PDF of full thesis available at Martin Whitely PhD Thesis Copy – ADHD and Regulatory Capture in Australia PDF

A video and transcript of Colbert’s ‘Meducation’ rant is available at http://www.dailykos.com/story/2012/10/11/1143009/-Stephen-Colbert-on-medicating-children-to-improve-their-grades

On October 10 2012 American comedian Stephen Colbert coined the term “meducation” to describe the growing practice of drugging with ADHD amphetamines, American children with mediocre school grades, who do not have a diagnosis of ADHD.The catalyst for the mock right wing political commentator’s endorsement of ADHD drugs as smart pills was a front page article in the New York Times in which peadiatrician Dr Michael Anderson advocated their widespread use to compensate for America’s third rate public education system. Doctor Anderson said “we’ve decided as a society that it’s too expensive to modify the kid’s environment. So we have to modify the kid.” Unlike Colbert, Dr Anderson is not a comedian but unfortunately for some of the children of Ganton Georgia he is their doctor.

In his comedic monologue Colbert argues the child drugging program should be extended beyond amphetamines. “Folks, I believe this is a great fiscally responsible answer, but we can do more.  I mean, we might be cutting arts programs, but one tab of acid, and your kid will be seeing colours you can’t find in a Crayola box.” Colbert’s mock rant concludes with a serious warning; “Now, of course, eventually it may turn out that drugging poor students creates more problems than it solves.  In which case, we’ll have to stop trying to change our children, and think about changing ourselves.”

Despite Dr Anderson’s claims and Colbert’s mock endorsement, ADHD amphetamines are anything but ‘smart drugs’. Unique long term (8 year) Australian research shows that children diagnosed ADHD and ‘ever medicated’ with amphetamines were a staggering 950% more likely to be rated by their teacher as “performing below age-level” than children diagnosed with ADHD and ‘never medicated’. (see http://speedupsitstill.com/2010/02/17/excerpts-from-the-raine-study/ ) And as pointed out by Colbert the USA, the home of ADHD child drugging, lags most comparable developed nations (and a few second world nations) in terms of academic achievement.

The message is pretty clear – if you want to dumb down – speed up!

Excerpt  from ‘Attention Disorder or Not, Pills to Help in School’

by Alan Schwarz New York Times, page 1, October 9, 2012

full text available at http://www.nytimes.com/2012/10/09/health/attention-disorder-or-not-children-prescribed-pills-to-help-in-school.html?pagewanted=1&_r=1&emc=eta1

When (American paediatrician) Dr. Michael Anderson hears about his low-income patients struggling in elementary school, he usually gives them a taste of some powerful medicine: Adderall (a mixture of four amphetamine salts[1. See http://www.rxlist.com/adderall-drug.htm ])…

Although A.D.H.D is the diagnosis Dr. Anderson makes, he calls the disorder “made up” and “an excuse” to prescribe the pills to treat what he considers the children’s true ill — poor academic performance in inadequate schools. “I don’t have a whole lot of choice…We’ve decided as a society that it’s too expensive to modify the kid’s environment. So we have to modify the kid.”…

Dr. Anderson’s instinct, he said, is that of a “social justice thinker” who is “evening the scales a little bit.” He said that the children he sees with academic problems are essentially “mismatched with their environment” — square pegs chafing the round holes of public education…

About 9.5 percent of Americans ages 4 to 17 were judged to have it (ADHD) in 2007, or about 5.4 million children, according to the Centers for Disease Control and Prevention[2. See http://www.cdc.gov/ncbddd/adhd/data.html]…

According to guidelines published last year by the American Academy of Pediatrics, physicians should use one of several behavior rating scales, some of which feature dozens of categories, to make sure that a child not only fits criteria for A.D.H.D., but also has no related condition like dyslexia or oppositional defiant disorder, in which intense anger is directed toward authority figures. However, a 2010 study in the Journal of Attention Disorders suggested that at least 20 percent of doctors said they did not follow this protocol when making their A.D.H.D. diagnoses, with many of them following personal instinct…

Dr. Anderson said (ADHD diagnostic criteria)…were codified only to “make something completely subjective look objective.”…

“This is my whole angst about the thing,” Dr. Anderson said. “We put a label on something that isn’t binary — you have it or you don’t. We won’t just say that there is a student who has problems in school, problems at home, and probably, according to the doctor with agreement of the parents, will try medical treatment.”

He added, “We might not know the long-term effects, but we do know the short-term costs of school failure, which are real. I am looking to the individual person and where they are right now. I am the doctor for the patient, not for society.”

Martin Whitely’s Comment – I am torn between loathing Doctor Anderson for his blatant disregard for the long term welfare of the children he is supposed to be helping; and respecting him for his honest assessment of the unscientific nature of an ADHD diagnosis and the American public education system. However, his justification for using Adderall on children with mediocre or worse grades is built on a very flawed premise; that is the belief that amphetamines are an academic performance enhancer.

By Martin Whitely MLA

The off colour Australian colloquialism ‘you can’t polish a turd but you can cover it in glitter’ is a fitting analogy for the danger of legitimising ADHD as a diagnosable mental illness by developing treatment guidelines. However, treatment guidelines are being developed and the more conservative the treatment guidelines, the fewer children risk damage with the long-term administration of amphetamines.

That is why I welcome the release by the National Health and Medical Research Council (NHMRC) of the Australian ADHD Clinical Practice Points (CPPs) as a small but significant step in the right direction. (The CPPs available at http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/mh26_adhd_cpp_2012_120903.pdf )

Eventually ADHD will be regarded as an embarrassing footnote of history and society will collectively wonder how anyone ever thought it would be a good idea to give amphetamines to children. But in the meantime improvements like those in the ADHD CPPs, although modest, will hopefully see fewer children diagnosed and drugged.

That said, the CPPs are far from perfect. The statement that, “…stimulants might be considered for this age group (under 7 years)” leaves the door open for drugging very young children.[1] The manufacturers prescribing information for all stimulants state they should not be used in children under 6 years, since safety and efficacy in this age group have not been established.[2] Any clinician ignoring the manufacturers warning is inviting a future law suit for negligence.

The ADHD CPPs were developed as a stop gap replacement for the corrupted NHMRC 2009 Draft Australian Guidelines on Attention Deficit Hyperactivity Disorder which in turn replaced the deeply flawed 1997 NHMRC ADHD Guidelines that were rescinded in 2005.[3] The ADHD CPPs state the 2009 Draft Guidelines were “not approved by NHMRC” as “…undisclosed sponsorship may have affected the findings of a large number of publications (co-authored by Prof Joseph Biederman and Drs Thomas Spencer and Timothy Wilens) relied on for the Draft Guidelines”.(Page 4)

Undue drug company influence went much deeper than simply relying on corrupted research. While I am not suggesting they were individually corrupt; the majority of members of the guidelines development group had ties to ADHD drug manufacturers and were enthusiastic proponents of ADHD child drugging. (For more detail on the corrupted guidelines development process refer to Open book approach a good start for the new National ADHD Guidelines Committee)

It took six years of determined advocacy to expose the connections and prompt the intervention of Mental Health Minister Mark Butler. In contrast to the indifference and incompetence of previously responsible ministers Nicola Roxon and Tony Abbott, Minister Butler established the relatively conflict of interest free[4] and transparent ADHD CPPs development process.

