Monday July 31 6:07 PM ET
Controversy Over Stimulant Use Among Children NEW YORK (Reuters Health) -
Experts continue to debate the use of stimulant medications, such as
Ritalin, among American children with and without
attention-deficit/hyperactivity disorder (ADHD). A recent study is
adding fuel to the fire. “We know little about the degree to which the
increased use of (Ritalin)
represents appropriate use of an effective medication for children with
ADHD, and there are some indications that many children receiving stimulants
may not meet current diagnostic criteria for ADHD,” according to Dr. Adrian
Angold of the Duke University Medical Center in Durham, North Carolina, and
colleagues.
[Dr. Baughman: It must be understood that ADHD has never been proved to be
a bona fide disease with a confirmatory, physical abnormality within the
child/patient. Until such time as an abnormality has been found on
physical exam, laboratory tests, x-rays, scans, biopsy, or, by some
other technology, the presence of a disease, has not been established.
To this day, not a single psychiatric disorder has been proved to be a
disease. ]
Their study findings are published in the August issue of the Journal of the
American Academy of Child and Adolescent Psychiatry.
The group’s report of their findings from a long-term study of ADHD and
prescription of Ritalin in western North Carolina has touched off another
round of debate as to whether children with ADHD are being properly treated,
and whether children without ADHD are receiving inappropriate prescriptions
for stimulants.
Angold and colleagues interviewed the parents of almost 5,000 children aged
9 to 16 over a 4-year period to determine the prevalence of ADHD and other
childhood disorders and to see which children were receiving prescriptions
for Ritalin.
The investigators also considered teachers’ reports on the children’s school
performance and behavior.
The authors write that “in the community, the majority of those who
received stimulants never met criteria for ADHD or ADHD-NOS (NOS: not otherwise specified, a less rigorous
set of criteria for ADHD). Of those who received stimulants at any point
during the study, 34% met full ADHD criteria, 9% had ADHD-NOS, and 57% never
had parent-reported impairing ADHD symptoms of any sort.”
Among children who did meet the criteria for ADHD, almost three-quarters
received stimulants, Angold and colleagues found, noting that Ritalin is
clearly appropriate and effective for children with ADHD.
What concerns the researchers most, however, is their finding that among
children receiving stimulants without meeting either standard of relaxed
criteria for ADHD, 29% had no ADHD symptoms at all, according to their
parents.
[Dr. Baughman: Stating "57% never had parent-reported impairing ADHD
symptoms of any sort" means 57% received stimulants when they should not
have (requiring disability in two domains, school and home), not even
according to psychiatry's definition of ADHD. But the main point, not
to be lost sight of, is that none of psychiatry's diagnostic criteria
for ADHD, not even ADHD-NOS, define a child with a disease; a child with
an abnormality. This being the fundamental fact of the matter, there
is no scientific, medical, ethical or moral justification for putting
any of them on Ritalin/stimulant medication or any other brain-altering
medication]
Comparing their findings with those of a previous similar study, Angold and
colleagues conclude that “both studies document a very unsatisfactory state
of affairs in the relationship between ADHD and its treatment with
stimulants in the community.” The authors add, “these results present a
troubling picture of a serious mismatch between need for stimulant treatment
and the provision of such treatment.”
In the same issue, four experts provide commentary on the findings of
Angold’s team.
“What if most of the symptoms (of ADHD) are seen in school?” asks Dr.
Peter S. Jensen of Columbia University in New York, pointing out that the
researchers did not get enough information from teachers.
Jensen maintains that the parent interviews relied on by Angold and
colleagues did not provide enough information to conclude that many of the
children receiving stimulants did not need them.
[Dr. Baughman: It is not the obligation of the critic to prove that therapy
is not necessary, it is for the diagnosing/prescribing physician to
prove that a disease is present and that the risk/benefit computation
regarding the treatment(s) is positive and justifiable. Again, ADHD is
not known to be a disease, children with it other than normal. Jensen,
a purveyor of ADHD as a disease, when it is not, also maintains that
its symptoms can manifest only, in school--an incredible stretch, all
the more so when we remind ourselves that in 20 years of ADD/ADHD
research, a confirmatory abnormality has yet to be found. With no
abnormality in the child how can 'treatment' with addictive, dangerous,
sometimes deadly stimulants be justified. It cannot!]
Dr. Daniel J. Safer of Johns Hopkins University in Baltimore, Maryland,
agrees, noting that “teachers tend to identify more students overall with
ADHD (than parents).”
Safer also points out that stimulant medication “has been shown to be
useful in the treatment of numerous other disorders” aside from ADHD, and
that the children in the North Carolina study may have been taking these
drugs for other reasons.
But Dr. Kelly J. Kelleher of the University of Pittsburgh, Pennsylvania,
disagrees. “Clearly, the ‘system’ for the treatment of ADHD among children
and adolescents is broken.” Kelleher adds, “we have evidence of much
higher rates of identification of emotional and behavioral disorder by
primary care clinicians, but no evidence of effective or even appropriate
treatment in routine practice.”
Kelleher calls for better tools for evaluating children that primary care
doctors can use in the office.
[Dr. Baughman: From Dr. Kelleher, we have a breath of fresh air.
Kelleher cites the high rates of emotional/behavioral practice by
primary care clinicians nowadays. No examinations needed, no objective
evidence or proof needed. Is this not the right prescription for
practices in trouble in these days of physician glut with too few new
patients and real diseases. From 1965 to the present the number of
physicians has grown 5 times the rate of the population from 140 to 280
physicians per 100,000, equating to each physicians having ½ the number
of patients today they had when I began practice in 1965. We saw enough
new patients and real disease and made a fine living then without having
to invent unnecessary treatments or illusory diseases, such as all of
those in biological psychiatry are.]
“The results of Angold and colleagues’ study are consistent with some
reports that have suggested a substantial overdiagnosing of ADHD and
stimulant overprescribing in certain communities,” writes Dr. Benedetto
Vitiello of the National Institute of Mental Health in Bethesda, Maryland.
[Dr. Baughman: It cannot be otherwise, when there is no identifying physical
marker or abnormality by which to confirm/diagnose the presence of a
particular condition. So it goes with all emotional/behavioral,
psychiatric disorders. The fraud of claiming that the disorders they
invent, then diagnose and treat, must be acknowledged, challenged and
brought to a halt. This victimization is a massive assault on human
rights, and a massive perversion of science and the healing arts.]
‘Vitiello notes that although some research does suggest that stimulants
can be effective in treating other childhood disorders, parents may
insist on treating their children for less urgent reasons.’
[Dr. Baughman: No childhood psychiatric disorder is a disease; an
abnormality in the child; none (ADHD included), justify giving
addictive, dangerous, sometimes deadly, stimulants. Futher, Vitiello,
knows very well that prescribing is the responsibility of the physician
and that they should not defer to wishes of the parents even if, in the
harsh economic environment of modern-day medical practice, this might
mean losing a patient. Ultimately, the physician is responsible for
diagnosis and treatment]
“One can suspect that, in some cases, academic difficulties unrelated to
ADHD may lead to stimulant treatment.” Vitiello adds that “such use of
stimulants would be not only ‘off label,’ but unsupported by any current
treatment guideline, or even minority expert opinion.”
These experts seem to agree that the debate is far from over, and more
research is indicated. Vitiello concludes that “research is urgently needed
to elucidate the most common pathways leading to children’s referral,
diagnosis and treatment.”
SOURCE: Journal of the American Academy of Child and Adolescent Psychiatry
2000;39:975-984, 984-994.