As a physician I don't believe diseases are real, just as the digital numbers on my savings account aren't real. But the frustration and suffering that comes with not being able to focus and maintain attention in a world that remunerates focus and attention is as real as the things I can buy with those digital dollars in my account.
I'm not a health care provider, but I think at some point ADHD became a convenient "catch all" diagnosis that was often applied to naturally restless school children who didn't like having to sit still and stay quiet for long periods of time. I attended Chicago public schools for K-12 from 1949 to 1961, and I remember one boy in grade school who got up and ran around the classroom drawing pictures on the old-style black chalk boards of volcano-like objects that he labeled "Mount Vesuvius". He did this spontaneously, unbidden by the teacher. I suppose that these days he might be diagnosed with ADHD and put on drugs that kept him docile but deprived his classmates of his entertaining behavior and artistic creations.
There was an amusing episode of the cartoon show "The Simpsons" in 1999 called "Brother's Little Helper", which addressed this issue. Bart Simpson, acting out (as usual), is diagnosed by his school principal with Attention Deficit Disorder. His parents are persuaded to put him on the fictional (and insufficiently tested) drug "Focusyn". At first the effects are positive, and Bart turns into a well-behaved, diligent student. But later the drug's negative side effects kick in and he becomes a paranoid conspiracy theorist, and after swallowing a bunch of the pills goes on a spree of chaotic and destructive behavior. Bart's parents finally take him off Focusyn and put him on Ritalin, which seems to cure him.
Amethyst: I agree, many of them may be able to focus, just not on the "correct" things as determined by the people around them. I also wonder to what extent ADHD diagnoses are also applied to people with symptoms of "Obsessive Compulsive Disorder" or "High-functioning Autism". A caveat: I'm not a health care professional, and these are just my personal layman's opinions.
Balanced thoughtful article. One of the reasons that we have so much ADHD is that over the last 2 centuries people have been forced to sit in classrooms all day or do repetitive functions at work. This does not work for people with ADHD. I fell saddened when someone comes in at age 40 to be first diagnosed after having first struggled for so long.
I do not think the intent of the article was to say say meds are the only treatment. Most of us make sure that non pharma strategies are used either with or without medication.
The "disease" question seems like another human foible. Except for insurance coverage, it is a distractor. Is your "condition" imparing you/your life? Then maybe we should address it instead of bantering about etymology. (BTW the answer should come from not only the patient but also their close friends and family, if possible.) But see below. ADHD meds correlate with reduced rates of death due to many causes - most not "natural." I'm too lazy to read them to see if they are all observational, which brings up a large risk for confounding. And there aren't a lot of them. But it's another data point to use when deciding if it is a treatable "disease".
Also important to note ADHD ( like autism) is covered by ADA rules for accommodation in the work place. Far from being a stigmatized condition, it allows entrance into a protected class.
I have had a nursing student who used a combination of magnesium and other herbs to help rebalance herr body and minimize her attention deficit disorder symptoms. Have you investigated that route as a first line possibility to see if it works?
I have not found convincing evidence for really anything other than stimulants. I do think there are supplements, herbs, etc. that do work for some patients and I encourage patients to try things they read about online to see if they help. If they help I encourage them to bring the information back to me so I can look into them further.
ADHD is *REAL* *REAL* profit for phama. Anyone who says otherwise has an agenda. Or worst, an Xists - where X=(Fasc; Rac; and whatever else is trending these days)
Someone should study the correlation between corporal punishment ending (by parents and teachers) and the diagnosis of new drug for life disease.
Adult ADHD can be addressed with interventions other than medication.
Behavioral and schedule changes.
Structured activity. Dietary modifications.
A prescription should not be the first choice, although too often it is the go to solution.
The other important consideration is amphetamine addiction ( Stimulant Use Disorder) estimated at aprox. 1.8 million individuals in the US. This is not s small problem or side effect to be ignored.
Definitely true and my preference is for patients to not take medications. However, I have never seen a patient to discuss ADHD that has not tried lifestyle changes. If I do, I will definitely discuss them, but honestly the internet is a better source for this sort of information than me!