Although the ADHD CPPS are described as being “based on expert consensus” it would probably have been more accurate if they were described as being “based on expert compromise”. This was an inevitable product of a committee which contained members with diametrically opposed views like ADHD sceptic, Professor Jon Jureidini, and ADHD prescribing enthusiast, Professor Michael Kohn. (see Where is the evidence to support ‘ADHD expert’ Prof Kohn’s claim that amphetamines aid brain development? ) As a result in several places the ADHD CPPs are contradictory.

Despite their limitations Mental Health Minister Mark Butler deserves credit for establishing the ADHD CPPs process. There was significant opportunity for public input with approximately 140 submissions spanning the divergent range of views on ADHD and resulting in significant differences between draft and final guidelines.[5]

One of the more notable improvements from the draft was the removal of the statement that “as with any medical intervention, the inability of parents to implement strategies may raise child protection concerns”.[6] This statement attracted widespread media attention and condemnation.[7]  On 23 November 2011 the NHMRC issued a media release denying that a failure to medicate may result in the intervention of child protection authorities.[8] This statement was welcome however it should never have been included in the draft ADHD CPPs in the first place.

Overall the final September 2012 ADHD CPPs represent a significant improvement on the November 2011 draft ADHD CPPs and a vast improvement on the corrupted 2009 Draft Australian Guidelines. Below I have listed both positive and negative features of the final ADHD CPPs.

Positive features of the final ADHD CPPs include the statements that:

• “The clinician should always be mindful of seeking a more meaningful explanation of the child/adolescent’s behaviour than simply labelling it as ADHD because it meets diagnostic criteria.” (Page 14)
• “ADHD is a description rather than an explanation of a pervasive, persistent, disabling pattern of inattentiveness, overactivity and/or impulsivity. A child/adolescent who meets diagnostic criteria for ADHD may not be always best served by making that diagnosis. For example, their behaviour could be understood as a reaction to specific cognitive difficulties or family/environmental circumstances.” (Page 6)
• Comment- A very good statement, however I would argue that a child is never best served by applying a one size fits all label that fails to explain their unique circumstances.

• “All children and adolescents can display active, impulsive and inattentive behaviour as part of normal development. This does not mean that they have a disorder, and important controversies exist about the use of ADHD as a diagnosis for children and adolescents.” (Page 10)
• “Parents/carers must be given information on the diagnosis and management plan, including any potential adverse effects of treatment in order to fully inform them and to have them make a decision regarding the treatment that is offered to their child.” (Page 16)
• Potential “adverse-effects” of stimulants identified in the ADHD CPPs include sleep disturbance, reduced appetite, abdominal pain, headaches, crying spells, repetitive movements, slowed growth (height and weight), restlessness, dizziness, anxiety, irritability cardiovascular effects such as tachycardia, palpitations and minor increases in blood pressure and psychosis or mania.  In addition the ADHD CPPS say where to report side-effects in Australia (to the TGA) and acknowledge that stimulants are Schedule 8 drugs because they can be addictive and are abused.  (Page 20)
• “Children/adolescents on stimulant medication require 3-6 monthly clinical assessment and review to ensure the management strategies remain appropriate and effective. Monitoring should include assessment of side effects and particularly psychological symptoms and plotting of growth parameters, pubertal development, heart rate and blood pressure.” (Page 8)
• “Not all children and adolescents with ADHD will require, or benefit from, pharmacological management.”  (Page 8)
• Comment- A double edged sword but nonetheless an improvement from previous guidelines that promoted the use of ADHD amphetamines as the first line treatment for all children diagnosed with ADHD.

• “Practical supports for families, such as respite care, parenting education and guidance and counselling, may be helpful or even a sufficient intervention perhaps obviating the need for specific treatment and psychological management of the child.” (Page 17)
• “When stimulant treatment is used it should only be continued if there is demonstrated benefit in the absence of unacceptable side effects. “ (Page 8).
• Comment- Again a double edged sword but an improvement from previous guidelines.

• “There is no one single known cause of ADHD….” (Page 10).
• Comment- Would have been more accurate to say there is no one single known cause of the inattentive and/or impulsive behaviours characterised as ADHD

• “….the effect of medication and behavioural or educational interventions on long-term outcomes such as academic and social and emotional outcomes, has not been established…..“ (Page 11) AND “Considering that there is insufficient evidence on the long-term outcomes and long-term adverse effects following use of stimulants, the continuing benefit from, and need for medication should be regularly assessed.” (Page 21)
• Comment- The limited long term evidence available indicates that children diagnosed with ADHD and never medicated do much better than children diagnosed with ADHD and medicated. Therefore the prudent ‘first do no harm’ step would be to never medicate or time limit the use of stimulants by children to a year. For more information on the long term effects of stimulants see One year on from the Raine Study ADHD Medication Review – Will the analysis of this unique long term data source continue and if so can we trust those doing the analysis?

• “….there are no specific treatments to ‘cure’ ADHD…..” (Page 16)
• “In the absence of another diagnosis, neuroleptics (anti-psychotics) have no role in the treatment of ADHD.” (Page 18)On the negative side the ADHD CPPs include the statements that:

• “The risk of not making a diagnosis is that the child/adolescent may not receive appropriate management and care.” (Page 12)
• Comment-This is one of the most disturbing statements in the CPPs. ADHD is a dumbed down label that does nothing to explain a child’s individual circumstances. It prevents understanding and invites a dangerous one size fits all treatment, stimulants, that mask behaviours without addressing any underlying problems. 

• “Regardless of whether the cause is explicable or not these symptoms impact so adversely on the child or adolescent and their family that the symptoms cannot be left untreated.” (Page 11)
• Comment- These first two statements may panic clinicians and parents in premature treatment with unnecessary and potentially dangerous drugs, i.e. amphetamines. The statements are inconsistent with the precautionary first do no harm principal of medicine. Understanding the cause of any problem is essential to identifying appropriate long term solutions.

• “Use of stimulant medications (methylphenidate and dexamphetamine sulphate) can reduce core ADHD symptoms and improve social skills and peer relations in children and adolescents diagnosed with ADHD in the short term (up to 3 years).” (Page 8)
• Comment- I agree that drugs will alter behaviour immediately and in some cases make boisterous, even annoying and in some cases traumatised children more compliant. However, achieving social control and compliance in that manner is a violation of the rights of the child and frequently covers up underlying serious problems including in some cases the traumatic effects of child abuse and neglect.

• “Both medication and combined medication and behavioural treatment have been shown to be more effective in treating ADHD symptoms than psychosocial or behavioural interventions alone.” (Page 19)
• Comment- Again I agree that drugs will alter behaviour immediately, however achieving compliant behaviour in the short term is not an appropriate way to measure child welfare. The only consideration that should matter is the long-term welfare of the child not the convenience of others. The limited long term evidence available indicates that children diagnosed with ADHD and never medicated do much better than children diagnosed with ADHD and medicated.

• “For young children (under 7 years) psychological, environmental and family interventions should, if possible, be trialed and evaluated before initiating pharmacological treatment. If all these other interventions have not been effective then stimulants might be considered for this age group in consultation with the parents or guardians and including when appropriate teachers or other carers.” (Page 9)
• Comment- This is the most concerning recommendation as it leaves the door open for drugging very young children. The manufacturers prescribing information for all stimulants state stimulants should not be used in children under 6 years, since safety and efficacy in this age group have not been established.[9]

• “It is rare that symptoms of ADHD occur in isolation. In the assessment of a child/adolescent with ADHD the specialist clinician should assess for other psychological, social, emotional and behavioural difficulties that might coexist with ADHD (comorbidities).” (Page 11)
• Comment – Psychological, social and emotional difficulties are often the causes of ADHD type behaviours. In these cases ADHD doesn’t coexist, rather the ADHD type behaviours are caused by psychological, social and emotional difficulties.

