May 25 2018

ADHD Is Not a Fake Illness

The headline on this dubious health website reads: “ADHD is a FAKE Disease Invented by Big Pharma to Drug Children for Profit.” Every bit of that headline is made up, ironically – it’s fake. I have written about ADHD previously, and also about mental illness denial itself. This is a common theme among proponents of alternative medicine or snake oil treatments, because it is a rhetorically convenient way to attack mainstream medicine and bolster medical conspiracy theories.

Let me dispense with the easy parts first – the diagnosis of attention deficit hyperactivity disorder (ADHD) was not “invented by Big Pharma.” Unsurprisingly, the article provides exactly zero evidence to support this conspiracy claim. Right there the author of this article, and the hosting site, have lost all credibility. This is a specific and dramatic factual claim. Any responsible journalist, or author on a site that takes it upon itself to dispense medical advice, would have invested the five minutes it would take to discover that it is not true.

It literally took me 30 seconds to find this reference, a published article detailing the history of the ADHD diagnosis (so someone less Google savvy might take 5-10 minutes, but I just searched on “history of ADHD diagnosis”). The medical profession does have a tendency to write things down and publish their observations and musings about medicine. This leaves a nice paper trail for any medical historian to follow. The first descriptions of something similar to ADHD go back to the 18th century. Sir Alexander Crichton published an entire book “On Attention and its Diseases” in 1798.

It is also interesting to note that, right from the beginning, it was recognized that disorders of attention are multifactorial:

“A distraction of attention does not necessarily have to be pathological, e.g. mental stimuli, volition, or education can have a great impact on healthy attention.”

What a concept – a behavior as complex as attention is the result of a combination of inherent ability and environment. In the subsequent 200 plus years our concept and knowledge of ADHD evolved, documented in the DSM, the standard manual of mental disorders. There is also a vast published literature on ADHD. Searching PubMed on ADHD results in over 2000 references. The second of which is a helpful review of the genetics of ADHD, in which they estimate that the heritability of ADHD is 30-40%. Roughly that means that the disorder is 30-40% genetic and 60-70% developmental or environmental.

Nowhere in the process of researching or developing the concept of ADHD does the pharmaceutical industry have any influence. There isn’t one tiny bit of evidence that they “invented” the diagnosis, nor does that claim make any sense to anyone even the slightest bit familiar with how the medical profession works. Pharmaceutical companies look to the published literature, and consult experts to find medical conditions that they can potentially develop treatments for. They don’t have any mechanism by which they can invent their own diseases. How would that even work?

The only sliver of legitimacy to this concept is that pharmaceutical companies may push their treatments for milder cases of the conditions they treat, in an attempt to expand the indications for their drugs. But even here their influence is limited, and they are legally not supposed to do this. When they have been cause ghost writing white papers, for example, they have been fined and criticized. The FDA closely regulates what the industry can say – they have to stay entirely on label when promoting their products. None of this gets anywhere near inventing and entire disease out of whole cloth.

A False Dichotomy

The bulk of the article presents the usual false dichotomies – is ADHD real or fake, for example. The usual mental illness denial strategy is to create a false dichotomy between a pathological disease and normality. If there is no disease, then there is nothing to treat. This is naive, however. ADHD is not even claimed to be a disease – it is a disorder.

The distinction is important to understanding how we conceptualize various types of illness. The brain in particular is a complex organ and its function is dependent not only on the health of brain cells (absence of classic pathology) but on the particular function of those cells and the patterns of connections among them. A particular network in the brain, for example, might have a paucity of connections, affecting the function of that network, but in the absence of anything recognizable as pathology. We don’t call these conditions “diseases” but rather they are “disorders.”

A disorder is a condition in which an individual lacks a function or ability that most people have to such a degree that it results in demonstrable objective harm. Attention can certainly qualify.

Most non-neuroscientists may not realize that the ability to attend is actually a specific ability of the brain, and a particularly demanding one. Large parts of the frontal lobes of the brain are involved in attention and what is called executive function – the ability not only to control one’s own attention, but to moderate one’s behavior in order to achieve strategic goals. This strongly involves the ability to inhibit one’s own thoughts and behaviors –  the frontal lobes have a large inhibitory function.

Like all human traits, attention and executive function vary among individuals, often on a Bell curve or something close to it. So even if you think low executive function is part of the normal distribution of human variation, those two standard deviations below average may have sufficiently low executive function that it impedes their ability to function in the world, resulting in demonstrable harm. We can clinically recognize this syndrome, and find ways to mitigate its negative effects.

Treatments for this disorder include education and behavior interventions. Of course they do – because the brain is the organ of behavior, and ADHD is largely a behavioral disorder. But ADHD also responds very well to stimulants, because they increase the inhibitory activity of the frontal lobes. Some people (children and adults) simply function better with the judicious use of carefully dosed stimulants. They perform better in school, on their job, are less likely to get into trouble, and less likely to get arrested, get divorced, and die from trauma.

Characterizing all this as “drugging kids for profit” is beyond irresponsible. It is willfully ignorant, apparently in order to promote an alternative narrative in which the many players involved in mainstream medicine are the villains, and the alternative “natural” medicine sellers are the heroes.

But in order to sell their narrative they have to completely distort reality. Their narrative is “fake.”

 

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