Biopsychiatry Illuminated

THE CANDLELIGHT PROJECT
by Bob Collier

5 April 2004
Issue 88

The International Consensus Statement on ADHD
January 2002

We, the undersigned consortium of 75 international scientists, are deeply concerned about the periodic inaccurate portrayal of attention deficit hyperactivity disorder (ADHD) in media reports. This is a disorder with which we are all very familiar and toward which many of us have dedicated scientific studies if not entire careers. We fear that inaccurate stories rendering ADHD as myth, fraud, or benign condition may cause thousands of sufferers not to seek treatment for their disorder. It also leaves the public with a general sense that this disorder is not valid or real or consists of a rather trivial affliction.

We have created this consensus statement on ADHD as a reference on the status of the scientific findings concerning this disorder, its validity, and its adverse impact on the lives of those diagnosed with the disorder as of this writing (January 2002).

Occasional coverage of the disorder casts the story in the form of a sporting event with evenly matched competitors. The views of a handful of non-expert doctors that ADHD does not exist are contrasted against mainstream scientific views that it does, as if both views had equal merit. Such attempts at balance give the public the impression that there is substantial scientific disagreement over whether ADHD is a real medical condition. In fact, there is no such disagreement --at least no more so than there is over whether smoking causes cancer, for example, or whether a virus causes HIV/AIDS.

The U.S. Surgeon General, the American Medical Association (AMA), the American Psychiatric Association, the American Academy of Child and Adolescent Psychiatry (AACAP), the American Psychological Association, and the American Academy of Pediatrics (AAP), among others, all recognize ADHD as a valid disorder. While some of these organizations have issued guidelines for evaluation and management of the disorder for their membership, this is the first consensus statement issued by an independent consortium of leading scientists concerning the status of the disorder. Among scientists who have devoted years, if not entire careers, to the study of this disorder there is no controversy regarding its existence.

ADHD and Science

We cannot over emphasize the point that, as a matter of science, the notion that ADHD does not exist is simply wrong. All of the major medical associations and government health agencies recognize ADHD as a genuine disorder because the scientific evidence indicating it is so is overwhelming.

Various approaches have been used to establish whether a condition rises to the level of a valid medical or psychiatric disorder. A very useful one stipulates that there must be scientifically established evidence that those suffering the condition have a serious deficiency in or failure of a physical or psychological mechanism that is universal to humans. That is, all humans normally would be expected, regardless of culture, to have developed that mental ability.

And there must be equally incontrovertible scientific evidence that this serious deficiency leads to harm to the individual. Harm is established through evidence of increased mortality, morbidity, or impairment in the major life activities required of one's developmental stage in life. Major life activities are those domains of functioning such as education, social relationships, family functioning, independence and self-sufficiency, and occupational functioning that all humans of that developmental level are expected to perform.

As attested to by the numerous scientists signing this document, there is no question among the world's leading clinical researchers that ADHD involves a serious deficiency in a set of psychological abilities and that these deficiencies pose serious harm to most individuals possessing the disorder. Current evidence indicates that deficits in behavioral inhibition and sustained attention are central to this disorder -- facts demonstrated through hundreds of scientific studies. And there is no doubt that ADHD leads to impairments in major life activities, including social relations, education, family functioning, occupational functioning, self-sufficiency, and adherence to social rules, norms, and laws. Evidence also indicates that those with ADHD are more prone to physical injury and accidental poisonings. This is why no professional medical, psychological, or scientific organization doubts the existence of ADHD as a legitimate disorder.

The central psychological deficits in those with ADHD have now been linked through numerous studies using various scientific methods to several specific brain regions (the frontal lobe, its connections to the basal ganglia, and their relationship to the central aspects of the cerebellum). Most neurological studies find that as a group those with ADHD have less brain electrical activity and show less reactivity to stimulation in one or more of these regions. And neuro-imaging studies of groups of those with ADHD also demonstrate relatively smaller areas of brain matter and less metabolic activity of this brain matter than is the case in control groups used in these studies.

These same psychological deficits in inhibition and attention have been found in numerous studies of identical and fraternal twins conducted across various countries (US, Great Britain, Norway, Australia, etc.) to be primarily inherited. The genetic contribution to these traits is routinely found to be among the highest for any psychiatric disorder (70-95% of trait variation in the population), nearly approaching the genetic contribution to human height. One gene has recently been reliably demonstrated to be associated with this disorder and the search for more is underway by more than 12 different scientific teams worldwide at this time.

