ADHD is Not an Illness and Ritalin is Not a Cure

The following sections are included:

• Dedication
• Personal Prologue A late apology to Queen Sarabi
• Contents

Is Attention Deficit Hyperactivity Disorder (ADHD) a valid medical condition? Allegedly, the answer to this question is simple (and why bother writing a whole book about it?). According to the International Consensus Statement, published by a large consortium of experts led by Prof. Russell Barkley, there is “overwhelming” evidence that ADHD is a genuine and dangerous disorder with traceable bioneurological markers and genetic foundations [2]. ADHD, the most prevalent neuropsychiatric label in children [3, 4], is repeatedly depicted by leaders of the field as an objective and chronic medical condition that should be managed regularly, preferably with stimulant medications [2, 5–8]. But what if they are all wrong? What if ADHD does not meet the required criteria for a neuropsychiatric disorder? Is it possible that millions of children are being labeled and treated unjustifiably, with powerful and highly dangerous psychoactive drugs?…

The opening quote of this chapter has been taken from the website of the leading non-profit organization for Children and Adults with ADHD in the US, known as CHADD. According to the organization’s description in Facebook, “CHADD is the most trusted source for reliable, science-based information regarding current medical research and ADHD management”; so, when CHADD says that “real science defines ADHD as real disorder”, it contributes to the dismissal of the vibrant debate over the validity of the diagnosis presented in the Introduction. Moreover, the usage of the terms “real science” and “real disorder” might create an inaccurate impression among non-scientists, as if Attention Deficit Hyperactivity Disorder (ADHD) is a physiological disorder — a unique neurodevelopmental construct that is distinguished from the rest of the mental disorders. The biomedical conceptualization of ADHD as a chronic “brain disorder” or as “the diabetes of psychiatry” (Introduction) may lead people to believe that ADHD can be diagnosed through objective biological measures that prove, without a doubt, that the person has a tangible brain deficit. However, the truth is that ADHD does not have any physiological advantage over other mental health disorders (Chapter 6).

We begin our inquiry of the “Four Ds” criteria of psychiatric diagnosis (Chapter 1), with the first and prerequisite criterion of Deviance. Like all other psychiatric disorders, we expect that cases of Attention Deficit Hyperactivity Disorder (ADHD) will be relatively uncommon, otherwise the behaviors associated with the disorder could not have been categorized as abnormal. In fact, the very use of the term ‘Hyperactivity’ indicates that there are normative levels of activity and ‘hyper’ (i.e., above normal) levels of activity. In other words, by definition, ADHD is conceptualized as a deviant phenomenon. The mission of the current chapter should therefore be relatively simple (especially considering the consensual, biomedical perception of ADHD) — to investigate two straightforward questions: What is the prevalence of ADHD-related behaviors in the general population and to what extent do these behaviors deviate from normal human behaviors? Nevertheless, as illustrated in the opening quotes of this chapter, the answers to these questions may not be so simple. Although all four quotations were taken from new articles published in the same year (2021), and although all four served as opening statements that supposedly reflect a well-established truth about the prevalence of ADHD, they still present significantly different prevalence estimates (e.g., 5% vs. 9.4%). Moreover, even if we manage to settle these discrepancies and scrutinize the exact rates of ADHD, how do we decide whether these rates are deviant? After all, human beings differ from one another on multiple traits, and to my knowledge, there is no formal quantitative cutoff point at which all agree that a given trait or behavior deviates from the standard norm.

The diabetes metaphor, which was presented in the Introduction of this book to illustrate the biomedical consensus regarding Attention Deficit Hyperactivity Disorder (ADHD), is sometimes replaced by less disturbing similes, such as the “bicycle brakes” by Dr. Edward Hallowell. When talking to children, Dr. Hallowell, another influential authority in the field of ADHD, recommends the readership of ADDitude (a highly popular information source about ADHD) to begin with the child’s strengths (“your brain is like a Ferrari”) and only then move to describe her/his brain deficit (“you have bicycle brakes”). This communication tactic probably has some value for some children. However, it still holds the same biological deterministic message, something along the following lines: You have a chronic brain problem that could cause you a lot of trouble throughout your life. It has nothing to do with school setting or academic functioning. You were born with a brain deficit, which should be managed medically [2, 3]. You therefore need a “brake specialist” physician that could prescribe you the appropriate treatment of choice (Introduction) that will “strengthen” (but not ‘fix’) your impaired “brain brakes”…

The shuddering tragedy of Ron Barkley, the brother of Prof. Russell Barkley who leads the field of Attention Deficit Hyperactivity Disorder (ADHD) (Introduction), provokes painful questions: Could ADHD medications have saved Ron’s life? Does untreated ADHD lead to premature death? I cannot imagine the grief and regret of Prof. Barkley, but I urge us to try and take some psychological distance from Ron’s tragedy, and discuss the more general issue at hand: Does ADHD meet the criterion of danger for psychiatric diagnosis? And more specifically, for the millions of diagnosed children around the world who have less freedom of choice than adults whether to use ADHD medications, are they at a tangible risk for dying prematurely? Should they all use stimulant medications (that work for several hours only) on a daily basis, regardless of their school performance, to make sure that they are not in danger?

