Massachusetts News--March, 2000

By Ron Schneebaum, M.D.

Attention Deficit is not 

• a disease, 
• a disorder, 
• a psychiatric condition, or 
• a medical condition.

We have to be very clear because this is absolutely pivotal. If it is a medical condition, then it has to be addressed and treated as one. If it is not, our entire view of the issue has to be overhauled. 

A Disease?

It obviously is not a disease in the classic sense. Its official name is "Attention Deficit Hyperactivity Disorder."

No one dies from ADHD; It doesn’t progress

Alzheimer’s disease, to pick an example, gets steadily worse over time, and we have to plan for that eventuality. This is not the case with ADHD. The right teacher, the right school, the right summer camp, or the right career can have a dramatic and profound effect, turning what was a problem into a gift. The nature lover, for example, who couldn’t stand being cooped up in a classroom, could become a wilderness guide or naturalist, leading his/her field in a whole host of important findings. 

Doesn’t worsen if untreated 

Almost by definition, with the exception of a few self-limiting infections, untreated diseases will worsen or cause obvious complications if left alone. This is true for cancer, diabetes, heart disease, high blood pressure and the whole host of illnesses that bring us to the doctor. 

A look at the history of medicine points this out by allowing us to see the effects of illness before modern treatments were available. Common infections were the number one cause of death, and life expectancy was about half of what it is today. We can also view the effects of untreated disease when we look at the poor nations of the world today. 

When we are armed with this perspective and look for signs of devastation caused by ADHD in the past, we don’t find it. Instead, the leaders in the field proudly point to the great geniuses of the past who would have been so diagnosed in our modern era.

We don’t find ADHD in the poorer countries either. The number of those diagnosed with ADHD is greatest by far in the US, and it’s at a rate unmatched in the world. Possibly by looking at our own past we might find historical insight and see epidemics of untreated ADHD. When we do so, we see something far from it, we see a nation built by rugged individuals, a nation that was built on the backs of pioneers and millions and millions of immigrants. This includes slaves who were horribly dragged here against their wishes, chosen for their strong physical frames, unbreakable character and their ability to work with uncommon strength. It’s no wonder that several generations later, grandchildren of these hardworking men and women feel oppressed by having to spend six hours a day in a classroom and with a directive to spend several more hours at a desk when they get home.

Patients have no medical complaints

Patient complaints bring them to the doctor. That is central to the doctor patient relationship. It’s the case with those who have painful headaches, unexplained exhaustion or aching joints. The doctor is sought out because something is wrong. Nothing of the sort happens with the person with ADHD. They feel fine. No one wakes up and says, "I feel horrible today. I’m not going to school. My ADHD is killing me." No one asks to go to the nurse because his/her ADHD is acting up. 

These children are sent to the school nurse because they are of concern to others. They don’t complain of not feeling well, though if we stop to listen we will hear complaints: they complain of being bored in school, of having to sit still in a restaurant or of not being able to play instead of doing homework. 

No one says, "You look horrible today"

Doctors don’t say, "It’s a good thing you came in today. If we hadn’t caught it now you would have been in big trouble."

No complications

Even those afflicted with birth defects, not a classic disease, can have later complications if the problem isn’t addressed. The short leg, for example, can lead to later hip problems. The muscle tightening from cerebral palsy will get worse and will lead to greater complications without therapy and appropriate surgery, etc.

No biochemical tests measure it

No laboratory tests of any sort aid in the diagnosis of ADHD. Detailed examination of any of the body’s fluids show no abnormalities. Experts have been searching for physical proof. They are looking to the brain to find the defect, and some think they have found it. A recent study in Lancet, a respected British medical journal, stated that researchers at Massachusetts General Hospital (one of the world’s premier medical institutions and the main hospital of the Harvard University School of Medicine) found something. It was seen by looking at pet scans, an instrument that can detect the body’s oxygen use. They noted a difference in the brains of those with ADHD when compared to normals [sic]. Those with ADHD could be diagnosed with such a technique, bringing more into treatment. 

As of this writing these findings have not been confirmed by other researchers, but that is not the point. Assuming there is a difference in the brain’s oxygen use or in the brain’s appearance, as other researchers have claimed, what have we learned? A spot of cancer on a chest X-ray or a fracture on a bone X-ray are signs of disease, but a difference in oxygen use or in subtle aspects of brain structure show difference; they don’t show disease. Wouldn’t we expect sensitive tools to find the wonderful differences in brain activity or subtle differences in brain structure amongst people who are different? We are marching into this field and we have to be careful. We are getting into ethics and moving away from medicine.

Severe neurotransmitter disease doesn’t exist

If there were an actual disease of neurotransmitter deficiency, as hypothesized, we would see those afflicted with an inability to concentrate on anything akin to a flighty bird at a feeding station, and such an entity doesn’t exist. It doesn’t exist because the idea of a neurotransmitter deficiency is a theoretical construct with no basis in reality, and it is false.