I like to recall the reports of JFK running naked through a hallway at the Carlisle Hotel amped up on vitamins now known to be amphetamines administered by the infamous Dr. Feelgood. After this debacle, Big Pharma took some time to rebrand. It seems they have done a pretty good job!
A deep dive for those interested. All pediatric ADHD related (sorry, imma pediatrician!)
1. How ADHD began and the mass side effects doctors don’t even pretend to care about:
“ However, the practical question is whether the label helps us care for a patient.”
To clarify, the only reason the label exists is because children act differently when on small doses of cocaine:
Medicine bothers with attentiveness for one simple reason: We have a drug for it. If Ritalin did not exist, neither would ADHD; the treatment conjures the disease. If there were a pill to make you funnier, by next week millions would be diagnosed with humor deficit disorder…
After the accidental discovery that amphetamines—widely used to help soldiers stay alert in the trenches—also helped children sit still in class, drugmakers sensed a new market for their “pep pills” and started pushing the use of stimulants in school decades before the medical community figured out a plausible diagnosis to justify the treatment. As one infamous ad campaign put it, “Whatever the terms used to identify the affliction . . . Ritalin helps ‘the problem child’ become lovable again.”
And it was mostly used at first to drug black children into submission - this was a long-forgotten scandal in the 70s…
When the National Institutes of Health finally convened an expert panel on the matter in 1998, the takeaway was, in the memorable words of one participant: “The diagnosis is a mess.” Nonetheless, the everyday experience of parents, doctors, teachers, and students showed that cocaine-like drugs rather unsurprisingly gave children cocaine-like levels of focus—in other words, the drugs “work.” Indeed they do, as any Wall Street trader who lived through the eighties could tell you. Yet, for all the debate over the ethics of daily amphetamine use on individual children over the years, few have raised an equally important concern: the repercussions of the mass drugging of our student population.
2. What is attention? Is it a dial you fiddle with to focus more on paperwork, or is it a profound moral act that sits at the foundation of love and faith? Doctors don’t care, but here’s the answer, from the best scientists and thinkers around:
Attention is a moral act. When attention is misleadingly framed as a cognitive function, some generic skill, I understand how parents can be pressured into agreeing to medically manipulate their child’s focus. However, once attention is properly understood as the fundamental way in which one’s consciousness is disposed to the whole world, the use of drugs to experiment on a child’s attention is revealed as sacrilege.
To illustrate the mad-scientist-level irresponsibility of altering dopamine and norepinephrine levels in your child’s brain for a better GPA, let’s imagine going to the doctor and asking her to harness those neurotransmitters for a different goal: helping your teenager’s love life. Your fourteen-year-old is not really into the dating thing yet, cares more about his sports and his schoolwork. Meanwhile, there’s this lovely girl three houses down, you know her parents, they’re good people. “Doc,” you implore, “you need to prescribe a good love potion for my boy. I’ve found just the girl for him, they’d be great together if only he’d get his nose out of his books long enough to notice her, please, his future happiness is at stake, prescribe something to get his dopamine flowing. Yes, of course I have insurance.”
3. To clarify on how the sausage is made, much more on the absurd diagnostic process here:
4. More history! The fascinating true story of how the investor of ADHD realized his horrible mistake and implored the world to stop drugging kids - imagine Fauci coming out tearfully against the dangers of COVID vaccines - only to be completely ignored by his colleagues:
“He ended his career not promoting ADHD, but denouncing it with passion, apologizing for his work on behalf of pharmaceutical companies and calling the state of ADHD in America “a national disaster of dangerous proportions.””
I could go on and on and on, as y’all can see! Thanks again for such a stimulating essay!
Thanks for your additional insights! I agree that the diagnostic/treatment situation in children is much more morally complex and needs more careful evaluation, especially with regards to long-term adverse effects. I also love the idea of humor deficit disorder. I think if there were ever a pill that could improve humor as much as stimulants improve attention I would probably take it.
