by, Austin Ellsworth
While the United States comprises less than 5% of the world’s population it consumes roughly 80% of the world’s supply of prescription stimulants such as Ritalin and Adderall. The vast majority of these stimulants are prescribed for the treatment of Attention Deficit Hyperactivity Disorder (ADHD). One would assume that such a staggering statistic could only represent the absolute certainty we must have in both treating and defining this mental disorder. On the contrary, the very definition of ADHD seems to be a source disagreement among medical professionals and scientist. If the definition of a disorder is uncertain, it would be logical to assume the methods we use to treat that disorder would be just as uncertain. The mere existence of this disorder has been called into question by new genetic research uncovering the origins of ADHD. Consumer advocacy groups toting research have been long entrenched with the United States Food and Drug Administration (FDA) over nutritional guideline and food labeling. Adding to the confusion are a myriad of conspiracy theories involving pharmaceutical giants which have surprisingly made it all the way to our court system. We are left asking ourselves the question, what exactly is ADHD?
Dr. Keith Conners, psychologist and professor emeritus at Duke University once said this about ADHD, “This is a concoction to justify the giving out of medication at unprecedented and unjustifiable levels.” ADHD with a fairly young clinical history having appeared in a diagnostic manual for the first time in 1980 as Attention Deficit Disorder (ADD). A short time later in 1990 congress passed the Individuals with Disabilities Education Act (IDEA) which gives federal funding to public schools based on the number of learning disabled students they have in attendance. For the schools, the congressional act monetized disabled children including those with an ADHD diagnosis. With the bill passing in congress, pharmaceutical companies put on a large publicity push marketing the disorder and medications like Ritalin to doctors, educators and parents. Drug sales of legalized amphetamines boomed as more and more children began receiving the diagnosis. We should mention that the Individuals with Disabilities Education Act was the continuation of a similarly named act passed in 1975 and was largely supported by grassroots lobbying for the disabled. ADHD or ADD had not existed as a diagnosis or disorder at that time.
The conspiracy theory came in 2002 when the law firm Waters & Krauss, on the behalf of the Church of Scientology filed a class action lawsuit against the drug manufacturer Novartis as well as the organization Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD) and the American Psychiatric Association for conspiring to invent the diagnosis of ADHD, to promote the over-diagnosis of the disorder and to popularize Ritalin (methylphenidate) as the drug and treatment of choice. CHADD had received over a million dollars in donations from drug manufacturers in 2000 and disclosed receiving close to that amount directly from Novartis between 1991 and 1994. The suit also alleged that members of the American Psychiatric Association received finances from Novartis and that the company’s promotional material about Ritalin was negligent in not properly disclosing the harmful side-effects of the drug such as stunting growth, hallucinations, psychosis, depression and sudden death. The court battle eventually ended with a dismissal and a year later the US government via the CDC gave hundreds of thousands of dollars in funding to CHADD which became a “National Resource on ADHD.” More lawsuits were to follow.
Theories involving pharmaceutical companies, learning institutions and the United States government secretly conspiring to produce a zombie apocalypse are abound. In lieu of dispelling these theories or giving credence to there merits, let us examine some of the data that may have attributed to their rise. In 1990 the stimulant prescription of choice was Ritalin and there was still a distinction between the “non-hyperactive” Attention Deficit Disorder, ADD and “hyperactive” Attention Deficit Hyperactivity Disorder, ADHD. That year there were roughly 600,000 children taking prescribed stimulants and by 2013 that number jumped to 3.5 million. In 2013, the US alone produced 211 tons of prescription stimulant medication, enough for every man, woman and child in the country to take 24 pills. Adults being prescribed the medications more than doubled between 2008 and 2012. By 2004 prescription stimulants rose to become the second most popular recreational drug used on college campuses falling only behind marijuana. Consequently we have seen ER visits to the hospital for prescription stimulant related cases quadruple from 5,600 in 2005 to 23,000 in 2011.
What exactly are these prescription stimulant medications? Adderall, Ritalin, Concerta and Dexedrine are some of the most common brand names prescribed to children and adults. Generically they are known as amphetamine, dextroamphetamine and methylphenidate. Adderall is a mixture of amphetamine and dextroamphetamine, Ritalin is methylphenidate. All of these substances are classified by the Drug Enforcement Agency (DEA) as Schedule II which is the same classification they give to cocaine and morphine based on their addictive properties and potential for abuse. Studies of these drugs have been often criticized as being insufficient or slanted being that the drug companies themselves are the ones funding their own research. CDC Principal Deputy Director Ileana Arias, Ph.D. recently said this, “We do not know what the long-term effects of psychotropic medication are on the developing brains and bodies of little kids.” One study from Berkley showed ADHD medications to improve test scores while another study published in 2014 actually concluded that these medications cause accumulated deterioration in various academic outcomes.
