ADHD - Urban Legends

Your long-awaited appointment with the pediatric neurologist had finally arrived. After a 20-minute interview he states his diagnosis.

Doc #1: Your child has a disorder called #ADHD. This means that his brain has structural and chemical differences from a normative brain, resulting in his attention deficit. The best treatment is a combination of #pharmaceuticaldrugs and behavior therapy.

Doc #2: Your child is exhibiting symptoms of ADHD. There are no tests to determine a brain dysfunction, and very sparse and unreliable studies demonstrating an imbalance. Therefore, we can assume that your child is perfectly healthy. We must explore different possible causes of these symptoms to know what ADHD is actually like and build a program to help him flourish.

Which doctor would attract more patients to his practice?

Who would you prefer meeting?

Which diagnosis seems more scientifically based?

I’ve been lecturing parent and teacher groups about ADHD for many years. In the past, my series began with an explanation of the science that proves that ADHD is a neurological disorder, and discussed the value of medication. My message was clear; although there is not much a parent can do to fix her child’s broken brain, she could discipline more compassionately and help him develop better habits.

My delivery was so convincing that about 80% of the parents in the audience registered for the entire series each time.

A few astute parents asked some fantastic questions, creating a crack in my presentation…. Why don't we have a child take an MRI to determine if there is indeed a problem? Why are doctors concluding that my child has a broken brain based on images taken from a study of someone else’s brain? There is no other discipline of medicine where a patient is prescribed a drug without proof of pathology, why here? When the parameters for diagnoses were dramatically loosened from the DSM3 to the DSM5, was it due to a new scientific understanding, or a vote at the APA (American Psychiatric Association)? Where are the studies?

Things got more troubling when I started reading what leading psychiatrists were quietly saying.

“#MentalIllness is terribly misleading because the ‘mental disorders’ we diagnose are no more than descriptions of what clinicians observe people to do or say, not at all well established diseases” #DrAllenFrances, psychiatrist, DSM Task Force Chairman, 2013

“We do not have an independent, valid test for ADHD, and there is not data to indicate ADHD is due to a brain malfunction” final statement of the panel for the NIH consensus conference on ADHD.

“For mental/psychiatric disorders in general, including depression, anxiety, Schizophrenia, and ADHD, there are no confirmatory gross, microscopic or other chemical abnormalities that have been validated for objective physical diagnosis”. Quote from Dr. Supriya Sharma, Director General of Health Canada (Canadian FDA)

Here is the most shocking: “In truth, the ‘chemical imbalance’ notion was always a kind of urban legend-never a theory seriously propounded by well-informed psychiatrists”. #DrRonaldPies, Editor-in-chief of the Psychiatric Times, July 11, 2011

Really???? It’s an urban legend? So, most psychiatrists and neurologists are just not serious? Very influential doctors tell us lay people with a straight face that our children are struggling with a brain chemical imbalance, but amongst themselves they are chuckling about the urban legend? Is there an exclusive club that only permits the well-informed entry?

It’s a little dizzying trying to absorb these honest, behind the scenes statements. Vertigo may set in when being presented with the following hot off the press study:

“We confirm, with high-powered analysis, that patients with ADHD have altered brains; therefore, ADHD is a disorder of the brain. This message is clear for clinicians to convey to parents and patients, which can help to reduce the stigma of ADHD and improve understanding of the disorder”.

This is the concluding statement made by Martine Hoogman and collogues upon publishing their mega-analysis of brain volume conducted at 23 sites, including 1,713 participants, in Lancet Psychiatry 01, April, 2017.

Here is a breathless review from the New York Times bringing the results of this very same study to their readers.

"The facts are in, ADHD is indeed a #BrainDisorder! This requires no more conversation. Use medication and behavioral therapy and you will save your child."

What??? How about our urban legend club? Who are we to believe?

Some digging was in order. I read past the headline of the Hoogman study, and unearthed its many critiques. The most glaring problem was that 95% of the scans of both participants and controls overlap. Meaning that it is utterly impossible to detect from a scan if a child has ADHD or not. To state this more clearly, the scientific finding in this huge study found that about 5% of the children in the ADHD group had a varied, although hard to determine if pathological, brain. IQ was also not factored in, nor was previous medication history. The evidence found simply did not support the conclusion (or the many headlines that followed) that ADHD is a brain disorder.

How did they get away with publishing a conclusion that completely contradicts the data collected? The fact that 2 out of the 4 lead researchers received major funding from the very pharmaceutical companies who produce ADHD drugs may point us in the right direction.

When Hoogman was challenged on the small effect size (meaning that the findings showed that the brain scans mainly overlapped for both groups, rendering the differences hardly statistically significant), this was her response:

“The criticisms of a small effect sizes raised by these letters imply that we should only use the term brain disorder when everyone with the disorder shows the same pattern of brain abnormalities. By that definition, no psychiatric disorder would be a brain disorder.”

Bingo! Thanks to Martine Hoogman and collogues for restoring clarity. Hoogman is saying exactly what Dr. Pies said, the ‘chemical imbalance’ notion is an urban legend. If the differences are so minor that Dr. Hoogman herself can not look at a scan and tell us if the person had ADHD symptoms or not, there is no detectable abnormality. If this study claims that ADHD is a brain disorder, meaning physiological, a list of symptoms and faith alone should not suffice for a diagnosis.

Indeed, Martine Hoogman, we should only use the term brain disorder when everyone with the disorder (or at least more than 5%?) shown the same brain abnormalities.

What a journey to understanding! Now I could rewrite my lecture to reflect the notion that kids with ADHD have no detectable pathology. I could explain how the power and money control the pharmaceutical companies have on our finest researchers skews the research and dictates the headlines.

I was so excited, I was finally giving the parents a truthful, well researched and very hopeful message. What could be more joyful than knowing your child is healthy.

The parents listened politely, asked many questions and …. Did not sign up for the series.

I presented again, and a 3rd time. Each time, I got very low registration for the course.

Doc #1 won the day. His message was the one the parents were looking for. Why?

#BigPharma cornered the market with their soothing legends because we let them. We did not question the doctors who proclaimed pathology because it was somehow comforting to understand that there was something wrong that could neatly explain why our kids were a little different. It was relieving to hear that the best possible solution was a pill, which would be correcting the imbalance. It was reassuring to know that the less labor-intensive rout was also the very best.

Suddenly the parents felt judged, and I don’t blame them. My new message, that raising healthy kids who are struggling is HARD, but doable, was a less accessible solution. I challenged the exhausted parents to consider the risk/reward of the medication option. Use the meds, I said, but don’t rely on them to heal your unbroken child. Think long-term, will he be better off with a medicated brain, but few long term skills, or can we raise him to be a confident, competent member of society?

No one is pulling the wool over our eyes; all the information exists in plain sight. Our questions, if we dare to ask them, have answers. The inconsistencies are glaring, if we chose to see them.

But we unquestioningly perpetuate the urban legend. And urban legends usually don’t end well.