A sad situation, a normal variant in behavior and interaction with the world is declared a pathology. Why should you treat normal behavior, just because it is not to your liking?
Thank you for this, I admit I don’t understand the reluctance of people to at least trial stimulants for anyone who feels as though they are struggling. I see stimulants being lumped in with narcotics as far as reluctance on behalf of prescribers to offer them. I have seen many people drive great benefit from low-dose stimulant medication even taken on as needed basis for work or school, etc. The next best thing would be to change them from cat 2 to 3 to allow for refills.
I have read articles with the arguments against using stimulant medications, about misuse and diversion, but I do feel that people access stimulants through non-medical channels precisely because of the reluctance on many providers to offer them.
Thanks for bringing the topic to light, it is clear that we in primary care manage many issues that are difficult to classify as “ disease”.
People also access opioids through non-medical channels precisely because of the reluctance of many providers to offer them. This is a very two-edged argument.
Jury is still out on daily stimulants although I concede some people have significant benefit. But prescribing a medication because people will get it elsewhere if you don’t? UH UH. That sounds like free narcotics to all in the ER to prevent heroin use. Doesn’t work.
As a physician I don't believe diseases are real, just as the digital numbers on my savings account aren't real. But the frustration and suffering that comes with not being able to focus and maintain attention in a world that remunerates focus and attention is as real as the things I can buy with those digital dollars in my account.
I'm not a health care provider, but I think at some point ADHD became a convenient "catch all" diagnosis that was often applied to naturally restless school children who didn't like having to sit still and stay quiet for long periods of time. I attended Chicago public schools for K-12 from 1949 to 1961, and I remember one boy in grade school who got up and ran around the classroom drawing pictures on the old-style black chalk boards of volcano-like objects that he labeled "Mount Vesuvius". He did this spontaneously, unbidden by the teacher. I suppose that these days he might be diagnosed with ADHD and put on drugs that kept him docile but deprived his classmates of his entertaining behavior and artistic creations.
There was an amusing episode of the cartoon show "The Simpsons" in 1999 called "Brother's Little Helper", which addressed this issue. Bart Simpson, acting out (as usual), is diagnosed by his school principal with Attention Deficit Disorder. His parents are persuaded to put him on the fictional (and insufficiently tested) drug "Focusyn". At first the effects are positive, and Bart turns into a well-behaved, diligent student. But later the drug's negative side effects kick in and he becomes a paranoid conspiracy theorist, and after swallowing a bunch of the pills goes on a spree of chaotic and destructive behavior. Bart's parents finally take him off Focusyn and put him on Ritalin, which seems to cure him.
What is a hyperactive child? I child that has more energy than the adults around it can cope with.
Can someone explain why people with "attention deficit" are also able to hyper focus depending on the situation?
Amethyst: I agree, many of them may be able to focus, just not on the "correct" things as determined by the people around them. I also wonder to what extent ADHD diagnoses are also applied to people with symptoms of "Obsessive Compulsive Disorder" or "High-functioning Autism". A caveat: I'm not a health care professional, and these are just my personal layman's opinions.
Interesting read.
Always difficult to be black and white about clinical diagnoses that have no confirmatory modalities or validated criteria.
Much like fibromyalgia. Or depression. Among many others.
I think this is where EBM hits its limits. And I think, where clinical suspicion is valid and sufficient, N of 1 trials seem to make sense to me.
As for long term safety, that’s another one of those known unknowns.
Balanced thoughtful article. One of the reasons that we have so much ADHD is that over the last 2 centuries people have been forced to sit in classrooms all day or do repetitive functions at work. This does not work for people with ADHD. I fell saddened when someone comes in at age 40 to be first diagnosed after having first struggled for so long.
I do not think the intent of the article was to say say meds are the only treatment. Most of us make sure that non pharma strategies are used either with or without medication.