• “Children/adolescents with ADHD may have other mental health problems, such as depression, which may be associated with an increased risk of suicidal ideation. Conducting a mental health assessment, where indicated, can detect mental health problems and inform appropriate management.” (Page 15)
• Comment – Inviting multiple diagnoses invites poly-pharmacy in the minds of some medical practitioners. Antidepressants are not approved for use in young people as studies show they increase suicidality by approximately 80%.[10]

• “Assessment of response to treatment and periodic review of progress is facilitated by the use of questionnaires from parents/carers, teachers and if possible the child/adolescent using psychometrically sound, evidence-based checklists such as the Conners’ ADHD/DSM-IV Scales (CADS).” (Page 16)
• Comment- Please let’s all stop pretending the diagnosis of ADHD involves scientific testing. These so-called psychometrically sound, evidence-based checklists are no more than loosely defined behavioural tick-lists and are reminiscent of a Dolly Magazine find your perfect boyfriend tick-box questionnaire.

• “Heredity, genetic, neuro-imaging and neuro-psychological studies provide evidence for a biological basis for inattention and impulsiveness.” (Page 10)
• Comment- This is concerning for two reasons. Firstly it overstates the validity of this evidence. Secondly and most significantly even if a biological basis for ” for inattention and impulsiveness” is established this does not make a disease or disorder any more than other genetic variations like height or skin colour. Refer to The ‘Genetic basis of ADHD’ – much ado about nothing

• “Data from 2000 indicates the prevalence rate of ADHD symptoms among 6–17 year-olds in Australia is around 11%.” (Page 11)Related Media
•  Experts alarmed at new ADHD guidelines | News.com.au Sue Dunlevy, News Limited Network, October 03, 2012
• Comment- This is a massive overestimate of the proportion of children who would qualify for a DSMIV diagnosis as when conducting this research there was no assessment for impairment or requirement for children to display sustained ADHD in multiple settings. Nonetheless the garbage research continues to be quoted by the ADHD industry, the NHMRC and even Commonwealth Ministers.[11]

[1] Page 9 of the ADHD CPPs available at http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/mh26_adhd_cpp_2012_120903.pdf

[2] Ritalin prescribing information says “Ritalin should not be used in children under 6 years, since safety and efficacy in this age group have not been established” see http://www.pharma.us.novartis.com/product/pi/pdf/ritalin_ritalin-sr.pdf   Concerta’s says “safety and efficacy has not been established in children less than six years old or elderly patients greater than 65 years of age” see http://www.concerta.net/sites/default/files/pdf/Prescribing_Info-short.pdf#zoom=56  Dexedrine’s (brand of dexamphetamine) says “Long-term effects of amphetamines in pediatric patients have not been well established. DEXEDRINE is not recommended for use in pediatric patients younger than 6 years of age with Attention Deficit Disorder with Hyperactivity” see http://www.dexedrine.com/docs/dexedrine_PI.pdf

[3] National Health and Medical Research Council, Attention Deficit Hyperactivity Disorder (ADHD), Canberra, 1997. http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/ch36.pdf

[4] Conflict of Interest details available at http://www.nhmrc.gov.au/guidelines/adhd-conflicts-interest

[5] For details of the effect of the submissions on the final ADHD CPPs see appendix D page 16 available at http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/mh26_adhd_cpp_appendices_120903_0.pdf

[6] National Health and Medical Research Council, Public Consultation on the Draft Clinical Practice Points on the Diagnosis, Assessment and Management of Attention Deficit Hyperactivity Disorder in Children and Adolescents, Australian Government, November 2011 p15. Available http://consultations.nhmrc.gov.au/open_public_consultations/a-d-h-d

[7] Sue Dunleavy, The Australian medicate ADHD kids or else parents told 21/11/2011 http://www.theaustralian.com.au/national-affairs/medicate-adhd-kids-or-else-parents-told/story-fn59niix-1226200652633

[8] 8. see http://www.nhmrc.gov.au/media/releases/2011/reassuring-parents-new-draft-adhd-clinical-practice-points-do-not-mandate-medica

[9] Ritalin prescribing information says “Ritalin should not be used in children under 6 years, since safety and efficacy in this age group have not been established” see http://www.pharma.us.novartis.com/product/pi/pdf/ritalin_ritalin-sr.pdf   Concerta’s says “safety and efficacy has not been established in children less than six years old or elderly patients greater than 65 years of age” see http://www.concerta.net/sites/default/files/pdf/Prescribing_Info-short.pdf#zoom=56  Dexedrine’s (brand of dexamphetamine) says “Long-term effects of amphetamines in pediatric patients have not been well established. DEXEDRINE is not recommended for use in pediatric patients younger than 6 years of age with Attention Deficit Disorder with Hyperactivity” see http://www.dexedrine.com/docs/dexedrine_PI.pdf

[10] See http://www.fda.gov/Drugs/DrugSafety/InformationbyDrugClass/ucm096273.htm

[11] Draft ADHD Guidelines Released, Joint Media Release, 30 November 2009.  The Hon Nicola Roxon MP, Minister for Health and Ageing, National Health and Medical Research Council, and Royal Australasian College of Physicians.]

]]> http://speedupsitstill.com/2012/10/02/australian-adhd-clinical-practice-points-6-years-frustrated-advocacy-small-step-direction/feed/ 5 http://speedupsitstill.com/2012/09/03/adhd-drug-concerta-dangerous-adults-kids/ http://speedupsitstill.com/2012/09/03/adhd-drug-concerta-dangerous-adults-kids/#comments Mon, 03 Sep 2012 04:57:58 +0000 http://speedupsitstill.com/?p=3334 How can this be? Don’t bother asking because privacy laws shield the drug company applications for PBS listing from public scrutiny.

by Dr Martin Whitely

ADHD drug Concerta is a slow release form of methylphenidate (the active ingredient in Ritalin) that can be taken once daily.  It was first licensed for use in Australia by the Therapeutic Goods Administration (TGA) in 2003 and subsidised via the Pharmaceutical Benefits Scheme (PBS) for use by children in 2007.

Recently Concerta’s manufacturer Janssen-Cilag (a subsidiary of Johnson and Johnson) applied to “extend the current Authority required listing” on the Pharmaceutical Benefits Scheme for Concerta “to include use in patients diagnosed with attention deficit hyperactivity disorder (ADHD) after the age of 18 years”. The Pharmaceutical Benefits Scheme Advisory Committee (PBAC) “rejected the application on the basis of uncertain efficacy and safety in the proposed PBS population and hence uncertain cost-effectiveness, and high and highly uncertain cost to the PBS.”[1] In response Janssen Cilag commented that “Concerta is already available on the PBS for use in adults who were diagnosed with ADHD ≤ 18 years. This submission requested the same access for all adult patients regardless of the age at which they were diagnosed. We will consult with the PBAC with regards to a future resubmission.”[2]

Janssen Cilag raise a valid point; How can Concerta be ok for children and yet have “uncertain efficacy and safety” for adults? They believe that contradiction should justify taxpayers subsidising Concerta available for adults. In contrast I argue that if Concerta isn’t proved to be safe enough for adults there is no way it should be given to children. However, the history of Strattera shows that once an ADHD drug is licensed and subsidised for use in children even a trail of horrific adverse events are not enough to see it removed from the market or even the PBS.