The opening quote of this chapter touches on the last, and in my view, the most pivotal, ‘D’ criterion of psychiatric diagnosis — the criterion of Distress. According to its author, James Ochoa from the medical review panel of ADDitude (see Chapter 3), as well as multiple other representatives of the consensus, individuals with Attention Deficit Hyperactivity Disorder (ADHD) are bound to exhibit profound emotional distress throughout their lives [2]. The leading narrative regarding the distress component of ADHD may be illustrated using an ‘onion layers’ metaphor: The primary implications of the “brain deficit” known as ADHD, located at the heart of this medical onion, are symptoms of inattention, hyperactivity, and impulsivity (Introduction). Then, throughout life, children who experience these symptoms grow secondary layers of poor self-esteem and emotional distress. Starting from early childhood, ADHD-type children enter an ever-escalating negative loop. They are requested repeatedly by teachers and other caregivers to be attentive, sit still, be quiet, and inhibit their spontaneous movements — the very behaviors they struggle with. Bit by bit, they accumulate failures and discouraging feedbacks from their surroundings, which can threaten their self-esteem and trigger what Ochoa called an Emotional Distress Syndrome — “a chronic state of stress related to the struggle to live with ADHD” [1]…

With all due respect to the “Four Ds” criteria discussed so far (Chapters 2–5), we all heard that Attention Deficit Hyperactivity Disorder (ADHD) is an objective “brain disorder” (Introduction). How can I claim that ADHD is not a valid medical illness, when “real science defines ADHD as real disorder” (Chapter 1), when the European consensus statement is so clear regarding the “neurobiological underpinnings of ADHD” [2, p. 26], and when the medical review panel of ADDitude approves the opening quotation of this chapter, which received the provocative title: “The Neuroscience of the ADHD Brain: Truths about the ADHD brain that most people don’t understand” (bold added by Y.O.)?…

As you might recall, the introductory question of this book is: Is Attention Deficit Hyperactivity Disorder (ADHD) a valid medical condition? To be more specific, this book investigates whether ADHD should be considered as the “diabetes of psychiatry”, that is, a distinct and chronic neuropsychiatric condition with multiple negative implications? After laying the philosophical ground needed to answer this question (Chapter 1), Part One of this book explored the available evidence regarding the “Four Ds” criteria of psychiatric diagnosis (Chapters 2-5). The General Discussion section at the end of the book (Table 4) provides an overview of the numerous reliability and validity gaps that emerged throughout this investigation (alongside the ones that emerged in Part Two) — gaps that dismantle the theoretical concept of ADHD and undermine the justification to manage this (invalid) disorder through stimulant medications. The aim of the current Interim Summary is not to replace the General Discussion, but to provide readers with a short synopsis of the main rebuttal points so far (before we enter the second, and probably the more shocking part of the book that targets the medications for ADHD)…

The second part of the book, as implied by the ending of the first part, consists of the main reason why I have embarked on this perilous and unrewarding voyage. The consistent increase in Attention Deficit Hyperactivity Disorder (ADHD) rates over the past decades (Chapter 2) was accompanied by a noteworthy increase in the number of children and adults using a cluster of psychoactive substances known as stimulant drugs [2–4]. Although stimulant drugs, as suggested by their name, are frequently abused for stimulating (potentially addictive) exciting sensations of high energy, euphoria, and potency, in ADHD, they are often believed to produce paradoxical calming effects (Chapter 6) and to be highly beneficial and safe. Multiple health organizations and expert consortiums determined that stimulant medications should be considered as the first-line treatment for ADHD [5–8]. These medications vary from methylphenidate (e.g., Ritalin and Concerta) to amphetamines (e.g., Adderall) and methamphetamines (e.g., Desoxyn) and their desirable effects on ADHD are achieved through their ability to increase the levels of key neurotransmitters in central parts of the brain, including in the prefrontal cortex [9] — the region of the brain that is in charge of the cognitive control functions that are said to be impaired in individuals with ADHD [10, 11]…

If so many children are treated with stimulant medications, they must be highly effective, are they not? Well, if you ask CHADD, as well as multiple other organizations, health officials, and consortiums, the efficacy of stimulant medications — the treatment of choice for Attention Deficit Hyperactivity Disorder (ADHD) (Chapter 7) — has been proven, beyond a shadow of a doubt, in decades of medical research [e.g., 2, 3]. However, when we start to dig a bit further into the available studies, the bright efficacy sand becomes pretty muddy. In Chapter 9, I will target the long-term (and less researched) clinical value of daily usage of stimulant medications, but first, let’s examine the validity of the ‘easy’ and allegedly proven claim that ADHD medications are effective for most children in the short term…

