug companies and academic institutions is no longer
    at arm's length, as was the practice in the past, she said. "Companies now
    design studies to be carried out by investigators in academic medical centers
    who are little more than hired hands supplying the human subjects and
    collecting data.

    "The academic medical institutions are increasingly dependent on pharmaceutical
    companies," Angell told Education World. "I saw this myself as an editor of The
    New England Journal of Medicine for over 21 years. The mission of the academic
    institutions has been corrupted by the investor-owned businesses, mainly the
    drug companies.

    "I think there is fairly good evidence that the research has been tainted
    because of the financial relationships between academic researchers and drug
    companies. Researchers who have a financial relationship with a drug company
    write papers more favorable to the company's product than other researchers."

    Disclosure by the researcher of a financial interest in the drug company merely
    passes the buck to the subjects of the study, Angell maintains. "Researchers
    have good jobs, and they don't have to supplement their income in a way that
    strikes at the heart of what they are doing -- objective research," Angell
    said. "The standards should be: No equity in the drug company whose product you
    are testing and no consulting for the drug company whose product you are

    Angell states she is not aware of financial conflicts of interest with
    researchers of medication to treat ADHD, however she is aware of the financial
    ties between researchers and manufacturers of other psychotropic medications.
    In an editorial, Is Academic Medicine for Sale? published in The New England
    Journal of Medicine (May 18, 2000), Angell states that a researcher's ties with
    drug companies that make antidepressant drugs were so extensive that it would
    have used too much space to disclose them fully in the journal.

    Angell said feedback from her article varied; some researchers agreed with her
    stance, some completely disagreed, and others were in the middle.

    Howard Abikoff -- the Pevaroff Cohn professor of child and adolescent
    psychiatry, director of research at the New York University Child Study Center,
    and a lead researcher of a National Institute of Mental Health (NIMH) study --
    hasn't seen any examples of academic researchers slanting their findings
    because of financial interests.

    "The work we are doing is based on sound science," Abikoff said. "Steps are
    taken to ensure the research is valid." There are many examples of researchers
    failing to find benefits in clinical trials, and those findings are reported to
    the drug company; consequently, the drug company stops production of that
    particular medication, he said.

    According to the National Institutes of Health (NIH), financial interest isn't
    always a bad thing. In announcing the Health and Human Services Forum on
    Financial Conflicts of Interest, the agency stated: "The opportunity for
    investigators' personal financial gain or reward is not intrinsically
    unacceptable. However, the recent highly publicized instances of apparent
    financial conflicts of interest have generated concern within the research and
    lay communities."

    The Food and Drug Administration (FDA) also does not prohibit researchers from
    having financial interests with the drug companies whose products they are
    testing. However, they do require disclosure under certain circumstances,
    according to Crystal Rice, a spokesperson for the FDA Center for Drug
    Evaluation and Research. "With regards to financial disclosure by researchers,
    to summarize, I have been told that if the manufacturing company is a publicly
    traded company and the clinical investigator/researcher has financial ties of
    $50,000 or more, then [the relationship] must be disclosed to the FDA. If it is
    a non-publicly traded company, [the researcher] must disclose any amount of
    financial ties to the FDA."

    It is common practice for researchers to take money from drug companies in
    order to conduct drug studies, including those studying ADHD medications, said
    Lawrence Diller, who practices behavioral pediatrics in California and is
    author of Running on Ritalin: A Physician Reflects on Children, Society and
    Performance in a Pill (Bantam Books, 1998).

    "Does drug money influence the researcher?" Diller asks. "There is evidence,
    there is influence, and there is a perception there is influence.

    "You don't need to have an active conspiracy to account for the huge increases
    in children using medication for ADHD," Diller told Education World. "There are
    very powerful market forces operating on the system to promote drugs. And there
    are no market forces to promote special education and counseling."