Unfortunately due to an absurd interpretation of privacy provisions in the National Health Act 1953 by the Administrative Appeals Tribunal, documents about PBS listing decisions are FOI exempt in the same way as individual patient records.[3] Therefore the public has no way of knowing the detail of why the PBAC made its decisions to oppose Concerta’s subsidisation for adults (in 2012) and yet support it for children (in 2007). Of course Janssen Cilag has full access to these documents and can have another go at obtaining subsidisation later.

Without access to the documents the PBAC use to reach its decision we can only speculate on the reasons for the seemingly absurd inconsistency. One possible explanation is that children can’t give informed consent to participate in drug trials that establish the safety and efficacy of drugs used on children. Ironically this often results in drugs being used by millions of children worldwide without any paediatric safety and efficacy testing.

Could it be that authorities established to protect the public interest including the PBAC and the TGA, have in the absence of supporting information, simply assumed that Concerta is safe and efficacious for children?

Note: The PBAC decision mirrors a 2011 decision by European drug regulators to disallow Concerta’s use by adults unless they were originally prescribed Concerta before their 19th birthday. According to information provided by Janssen Cilag on a UK website “the safety and efficacy of long-term use of methylphenidate (by children) has not been systematically evaluated in controlled trials” and the “safety and efficacy have not been established for the initiation of treatment in adults or the routine continuation of treatment beyond 18 years of age.”[4] However, off label prescribing is common and many adults both in Europe and Australia use methylphenidate either in Ritalin or Concerta and many children use it for years on end.

For more on the long term effects of stimulants on children diagnosed with ADHD see One year on from the Raine Study ADHD Medication Review – Will the analysis of this unique long term data source continue and if so can we trust those doing the analysis?

Related Media

Australia’s News Limited Sunday papers (Perth’s Sunday Times, Sydney’s Telegraph, Melbourne’s Herald Sun etc.) carried a story about the above written by Sue Dunlevy on 9 September 2012. See http://www.heraldsun.com.au/news/national/kids-use-rejected-adhd-drug/story-fndo48ca-1226468130766

[1] see http://www.health.gov.au/internet/main/publishing.nsf/Content/pbacrec-july12-first-time-rejections

[2] see http://www.health.gov.au/internet/main/publishing.nsf/Content/pbacrec-july12-first-time-rejections

[3] see http://www.martinwhitely.com/foi/

[4] see http://www.medicines.org.uk/emc/medicine/8382/SPC/Concerta+XL+18+mg+-+36+mg+prolonged+release+tablets/

]]> http://speedupsitstill.com/2012/09/03/adhd-drug-concerta-dangerous-adults-kids/feed/ 6 http://speedupsitstill.com/2012/05/17/not-so-quick-fix-behavioral-therapy-drugs-long-run/ http://speedupsitstill.com/2012/05/17/not-so-quick-fix-behavioral-therapy-drugs-long-run/#comments Thu, 17 May 2012 09:33:20 +0000 http://speedupsitstill.com/?p=2965 The Scientific American recently published an article suggesting that “cognitive and behavioral therapies that help young people reduce impulsivity and cultivate good study habits are costlier and take longer to administer [than ADHD drugs], but may be more efficacious over time”.

The article states;

A new synthesis of behavioral, cognitive and pharmacological findings emerged at the recent Experimental Biology meeting, held last month in San Diego, where experts in ADHD research and treatment gathered to present their work. Their findings suggest that behavioral and cognitive therapies focused on reducing impulsivity and reinforcing positive long-term habits may be able to replace current high doses of stimulant treatment in children and young adults…

Psychologist Claire Advokat of Louisiana State University has been looking at the effects of stimulant medications in college students to see what improves with medication and what does not. As expected, she found that people diagnosed with ADHD had lower grades and ACT (American College Testing) scores; they also dropped more classes than their peers. But she also found that these issues were not improved by stimulant medication treatment.

Instead, Advokat’s new findings indicate that the ADHD students naturally divided into those who had good study habits and those who did not, regardless of treatment. If students had good study habits, they did not need the medication to bolster their grades.

(The full article is available at http://www.scientificamerican.com/article.cfm?id=adhd-behavioral-therapy-more-effective-drugs-long-term&WT.mc_id=SA_CAT_MB_20120516 )

Temporarily putting aside concerns with the validity of ADHD as a diagnosable disorder, I welcome the long overdue recognition of what should be obvious. That is, cheap and messy drug interventions may immediately alter behaviour but there are no chemical short cuts to long-term academic success.

1- Tends to act without thinking, such as starting tasks without adequate preparation or avoiding reading or listening to instructions. May speak out without considering consequences or make important decisions on the spur of the moment, such as impulsively buying items, suddenly quitting a job, or breaking up with a friend.

2- Is often impatient, as shown by feeling restless when waiting for others and wanting to move faster than others, wanting people to get to the point, speeding while driving, and cutting into traffic to go faster than others.

3- Is uncomfortable doing things slowly and systematically and often rushes through activities or tasks.

4- Finds it difficult to resist temptations or opportunities, even if it means taking risks (A child may grab toys off a store shelf or play with dangerous objects; adults may commit to a relationship after only a brief acquaintance or take a job or enter into a business arrangement without doing due diligence).[2. for full details of the now abandoned DSM5 ADHD proposal refer to http://speedupsitstill.com/dsm-5-proposal-adhd-%e2%80%93-making-lifelong-patients-healthy-people ]

It is good news that these ridiculous additions have been removed along with the extremely worrying proposal to lower the bar for anyone over 16 years so that exhibiting 4 criteria of a subtype instead of 6 could be enough to get a diagnosis of ADHD.  However, the existing 18 diagnostic criteria have been reworded to be equally applicable to adults as well as children, reflecting the ADHD industries persistent and successful efforts to expand the adult market. (The revised proposed criteria are listed at the end of this blog)[3. see http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=383 ]

Another remaining concern is the proposal for an ADHD category titled Attention Deficit/Hyperactivity Disorder Not Elsewhere Classified must be removed.  This additional category reads: Attention Deficit/Hyperactivity Disorder (ADHD) Not Elsewhere Classified may be coded in cases in which the individuals are below threshold for ADHD or for whom there is insufficient opportunity to verify all criteria. However, ADHD-related symptoms should be associated with impairment, and they are not better explained by any other mental disorder.[4. see http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=102] The inclusion of this additional category effectively enables clinicians to diagnose and prescribe without even the flimsy protection offered by the already extremely broad DSM4 diagnostic criteria. It cannot be allowed to stand unchallenged.

While the back-downs from the original DSM5 proposals for Psychosis Risk, ADHD and a number of other dubious disorders are welcome they do not begin to go far enough.  Continued pressure through protest and common-sense advocacy must be brought to bear on the American Psychiatric Association (APA).

The APA only responded after significant past users of the DSM, including the British Psychological Association and chapters of the American Psychological Association threatened a boycott of DSM5.[5. refer to http://speedupsitstill.com/sign-on-line-petition-proposed-dsm5 and http://speedupsitstill.com/dr-allen-frances-lead-author-dsmiv-british-psychological-association-lead-chorus-opposition-disease-mongering-proposals-dsm5] This demonstrates that the APA’s DSM development process is driven by politics and money, rather than science and patient welfare. If their proposals were scientifically robust they would have defended them rather than compromising when the going got tough.

