Last week Reuters ran an article by Toni Clarke:  “Insight: Shortage of ADHD Drug Adderall seen persisting.”

Here are the first five paragraphs:

“A shortage of Adderall, which is used to treat attention deficit hyperactivity disorder, shows little sign of easing as manufacturers struggle to get enough active ingredient to make the drug and demand climbs.

Adderall, a stimulant, is a controlled substance, meaning it is addictive and has the potential to be abused. The Drug Enforcement Administration tightly regulates how much of the drug’s active pharmaceutical ingredient (API) can be distributed to manufacturers each year.

The system is designed to prevent the creation of stockpiles that could be diverted for inappropriate use. Adderall and other stimulants are popular with students who may not have ADHD but are seeking to improve their test scores.

The DEA authorizes a certain amount of the API in Adderall – mixed amphetamine salts – to be released to drugmakers each year based on what the agency considers to be the country’s legitimate medical need.

Increasingly that estimate is coming into conflict with what companies themselves say they need to meet demand for the drug, which is reaching all-time highs. In 2010, more than 18 million prescriptions were written for Adderall, up 13.4 percent from 2009, according to IMS Health, which tracks prescription data.”

I have written on the behaviors known as ADHD elsewhere.  My position is that what’s involved here essentially is misbehavior, the most likely cause of which is ineffective parental discipline.  The APA have successfully medicalized this misbehavior, and in concert with their pharmaceutical allies, have established the notion that the “illness” can be “treated” with schedule II addictive drugs.

But of course ADHD is not a real disease – anyone can “get” it.  All you have to do is behave in a certain way – and voila – you have the illness!

Now schedule II substances are addictive.  This means that people find them pleasant to take.  School children sell them to classmates for $5-$10 a pill.  Once children get a taste for them, it doesn’t take them long to figure out how to get a prescription of their own – behave like a brat – make errors on homework – daydream a lot – act restless and inattentive, etc..  There are no limits to the inventiveness of a drug-seeking American child.  And more and more people are climbing on the candy train (13.4% more in 2010 than 2009!)

This is a completely open-ended situation.  There are no natural limits on how many people can “succumb” to this “illness.”  If a child misbehaves in a manner consistent with the APA checklist – then he has ADHD.  Nothing else is needed.  There are no blood tests; no neurological tests; no pain!  Just bounce around like a brat for a few weeks – and the drugs come rolling in. Is this a great country or what?

Attention Deficit/Hyperactivity Disorder is defined as “a persistent pattern of inattention and/or hyperimpulsivity that is more frequent and severe than is typically observed in individuals at a comparable level of development.” There is a requirement that the problem existed before age seven and that some of the problems are present in at least two settings. There also must be clear evidence that the inappropriate activity interferes with the individual’s social, academic, or occupational functioning. With regards to the actual diagnostic procedure, the APA lists eighteen behavioral indicators, nine under the heading “inattention,” six under “hyperactivity,” and three under “impulsivity.” For the diagnosis to be considered positive, the child must exhibit at least six problems from either the inattention list or the hyperimpulsivity lists.

Prevalence
DSM-IV-TR (2000) cites a prevalence rate of three to five percent for school-aged children, but even the most cursory familiarity with the reality makes it clear that at least in the U.S., the diagnosis is being assigned with increasing frequency with the passing of years. A CDC study from 2003, for instance, reports a 7.5% nationwide prevalence, the highest rate being in Alabama (11%) and the lowest in Colorado (5%).

Diagnostic Criteria
Attention Deficit/Hyperactivity Disorder is one of the most blatantly abused mental disorder diagnoses and is having an extraordinarily destructive effect within our society. To enable the reader to readily appreciate this matter, and facilitate a discussion, the APA’s eighteen criteria for this fictitious illness are set out below:
Inattention
a) often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
b) often has difficulty sustaining attention in tasks or play activities
c) often does not seem to listen when spoken to directly
d) often does not follow through on instructions, and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)
e) often has difficulty organizing tasks and activities
f) often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)
g) often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)
h) is often easily distracted by extraneous stimuli
i) is often forgetful in daily activities
Hyperactivity/Impulsivity
a) often fidgets with hands or feet, or squirms in seat
b) often leaves seat in classroom or in other situations in which remaining seated is expected
c) often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults may be limited to subjective feelings of restlessness)
d) often has difficulty playing or engaging in leisure activities quietly
e) is often “on the go” or often acts as if “driven by a motor”
f) often talks excessively
g) often blurts out answers before questions have been completed
h) often has difficulty awaiting turn
i) often interrupts or intrudes on others (e.g., butts into conversations or games)

