ADHD and the Medication Feeding Frenzy in America

CORRECTION: In the post below, I make mention that there has been no U.S. media coverage on the MTA report. But after some further digging, I found coverage from Investor’s Business Daily, along with popular sources the New York Post, and Fox News and technical/niche publications like Planet Chiropractic. So there is some American coverage.

But if you click around you can see that the American stories are much more brief than their international counterparts. Each of the stories in the mainstream outlets is more of a newswire dispatch than an actual article, where as the international stories are comprehensive. And while pretty much all of the news sources of record in the U.K. covered the story, the major U.S. outlets–like the WSJ, NYT, Time, Newsweek, etc–seem to have had nothing.

Given that the U.S. is 90 percent of the ADHD drug market, you’d think that MTA’s findings would make nation-wide headlines. But instead coverage is scattered and superficial. Stories are relegated to quasi-interest group literature (investors who may lose money on the drugs, chiropractors who have a professional interest in questioning medication), or to the News Corporation (which owns both the Post and Fox news)–a multinational company with a strong Australian and British component. There’s still no convincing evidence that the American media is, on the whole, ready to meaningfully cover MTA’s findings.

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Earlier this week the British press broke some startling news: the Multimodal Treatment Study of Children with ADHD (MTA), has issued a report that claims there are no long-term benefits of ADHD medication for hyperactive children. Report co-author Professor William Pelham of the University of Buffalo, is quoted in the British press as concluding that ADHD medication is, in the long-term, all risk and no reward.

“The children [on ADHD medication] had a substantial decrease in their rate of growth so they weren’t growing as much as other kids both in terms of their height and in terms of their weight,” he says. “And…there were no beneficial effects – none.”

This is an about face from MTA’s benchmark report in 1999 that asserted with certainty that ADHD drugs were the best way to address ADHD in children. The 1999 study claimed that “combination treatments” (i.e. drugs and behavioral training) along with “medication-management alone” (i.e. drugs) are “both significantly superior” to other ADHD treatments that don’t include medication.

But, according to Pelham, “we exaggerated the beneficial impact of medication in the first study. We had thought that children medicated longer would have better outcomes. That didn’t happen to be the case.” So, according to Pelham, here’s the bottom line: “in the short run [medication] will help the child behave better, in the long run it won’t.”

To some, Pelham’s report might be unwelcome news. Thanks in part to the medical credibility that MTA and other studies have conferred on ADHD medications, global sales of ADHD drugs are predicted to be $4.3 billion by 2012. This ADHD boom is a recent phenomenon, largely a product of the 1990s. According to the US National Ambulatory Medical Care Survey, the number of children who received a diagnosis of ADHD increased 250 percent from 1990 to 1998. A study from 1996 showed that from 1990-1995 child use of ADHD medication increased by a factor of 2.5 and drug production increased six-fold. The production of Ritalin (the most common ADHD medication) increased by 700 percent from 1990-1999.

As these numbers make clear, the 1990s were the heyday of ADHD, the
time when the disorder and its medications ascended to a prominent
position in the national consciousness.  By the time the decade was
over, most of America was convinced that ADHD was a slam-dunk—a
disorder that we had picked apart, analyzed, and for which we had
concocted the perfect remedy. In 1998 the American Medical Association
Council on Scientific Affairs declared that "ADHD is one of the
best-researched disorders in psychiatry, and the overall data…are far
more compelling than for most mental disorders and even many medical
conditions.”

But the most recent MTA report shows that AMA spoke too soon.
Interestingly, this premature certainty is a peculiarly American
phenomenon. More so than other nations, we have a history of insisting
that ADHD is a purely medical disorder that can, and should, be treated
primarily through drugs. As one ADHD information site puts it,
the U.S. has a “medical-disease model” while countries like Britain and
France have “deemed ADHD to be a function of the constructed world.” In
other words, as in so many other realms, “the United States places the
cause of ADHD within the individual while the other two countries place
the cause of ADHD…within the environment in which the individual must
function.”

This isn’t to say that other countries don’t
acknowledge ADHD can be addressed through medication—in fact, most
countries in the world have relied on MTA’s 1999 report to argue this
very fact (as in the U.K.,
for example). But, for whatever reason, other nations seem less primed
to embrace—and insist upon—the exclusive dominance of the
medical-disease model at the cost of other considerations.

American stubbornness on the matter isn’t limited to medical
practitioners. Our regulators, our companies, and even our media all
seem eager to follow the course they set in the 1990s  when they
trumpeted ADHD “breakthroughs.” Two years ago, for example, Canadian
regulators pulled ADHD drugs from the market after
a string of sudden deaths and strokes. That same year in the U.S., an
ADHD medication called Cylert was also recalled after health scares.
But the next year, 2006, the FDA refused to even put a warning on ADHD
medications that were still on the market—despite the fact that an FDA
advisory panel overwhelmingly recommended that it do so.

Other governments have also seemed more earnestly receptive to MTA’s
newest study. When the news of the report broke, Dr Tim Kendall, who is
helping prepare new National Health Service guidelines for the
treatment of ADHD in the U.K., said that the new report affirms that
“the important thing is [to] have a comprehensive approach that doesn’t
focus on just one type of treatment." Australia too is redrafting its
ADHD guidelines. No comment as of yet from the U.S.

The international media also seems more prepared to embrace the news
that ADHD is not a purely pharmacological affair. Even though the
authors of the MTA report are American, I couldn’t find any major U.S. news coverage of the report. But The Guardian, The Telegraph, and the BBC in the U.K., ABC in Australia,and the Edmonton Journal in Canada have all already covered MTA’s findings. The big national American news on the day of the MTA report was an AP story on how ADHD kids’ brains develop slower than those of other children.

Why is the U.S. institutionally reluctant to question the “quick
fix” mentality that views ADHD as an isolatable problem with a clearly
defined medical solution? That’s a question that brings us to the final
player in the ADHD game: drug companies. It’s no small matter that 90
percent of ADHD drug sales are from the U.S.–nor that ADHD is 50 times
more likely to be diagnosed in the U.S. than in Britain or France. The
market for ADHD is almost entirely American. 

Drug manufacturers thus have a serious interest in keeping the U.S.
discussion on ADHD married to the medical-disease model. I don’t want
to suggest that medication doesn’t help ADHD, or that ADHD isn’t a real
disorder, or even that there is some vast conspiracy afoot. But the
simple truth is that in the U.S. drug companies have vastly more
leverage and institutional wiggle room than they do in other health
care systems. Our boundary between medicine and commerce is a blurry
one, and more often than not the American way of health care looks
alarmingly like the American way of business—or even of politics.

Take for example, Children and Adults with Attention Deficit
Disorder (CHADD), the leading non-profit for ADHD awareness. Spend some
time on the CHADD website and you quickly feel like you are looking at a lobbying organization rather than a medical community.  CHADD has paid membership, local chapters, and even a magazine for members, the aptly named “Attention.”

Other countries have similar ADHD advocacy groups. But compare the website of the ADHD organization from the U.K. or that of the ADHD Foundation of Canada—which has ceased operations because of financial woes—to CHADD. It’s like comparing a bicycle to a Ferrari.

The obvious reason for these disparities is the fact that CHADD has
more money than its international counterparts. And guess where it
finds its funds? As of June 30, 2007, 26.1 percent of CHADD’s budget
came from pharmaceutical donations, according to documents on the organization’s website. (No wonder then, that CHADD categorically insists that ADHD is neither over-diagnosed nor over-medicated).

Does CHADD silence ADHD dissent? No—and there has been activity in
the U.S. by ADHD skeptics, including five class-action lawsuits in 2000
(all dismissed by 2002). But the fact that CHADD is so well-developed
speaks to the extent to which the voice of pharmaceutical companies is
amplified in the U.S. health care system.

And, as we all know, the influence of drug companies isn’t always
limited to funding a consumer community. According to one the primary
co-authors of MTA’s reports, William Pelham, drug companies got pretty
ugly when it came to ADHD. In 2004 he spoke to AlterNet and recounted his experience with pharmaceutical companies at the height of the ADHD craze in the late 1990s. 

Pelham notes that when McNeil Inc. wanted FDA approval for its ADHD
drug, Concerta, the company funded studies that required that subjects
already be on the drug, and responding well to it, in order to
participate. As Pelham puts it, “by stacking the studies with patients
already successfully taking stimulants, McNeil ensured the subjects
would be unlikely to register side effects.” Pelham says "it’s really
misleading and I’m surprised the FDA is letting them use the studies to
advertise no side effects.”

Pelham also had a tough time protecting his work from being a
“whitewash” or “a praise to Concerta.” Pelham claims that papers from
McNeil were submitted to—and accepted by—the Journal of the American
Academy of Child and Adolescent Psychiatry, despite the fact that he
claims he never consented to its publication.

Is any of this confirmation of a vast, corporate ADHD conspiracy?
Not necessarily—nor is it an indication that ADHD isn’t a real disorder
that needs to be addressed. But, for better or worse, it’s clear that
entities with an interest in fueling the medication feeding frenzy have
more opportunities and access points to flex their muscles in the U.S.
than in other countries. There’s a ripple effect to that—our government
is less willing to intervene, our press less willing to question, and
our medical establishment less willing to rollback so-called “medical
progress.”

In short, the U.S. is institutionally primed to jump the gun when it
comes to insisting on a "case closed" mentality for new medication. And
sometimes, as is the case with ADHD, we think it’s a done deal before
we have all the facts.