The "disease" question seems like another human foible. Except for insurance coverage, it is a distractor. Is your "condition" imparing you/your life? Then maybe we should address it instead of bantering about etymology. (BTW the answer should come from not only the patient but also their close friends and family, if possible.) But see below. ADHD meds correlate with reduced rates of death due to many causes - most not "natural." I'm too lazy to read them to see if they are all observational, which brings up a large risk for confounding. And there aren't a lot of them. But it's another data point to use when deciding if it is a treatable "disease".
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2855472?guestAccessKey=f87ec9c1-7588-4c67-97dd-cdc397670c79&utm_medium=email&utm_source=postup_jn&utm_campaign=article_alert-jamanetworkopen&utm_content=olf-tfl_
Also important to note ADHD ( like autism) is covered by ADA rules for accommodation in the work place. Far from being a stigmatized condition, it allows entrance into a protected class.
I have had a nursing student who used a combination of magnesium and other herbs to help rebalance herr body and minimize her attention deficit disorder symptoms. Have you investigated that route as a first line possibility to see if it works?
I have not found convincing evidence for really anything other than stimulants. I do think there are supplements, herbs, etc. that do work for some patients and I encourage patients to try things they read about online to see if they help. If they help I encourage them to bring the information back to me so I can look into them further.
ADHD is *REAL* *REAL* profit for phama. Anyone who says otherwise has an agenda. Or worst, an Xists - where X=(Fasc; Rac; and whatever else is trending these days)
Someone should study the correlation between corporal punishment ending (by parents and teachers) and the diagnosis of new drug for life disease.
Yeah, color me jaded.
Adult ADHD can be addressed with interventions other than medication.
Behavioral and schedule changes.
Structured activity. Dietary modifications.
A prescription should not be the first choice, although too often it is the go to solution.
The other important consideration is amphetamine addiction ( Stimulant Use Disorder) estimated at aprox. 1.8 million individuals in the US. This is not s small problem or side effect to be ignored.
Definitely true and my preference is for patients to not take medications. However, I have never seen a patient to discuss ADHD that has not tried lifestyle changes. If I do, I will definitely discuss them, but honestly the internet is a better source for this sort of information than me!
The other question to be answered is duration of therapy.
Is it an indefinite tome frame? Is there an end point to achieve and discontinue the medication?
There is a deficit of research regarding these questions, as there is with antidepressants for long term use.
Seems similar to the rise and fall of benzodiazepines from the 1960’s to the 1990’s.
Typical. Damn those pharmaceutical groups.
I like to recall the reports of JFK running naked through a hallway at the Carlisle Hotel amped up on vitamins now known to be amphetamines administered by the infamous Dr. Feelgood. After this debacle, Big Pharma took some time to rebrand. It seems they have done a pretty good job!
Thank you for this interesting info!
A deep dive for those interested. All pediatric ADHD related (sorry, imma pediatrician!)
1. How ADHD began and the mass side effects doctors don’t even pretend to care about:
“ However, the practical question is whether the label helps us care for a patient.”
To clarify, the only reason the label exists is because children act differently when on small doses of cocaine:
Medicine bothers with attentiveness for one simple reason: We have a drug for it. If Ritalin did not exist, neither would ADHD; the treatment conjures the disease. If there were a pill to make you funnier, by next week millions would be diagnosed with humor deficit disorder…
After the accidental discovery that amphetamines—widely used to help soldiers stay alert in the trenches—also helped children sit still in class, drugmakers sensed a new market for their “pep pills” and started pushing the use of stimulants in school decades before the medical community figured out a plausible diagnosis to justify the treatment. As one infamous ad campaign put it, “Whatever the terms used to identify the affliction . . . Ritalin helps ‘the problem child’ become lovable again.”
And it was mostly used at first to drug black children into submission - this was a long-forgotten scandal in the 70s…
When the National Institutes of Health finally convened an expert panel on the matter in 1998, the takeaway was, in the memorable words of one participant: “The diagnosis is a mess.” Nonetheless, the everyday experience of parents, doctors, teachers, and students showed that cocaine-like drugs rather unsurprisingly gave children cocaine-like levels of focus—in other words, the drugs “work.” Indeed they do, as any Wall Street trader who lived through the eighties could tell you. Yet, for all the debate over the ethics of daily amphetamine use on individual children over the years, few have raised an equally important concern: the repercussions of the mass drugging of our student population.