The backlash against these medications comes not as a surprise. Alternative forms of treatment including nutrition and behavioral therapy are gaining popularity. These treatment options are non-addictive and come without paying the price of heart palpitations and unwanted psychosis. Nutritional supplementation includes vitamins and minerals that metabolize and regulate neurotransmitters, omega-3 fatty acids that support cognitive function and amino-acids that are synthesized into the same neurotransmitters that prescription medications like Adderall are seeking to increase.
Here are four illnesses with the very similar symptoms, acute bronchitis, asthma, bronchiectasis and lung cancer. Imagine going to your doctor with a case of bronchitis (caused by a virus) but getting diagnosed with lung cancer and then going through the subsequent rounds of chemotherapy. Now imagine going to your doctor with a common food allergy but, getting diagnosed with ADHD and being put on amphetamines for the rest of your childhood and adult life. That would certainly be a lot of unnecessary stigmatization and speed.
There are two types of food allergies that are common to those labeled as ADHD. The first type of allergy or sensitivity can also be found in the rest of the population but occurs with higher incidence in those positively diagnosed. Most often these are sensitivities to dairy, gluten, soy and eggs and cause an immune response in the body which can often be difficult to detect aside from the occasional upset stomach. A blood test is required to discern which foods create immune responses. The immune responses create a weakened digestive system which in turn decreases the absorption of essential nutrients required for normal mental and bodily functions.
The more heavily debated allergy is the second type. This battle has been raging for years between consumer safety advocates, food manufacturers and the FDA. Since the 1970’s allergists and researchers have been connecting the dots between synthetic food dyes and additives made from petrochemicals with inattention a hyperactivity. The vast majority of double blind placebo studies highlight the adverse effects of these neurobehavioral toxins on children. The last time the topic was reviewed by the FDA was in 2011 when it was presented in conjunction with eight independent analysis which all found that eliminating food dyes reduces adverse behavior. The FDA made a broad dismissal of the research whereas the European Union instead has implemented new restrictions and labeling on food additives. Any food containing certain dyes in the EU has a label that actually states “May have an adverse effect on activity and attention in children.” With around 90% of children’s snacks containing these additives, the effect on US children could be sprawling. The dyes of course hold no nutritional value but their bright and vibrant colors are used to attract consumers associating the reds, yellows and blues with certain flavors which are also often synthetic. Take Cherry Kool-Aid for example, both its cherry color and cherry flavor are artificial. There are some estimated 15,000 chemical food additives approved by the FDA which include colors and flavors made from petroleum and paper factory waste as well as carcinogenic preservatives used to artificially ripen fruits and keep foods fresh. Additives are legally allowed to be contaminated with byproducts containing lead, mercury and arsenic. It’s not all that surprising that consuming them can have negative mental effects. This raises yet another question, if there are large numbers of children having neurobehavioral reactions from consuming petrochemicals, why are we treating them with amphetamines?
We know that children with lead exposure have a much higher incidence of being diagnosed with ADHD. Is the presence of lead creating the mental disorder or is it simply creating symptoms similar to the mental disorder? Do the symptoms go away in these same children once the lead has been successfully detoxified from their systems? This seems like the direction our research should be heading. Toxins are not the only thing clouding the waters of diagnosis. Studies also show that unfavorable home-life and school conditions can also chances of a positive ADHD diagnosis.
When compared to the United States, France has an insignificant number of children diagnosed with ADHD at only half a percent of the population. How is this possible? Is the secret in all of those wonderful cheeses or are the French just paying attention to all of the discouraging food labels? The answer is probably much simpler. French criteria for diagnosing ADHD is plainly different. To illustrate the divide, if you took the same child and examined him both in France and in the United States, he would be 20 times more likely to be diagnosed with ADHD in the US.
Perhaps some of the most interesting developments in understanding ADHD has come from scientific advances in genetics. Understanding the genetics of ADHD can allow us to peer far into the past in order gain a better understanding of its origin and proper place in human evolution. What scientist are uncovering is shocking and will certainly rewrite the definition of what has been labeled a mental disorder. In fact, it may not be a disorder at all. Much of the current genetic focus is surrounding the gene DRD4 which is critical for the function of the dopamine receptor D4 in the brain. Dopamine receptors are involved in neurological processes for pleasure, motivation, memory and learning. They are truly the reward centers of the brain. Studies have found that ADHD individuals typically have low levels of dopamine and therefore, the things that they find rewarding greatly differ from the rest of the population. Our experiences trigger the release of dopamine. The bigger and more unpredictable the experience, the greater the release of dopamine. It is easy to imagine ADHD individuals with their low levels of dopamine, walking around in constant state of under-stimulation. This would explain why they may find routine activities and repetitive tasks painful and unrewarding in comparison to others. ADHD individuals have been described as focusing on what they find interesting rather than focusing on what they are told is important, hence all of the friction in the classroom. An environment that the average person might find overstimulating or even frightening might be perfectly acceptable or even preferable to an ADHD person. Back to the subject of medication, ADHD drugs work by flooding receptors with dopamine which in a sense, flattens and broadens the plane of focus requiring less stimulus for a task or subject to become interesting and rewarding.