Not A Chemical Imbalance
As with most of the DSM diagnoses, no physical damage or etiology is required for a diagnosis to be assigned. Indeed, with regards to ADHD, DSM acknowledges that there “are no lab tests that have been established as diagnostic in the clinical assessment of” this disorder, nor are there any “specific physical features” associated with it. This is particularly noteworthy in that the notion that ADHD is caused by a malfunction in the brain is widely and actively promoted by psychiatrists and other mental health professionals. Parents, teachers, and other professionals, as well as the general public, are being told that the child can’t pay attention or sit still because of “a chemical imbalance” in the brain. The fact, however, is that there is no evidence to support such contentions, and it is just as reasonable, and far more plausible, to conceptualize the matter as plain, old-fashioned misbehavior. Certainly no one could dispute that problems in brain structure and chemistry can lead to problems in behavior, e.g. Hatfield-McCoy (or Von Hippel-Lindau) disease, but it is equally obvious that problems in behavior can and do occur in the absence of neurological problems. To infer neurological problems purely on the evidence of misbehavior is illogical, unwarranted, and even reckless.

Children who display the misbehaviors listed in the DSM criteria are clearly difficult to manage, and present problems in the classroom and possibly other settings. Parents and teachers are frequently all too relieved to refer these children to a psychiatrist and to accept the chemical imbalance explanation. The psychiatrist prescribes a pill, which by and large keeps the worst of the misbehavior under control. Once again, everybody is off the hook, and the psychiatrists and the pharmaceutical companies are making money.

At the risk of stating the obvious, just because a child doesn’t pay attention, does not mean that he can’t learn to pay attention. There is hardly a child in the world who would not prefer to be outside playing, rather than doing homework or sitting in class learning multiplication tables. Previous generations saw this clearly, and our parents and grandparents accepted the task of teaching their children the necessary skill of applying oneself to difficult and boring tasks and paying attention respectfully to authority figures. Today, tragically, if this training has been neglected, and the child reaches the age of six or seven without this skill, the entirely unwarranted assumption is made that he has a brain problem which prevents him from developing appropriately in this area. The far more likely assumption, that his training and discipline have been blatantly neglected in the home, is almost never even considered.

Former Times
Almost all of the so-called diagnostic criteria listed earlier can be conceptualized as disobedience, laziness, defiance, and misbehavior, and the fact that the misbehaviors are not routinely seen as such is an indication of how far standards have been allowed to slip. The notion that a child of normal intelligence who leaves his seat in the classroom and wanders about the room at will, or climbs or talks excessively, or refuses to wait his turn, or interrupts or intrudes on others, is displaying symptoms of a mental disorder, borders on the bizarre. In former generations expectations were higher. Children who had the temerity to engage in such activity were quickly corrected (usually within the first few weeks of starting school) and readily acquired the appropriate level of self-discipline and control for an academic setting. As the child progressed through the successive grades, expectations were raised, and appropriate correction was provided for problems such as careless mistakes, not listening, not following through on instructions, and avoiding difficult tasks. It might be argued that classrooms in former times were over-regulated and regimented, but there certainly were not large numbers of children routinely misbehaving in the ways listed in the DSM criteria. So either some incredible change has occurred in the brain chemistry of our nation’s children across the last generation or two (which seems unlikely), or else the widespread and highly profitable prescription of psychoactive drugs to control this misbehavior is unwarranted. Nevertheless, these prescriptions have become the standard treatment for this so-called mental disorder.

Circular Explanation

The parent bringing a child to a psychiatrist and asking why he is so restless, why can’t he pay attention, etc., is told “because he has a mental disorder, a chemical imbalance in his brain that prevents him from functioning appropriately in these areas.” If the parent were to push the matter and ask “how do you know he has this disorder, this imbalance?” the only possible response is: “because he is so restless and inattentive.” The “explanation” is entirely circular, and in fact explains nothing. The problem behavior that the APA refer to as ADHD is not something a child has, but rather something he does. It is voluntary behavior which can be trained and modified using the normal methods of parental discipline and control. Parents of children who have been assigned this diagnosis, when confronted with this reality, usually protest that they “have tried everything,” but that their child is simply unamenable to any kind of normal training and correction. In fact, however, what is usually the case with parents in this kind of situation is that they have tried little or nothing in the way of creative discipline and correction, and routinely afford very little time and energy to the task of monitoring and directing their children’s activities. They tend to be extremely unconfident in parenting matters, want to “give” their children as much as possible, routinely fail to say “no” and to enforce sanctions even in situations where this is clearly needed. The mental disorder explanation actively promoted by the psychiatrists and pharmaceutical companies eases their consciences, and the drugs control the worst of the misbehavior. Tragically the child is given the expectation that he is damaged and that he can’t acquire the normal developmental skills in these areas without psychoactive drugs. He is also exposed to an array of side effects that sometimes make the original problem look fairly benign.

