Dramatic Rise In ADHD



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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.


CONFLICTS OF INTEREST RAISE CONCERNS
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
testing."

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.


SCIENCE IS SCIENCE
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."


MARKET FORCES AT WORK
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.


ALTERNATIVES TO DRUG TREATMENTS BEING STUDIED
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.


NEED FOR BIOLOGICAL MARKERS
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
writes.

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."


ADHD ISN'T A MYTH
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®
Copyright © 2000 Education World