Looking into ADHD.

This impression of scientific certitude in the midst of substantial and potentially crippling problems is a tribute to the ability of psychologists and the psychiatric profession to acquire and wield power ... the salient point is that the mental health professions have a track record of advancing diagnostic categories that lack clear underlying unity based on scientific evidence, but that, nonetheless, have the effect of responding to popular needs and aggrandizing the power and authority of mental health professionals [1, pp200-02].

So said Eric Dean, a historian and lawyer who studied post-traumatic mental disorders in both the American Civil War and what the Vietnamese know as the American War.

The power and reach of the psychiatric industry we have discussed previously and will discuss again. This week's exploding landmine is news from the office of WA Greens Senator Jordan Steele-John, who holds the Australian Greens’ Health and Mental Health portfolio, that he has convinced the Senate to hold an enquiry into what is now called ADHD. The honourable Senator has a BA in politics and history and worked briefly as an "advocate and activist" in between his numerous attempts to win an election. At age 23, he had the good fortune to land in the Senate after Scott Ludlum was declared ineligible to sit.

Over the past few months, I have received a number of emails from the senator's office, starting with a survey on attitudes toward and needs for greatly expanded services directed at ADHD. My surly response to his survey must have been lost in the crush. Instead, 10,000 wildly excited submissions have fired him up to promote this, ah, topic to a higher priority than global warming, the threat of nuclear war, inequality and the usual gripes from the whining classes. In an email dated March 29th, he announced:

I am absolutely beside myself to share this news with you: last night the Senate formally backed the Greens’ motion to hold a parliamentary inquiry into ADHD assessment and support services! It’s such a huge win for the ADHD community, by the ADHD community. And I couldn’t be prouder to have worked alongside you to make it happen (his emphasis).

The terms of reference for the enquiry are on the Senate website, under Parliamentary Business.

It's probably coincidence that, a few weeks ago, the Royal Australian and New Zealand College of Psychiatrists (RANZCP) issued another of its Position Statements (No. 55), entitled ADHD across the lifespan. It starts with the bad news:

ADHD is a high prevalence neurodevelopmental disorder, often associated with impairment that extends across the lifespan... ADHD is the most common neurodevelopmental disorder, affecting 8.2% of children and 2.5% of adults in Australia ... Often dismissed as a behavioural problem or personality disorder, it is underdiagnosed and undertreated in public sector mental health services.

Later, it says there is hardly a complication in the book that doesn't afflict the untreated but, fortunately, ...

Effective ADHD diagnosis and treatment follows expert guidelines that use contemporary scientific evidence and a holistic approach ... Psychiatrists' unique and comprehensive understanding of the bio-psycho-social assessment and treatment of ADHD, puts them at the centre of ADHD services and in a position of clinical leadership within a multidisciplinary team.

All this is in addition to a free quarterly publication for medical and other health workers entitled ADHD Research Review. These are professionally-produced summaries of recent journal articles, with commentaries by local experts, compiled by a group called Research Reviews. Who are they? Where are they? We don't know, their website doesn't give any details, beyond saying they are "supported by sponsorship from companies with an interest in the area." For psychiatry especially, that means drug companies. All this is for a " major ... high prevalence neurodevelopmental disorder" that didn't exist when I started training in psychiatry.

In 1977, during my child psychiatry placement, each of us had to give talks on different topics. One of mine was what was known as "hyperactivity," "hyperkinesis," "minimal brain damage/dysfunction" and other names. This was considered an uncommon condition affecting boys a lot more than girls but not much more was known. Boys with the diagnosis were more active, including fidgeting and moving around in the classroom, not concentrating and not keeping up with the classwork. One of the checklists used to make the diagnosis included the item: "Unable to watch television on Saturday mornings." Most of them included the item "Soft neurological signs." We don't normally think of neurological signs as "soft," so what were they? They were neurological signs which were difficult to diagnose and "may or may not be present" leading to "disagreement among clinicians."

I reviewed several dozen papers, almost all of them American, and found there was no diagnostic point on which they all agreed. They couldn't even agree on whether it was a psychiatric disorder or neurological, and if psychiatric, whether psychological or brain-related. Studies from different countries or different parts of the same country using the same checklists found wildly differing results. While some American centres were reporting rates of up to 20% in boys, other countries reported that they were unable to find a single case. A few lonely souls tentatively suggested that as it clearly clustered in middle- and upper-middle class families, especially high-achieving professionals where both parents worked, it should not be seen as a "mental illness." However, they were immediately shouted down by the biological camp because, after all, they had the treatment: amphetamines. It had long been known that giving amphetamines to fidgety, irritating or day-dreamy children improved their performance in school. This was taken to mean "biological" and was quickly followed by floods of money to research the diagnosis. My conclusion was that there was no such "disorder" and the whole thing was pseudoscience. That got me a bad mark from the lecturer who was devoutly convinced it was real but who declined to answer any of the points in my talk.