The resistance of DSM5 must continue.  Ideally Australia should reject the permanent disability model of mental health embedded in the DSM and develop a model of treating mental illness designed to enhance individual resilience and assist the natural capacity of most mentally ill people to make a full recovery.

Continuing to follow the APA’s lead, will unnecessarily doom many more Australians to a vicious cycle of difficult personal circumstances, behavioural difficulties, dumbed down labelling, inappropriate prescribing and further prescribing to manage adverse side effects.

Nonetheless yesterday’s back-downs are a welcome first step in the right direction.  More than any other individual former DSMIV chairperson, Doctor Allen Frances, deserves credit for leading the ongoing fight against the excesses of DSM5. Doctor Frances’ blog which deals with progress made and the need for continued advocacy is copied below.[6. The original is available at http://www.psychologytoday.com/blog/dsm5-in-distress/201205/wonderful-news-dsm-5-finally-begins-its-belated-and-necessary-retreat ]

Hear Martin Whitely interviewed on Brisbane Radio 4BC about the backdown on ADHD for the proposed DSM5 at http://www.4bc.com.au/blogs/4bc-blog/adhd-and-its-psychosis-listing/20120524-1z6rg.html

Hear the ABC World Today Program interview Patrick McGorry and Martin Whitely regarding the DSM5 Psychosis Risk Disorder backdown at http://www.abc.net.au/worldtoday/content/2012/s3511017.htm

Wonderful News: DSM 5 Finally Begins Its Belated and Necessary Retreat

Perhaps this will be the beginning of real reform.

Published on May 2, 2012 by Allen J. Frances, M.D. in DSM5 in Distress

Sigh of relief. The DSM 5 website announced this morning that two of its most controversial proposals have finally been dropped. We have dodged bullets on Psychosis Risk and Mixed Anxiety Depression. Both are now definitively rejected as official DSM 5 diagnoses and instead are being exiled to the appendix. And one other piece of good news; the criteria set for Attention Deficit/Hyperactivity Disorder has been tightened (not enough, but every little bit helps).

The world is a safer place now that ‘Psychosis Risk’ will not be in DSM 5. Its rejection saves our kids from the risk of unnecessary exposure to antipsychotic drugs (with their side effects of obesity, diabetes, cardiovascular problems, and shortened life expectancy). ‘Psychosis Risk’ was the single worst DSM 5 proposal—we should all be grateful that DSM 5 has finally come to its senses in dropping it.

For the first time in its history, DSM 5 has shown some flexibility and capacity to correct itself. Hopefully, this is just the beginning of what will turn out to be a number of other necessary DSM 5 retreats. Today’s revisions should be just the first step in a systematic program of reform—a prelude to all the other changes needed before DSM 5 can become a safe and scientifically sound document.

The turnabout here can be attributed to the combination of: 1) extensive criticism from experts in the field; 2) public outrage; 3) uniformly negative press coverage and; 4) the abysmal results in DSM 5 field testing. The same factors working together should deep six many of the other risky DSM 5 proposals. This is certainly no time for complacency. Much of the rest of DSM 5 is still a mess. The reliabilities achieved for many of the other disorders are apparently unbelievably low and the writing of the criteria sets is still unacceptably imprecise. The following specific questions need to be answered.

1) Why introduce Disruptive Mood Dysregulation Disorder when it has been studied by only one research team for only six years and risks further encouraging the inappropriate use of antipsychotic drugs for kids with temper tantrums?

2) Why have a diagnosis for Minor Neurocognitive Disorder that will unnecessarily frighten many people who have no more than the memory problems of old age?

3) Why insist on removing the Bereavement exclusion—thus allowing the inappropriate diagnosis of Major Depressive Disorder in people who are experiencing normal grief?

4) Why open the floodgates to even more over-diagnosis and over-medication of Attention Deficit Disorder (by raising the allowed age of onset to 12)?

5) Why dramatically lower the threshold for Generalized Anxiety Disorder when this will confound mental disorder with the anxiety and sadness of everyday life?

6) Why combine substance abuse with substance dependence under the rubric of Addictive Disorders—when this confuses their different treatment needs and creates unnecessary stigma for many young people who will never go on to ‘addiction’?

7) Why include a category for Behavioral Addictions that will open the door to the mislabelling as mental disorder all sorts of normal interests and passions? The DSM 5 suggestion to include ‘internet addiction’ in the Appendix is an ominous first step.

8) Why include wording in the Pedophilia criteria set that will invite further forensic abuse of the already much misused Paraphilia section?

9) Why label as mental disorder the experience of indulging in one binge eating episode a week for three months?

10) Why introduce a system of personality diagnosis so complicated it will never be used and will give dimensional diagnosis an undeserved bad name?

11) Why not delay publication of DSM 5 to allow enough time to complete the previously planned and crucial second stage of field testing that was abruptly cancelled because of the constant administrative delays in completing the first stage? This is the only way to guarantee acceptable reliability. We should not accept ambiguously worded DSM 5 diagnoses whose reliability barely exceeds chance?

12) And most fundamental. Why not allow for an independent scientific review of all the remaining controversial DSM 5 changes. This has been proposed by fifty-one mental health organizations as the only way to guarantee a credible DSM 5?

The public has 6 weeks to comment on the current DSM 5 suggestions. Then there will be a round of final decisions- with everything probably sewn up by mid-fall. This opening chink in the previously impervious DSM 5 armour should spur renewed efforts to get the rest of DSM 5 right.

For more on the latest revisions of the DSM 5 criteria sets, see here.

Take this last opportunity to be heard.

To comment directly to the American Psychiatric Association on their proposals click on http://www.dsm5.org/Pages/Registration.aspx

Related Media

Psychiatry Manual Drafters Back Down on Diagnoses by BENEDICT CAREY in New York Times 8 May 2012

Sue Dunlevy, Medical ‘Bible’ Squabble, The Weekend Australian, 19 May 2012 available at http://www.theaustralian.com.au/news/health-science/medical-bible-squabble/story-e6frg8y6-1226359242372

Below are the (revised) proposed DSM5 diagnostic criteria for ADHD

(see http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=383 )

AD/HD consists of a pattern of behavior that is present in multiple settings where it gives rise to social, educational or work performance difficulties.

A. Either (A1) and/or (A2).

A1. Inattention: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that impact directly on social and academic/occupational activities.

a.   Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities (e.g., overlooks or misses details, work is inaccurate).

b.   Often has difficulty sustaining attention in tasks or play activities (e.g., has difficulty remaining focused during lectures, conversations, or reading lengthy writings).

c.   Often does not seem to listen when spoken to directly (e.g., mind seems elsewhere, even in the absence of any obvious distraction).

d.   Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., starts tasks but quickly loses focus and is easily sidetracked;  fails to finish schoolwork, household chores, or tasks in the workplace).

e.   Often has difficulty organizing tasks and activities (e.g., difficulty managing sequential tasks; difficulty keeping materials and belongings in order; messy, disorganized, work; poor time management; tends to fail to meet deadlines).

f.    Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework; for older adolescents and adults, preparing reports, completing forms, or reviewing lengthy papers).

g.   Often loses things necessary for tasks or activities (e.g., school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, or mobile telephones).

h.   Is often easily distracted by extraneous stimuli (for older adolescents and adults, may include unrelated thoughts).

i.    Is often forgetful in daily activities (e.g., chores, running errands; for older adolescents and adults, returning calls, paying bills, keeping appointments).