This can be seen in another way. Experts acknowledge that those with ADHD can focus with remarkable intensity. The truth is that they just don’t have enough neurotransmitter for that which isn’t appealing. Twisting a hypothesis to fit an observation is neither good science nor good medicine. I know teenagers with the diagnosis of ADHD who devour advanced physics books but have little interest in their other studies, who practice musical instruments for untold hours, or who spend hours fishing at a pond in wrapped concentration. These kids are told they have a deficit disorder. If someone doesn’t like the food in a restaurant do they have a taste bud disorder? Would we await a medical advance to bring treatment?

The only thing that holds the diagnosis together is the medical use of Ritalin/amphetamine. Those with a particular constellation of behaviors are seen to settle down and focus with the use of drugs. We are not seeing the treatment of a disease. We are simply seeing the powerful effects of these drugs. If someone gets nervous before public speaking engagements and at times takes a small amount of medication, does that person have a "settling down" disease? 

Genetic inheritance doesn’t prove it

I’ve heard lecturing physicians state their conviction about ADHD’s biological origins because of its genetic component, i.e., it runs in families as do many other diseases. I can only respond to that as one of my daughters might, "Well ... duh." What traits don’t? Hair and skin color run in families as do body build, athletic and musical and artistic ability along with temper, mood and personality. Even what people like to eat runs in families. 

Change of environment cures it 

This point, alone, should be enough to make a clear case that we are not dealing with a medical condition. There is no other medical illness, with the exception of allergies, that can be cured by a change in environment. One teacher can bring out the worst in a particular student and a different teacher could not only see no problem but act in a way that can change the student’s life.

Many children with ADHD take no medication after school because that time of day is not a problem, if homework is not an issue. Many don’t take it on weekends and holidays and most don’t take it during the summer for the same reason. I somehow don’t think people stop cancer chemotherapy or treatment for seizure disorders during vacation or on holidays.

A Disorder? 

To call ADHD a disorder is a way to skirt the issue. In the early days ADHD was called "Minimal Brain Disease." Too many negative connotations went with that name and it was changed to Minimal Brain Dysfunction. That sounded more palatable. These children no longer had a brain disease, now they had a brain dysfunction. This name sounded less sinister, but it still meant that their brains weren’t working right. As more "normal" kids – kids who were nice kids but weren’t doing well in school – got diagnosed, a more politically correct name was reached. It was called a "disorder." In name, it wasn’t their brain’s fault. They just had an attention deficit. 

According to Dorland’s Medical Dictionary a disorder is, "A derangement or abnormality of function," i.e., something doesn’t work right. Medical disorders are exactly what we’ve been discussing. The term just covers a broader range of problems. We speak of an immune disorder, a genetic disorder and sleep disorders. 

The last one provides an excellent point on which we can end this part of the discussion. Some sleep disorders are true medical conditions and some are not. Sleep apnea is a true sleep disorder. It is a term used for people who have difficulty breathing while in deep sleep. They struggle to inhale and often need a machine to keep their airway open at night. Besides not being well-rested, this problem can lead to lung and heart complications. Other people have sleep disorders because of work pressures or other worries. Good sleep returns when the problem is lifted. Obviously they don’t have a medical condition.

Psychiatric?

Common sense must again be our friend and guide. As a non-psychiatrist, I break psychiatric problems into two types, the severe ones and those that aren’t. The first group includes those mental illnesses with severely impaired thought processes. Such patients are a threat to themselves or to others because of their function. The other group includes all those problems that are related to difficulties with daily life. 

Medication for this latter group of individuals depends on the individual. If a psychological problem can be turned around without medication we generally feel a person is stronger for the process. We also know that medication can be very helpful and is not a sign of weakness. 

Now if we were to put ADHD into the groups of psychiatric illnesses (and even this is not a proper classification) it is certainly not one of the severe ones. No one is in danger. Why then, unlike anything else in its category, is there so much pressure to medicate? The fear that others have for the future of these children is the driving force. It is not the severity of the problem itself. This too is unparalleled in medicine. 

These children have a psychiatric condition?

The Diagnostic and Statistical Manual, DSM-IV, is psychiatry’s defining work, containing every psychiatric diagnosis and its definition. This gold standard holds the accepted diagnostic criteria for ADHD and states that symptoms must have started before the age of seven to fit under this term. In other words, all of the millions of people who have ever been diagnosed with ADHD had the start of their symptoms prior to age seven. Now picture the seven-year-old children you know. Will common sense let you say that 5%-10% of them have a psychiatric illness, and that this supposed illness had symptoms before the age of seven? 

No, what we have, at the most, is a behavioral disorder and we know that medicating children is not the preferred treatment for behavioral disorders.

Medical Condition?

When all these points are put together we can see that all we, as physicians, hold dear and true about this issue has to be rethought. It is not a medical condition.
 

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