Although most parents of these children fit the profile outlined above, there are a few who do not want their children on drugs, and who resist the referral to psychiatric services. The Elementary and Secondary Education Reauthorization Bill, debated in the U.S. Senate and House in October 2001, contained provisions whereby schools could refer children to psychiatrists for mental health treatment only with parental permission. On their website at that time, the APA was actively encouraging readers to contact their political representatives and lobby for the deletion of that particular section of the bill. The question naturally arises as to why the APA would want to see these children without their parents’ permission. The psychiatrists say it’s to ensure that the parents’ resistance does not cause the child to miss out on needed services, but their track record in the marketing and lobbying area, and their ever-vigilant search for ways to expand their services, suggest that their agenda may also have had a more self-centered aspect.

Adult ADHD: A Marketing Success
In the context of marketing, it is worth noting that Attention Deficit/Hyperactivity Disorder is no longer considered exclusively a childhood condition. In recent years adults who exhibit these dysfunctional behaviors are being given the ADHD diagnosis by mental health practitioners, and are being encouraged to think of themselves as having a chemical imbalance in their brain. They are also, of course, being prescribed psychoactive drugs. Like their childhood counterparts, these adults are given the false message that their laziness, inconsideration, and lack of attention are perfectly acceptable, and that problems of this sort can be resolved pharmaceutically without any effort or difficulty on their part.

Success Through Effort
The notion of success through effort and perseverance has been fairly fundamental in western culture. Throughout most of our history successive generations have been encouraged to strive towards high standards in various areas, and there has always been the recognition that this is not easy. Habits of work and application have been encouraged formally and informally throughout our history. The ADHD diagnosis is a direct attack on the notion of success through effort and hard work. The fact is that most parents still take their responsibilities seriously, and teach their children to sit still, pay attention, etc.. Attributing the dysfunctional behavior of the children who do not receive this training to a mental disorder essentially belittles the efforts of the parents who have been successful in this area. It is noteworthy that the phrase “has difficulty” is used four times in the ADHD criteria: “often has difficulty sustaining attention…”; “often has difficulty organizing tasks and activities…”; often has difficulty playing…quietly”; and “often has difficulty awaiting turn.” The assumption being made here is that the child who is misbehaving somehow has more difficulty acquiring the appropriate habits of discipline and self-control than the child who is behaving appropriately. This assumption is entirely unwarranted. The well-behaved child may, in fact, be experiencing enormous difficulty staying on track, but he continues to do so because he has received appropriate training, discipline, correction, etc., from his parents. The chronically misbehaved child, on the other hand, usually has never been exposed to the notion of success through personal effort, and has never received systematic discipline and training in these areas. He does not, in fact, experience any more difficulty waiting his turn than other children. He has simply never been required to make the effort in this or other areas.

ADHD and DisabilityIn 2006, more than half a million children in the US were receiving disability SSI from the Social Security Administration for mental disorders other than retardation. This was 49% of the total number of children receiving benefits for all disabilities. In other words, of all the children receiving disability benefits, 49% were awarded disability status on the basis of mental disorders other than retardation! In 2003, the percentage was 40%. This increase is part of a trend dating back to 1990, when new criteria for establishing childhood disability were put in place. The new criteria focussed on the child’s functioning, where the previous criteria were based more on proven etiology. The SSA website describes these trends in detail and offers this comment:

“A significant portion of the increase in awards involved mental disorders rather than mental retardation, with much attention directed at awards based on attention deficit hyperactivity disorder (ADHD) and various mental disorders manifesting themselves in maladaptive behaviors.”

An interesting sidebar in this area is that the welfare reform legislation passed in 1996 was expected to reduce the number of childhood disability awards. In fact, the number of awards continued to increase after 1997. It is clear both from the figures and from my personal knowledge of the system at the time, that Social Services departments were routinely referring their problem families to the mental health services, where the children could receive a “diagnosis” and be declared disabled. So they came off the welfare roles and went onto the disability roles. It is also my impression from this period that at least some parents were actively coaching their children in the ADHD symptoms to increase the likelihood of a disability determination. If the reader will glance back to the ADHD criteria listed earlier, it will be apparent that coaching of this sort would present no great challenge. What’s particularly interesting here is that a child who was successfully coached and encouraged to display these misbehaviors would really have ADHD. He would not be faking ADHD. The only requirement for a diagnosis is that the child misbehaves in the ways stated. If the child does these things, then he has ADHD, and if the misbehaviors are severe enough, then he will qualify for disability payments. Why he is behaving this way – or how he got to this position – is of no concern. SSI payments vary from state to state, but are usually about $500 per month per child ($640 in California; $476 in Alaska as of 2006.)

The abuse of these so-called diagnoses is a logical outcome of the APA’s spurious taxonomy. The APA’s position is that these misbehaviors are really symptoms of an illness, and that no other evidence is required to establish the diagnosis. Once this notion gains currency, it can be only a matter of time before someone says: “If my child is sick then why can’t he qualify for disability benefits?”

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