Innocent Until Proven Guilty; An Approach to ADHD

A New York Times article published in December 2013 entitled, “The Selling of Attention Deficit Disorder” by Alan Schwarz made waves that rocked the boat many therapists treating ADHD had been sitting comfortably in. The article captured the growing sentiment in America that far too many children were being hastily diagnosed with ADHD and treated with stimulant medications, all to the benefit of the drug companies driving the industry. Even to the most skeptical of readers averse to conspiracy theories, the article forces one to give pause and consider the issues raised. Indeed, over the past number of years, there seems to be a rising skepticism among parents regarding the validity of ADHD as a legitimate medical diagnosis and a growing concern about adverse effects of medications used in treating the disorder. Today, it seems, any self respecting parent chooses natural or alternative medical therapies to treat their child’s symptoms versus “drugging” them into “compliant zombies”. Those who do fill the prescription for medications often feel the burden of guilt and shame for having done so.

But how did we get here? Children diagnosed with diabetes are given insulin. Their diagnosis is not questioned, and there are no vocal anti-insulin parent groups fighting the drug companies who produce the life-saving hormone. Not many parents have decided to forgo treatment with insulin in favor of art therapy or horseback riding to cure their child’s diabetes. Why is it different with ADHD and medications used to treat it?

Some might argue that it is absurd to compare the two. But as we learn more about ADHD and the medications used to treat it, the comparison might well be valid.

Ground breaking work by leading researchers such as Dr. Francisco Castellanos have used advanced neuroimaging techniques to study the brains of ADHD patients. The results have shown clear and measurable differences in both structure and functioning of areas of the brain responsible for self regulation, attention and concentration. More impressive, are the studies that show improvement in ADHD patients who are treated with medications versus those who are untreated. Research in genetics has identified numerous genes likely responsible for ADHD symptoms, most affecting metabolism of key neurotransmitters such as dopamine and noradrenalin. Neurometabolic studies indicate that those afflicted with ADHD have a deficiency and impaired functioning of these neurotransmitters in the spaces between neurons called synapses causing under-stimulation of critical brain areas. This explains how medications such as the stimulants, can help alleviate the symptoms of ADHD. The stimulants act by blocking the little janitor in the brain who sweeps up these neurotransmitters allowing their accumulation and attainment of more normal and effective levels. The previously under-stimulated areas of the brain responsible for such executive functions as attention, concentration and impulse control are put to work, alleviating the symptoms. It is the person’s own, naturally produced neurotransmitters that are responsible for the therapeutic effects.

And as far as the seriousness of the condition, ponder this; A recent study published in The Lancet found that “ADHD was associated with significantly increased mortality rates… mainly driven by deaths from unnatural causes, especially accidents”. Simply put, untreated ADHD can be fatal. Not to mention a cause of significantly increased rates of unemployment, health problems, impaired interpersonal relationships, substance abuse, incarceration – just to name a few.

So, ADHD is a true medical disorder with a genetic basis, causing clear and measurable pathology in the body that can be treated by increasing levels of a deficient biological chemical. Substitute a brain for a pancreas, dopamine for insulin, and you get one very legitimate medical disorder.

One significant factor causing the ADHD backlash, might relate to the relatively intangible nature of ADHD and the diagnostic process. Diabetes can be confirmed with a simple blood test. Not much room for doubt there. ADHD, however, has no biological marker readily available to clinicians that can be measured to objectively confirm the diagnosis. (Use of advanced neuroimaging studies are reserved for research and are not yet available for general clinical use. Development of computerized tests such as the T.O.V.A. and MOXO represent an attempt to bring objective data to the diagnostic process, but their use is not without controversy and additional benefit from these tests is often questionable.) Evaluation for ADHD requires interpretation of observed behaviors, and is a heavily subjective process requiring at least a small leap of faith that the diagnosis is correct. Even after the most thorough of evaluations allowing for some doubt seems reasonable and even healthy.

But what happens when evaluations are perceived by patients as being rushed and superficial? Insecurity can quickly turn a gap into an abyss demanding a risky leap of faith that most patients aren’t willing to make. Back in medical school, we were taught that medicine is as much an art as it is a science. Seeing is believing, and when hard objective data is lacking, doctors need to rely more on the “art” of medicine to compensate and accurately arrive at the correct diagnosis. Detailed clinical history, information gathering, thorough physical examination, observation, patient education and reassurance are the cornerstones of this artwork. We were also taught the principle of “Primum no nocere”, Latin for First do no harm. The principle mandates careful consideration of risks versus benefits of any treatment and the understanding that sometimes no treatment might be the best course of action if the risk of causing harm is significant. Medications used to treat ADHD including the stimulants have consistently been shown to be safe, but a hastily given prescription handed to the patient only adds insult to injury and exacerbates the problem.

In a court of law, defendants are presumed innocent until proven guilty. This important principle is based on the ideal that it is better for a guilty person to walk free than an innocent one be sent to prison. The heavy burden of proof is placed squarely on the prosecution, and this “show me the money” approach should be applied to those being evaluated for ADHD. Indeed, the guidelines set out for diagnosing ADHD require consideration and ruling out of other medical and psychiatric conditions that can mimic ADHD, evidence of long standing chronic symptoms and significant impairment and suffering. Until proven beyond a reasonable doubt, caution should be exercised before a formal diagnosis of ADHD is made and medications are prescribed. As opposed to a court of law where double jeopardy prevents re-trial for a crime, frequent re-evaluation of patients can prevent missing the boat in those who actually do have ADHD and ensure treatment is started as soon as it is clinically indicated.

So the degree to which patients feel secure about their diagnosis and treatment plan is directly proportional to the perceived effort that went into making them. Avoidance of short, superficial evaluations and “Ritalin trigger finger” is critical to improve diagnostic accuracy; show the patients solid ground and they will have enough faith to make that leap.

Any treatment plan for ADHD must be holistic and the importance of basics such as sleep, nutrition and exercise can not be understated. Younger children can benefit greatly from behavioral modification programs and parents can attend seminars designed to teach parenting skills for children with ADHD. Education and cognitive behavioral therapy can be powerful tools for adults, and newer non-pharmalogical treatments such as neuro-feedback show promise and are currently being investigated. But for some patients who have ADHD, medications such as the stimulants provide the most effective treatment. Understanding the very biological nature of the disorder should make this fact more palatable. Of course there are often side effects, especially when starting a new medication or with dose change. Loss of appetite, headaches, nausea, the rebound and “zombie” effects are all common, just to name a few. But with carefully selected regimens, dose titration and close follow-up, most patients can have those side effects reduced to a minimum or eliminated all together. Long term effects of any medication are a legitimate concern for both doctors and patients, but to date the evidence is reassuring. For many who suffer from ADHD, medications save lives and are no less vital to them than insulin is to the diabetic.

All too often, anti-medication activists spread misinformation that leads the well intentioned astray. Education is the key to alleviating fears and dispelling myths.

But the medical establishment must work harder to avoid fueling the fire and earn the trust of the patients. Adhering to the guidelines set out for diagnosing ADHD and careful consideration of the need for medications on a case by case basis should do much to further the cause. The prescription one holds on line at the pharmacy should provide for a sense of relief, certainly not one of shame or guilt.