Hyperfocus is likely a product of this unique pattern of dopamine function in the “ADHD” brain. This term defines the deep and intense concentration that someone with ADHD can apply to tasks that they find stimulating or interesting. It is a concept similar to tunnel vision and can be observed in someone playing music, producing a work of art or deep into research. It has been described as a state of mind that is meditative and transportive. In addition to hyperfocus, these individuals display the signature fleeting attention span. As their minds wander they pick up on the finer details that are often overlooked by others. Studies of individuals diagnosed with ADHD are generally more explorative, impulsive, promiscuous, adventurous, mentally flexible, curious and mobile. Once again, the more intense the experience, the larger the release of dopamine.
Imagine someone with these traits living in a hunter gatherer society or a primitive life-style, environments where impulsive thrill seekers would thrive. For societies that are constantly on the move and looking for new sources of food and water, individuals with a higher tendency to pursue stimulating activities such as hunting, toolmaking, risk taking and reproduction could prove to be more successful and have a higher chance of passing on their genes to future generations. Anthropologist Dan Eisenberg, Ph.D., believes one such gene emerged 45,000 years in the human genome and he is not alone in his findings. Most interestingly, genetic techniques reveal that this gene was not the result of some random mutation but was actually positively selected for, meaning that it must have been advantageous. The gene was the variant of DRD4 known as 7R which is responsible for regulating dopamine in the D4 receptor and strongly linked to ADHD. Aside from the loud disruptive and unfocused kids in the back of the class, today the gene is most prevalent in groups of people who are nomadic or have long histories of moving great distances.
To test Eisenberg’s hypothesis, Chuansheng Chen Ph.D., of the University of Michigan devised a study of the Ariaal people in Kenya. There are two groups of the Ariaal people living today. One group continues to live their traditional nomadic, pastoralist lifestyle, moving great distances and seeking out new food and water sources for themselves and their livestock. The other group has split off to become sedentary, growing food, selling goods at market and going to school. The study looked at the health and weight of men in both groups. In the nomadic group they found that the men possessing the ADHD-associated DRD4-7R gene were less underweight than the other men. Contrarily, in the sedentary group, men possessing the DRD4-7R gene were more underweight than the men without it. The results suggest that the presence of the gene in the nomadic group was advantageous while its presence in sedentary group came with a disadvantage.
What does all of this mean? To put things in evolutionary perspective, modern humans have been evolving for roughly 200,000 years. It took 155,000 years for the evolutionary chisel to sculpt the DRD4-7R gene variant through natural selection. Scientist say the evidence all points to it being superior and increasing the chance of survival to those who possessed it during our human evolution. The domestication of plants and animals and transition to an agricultural subsistence really only took root about 10,000 years ago. Forcing present day carriers of the gene to assimilate into modern classroom structures and learning models seems like the equivalent of trying to force a round peg through a square hole. So far our most widely excepted practice to is accomplish this is through the mass drugging of minors. Understanding the biology of some of these children now presents a true ethical dilemma when medicating them. The D4 receptor is not the only dopamine receptor and work in genetics continues.
ADHD label is based on Interpretation
The Hastings Center, a bioethics research institute states this, (1) The ADHD label is based on the interpretation of a heterogeneous set of symptoms that cause impairment. (2) Because symptoms and impairments are dimensional, there is an inevitable "zone of ambiguity," which reasonable people will interpret differently.
The ADHD symptoms are a result of what, a genetic legacy from our evolutionary past, intake levels of dietary toxins, lead exposure, social disfunction or a mental disorder? The root ADHD-like symptoms or behaviors can come from various causes, this article has only discussed a few. In the US we are treating mostly everyone displaying these behaviors and tendencies with a “one pill cures all” philosophy. Treating an illness of any kind before understanding its cause seems truly illogical. What if the thing we are treating is not an illness at all? Research dollars are certainly more focused on the treatment than the cause. Perhaps one day in the future, people will look back on some of our current medical practices and find them as barbaric and archaic as bloodletting and lobotomy.
While some medical professionals are still stuck arguing whether social, biological or environmental influences can impact the diagnosis of ADHD, data and evidence suggests that we are well beyond this phase of the controversy. We are living in an era when geneticists have discovered that emotional trauma in the early years of life can change the gene expression of our DNA. This is uncharted territory that rewrites scientific rules as we knew them and completely changes our understanding of human physiology. The very fiber of our biological-being which was once considered rigid and absolute has now been shown to be malleable and in flux. Science itself is constantly in a state of flux. In a recent article, one psychiatrist wrote that some doctors questioning the role of trauma leading to inaccurate ADHD diagnoses as “jumping on the anti-ADHD bandwagon.” One thing is for certain, when medicine and psychiatry cease to ask questions and reexamine assumptions, they will cease to be scientific. At this time it seems safe to say, the current understanding and generally accepted label of ADHD is at best, out-dated.
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