A2. Hyperactivity and Impulsivity: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that impact directly on social and academic/occupational activities.

a.   Often fidgets with or taps hands or feet or squirms in seat.

b.   Often leaves seat in situations when remaining seated is expected (e.g., leaves his or her place in the classroom, office or other workplace, or in other situations that require remaining seated).

c.   Often runs about or climbs in situations where it is inappropriate. (In adolescents or adults, may be limited to feeling restless).

d.   Often unable to play or engage in leisure activities quietly. 

e.   Is often “on the go,” acting as if “driven by a motor” (e.g., is unable or uncomfortable being still for an extended time, as in restaurants, meetings, etc; may be experienced by others as being restless and difficult to keep up with).

f.    Often talks excessively.

g.   Often blurts out an answer before a question has been completed (e.g., completes people’s sentences and “jumps the gun” in conversations, cannot wait for next turn in conversation).

h.   Often has difficulty waiting his or her turn (e.g., while waiting in line).

i.    Often interrupts or intrudes on others (e.g., butts into conversations, games, or activities; may start using other people’s things without asking or receiving permission, adolescents or adults may intrude into or take over what others are doing).

B.   Several inattentive or hyperactive-impulsive symptoms were present prior to age 12.

C.   Criteria for the disorder are met in two or more settings (e.g., at home, school or work, with friends or relatives, or in other activities).

D.   There must be clear evidence that the symptoms interfere with or reduce the quality of social, academic, or occupational functioning.

E.   The symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder and are not better accounted for by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, or a personality disorder).

 Specify Based on Current Presentation

Combined Presentation: If both Criterion A1 (Inattention) and Criterion A2 (Hyperactivity-Impulsivity) are met for the past 6 months.

Predominantly Inattentive Presentation: If Criterion A1 (Inattention) is met but Criterion A2 (Hyperactivity-Impulsivity) is not met and 3 or more symptoms from Criterion A2 have been present for the past 6 months.

Inattentive Presentation (Restrictive): If Criterion A1 (Inattention) is met but no more than 2 symptoms from Criterion A2 (Hyperactivity-Impulsivity) have been present for the past 6 months.

Predominantly Hyperactive/Impulsive Presentation: If Criterion A2 (Hyperactivity-Impulsivity) is met and Criterion A1 (Inattention) is not met for the past 6 months. 

Coding note: For individuals (especially adolescents and adults) who currently have symptoms with impairment that no longer meet full criteria, “In Partial Remission” should be specified.

The eleven year study of children aged six to twelve in the Canadian province of British Columbia, titled Influence of relative age on diagnosis and treatment of attention-deficit/hyperactivity disorder in children[1. Richard L. Morrow MA (et al), ‘Influence of relative age on diagnosis and treatment of attention-deficit/hyperactivity disorder in children’ CMAJ, March 5, 2012, http://www.cmaj.ca/content/early/2012/03/05/cmaj.111619.full.pdf+html ], confirms the ADHD late birthdate effect found in two recent smaller US studies described in my previous blog post.

The late birthday effect in the massive new Canadian study was very significant. Boys who were born in December were 30% more likely to have a diagnosis and 41% more likely to have a prescription for ADHD than their peers born in January.

The effect was even stronger for girls.  Girls born in December were 70% more likely to have a diagnosis and 77% more likely, to have a prescription for ADHD than their peers born in January.

British Columbia children exhibited the general worldwide trend that ADHD diagnosis and prescribing rates for boys are approximately three times greater than for girls.[2. Boyles, S. ‘Study confirms ADHD is more common in boys’, WebMD Health News, 15 September 2004 <http://www.webmd.com/add-adhd/news/20040915/study-confirms-adhd-is-more-common-in-boys> (accessed 10 March 2011)]  This is consistent with the traditional wisdom that girls grow up faster than boys.

Drugging boys to make them behave more like girls in class demonstrates just how empty modern educational ‘philosophies of inclusion’ are.  But many girls are also chemically punished for their childishness when compared to their older classmates.

Obviously younger children are more likely to be immature with the youngest kindergarten children having 20% less life experience than their oldest classmates. However, it should not be lost that children develop at different rates.

If a child is less mature than other children their own age, or even younger, they are not diseased, they are different.  Classing relative immaturity as a disease to be treated with amphetamines, is a barbaric abuse of a child’s right to grow at their own pace.

If, as the ADHD Industry frequently claims, ADHD is a neurobiological disease, a child’s birth date should have no bearing on their chances of being diagnosed and ‘medicated’.  Yet the ADHD Industry will respond as it always does and ignore or spin yet another inconvenient truth revealed in this study.

 Related Media:

Martin Whitely interviewed by Greg Carey, Radio 4BC, Brisbane 20 March 2012. http://www.4bc.com.au/blogs/4bc-blog/adhd-misdiagnosis/20120320-1vh3e.html

Sue Dunlevy, Immature Children prone to ADHD Tag, The Australian, 20 March 2012 http://www.theaustralian.com.au/news/health-science/immature-children-prone-to-adhd-tag/story-e6frg8y6-1226304525855

For more related information see Pseudoscience supporting ADHD and How is ADHD Diagnosed?

Taming the ADD Epidemic

The first co-authored by Emeritus Professor of Psychiatry at Duke University and the former chair of the DSM-IV development task force Doctor Allen Frances and myself was titled Taming the ADD Epidemic. (available at http://www.huffingtonpost.com/allen-frances/add-epidemic-_b_1293556.html)

The blog outlines the experience of Perth, Western Australia, the world’s first ADHD hotspot to see a massive downturn in child prescribing rates.  It describes how the implementation of tighter prescribing accountability measures that I advocated were followed by a 60-70% fall in Western Australian child ADHD prescribing numbers[1. See http://speedupsitstill.com/rise-and-fall-of-child-adhd-in-wa for more detail.] and a 51% fall in self reporting of teenage amphetamine abuse.[2. See http://speedupsitstill.com/perth-a-case-study-in-adhd-abuse for more detail.]

Dr Frances kindly concludes, “There are two potential tools that would allow us to tame the current ADD fad: 1) narrowed and more carefully applied diagnostic criteria and 2) rigorous quality controls over stimulant prescription. DSM-5 will lead us in just the wrong direction on the first; Mr. Whitely shows us the way on the second.”