    Diller cites as an example of market forces at work in a national advertising
    campaign by Alza Corporation, the manufacturer of Concerta. Concerta is a
    long-acting stimulant medication recently approved by the FDA for use with
    children who have ADHD. Alza's one- and two-page advertisements have been
    appearing in national parent and family magazines. The ads promise that this
    latest treatment for ADHD can help make homework a more relaxing time. Diller
    said the ads remind him of the Stepford children; the children, with
    schoolbooks placed in front of them, are smiling, and so are the parents. "It
    had a spooky effect on me," he said. (The Stepford Wives is a 1975 movie in
    which all the wives in the suburb of Stepford happily shop, clean, and cook for
    their husbands, but the wives turn out to be robots, not people.)

    The high rate of stimulant use by children is a concern to Diller. He doesn't
    dispute that ADHD exists and prescribes Ritalin and other stimulant medications
    to his own patients. But he does question the large number of children being
    diagnosed with ADHD and advises all parents and schools to first conduct
    comprehensive examinations of a child before considering medication.

    The NIMH is exploring alternatives to pharmaceutical treatments for ADHD,
    according to Kimberly Hoagwood, the NIMH associate director for child and
    adolescent mental health research. The institute is funding a range of studies
    about intervention and service approaches for children with ADHD, including
    five nonpharmaceutical studies, Hoagwood told Education World. In particular,
    the NIMH is most interested in the assessment and treatment practices in
    schools and pediatric settings, she said.

    However, those studies do not include an in-depth study of neurofeedback, a
    method in which a person learns to modify a behavior or a physiological
    function by monitoring brain waves. M. Barry Sterman, professor emeritus in the
    departments of neurobiology and biobehavioral psychiatry at the School of
    Medicine of the University of California (Los Angeles), maintains one of the
    most promising alternative treatments for ADHD is neurofeedback, commonly
    referred to as biofeedback. Sterman said alternative treatments are very much
    needed because medication is "merely palliative" and not a cure.

    Sterman is responsible for discovering biofeedback nearly 40 years ago. He said
    neurofeedback is a well-established scientific method. Sterman cites several
    studies that have proved neurofeedback's effectiveness in treating ADHD.

    "It is unfortunate that some so-called experts in the field of ADHD have been
    critical of this literature because of the relatively small number of subjects
    and the lack of robust controls," Sterman states in a paper. Research has been
    conducted in clinical settings with large numbers of homogeneous subjects that
    have documented physiological changes as a result of neurofeedback, according
    to Sterman.

    Diagnosis of ADHD is subjective and based on a child's behavior at home,
    school, and in other social settings. Sterman said there is a need for
    physicians to rely on biological markers instead of behavioral markers.

    This is especially important because most children at one time or another
    exhibit some of the symptoms of ADHD. "Diagnosis is complicated further by the
    fact that these symptoms frequently appear in other disorders as well," he

    Brain scanning research, as well as quantitative EEG (electroencephalogram)
    assessments, has established ADHD as a physiological disorder, Sterman said. An
    instrument called an electroencephalograph measures and records the electric
    activity of the brain through electrodes to a patient's scalp pick up
    low-voltage signals. The QEEG is a more advanced measurement of the brain's
    electrical activities. Sterman says studies have found that the brains of
    children with ADHD have different electrical activities compared with the
    brains of children who do not have the disorder.

    Sterman suggests that QEEG "can serve as a reliable biological marker for ADHD
    and suggests that the disorder actually includes several different
    neurophysiological subtypes."

    A reliable, physiological test would go a long way in refuting the contention
    that ADHD is a myth. But so far, brain scanning and QEEG technology is still
    used as a research tool rather than as diagnostic instrument.

    Without a reliable tool to diagnose ADHD as a physical disorder, some believe
    ADHD is not a brain-based disorder, but rather a reflection of societal and
    family problems in the U.S. culture. But the dispute about whether ADHD is a
    real disorder gets personal for some whose children have been diagnosed with
    the disorder.

    "I am appalled at those who feel ADHD doesn't exist," said Beth Kaplanek,
    volunteer president of the National Board of Directors of CHADD, whose 18-year
    old son, Chris, was diagnosed with ADHD.

    "ADHD is a valid, diagnosable disorder, and clearly these authors don't know
    what they are talking about," Kaplanek said. "I'm offended by their words. They
    are out there to make money, and they are not living in my home."

    Diane Weaver Dunne
    Education World®
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