For the purpose of the discussion in this chapter, let’s assume that medications for Attention Deficit Hyperactivity Disorder (ADHD) do have some clinical value in the short term (a problematic assumption as described in Chapter 8), and ask: What will become of treated children in the future, if and when they decide to stop using their medications? Will the achieved short-term benefits last over time or will they fade? Alternatively, we must ask: What will become of treated children who adhere to their recommended medical plan and use stimulant medications for prolonged periods? After all, ADHD children are said to suffer from a chronic and dangerous brain disorder (Introduction) that should be managed medically throughout their entire development, including adulthood [2]. Medication, as explicitly admitted by CHADD’s authors, “does not cure ADHD”. The medication “helps regulate the symptoms”, as written in the official medication package insert (i.e., the patient leaflet) of the popular medication of Ritalin, “but [it] does not cure” (Figure 3, Chapter 10). It should therefore be used constantly, “like eyeglasses that help to improve vision only during the time the eyeglasses are actually worn” [1]. Unfortunately, these central questions of the current chapter have no reassuring answers.

Have you ever stopped for a moment to ask why, apart from the MTA study (Chapter 9), there are no other high-quality studies on the long-term efficacy of stimulant medications? Although such studies can be expensive and complex to carry out, they are probably worth the trouble, particularly for the pharmaceutical companies. After all, a high-quality study that will prove that a certain medication has a long-term efficacy could substantially amplify its sales. A preliminary answer to this question may be that longitudinal studies, as shown in the previous chapter, can expose undesirable results (from the perspective of the pharma industry, which typically funds such studies). However, another possible and more alarming answer may be that such high-quality longitudinal experiments would reveal the large proportions of dropouts — that is, the many participants who could not complete the study because they suffered extensive adverse events [2]. Forming additional longitudinal Randomized Controlled Trials (RCTs) might expose serious adverse outcomes of medications for Attention Deficit Hyperactivity Disorder (ADHD) — outcomes that will then be very difficult to minimize or dismiss, because of the high internal validity (Box 1, Chapter 1) of such controlled trials…

For those who still believe that the benefits of stimulant medications outweigh their risks, despite their limited efficacy (Chapters 8 and 9) and numerous unwanted adverse effects (Chapter 10), we must continue to discuss the serious and long-term adverse outcomes of the popular medications. Are these powerful and daily used drugs, which cross the blood-brain barrier, really comparable to the very seldom used (especially among children) over-the-counter painkillers, as suggested by Prof. Barkley in the opening quote of this chapter?…

Upon reaching the final chapter of Part Two, some readers probably wonder how it is possible that the public is unaware of the massive evidence against the efficacy and safety of stimulant medications. Does my family doctor not know about the risk for psychotic reaction (Chapter 11) or the increase in Attention Deficit Hyperactivity Disorder (ADHD) symptoms documented in the Multimodal Treatment of ADHD (MTA) study (Chapter 9)? To begin answering these questions, I recommend visiting the official webpage of the National Institute of Mental Health (NIMH) dedicated to “questions and answers” about the institute’s seminal project (i.e., the MTA study) [2]. Although this webpage has been revised in November 2009, it mainly presents findings from 1999, which were favorable towards the medications [3]. For some reason, the content of the webpage does not include the unfavorable results that were obtained in the years that followed [e.g., 4, 5]…

The medical-scientific picture that emerges from Part Two is bleak. When we quieten the commercial cacophony of the pharma industry, we are left with ineffective, highly dangerous, and potentially addictive drugs. The short-term clinical value of stimulant medications, the first-line treatment for Attention Deficit Hyperactivity Disorder (ADHD), is minor and questionable, and even if the medications do bring some improvement (especially for schoolteachers), the available evidence suggests that they have zero long-term efficacy against symptoms and dangers associated with ADHD. On the contrary, when used for prolonged periods, the medications seem to produce reverse efficacy, that is, aggravation of ADHD-related symptoms, Oppositional Defiant Disorder symptoms (a disorder that occurs in high comorbidity with ADHD), and general impairments in functioning…

I have deep respect for the authors of the 2002 International Consensus Statement who devoted their lifetime to research inattention and hyperactivity behaviors. I do not doubt their good intentions. I even believe that a small percentage of children derived some benefits from being diagnosed with Attention Deficit Hyperactivity Disorder (ADHD), whether through less judgmental and more compassionate feedback from their caregivers, or through their eligibility for concrete psycho-educational support. However, I respectfully disagree with the consensus members’ deterministic biomedical approach. The concern that ADHD is a “myth, fraud, or benign condition” does not emerge simply from “media reports” or “inaccurate stories”; it is voiced by multiple scientists and clinicians (Introduction), and it is anchored in firm empirical evidence, which is now organized and consolidated in one scientific source (this book)…

The following sections are included:

• Personal Epilogue A very special flamingo
• Acknowledgements
• About the Author
• Index