Why Bébé (French for Baby) Doesn’t Have ADHD

The second by family therapist and author Marilyn Wedge, Ph.D.  offers her theory as to why in the ‘United States, approximately 5 percent of school-aged children have been diagnosed with ADHD and are taking pharmaceutical medications. [Where as] In France the percentage is a mere 0.05 percent.’  (available at http://www.huffingtonpost.com/marilyn-wedge-phd/adhd_b_1310973.html )

Doctor Wedge offers two controversial explanations:

1. American psychiatrists tend to view ADHD as a ‘biological disorder with biological causes’ whereas ‘French child psychiatrists…view ADHD as a medical condition that has psycho-social and situational causes.’ Therefore, ‘Instead of treating children’s focusing and behavioral problems with drugs, French doctors prefer to look for the underlying issue that is causing the child distress — not in the child’s brain but in the child’s social context. They then choose to treat the underlying social context problem with psychotherapy or family counseling. This is a very different way of seeing things from the American tendency to attribute all symptoms to a biological dysfunction such as a chemical imbalance in the child’s brain.’
2. ‘There are the vastly different philosophies of child-rearing in the United States and France. These divergent philosophies could account for why French children are generally better-behaved than their American counterparts…From the time their children are born, French parents provide them with a firm cadre — the word means “frame” or “structure.” Children are not allowed, for example, to snack whenever they want. Mealtimes are at four specific times of the day. French children learn to wait patiently for meals, rather than eating snack foods whenever they feel like it… As a therapist who has worked with children for more than twenty years, it makes perfect sense to me that French children don’t need medications to control their behavior because they learn self-control early in their lives. The children have grown up in families in which the rules are well-understood and a clear hierarchy is firmly in place. “C’est moi qui décide” (“It’s I who decide”), asserts the French parent. In French families… parents are firmly in charge of their kids — instead of the American family style, in which the situation is all too often vice versa.

Parenting styles are individual choices and beyond the control of government or the psychiatric profession.  However, the Australian psychiatric profession could choose to do what the French psychiatric profession did in the early 1980’s.  ‘In part as a resistance to the influence of the DSM-III, the French Federation of Psychiatry developed an alternative classification system. This was the CFTMEA (Classification Française des Troubles Mentaux de L’Enfant et de L’Adolescent), first released in 1983 and updated in 1988 and 2000. The focus of CFTMEA is on identifying and addressing the underlying psychosocial causes of children’s symptoms, not on finding symptoms that will qualify for the best pharmacological bandaids to mask them.’

Given the further disease-mongering proposed in the published draft of DSM5,[3. For more information on what the American Psychiatric Association propose for ADHD in DSM5 see http://speedupsitstill.com/dsm-5-proposal-adhd-%e2%80%93-making-lifelong-patients-healthy-people  For information about the general backlash to DSM5 proposals see http://speedupsitstill.com/sign-on-line-petition-proposed-dsm5 and http://speedupsitstill.com/dr-allen-frances-lead-author-dsmiv-british-psychological-association-lead-chorus-opposition-disease-mongering-proposals-dsm5] it might be timely for the Australian and New Zealand College of Psychiatry to hire a French translator.

This blog was originally published without references on www.perthnow.com.au

When parents severely abuse or neglect Western Australian children it is the responsibility of the State Government, specifically the Minister for Child Protection Robyn McSweeney, to step in and protect them.  Regardless of whether Minister McSweeney delegates their care to foster parents or provides care in an institution it is her job to make sure their often complex needs are met.

Anecdotal evidence indicates that too many Western Australian children in the care of the state that are managed rather than cared for.  Managed with a range of psychotropic drugs including, antidepressants, anti-psychotics, amphetamines and anti-anxiety ‘medications’ as a cheap substitute for the intensive support they so desperately need.

On the numerous occasions I have requested hard data about the issue, Minister McSweeney and others in the Barnett Government, including the Premier[1. Barnett, Hon. Colin, Premier of Western Australia. (letter to Martin Whitely MLA) 14 July, 2009. Also Whitely, Martin. Western Australian Parliamentary Debates, Hansard 7 May 2009, pp3586d-3604a. http://www.parliament.wa.gov.au/Hansard/hansard.nsf/0/02539ddc227be544c82575ca00292c82/$FILE/A38%20S1%2020090507%20p3586d-3604a.pdf ], have refused to provide it. They have consistently argued that, providing this information “would be a significant drain on the Department’s resources”.[2. Whitely, Martin Western Australian Parliamentary Debates, Hansard: Questions on Notice 5 May 2009, p3378b-3378b ]  This is the oldest political trick in the book.  Refuse to do the research needed to confirm a problem exists and then you never have to accept responsibility for solving the problem.

Other state governments however, at least know the extent of the problem.  In 2008 the New South Wales Government found out a staggering 50% of children twelve years of age and younger in state government residential care were taking psychotropic medication.  This compared to 2% of their peers.[3. ‘Children in care drugged’, The Australian, 2008 http://www.theaustralian.com.au/news/nation/children-in-care-drugged/story-e6frg6nf-1111117927563   ] Similarly, recent Queensland[4. ‘Foster children doped in care’ (Brisbane) Sunday Mail 12 February 2011 http://www.couriermail.com.au/news/sunday-mail/foster-children-doped-up-in-care/story-e6frep2f-1226005048486 ] and US[5. ‘Financial and societal costs of medicating America’s foster children’, Government Accountability Office presented to Senate subcommittee on Federal Financial Management, Government Information, Federal Services and International Security 1 December 2011 www.hsgac.senate.gov/download/salo-testimony ]research indicate that psychotropic medications are the dominant first world method of governments managing damaged children.

Obviously given their tormented history these children are far more likely to have significant mental health issues.  But we treat the causes of these behaviours as if they are biological, i.e. biochemical brain imbalances, rather than being an inevitable result of abuse and neglect.  Surely having been abused and neglected by their carers of first resort, their parents; these blameless, voiceless, victims deserve the very best from their carer of last resort.

Minister McSweeney has no excuse. She is a former child protection worker who in opposition expressed outrage about the number of children ‘medicated’ to control their behaviour.[6. James, Amanda ‘ADHD drug linked to poverty: report’, The West Australian 25 September 2002 pg 2.  Also McSweeney, Hon Robyn Western Australian Parliamentary Debates, Legislative Council, Hansard 5 June 2007, pp2648c-2658a ] But now she is in charge, it appears likely that many of these children, having been physically and yes, sometimes sexually abused, are now being chemically abused in the care of Minister McSweeney.

If we continue to turn a blind eye, we doom too many of these children and eventually their children to a perpetual cycle of abuse, neglect, misery and medication.  Let Western Australia at least take a first step by researching the extent of the problem.

Ritalin Gone Wrong – New York Times, January 28, 2012 by L. Alan Sroufe

Three million children in this country take drugs for problems in focusing. Toward the end of last year, many of their parents were deeply alarmed because there was a shortage of drugs like Ritalin and Adderall that they considered absolutely essential to their children’s functioning.

But are these drugs really helping children? Should we really keep expanding the number of prescriptions filled?

In 30 years there has been a twentyfold increase in the consumption of drugs for attention-deficit disorder.

As a psychologist who has been studying the development of troubled children for more than 40 years, I believe we should be asking why we rely so heavily on these drugs.

Attention-deficit drugs increase concentration in the short term, which is why they work so well for college students cramming for exams. But when given to children over long periods of time, they neither improve school achievement nor reduce behavior problems. The drugs can also have serious side effects, including stunting growth.

Sadly, few physicians and parents seem to be aware of what we have been learning about the lack of effectiveness of these drugs.

What gets publicized are short-term results and studies on brain differences among children. Indeed, there are a number of incontrovertible facts that seem at first glance to support medication. It is because of this partial foundation in reality that the problem with the current approach to treating children has been so difficult to see.

Back in the 1960s I, like most psychologists, believed that children with difficulty concentrating were suffering from a brain problem of genetic or otherwise inborn origin. Just as Type I diabetics need insulin to correct problems with their inborn biochemistry, these children were believed to require attention-deficit drugs to correct theirs. It turns out, however, that there is little to no evidence to support this theory.