In the US, which was the epicentre of the diagnosis, the money came from two sources, mainly the drug companies but also from the National Institute for Mental Health (NIMH) which was being taken over by hard-core biological psychiatrists. Any child psychiatrist in academia who wanted to make a splash only had to apply for a grant and the money arrived, but there was one proviso: only biological research had much chance of being funded. Before long, the official line was that ADHD under its various names was a fully-fledged biological disease of the brain ("neurodevelopmental disorder") and that treatment with drugs was not only advisable but obligatory. In 1980, when the Americal Psychiatric Association's Diagnostic and Statistical Manual Third Edition was released (DSM III), it was given the new label of "Attention Deficit Disorder," ADD, later modified to ADHD. And an industry was born.

In Australia, prescription rates for stimulants (amphetamines and similar drugs) have exploded. In 1992/93, there were 16,559 individual prescriptions for these drugs. By 2018/19, that number had increased to 1,172,006 scripts, or about 7,100% increase. Just two years later, 2020/21, it was 1,983, 814, meaning 11,200% increase in under 30 years. In that year, about 4% of all children aged between 5-17 years were taking them, and up to 1.1% of the whole population. As scripts are normally for six months supply, we are talking of something of the order of half a billion tablets dispensed, of which a substantial proportion leak into the black market.

Originally, it was accepted that children "grow out of" the diagnosis so amphetamines could only be prescribed under age 18. However, once on amphetamines, always on amphetamines, and by the early noughties, pressure was mounting to extend the diagnosis to adults. And this is what we see today. The drug industry is concerned that its patents on antidepressants and antipsychotic drugs are running out and they have no new "miracle breakthroughs" in the pipeline so their only option, which has always worked in the past, is to give the same old drugs to more people. Amphetamines and other stimulants are expensive; by prescribing them for adults, the market is immediately four or five times larger, and a significant proportion of adults know exactly what amphetamines are, and they just lerve them.

But this time, the drug companies have been smarter, they've lined up their big guns like the Senate and the RANZCP to do their work for them. A few hyperenthusiastic "advocates" are actually moving the country in the direction of medicalising behaviour which has never been related to a brain disorder and which, in most countries, isn't even seen as "illness." In the excitement, the fact that the term "neurodevelopmental disorder" has no meaning has been overlooked. It is a shibboleth, a term for the in-crowd to toss around to give the impression they're where it's at and to stop pesky outsiders asking too many questions.

For myself, I do not believe that people who get "absolutely beside" themselves should be allowed anywhere near the controls of the drug industry, but pulling in big names is what drug companies do, that's what the advertising industry is built on. That the RANZCP has been recruited to the influencers' army is no surprise: Bob Whitaker and Lisa Cosgrove have dissected the guild functions of the psychiatry unions and show that this is one of their main roles [2]. We will talk more of this, specifically of how, as Eric Dean described, the diagnostic process has been suborned into implementing a social ambition. What is happening is very discouraging especially as the other side has unlimited money and very limited scruples.

For the hard facts on the ADHD industry, the most comprehensive and most readable source is the website psychwatchaustralia.com/ established by Martin Whitely, PhD, in Perth. Martin was a schoolteacher at one of Perth's most prestigious boys' schools who noticed how many boys were on drugs, and how they performed better off the drugs than on. He later entered WA Parliament and was able to influence legislation to tighten the (almost non-existent) regulations covering these drugs, so Perth was the first and only "ADHD hotspot" (meaning amphetamine hotspot) in the world to show a decline in diagnosis and prescription of the drugs. Later governments dropped the restrictions, so the figures rapidly caught up with the rest of the country. His book from 2010 is still relevant [3]. Remarkably, for somebody who has been immersed in this unsavoury business for nearly 30 years, he still has his sense of humour.

For some historical background on amphetamines, I wrote a book review for Mad in America some years ago: https://www.madinamerica.com/2017/03/book-review-blitzed-drugs-nazi-germany/

References:

1. Dean ET. Shook over hell: Post-traumatic stress, Vietnam and the Civil War. Harvard: University Press, 1997.

2. Whitaker R, Cosgrove L (2015). Psychiatry Under the Influence: Institutional Corruption, Social Injury, and Prescriptions for Reform. New York: Palgrave MacMillan.

3. Whitely M (2010). Speed Up and Sit Still: the controversies of ADHD diagnosis and treatment. University of Western Australia Press: Perth, WA.

In case anybody still thinks governments and public services work for the good of the citizenry, the Royal Commission into Robodebt will certainly cure that little fantasy. There is a commentator providing excellent summaries of each week of the hearings on Youtube. Knights in Shinging Llama, whoever he is, is able to sit through and then document up to 35 hours of excrutiating testimony per week. He has just released Week 4, which shows the advertising genius himself, Mr S Morrison, in fine form but if perhaps you are feeling a little elevated and need to come down to earth with a thump, start with Week 1: