1. Proceeding with Caution:
“Rethinking the ADHD Diagnosis”
Presented By:
Luke Ibach and Josh Kakar
April 1, 2009
Psychology 493

2. Video Clip
http://www.youtube.com/watch?v=SzdGrUcc bQ

3. Proponents of the ADHD Diagnosis
• Joseph Biederman - a Harvard child
psychiatrist who believes that ADHD is real.
Says 8-12% of all American children have the
disease.

4. Proponents of the ADHD Diagnosis
• Russell Barkley - a research professor at SUNY
Upstate Medical University in Syracuse. He
reports that in a classroom with 30 students 1
in 3 will have ADHD.

5. Refuting their ideas
• On the contrary, NIH reports that only about 3-5
% of all American school children have been
diagnosed with ADHD, which is considerably
lower then Biederman’s 8-12% statistic.
• Biederman is also being investigated for failing to
report almost 1.6 million dollars for consulting
fees from drug makers.
• In one case Biederman falsely reported only
receiving 3,500 dollars from Johnson & Johnson
when he actually received over 58,000 dollars in
grant money.

6. Critics of ADHD
• Thomas Armstrong - Argues that there is no
definitive criteria to determine who has ADHD
and who doesn’t. He also believes behaviors
that test for ADHD are highly context
dependent.

7. Critics of ADHD
• Peter Breggin – is a Harvard graduate who
believes that stimulants are not the answer
for ADHD. He claims that there is are no
scientific studies that validate ADHD.

8. Growth of ADHD Epidemic
• 1970- 150,000 school children diagnosed
• 1985- 500,00
• 1990- 1,000,000
• 2000- 6,000,000
• Possible reasons for such a dramatic increase

9. ADHD Medicating Our Kids
• 8.3 million stimulant tablets prescribed in
1984.
• 38.4 million stimulant tablets prescribed in
2001.
• 56% of children that were diagnosed with
ADHD were prescribed medication on the first
Dr’s visit.

10. ADHD Statistics
• Boys are diagnosed with ADHD 3 times more
often then girls.
• 1/3rd of children diagnosed with ADHD are
also diagnosed with ODD.
• 1/4th of children with ADHD are diagnosed
with CD.
• Overall about 1/3rd of children that have
ADHD are also diagnosed with another
disorder.

11. Introduction: What is ADHD?
DSM-IV Criteria: (A) Inattention or (B) Hyperactivity-
Impulsivity
• (A) Inattention: Six or more of the symptoms of
inattention have been present for at least 6 months to a
point that is disruptive and inappropriate for
developmental level:
– Often does not give close attention to details or
makes careless mistakes in schoolwork, work, or other
activities.
– Often has trouble keeping attention on tasks or play
activities.
– Often does not seem to listen when spoken to directly.
– Often does not follow instructions and fails to finish
schoolwork, chores, or duties in the workplace.

12. Introduction: What is ADHD?
(Continued)
– Often has trouble organizing activities.
– Often avoids, dislikes, or doesn't want to do things that
take a lot of mental effort for a long period of time.
– Often loses things needed for tasks and activities (e.g.
toys, school assignments, pencils, books, or tools).
– Is often easily distracted.
– Is often forgetful in daily activities.

13. Introduction: What is ADHD?
• (B)Hyperactivity-Impulsivity: Six or more of the following
symptoms of hyperactivity-impulsivity have been present
for at least 6 months to an extent that is disruptive and
inappropriate for developmental level:
– Often fidgets with hands or feet or squirms in seat.
– Often gets up from seat when remaining in seat is
expected.
– Often runs about or climbs when and where it is not
appropriate.
– Often has trouble playing or enjoying leisure activities
quietly.
– Is often quot;on the goquot; or often acts as if quot;driven by a motorquot;.
– Often talks excessively.

14. Introduction: What is ADHD?
• (B)Impulsivity (Continued)
– Often blurts out answers before questions have been
finished.
– Often has trouble waiting one's turn.
– Often interrupts or intrudes on others.
– Some symptoms that cause impairment were present
before age 7.
– Some impairment from the symptoms is present in two or
more settings (e.g. at school/work and at home).
– Must be clear evidence of significant impairment in
social, school, or work functioning.
– The symptoms are not better accounted for by another
mental disorder.

15. What is ADHD?
• ADHD, Combined Type: if both criteria 1A and
1B are met for the past 6 months
• ADHD, Predominantly Inattentive Type: if
criterion 1A is met but criterion 1B is not met
for the past six months
• ADHD, Predominantly Hyperactive-Impulsive
Type: if Criterion 1B is met but Criterion 1A is
not met for the past six months.

16. Criticisms of the ADHD Diagnosis:
Reliability of Diagnosis
– Research shows low interater reliability of ADHD
symptoms across countries, cultures, and even
within cultures (Timimi et. al. , 2004)
– Specifically, rates vary by a factor of 10 from
county to county within individual states in the
U.S.
– A U.S. study showed that teachers rated 49% of
boys as restless, 43% having short attention span
and 43% as inattentive during conversations.

17. Criticisms of the ADHD Diagnosis:
Reliability of Diagnosis
– An England Epidemiological study diagnosed only
two children out of 2,199 with hyperactivity(.09%)
(Armstrong, 1996).
– In contrast, a study in Israel found that teachers
rated 28% of students as hyperactive
– 80% of patients diagnosed do not show symptoms
in the physician’s office(Armstrong, 1996).
– Prevalence Estimates range between 1 – 20%

18. Criticisms of the ADHD Diagnosis:
Subjective Ratings of Behavior
– The most common assessment includes a
checklist of behavior and scales for the
frequency of the behavior exhibited.
Ex: Scale rating of 1 – 5
(1 = almost never) and (5 = almost always)
Items: “Restless(squirms in seat)”, “Fidgety(hands
always busy)”, “Follow a sequence of
instructions”

19. Iowa Connor’s Teacher Rating Scale

20. Criticisms of the ADHD Diagnosis:
Subjective Ratings of Behavior
• Children are rated by teachers and parents who have
subjective biases, standards and expectations about
their behavior.
• These authority figures may have a proclivity towards
the ADHD diagnoses in order to keep children
compliant in either the home or school setting, as a
result of medication or special education placement.

21. Criticisms of the ADHD Diagnosis:
Subjective Ratings of Behavior
• These subjective measures of behavior are limited in
scope considering they do not take into account the
context or environment in which the child is
currently in during time of assessment
• A child may be a 5(almost always) on fidgetiness in
one situation ( i.e. during school work) but a 1 at
during more stimulating activities (i.e. recess, play
time)
• Therefore, assigning one number for all contexts and
environments is not fully representative of a child’s
true behavior.

22. Criticisms of the ADHD Diagnosis:
Subjective Ratings of Behavior
• One study compared ratings of parents, teachers, and
physicians for 5,000 elementary children.
• 5% were considered hyperactive by one of the groups
but only 1% were rated hyperactive by all 3 groups of
raters.
• Another study revealed that agreement between
mothers and fathers on their child’s diagnosis of
hyperactivity was only 32%
• The study also showed that rating agreement between
parents and teachers was even lower, at 13%.

23. Criticisms of the ADHD Diagnosis:
Subjective Ratings of Behavior
• What is considered normal behavior in children?
• Many normal children have problems with
fidgetiness and attention. So where do we draw
the line?
• What about children at the other end of the
spectrum, who are too compliant, and too
focused? This issue is rarely addressed.
• These evaluations are purely subjective, prone to
error and bias, and not objective in their design.

24. Criticisms:
Objective Ratings of Behavior
• (CPTs) – Continuous Performance Tasks –
Measure patient’s selective attention to the
presence or absence of stimuli during sets of
distracters.
• Ex: (GDS) – Gordon Diagnostic System –
Patients press a button after specific sets of
ordered digits have been flashed up on a
computer screen. The number of correct
responses and incorrect responses are
recorded as “hits” and “ misses” respectively.

25. Criticisms of the ADHD Diagnosis:
Objective Ratings of Behavior
• These tests of vigilance were developed to select
promising candidates for radar operations during
World War II.
• Although CPTs intend to present an objective
measure of children’s selective attention, they
only tell how the child will perform on
repetitive, mundane, and non-stimulating tasks
irrelevant to what children encounter in their real
lives.
• Therefore, the validity of their current use with
children today should be questioned.

26. Criticisms of the ADHD Diagnosis:
Temperament
– Symptoms do not significantly differ from children who
have normal variations in temperament (Carey, 1998).
– This is especially true when children are given the chance
to choose their own learning activities and perform at
their own pace. (Armstrong, 1996).
– Children with ADHD behave normally when exposed to
interesting, novel, or stimulating tasks.
– 70% of children diagnosed find ADHD symptoms
disappear upon reaching adulthood.
– Temperament research shows only about 50% of most
populations sampled are attentive with the other 50%
displaying below average attentiveness.

27. Criticisms of the ADHD Diagnosis:
Temperament
• Currently, there is no supporting evidence for
arbitrary cut off scores for abnormal levels of high
activity and attentiveness (Levy, Hay, Mcstephen, et.
Al., 1997).
• Although children with difficult temperament (low
adaptability , negative mood) and low task
orientation (high energy, low persistence-attention
span, high distractibility) experience more social
problems and poor academic achievement
respectively, these traits do not lead to dysfunction
on their own, but only when other environmental
problems occur as well.

28. Criticisms:
Co-morbidity
• Co-existing conditions with ADHD include:
– Problems with parent-child interaction
– Family violence
– Parental Psychopathology
– Anxiety Disorder – (25-34%)
– Bipolar disorder - (18-60%)
– Depression – (18-60%)
– Learning disabilities – (12-60%)
– Conduct Disorder - (35-60%)
– Oppositional Defiant Disorder – (35-60%)

29. Co-morbidity
• According to Pliszka (2000) most children who
meet the criteria for conduct disorder or
oppositional defiant disorder will also meet the
criteria for ADHD.
• Although medication is claimed to successfully
treat all 3 conditions, Children with Conduct
Disorder require additional intervention when
there is also family psychopathology present.
• This raises an obvious question if ADHD is an
adequate diagnostic category to explain the
child’s functioning in other domains in life.

30. Co-morbidity
• Learning disabilities can cause inattention and
frustration and mask the presence of
ADHD(Furman, 2006).
• Although stimulants have been shown to
improve reading scores, it is believed that
these improvements are related to
performances requiring repetition and
concentration and not genuine learning.

31. Co-morbidity
• Although stimulants are used primarily to
treat ADHD, they can be extremely harmful in
treating co-morbid conditions such as mood
disorders
• Stimulants used to treat depression and
bipolar disorder can cause dysphoria and
harmful mood dysregulation. (Furman, 2006).
• Clinicians who use stimulants to treat these
co-morbid conditions must exercise extreme
caution.

32. Co-morbidity
• According to evidence-based
perspectives, Cognitive-Behavioral Therapy is the
best known treatment modality for children with
anxiety and ADHD.
• In addition, children with ADHD and anxiety
disorder do not respond as well to stimulant
medication.
• Unfortunately, symptoms of anxiety disorder are
overlooked by providers and not considered
during the assessment process as ADHD
symptoms are probably more salient
(Furman, 2006).

33. Co-morbidity
• The large amount of overlap between ADHD
and other co-ocurring psychopathology
provides additional support for the argument
that ADHD is not a separate psychological or
neurological condition.

34. Criticisms:
The Disease Model Of ADHD
• ADHD is believed to be a neurodevelopmental
brain disorder with biological predispositions and
distinct etiology.
• Potential causes include chemical abnormalities(
serotonin, dopamine, norepinephrine), neurologica
l damage, lead poisoning, thyroid
dysfunction, prenatal exposure to harmful
substances, and delayed transmission of nerve
impulses.
• Mechanistic view of human capacity, where the
mind functions much like a machine.

35. Criticisms:
The Disease Model Of ADHD
• Despite an emphasis on biological brain causes, no
clear biological markers have ever been discovered in
patients diagnosed with ADHD.
• According to Carey(1998), children with brain
damage show no clear pattern of hyperactivity or
inattention and children diagnosed with ADHD show
no consistent structural, functional or neurochemical
abnormality.
• Carey(1998) even points out that brain differences
are present in healthy children who display variations
in normal temperament.

36. The Disease Model Of ADHD
• Timimi(2002) also points out that there is no
medical test to detect the presence of ADHD.
• Neuroimaging studies have shown no clinical
abnormalities between the brains of children
diagnosed with ADHD and age matched-control
groups (Hynd & Hooper, 1995) (Baumeister and
Hawkins, 2001).
• A Federal Government report on ADHD concluded
that: “…there was no compelling evidence to
support the claim that ADHD was a biochemical
brain disorder” (National Institutes of
Health, 1998).

37. The Disease Model Of ADHD
• However, many studies that claim to show biological
evidence of ADHD have omitted important additional
research that contradicts original findings. This
notion is also reinforced by inaccurate media
coverage.
• For example, a study by Zametkin et. Al, 1990 at
NIMH found a link between reduced metabolism of
glucose and adult hyperactivity.
• They concluded that deficits in the premotor and
superior prefrontal cortex accounted for this
inhibited metabolism of glucose.

38. The Disease Model Of ADHD
• Despite positive attention by departments of
psychiatry and the media, an additional study
by Zametkin et. Al, in 1993 found no
significant differences between the brains of
normal and hyperactive adolescents.
• This contradictory finding to the study was not
reported by the media or the ADHD
community.

39. Criticisms:
Medication for ADHD
• Methylphenidate, dextroamphetamine, and
methamphetamine are the most popular
psychostimulant treatments for ADHD.
• An estimated “10-12 percent of all boys
between the ages of 6 and 14 in the United
States have been diagnosed as having ADHD
and are being treated with methylphenidate.”
• Breggin(1998) estimates that 4-5 million
children receive psychostimulants in the U.S.
each year.

40. Criticisms:
Medication for ADHD
• However, these medications produce toxicity and
general excitation of the Central Nervous System.
• Have effects on neurotransmitters such as
dopamine, norepinephrine, and serotonin.
• Symptoms such as increased
energy, hyperalertness, and hyperfocus are
reported.
• Other symptoms include
insomnia, OCD, agitation, hypomania, mania, seiz
ures, fatigue, lethargy, social withdrawal, and
depression, irritability, anxiety, and emotional
sensitivity.

41. Medication for ADHD
• Firestone et. al (1998), found preschool children
ADHD who were treated with methylphenidate
experienced greater social dampening effects when
compared to a placebo group.
• Such sideffects included:
– “Talks less with others” - increased from 21% to 50%
– “Uninterested in others” – increased from 31% to 75%
– “Sad/Unhappy” – increased 47% to 84%
– These findings are also consistent with those of Schleifer
et. al. (1975) who also found “less social behavior and
interaction, and increased solitary play” in ADHD
children treated with methylphenidate.

42. Medication for ADHD
• A study by Mayes and colleagues (1994) found that
children treated with methylphenidate were
reported as
“withdrawn, listless, depressed, dopey, dazed, subd
ued, and inactive”.
• This study also found that children suffered from
somatic complaints including
insomnia(13%), nausea or vomiting(11%), loss of
appetite(20%), and headache(4%).
• Schachar et. al. (1997) concluded that affective
symptoms develop in later stages of drug
treatment are often missed in most short term
drug studies.

43. Medication for ADHD
• Firestone et al. (1998) also found increases in
nervous movements (“tics”) in children
treated with stimulant medication, with an
increase from 3% (placebo) to 12% in children
on methylphenidate.
• Barkely et. al (1990) reported a 10% increase
in abnormal movements in children treated
with higher doses of methylphenidate.
• Borcherding et. al. found 58% of their
medicated children demonstrated abnormal
nervous movements, with one permanent
case of “tics”.

44. Medication for ADHD
• Breggin, 1998b; Kessler, 1993; Leber, 1992 highlight
2,821 reports of adverse reactions to
methylphenidate in the Spontaneous Reporting
System:
– 1. More than 150 reports of liver abnormalities
– 2. Sixty Nine reports of convulsions, 18 specifically grand
mal.
– 3. Eighty-seven reports of drug dependency, addiction
– 4. Thirty reports of drug withdrawal
– 5. Two hundred fifty reports of hair loss
– 6.Fifty reports of leukopenia (low white blood cell count)

45. Medication for ADHD
• According to Karch (1996) several studies now show
direct evidence that methylphenidate has cardiotoxic
effects.
• Specifically, Henderson & Fischer (1994) studied the
effects on mice and discovered toxic effects within 3
weeks after using only minimum doses
• Ishiguro & Morgan (1997) found that methylphenidate
adminstered to ferrets at levels equal to clinical usage
produced contraction problems in the heart muscles.
• FDAs Spontaneous Reporting System found 121 reports
of cardiovascular problems, with 9 cardiac arrests and
4 hearts failures (Elinwood & Tong, 1996).

46. Medication for ADHD
• According to the American Psychiatric Association
(1994), methylphenidate: “In clinical studies…produces
behavioral, psychological, subjective, and reinforcing
effects similar to d-amphetamine and cocaine.”
• “7% of Indiana high school students have used Ritalin
non-medically at least once, and that about 2.5% of
high school students use it on a monthly or more
frequent basis” (Indiana Prevention Resource
Center, 1998).
• Breggin (1998a) believes that over medicating children
teaches them to exert less control over their actions
and behavior.

47. Medication Research
• Much medication research has been
questionable in it’s design.
• For example, the (MTA) NIMH Multimodal
Treatment Study for ADHD had an abundance
of errors in methodology yet claimed that
stimulant treatment was superior to
behavioral and community treatment.
• Peter Breggin offers a critical analysis of this
study and points out many of it’s limitations

48. Medication Research
• 1. The MTA was not a placebo controlled, double
blind clinical trial.
– Investigators relied on ratings made by teachers and
parents who were not blind to the treatment - “Open label
studies” which are often discredited.
• 2. The study used no control group of untreated
children.
– The study only compared 3 drug conditions to behavioral
treatments
• 3. Thirty-two percent of the Medication
Management group was already taking medication
before hand.
– Created unequal participants for the study due to history

49. Medication Research
• 4. Blind classroom raters observed no
difference between treatment groups
– Although medication did not demonstrate any
superior benefits behavioral treatments, this
finding was withheld from the studies’
conclusions
• 5. Drug treatments exceeded behavioral
treatments in length of duration.
– This bias could appear to make medication a more
effective treatment then behavioral treatments

50. Medication Research
• 6. Children in the drug treatment group did not
rate themselves as feeling improved.
– This important finding was also omitted from the
study’s conclusions as well
• 7. All of the principal investigators were well
known drug advocates
– Received funding from Richwood, Bristol-
Myers, Solvay, Wyeth-Ayerst, Glaxo, and Eli Lilly
• 8. Parents and teachers were exposed to drug
propaganda.
– Parents were told their children would be treated with
“safe effective doses of medication”

51. Overlooked Factors:
Nutrition
• A nutrition approach takes longer to show
results. “With dietary supplements you can
see improvement in behavior in a week or
two,” says Zimmerman. “A food approach is
more of a long-term thing—a 30-day plan, for
example.”

52. George Washington University
• A study by George Washington University
found that hyperactive children who ate a
meal high in protein did equally well or
sometimes even better in school then non
hyperactive kids

53. Fatty acids
• What are they?
What are some examples?
Where do you get them from?

54. Oxford University
• Oxford University found that the ADHD
symptoms in children receiving essential fatty
acids improved over children in a control
group receiving a placebo

55. Overlooked Factors:
Nutrition
• Researchers further documented the essential
fatty acid deficiency tie to Attention Deficit
Disorder in a 1987 study. Then, a 1995 study
comparing essential fatty acid levels in ADHD
boys against a control group of boys without
ADHD found significantly lower levels of
Omega-3 fatty acids.