In 1973, I reviewed the literature on drug treatment of children for The New England Journal of Medicine. Dozens of well-controlled studies showed that these drugs immediately improved children’s performance on repetitive tasks requiring concentration and diligence. I had conducted one of these studies myself. Teachers and parents also reported improved behavior in almost every short-term study. This spurred an increase in drug treatment and led many to conclude that the “brain deficit” hypothesis had been confirmed.

But questions continued to be raised, especially concerning the drugs’ mechanism of action and the durability of effects. Ritalin and Adderall, a combination of dextroamphetamine and amphetamine, are stimulants. So why do they appear to calm children down? Some experts argued that because the brains of children with attention problems were different, the drugs had a mysterious paradoxical effect on them.

However, there really was no paradox. Versions of these drugs had been given to World War II radar operators to help them stay awake and focus on boring, repetitive tasks. And when we reviewed the literature on attention-deficit drugs again in 1990 we found that all children, whether they had attention problems or not, responded to stimulant drugs the same way. Moreover, while the drugs helped children settle down in class, they actually increased activity in the playground. Stimulants generally have the same effects for all children and adults. They enhance the ability to concentrate, especially on tasks that are not inherently interesting or when one is fatigued or bored, but they don’t improve broader learning abilities.

And just as in the many dieters who have used and abandoned similar drugs to lose weight, the effects of stimulants on children with attention problems fade after prolonged use. Some experts have argued that children with A.D.D. wouldn’t develop such tolerance because their brains were somehow different. But in fact, the loss of appetite and sleeplessness in children first prescribed attention-deficit drugs do fade, and, as we now know, so do the effects on behavior. They apparently develop a tolerance to the drug, and thus its efficacy disappears. Many parents who take their children off the drugs find that behavior worsens, which most likely confirms their belief that the drugs work. But the behavior worsens because the children’s bodies have become adapted to the drug. Adults may have similar reactions if they suddenly cut back on coffee, or stop smoking.

TO date, no study has found any long-term benefit of attention-deficit medication on academic performance, peer relationships or behavior problems, the very things we would most want to improve. Until recently, most studies of these drugs had not been properly randomized, and some of them had other methodological flaws.

But in 2009, findings were published from a well-controlled study that had been going on for more than a decade, and the results were very clear. The study randomly assigned almost 600 children with attention problems to four treatment conditions. Some received medication alone, some cognitive-behavior therapy alone, some medication plus therapy, and some were in a community-care control group that received no systematic treatment. At first this study suggested that medication, or medication plus therapy, produced the best results. However, after three years, these effects had faded, and by eight years there was no evidence that medication produced any academic or behavioral benefits.

Indeed, all of the treatment successes faded over time, although the study is continuing. Clearly, these children need a broader base of support than was offered in this medication study, support that begins earlier and lasts longer.

Nevertheless, findings in neuroscience are being used to prop up the argument for drugs to treat the hypothesized “inborn defect.” These studies show that children who receive an A.D.D. diagnosis have different patterns of neurotransmitters in their brains and other anomalies. While the technological sophistication of these studies may impress parents and nonprofessionals, they can be misleading. Of course the brains of children with behavior problems will show anomalies on brain scans. It could not be otherwise. Behavior and the brain are intertwined. Depression also waxes and wanes in many people, and as it does so, parallel changes in brain functioning occur, regardless of medication.

Many of the brain studies of children with A.D.D. involve examining participants while they are engaged in an attention task. If these children are not paying attention because of lack of motivation or an underdeveloped capacity to regulate their behavior, their brain scans are certain to be anomalous.

However brain functioning is measured, these studies tell us nothing about whether the observed anomalies were present at birth or whether they resulted from trauma, chronic stress or other early-childhood experiences. One of the most profound findings in behavioral neuroscience in recent years has been the clear evidence that the developing brain is shaped by experience.

It is certainly true that large numbers of children have problems with attention, self-regulation and behavior. But are these problems because of some aspect present at birth? Or are they caused by experiences in early childhood? These questions can be answered only by studying children and their surroundings from before birth through childhood and adolescence, as my colleagues at the University of Minnesota and I have been doing for decades.

Since 1975, we have followed 200 children who were born into poverty and were therefore more vulnerable to behavior problems. We enrolled their mothers during pregnancy, and over the course of their lives, we studied their relationships with their caregivers, teachers and peers. We followed their progress through school and their experiences in early adulthood. At regular intervals we measured their health, behavior, performance on intelligence tests and other characteristics.

By late adolescence, 50 percent of our sample qualified for some psychiatric diagnosis. Almost half displayed behavior problems at school on at least one occasion, and 24 percent dropped out by 12th grade; 14 percent met criteria for A.D.D. in either first or sixth grade.

Other large-scale epidemiological studies confirm such trends in the general population of disadvantaged children. Among all children, including all socioeconomic groups, the incidence of A.D.D. is estimated at 8 percent. What we found was that the environment of the child predicted development of A.D.D. problems. In stark contrast, measures of neurological anomalies at birth, I.Q. and infant temperament — including infant activity level — did not predict A.D.D.

Plenty of affluent children are also diagnosed with A.D.D. Behavior problems in children have many possible sources. Among them are family stresses like domestic violence, lack of social support from friends or relatives, chaotic living situations, including frequent moves, and, especially, patterns of parental intrusiveness that involve stimulation for which the baby is not prepared. For example, a 6-month-old baby is playing, and the parent picks it up quickly from behind and plunges it in the bath. Or a 3-year-old is becoming frustrated in solving a problem, and a parent taunts or ridicules. Such practices excessively stimulate and also compromise the child’s developing capacity for self-regulation.

Putting children on drugs does nothing to change the conditions that derail their development in the first place. Yet those conditions are receiving scant attention. Policy makers are so convinced that children with attention deficits have an organic disease that they have all but called off the search for a comprehensive understanding of the condition. The National Institute of Mental Health finances research aimed largely at physiological and brain components of A.D.D. While there is some research on other treatment approaches, very little is studied regarding the role of experience. Scientists, aware of this orientation, tend to submit only grants aimed at elucidating the biochemistry.

Thus, only one question is asked: are there aspects of brain functioning associated with childhood attention problems? The answer is always yes. Overlooked is the very real possibility that both the brain anomalies and the A.D.D. result from experience.

Our present course poses numerous risks. First, there will never be a single solution for all children with learning and behavior problems. While some smaller number may benefit from short-term drug treatment, large-scale, long-term treatment for millions of children is not the answer.

Second, the large-scale medication of children feeds into a societal view that all of life’s problems can be solved with a pill and gives millions of children the impression that there is something inherently defective in them.

Finally, the illusion that children’s behavior problems can be cured with drugs prevents us as a society from seeking the more complex solutions that will be necessary. Drugs get everyone — politicians, scientists, teachers and parents — off the hook. Everyone except the children, that is.

If drugs, which studies show work for four to eight weeks, are not the answer, what is? Many of these children have anxiety or depression; others are showing family stresses. We need to treat them as individuals.

As for shortages, they will continue to wax and wane. Because these drugs are habit forming, Congress decides how much can be produced. The number approved doesn’t keep pace with the tidal wave of prescriptions. By the end of this year, there will in all likelihood be another shortage, as we continue to rely on drugs that are not doing what so many well-meaning parents, therapists and teachers believe they are doing.

L. Alan Sroufe is a professor emeritus of psychology at the University of Minnesota’s Institute of Child Development (see http://www.cehd.umn.edu/icd/faculty/sroufe.html)