More here:
https://firstthings.com/medicating-the-masses/
2. What is attention? Is it a dial you fiddle with to focus more on paperwork, or is it a profound moral act that sits at the foundation of love and faith? Doctors don’t care, but here’s the answer, from the best scientists and thinkers around:
https://gaty.substack.com/p/attention-a-love-story
Attention is a moral act. When attention is misleadingly framed as a cognitive function, some generic skill, I understand how parents can be pressured into agreeing to medically manipulate their child’s focus. However, once attention is properly understood as the fundamental way in which one’s consciousness is disposed to the whole world, the use of drugs to experiment on a child’s attention is revealed as sacrilege.
To illustrate the mad-scientist-level irresponsibility of altering dopamine and norepinephrine levels in your child’s brain for a better GPA, let’s imagine going to the doctor and asking her to harness those neurotransmitters for a different goal: helping your teenager’s love life. Your fourteen-year-old is not really into the dating thing yet, cares more about his sports and his schoolwork. Meanwhile, there’s this lovely girl three houses down, you know her parents, they’re good people. “Doc,” you implore, “you need to prescribe a good love potion for my boy. I’ve found just the girl for him, they’d be great together if only he’d get his nose out of his books long enough to notice her, please, his future happiness is at stake, prescribe something to get his dopamine flowing. Yes, of course I have insurance.”
3. To clarify on how the sausage is made, much more on the absurd diagnostic process here:
https://gaty.substack.com/p/synthetic-children
4. More history! The fascinating true story of how the investor of ADHD realized his horrible mistake and implored the world to stop drugging kids - imagine Fauci coming out tearfully against the dangers of COVID vaccines - only to be completely ignored by his colleagues:
https://gaty.substack.com/p/the-dog-that-barked
“He ended his career not promoting ADHD, but denouncing it with passion, apologizing for his work on behalf of pharmaceutical companies and calling the state of ADHD in America “a national disaster of dangerous proportions.””
I could go on and on and on, as y’all can see! Thanks again for such a stimulating essay!
Thanks for your additional insights! I agree that the diagnostic/treatment situation in children is much more morally complex and needs more careful evaluation, especially with regards to long-term adverse effects. I also love the idea of humor deficit disorder. I think if there were ever a pill that could improve humor as much as stimulants improve attention I would probably take it.
A sad situation, a normal variant in behavior and interaction with the world is declared a pathology. Why should you treat normal behavior, just because it is not to your liking?
I know a psychiatrist who sees stimulants as "a curse for some, a blessing for others."
I was hoping this was going to answer the question. Sadly, it did not.
Thank you for this, I admit I don’t understand the reluctance of people to at least trial stimulants for anyone who feels as though they are struggling. I see stimulants being lumped in with narcotics as far as reluctance on behalf of prescribers to offer them. I have seen many people drive great benefit from low-dose stimulant medication even taken on as needed basis for work or school, etc. The next best thing would be to change them from cat 2 to 3 to allow for refills.
I have read articles with the arguments against using stimulant medications, about misuse and diversion, but I do feel that people access stimulants through non-medical channels precisely because of the reluctance on many providers to offer them.
Thanks for bringing the topic to light, it is clear that we in primary care manage many issues that are difficult to classify as “ disease”.
How about we ask Purdue Pharma.
Same rationale, we have an opioid that never causes dependency.
Virtuous intentions do not negate pharmaceutical reality.
People also access opioids through non-medical channels precisely because of the reluctance of many providers to offer them. This is a very two-edged argument.
Jury is still out on daily stimulants although I concede some people have significant benefit. But prescribing a medication because people will get it elsewhere if you don’t? UH UH. That sounds like free narcotics to all in the ER to prevent heroin use. Doesn’t work.
Really appreciate your thoughts on the subject. Thank you for your time.