15 thoughts on “ADHD and the Medication Feeding Frenzy in America

  1. In the last five years, I have developed adult ADHD. I think I have always had a mild form, or if not always, at least since my late teens. But in the last five years, it has gotten much worse. It is accompanied by nominal aphasia.
    I know the cause – acute sleep apnea. As I have gained weight over the years, my sleep apnea and my ADHD has grown worse, pound for pound. If I had good insurance, I would get a breathing machine.
    My brother has severe sleep apnea. He also suffered severe emotional disorders, plus high blood pressure. I finally talked him into asking his heart doctor to order a sleep study. He’s got a breath machine now, and he’s off all his medications. All of them.
    My 3 year old was beginning to exhibit behavorial problems. Our pediatrician noticed (not in relation to his problems) that he had enormous tonsils and adenoids that were probably restricting his sleep. We had a sleep study done on him, following by a tonsilectomy/adenoidectomy. The ENT said after the surgery that he had the biggest adenoids he’d ever seen in all his years of practice. My son’s behavorial problems have disappeared.
    I’m of the opinion that poor sleep, either due to lifestyle or medical conditions like sleep apnea, cause more emotional and behavioral problems in this country than are commonly recognized. I’m also of the opinion that when drugs like Ritalin and Prozac are given to children whose behavioral problems are caused by poor sleep, the drugs may only magnify the behavioral problems and make them worse, or at best, sedate otherwise normal children.

  2. This is soooo believable.
    Don’t forget that the schools have also bought into this situation.
    If the problem is the “child” then they don’t have to do or change themselves. And don’t forget that children with this “disability” allow them in some circumstances, to qualify for federal monies.

  3. For Jeff, it’s not hard to find cheap CPAP and perhaps BiPAP breathing machines in the Want Ad or similiar local classified listings. In most cases, a respiratory therapist will need to set the pressure because doing so needs special tools. If you can get something set, though, I’ve seen machines as cheap as $50.
    There was a comment, among many about pro- and anti-drug, about chiropractic. Disclaimer: I believe a chiropractor’s inability to know what he didn’t know, and refer, caused the death of a relative, from continued manipulation of obvious (to someone properly trained) visceral pain. The problem was an aneurysm of the abdomina aorta, nothing in the back.
    With that disclaimer, an NIH consensus panel found chiropractic the most efficient treatment for acute low back pain. We may be seeing changes in chiropractic, from a couple of directions. I know three (maybe 5 by now) who are dual-certified in physical therapy and chiropractic, see the disciplines as complementary, and work closely with physicians.
    The other is that there are some real research programs at chiropractic colleges, with results indicating they might be doing the right thing for the wrong reasons. Apparently, certain manipulations cause neurotransmitter and other cytokine release that, in turn, relieve inflammation and pain.

  4. I would have to pay for it myself, of course, because to get a breathing machine my very expensive health insurance requires that first I go see a doctor, who will then order a sleep study, which will then prescribe a breathing machine. My brother’s insurance paid for his. For me, I’d have to meet my deductible first (pay for the sleep study). Paying a respitory therapist would certainly be cheaper.
    I have found a machine, by the way, I just need to find someone to set it for me now. Thanks for the info.

  5. I am the parent of two ADHD children adn the wife of a husband with this condition also. For my older son, methylphenidate is a God send. For the younger one, he would be unable to be in a regular classroom without it. My husband is a PhD in Physics, who never had access to medication as a child, and has found caffeine instead. His heart rate is 120! For me, this is definitely a real disorder, with real palliation available. KMD

  6. Hi Jeff, I kinda of like your opinions on the possibility of emotional and behavioural problems being linked to poor sleep. As the real cause of ADHD remains unknown, your opinions may be relevant to current research on this medical disorder.

  7. I’m of the opinion that poor sleep, either due to lifestyle or medical conditions like sleep apnea, cause more emotional and behavioral problems in this country than are commonly recognized. I’m also of the opinion that when drugs like Ritalin and Prozac are given to children whose behavioral problems are caused by poor sleep, the drugs may only magnify the behavioral problems and make them worse, or at best, sedate otherwise normal children.

  8. With that disclaimer, an NIH consensus panel found chiropractic the most efficient treatment for acute low back pain. We may be seeing changes in chiropractic, from a couple of directions. I know three (maybe 5 by now) who are dual-certified in physical therapy and chiropractic, see the disciplines as complementary, and work closely with physicians.

  9. this is true…..
    parents should take time with their children and not just relying them to their teachers in school..the possibility if you have just neglected your children, the greater the possibility that your children may develop ADHD, they might be impulsive just to gain attentions…

  10. Academic difficulties are also frequent. The symptoms are especially difficult to define because it is hard to draw a line at where normal levels of inattention, hyperactivity, and impulsivity end and clinically significant levels requiring intervention begin. To be diagnosed with ADHD, symptoms must be observed in two different settings for six months or more and to a degree that is greater than other children of the same age.

    • Sam–

      Yes, “symptoms must be observed in two different settings for six months or more.”
      Too often, I’m afraid that one person makes the diagnsosis in just one setting.