56. Overlooked Factors:
Nutrition
• In 1996 Purdue University researchers have
found that boys with low blood levels of
Omega-3 fatty acids have a greater frequency
of Attention Deficit Disorder ADHD.

57. Food Coloring
• Study done by South Hampton University in
UK
• EFSA’s advice given to ADHD parents
• Types of food coloring used

58. Overlooked Factors:
American Culture
• Change in the cultural expectations of children
– Children now are expected to behave in ways that
are not always developmentally appropriate
– Many view these high expectations as an end to
childhood innocence, coupled with the fact that
children are constantly exposed to adult
information via media and television (Postman
1983).
– Children are now seen as a danger to society and
need to be controlled, reshaped and changed.

59. Overlooked Factors:
American Culture
• With more anxiety in place regarding
childrearing, but also fear of state intervention
in domestic affairs, ADHD offers a shift away
from social dilemmas and onto the child.
(Timimi, 2002).
• Parents feel economic pressures to work long
hours leaving medication the most convenient
“quick fix” treatment for ADHD and less time
for family therapy approaches involving
parent-child interaction (Furman, 2006).

60. Overlooked Factors:
American Schools
• Public school system curriculums are tailored
mainly towards academics such as
reading, writing, arithmetic, and standardized
testing, and leave less emphasis on creative
and engaging activities.
• Thus, students who do no excel in these areas
but in others such as the arts, physical
activities, or hands-on kinesthetic learning are
not in an environment that is conducive to
their style of learning

61. Overlooked Factors:
American Schools
• Therefore these students fall through the
cracks and receive less assistance for their
special needs of learning and are viewed as
having a biological brain disorder.

62. Overlooked Factors:
Alternative Treatment
• According to Breggin (2000), ADHD can be
treated through means other than medication
such as individualized family counseling and
educational approaches to empower
children, parents teachers and others.

63. Overlooked Factors:
Alternative Treatment
• Applied behavior analysis is an overlooked yet
effective method for improving behavior in
school.
• According to Packard (1970), classroom
attention can be achieved and maintained in
students when teacher instruction is coupled
with group contingencies.
• For example, in Packard’s (1970) study, the
instructor turned on a red light-timer device
whenever a student was not paying attention.

64. Overlooked Factors:
Alternative Treatment
• When all students showed proper attention, the
teacher turned off the device.
• Classrooms were rewarded with play activities
upon maintenance of attention and teachers gave
verbal feedback as to what percentage of the
class paid attention. All students achieved 90-
100% levels of classroom attention.
• Therefore, Packard (1970) concluded that it is
possible to motivate students to pay attention
when an appropriate and appealing reward
system is implemented.

65. Improving the ADHD Epidemic
(Carey) 2005
• 1. Improved diagnostic system - Distinctions must
be made between hyperkinetic children, who are
truly pervasively overactive or inattentive, and
those primarily having other problems
• 2. Better research - Much is still unknown about the
origin of ADHD and additional research is needed
to adequately conceptualize and treat what
appears not to be a biologically based psychological
disorder.

66. Improving the ADHD Epidemic
(Carey) 2005
• 3. More education of professionals and public –
People need more information about important
matters such as normal variations in
temperament and the non-specificity and
harmful side effects of stimulant medications.
• 4. Better evaluations – Children should undergo
educational testing to rule out learning
disabilities as the main cause of their behavior
and also examine the child’s temperament and
adjustment.

67. Improving the ADHD Epidemic
(Carey) 2005
• 5. Improved treatment – Greater reliance on
psychosocial and educational interventions.
Treatments should also be geared to build on
the child’s strengths and remediate their
weaknesses.
• 6. Close monitoring of drug company
advertising and promotion
• 7. Regulation of both medical diagnosis and
teacher insistence on medication.

68. Conclusion
• ADHD should be questioned until more sound
scientific evidence becomes available to
consider it a distinct neurological condition.
• Parents and practitioners should remain
skeptical of the disorder and be cautioned
against a quick assignment to the ADHD
diagnosis.
• The risks of medication and stigmatization are
too harmful to unique children who hold so
much potential.

69. The End
Thank you for watching.