Numerous studies of twins demonstrate that family environment makes no significant separate contribution to these traits. This is not to say that the home environment, parental management abilities, stressful life events, or deviant peer relationships are unimportant or have no influence on individuals having this disorder, as they certainly do. Genetic tendencies are expressed in interaction with the environment. Also, those having ADHD often have other associated disorders and problems, some of which are clearly related to their social environments. But it is to say that the underlying psychological deficits that comprise ADHD itself are not solely or primarily the result of these environmental factors.

This is why leading international scientists, such as the signers below, recognize the mounting evidence of neurological and genetic contributions to this disorder. This evidence, coupled with countless studies on the harm posed by the disorder and hundreds of studies on the effectiveness of medication, buttresses the need in many, though by no means all, cases for management of the disorder with multiple therapies. These include medication combined with educational, family, and other social accommodations. This is in striking contrast to the wholly unscientific views of some social critics in periodic media accounts that ADHD constitutes a fraud, that medicating those afflicted is questionable if not reprehensible, and that any behavior problems associated with ADHD are merely the result of problems in the home, excessive viewing of TV or playing of video games, diet, lack of love and attention, or teacher/school intolerance.

ADHD is not a benign disorder. For those it afflicts, ADHD can cause devastating problems. Follow-up studies of clinical samples suggest that sufferers are far more likely than normal people to drop out of school (32-40%), to rarely complete college (5-10%), to have few or no friends (50-70%), to under perform at work (70-80%), to engage in antisocial activities (40-50%), and to use tobacco or illicit drugs more than normal. Moreover, children growing up with ADHD are more likely to experience teen pregnancy (40%) and sexually transmitted diseases (16%), to speed excessively and have multiple car accidents, to experience depression (20-30%) and personality disorders (18-25%) as adults, and in hundreds of other ways mismanage and endanger their lives.

Yet despite these serious consequences, studies indicate that less than half of those with the disorder are receiving treatment. The media can help substantially to improve these circumstances. It can do so by portraying ADHD and the science about it as accurately and responsibly as possible while not purveying the propaganda of some social critics and fringe doctors whose political agenda would have you and the public believe there is no real disorder here. To publish stories that ADHD is a fictitious disorder or merely a conflict between today's Huckleberry Finns and their caregivers is tantamount to declaring the earth flat, the laws of gravity debatable, and the periodic table in chemistry a fraud. ADHD should be depicted in the media as realistically and accurately as it is depicted in science -- as a valid disorder having varied and substantial adverse impact on those who may suffer from it through no fault of their own or their parents and teachers.

Sincerely

Russell A. Barkley, Ph.D.
Professor, Depts. Of Psychiatry and Neurology, University of Massachusetts Medical School

[and 74 other signatories]

A Critique of the International Consensus Statement on ADHD
Sami Timimi, Consultant Child and Adolescent Psychiatrist, Sleaford, Lincolnshire, United Kingdom, and 33 Coendorsers
Clinical Child and Family Psychology Review, Vol. 7, No. 1, March 2004

Why did a group of eminent psychiatrists and psychologists produce a consensus statement that seeks to forestall debate on the merits of the widespread diagnosis and drug treatment of attention deficit hyperactivity disorder (ADHD) (Barkley et al., 2002)? If the evidence is already that good then no statement is needed. However, the reality is that claims about ADHD being a genuine medical disorder and psychotropics being genuine correctives have been shaken by criticism.

Not only is it completely counter to the spirit and practice of science to cease questioning the validity of ADHD as proposed by the consensus statement, there is an ethical and moral responsibility to do so. History teaches us again and again that one generation's most cherished therapeutic ideas and practices, especially when applied on the powerless, are repudiated by the next, but not without leaving countless victims in their wake. Lack of acknowledgement of the subjective nature of our psychiatric practice leaves it wide open to abuse (Kopelman, 1990). For these reasons we, another group of academics and practitioners, feel compelled to respond to this statement.

MERITS OF THE ADHD DIAGNOSIS

The evidence does not support the conclusion that ADHD identifies a group of children who suffer from a common and specific neurobiological disorder. There are no cognitive, metabolic, or neurological markers for ADHD and so there is no such thing as a medical test for this diagnosis. There is obvious uncertainty about how to define this disorder, with definitions changing over the past 30 years depending on what the current favourite theory about underlying aetiology is, and with each revision producing a higher number of potential children deemed to have the disorder (Timimi, 2002). It is hardly surprising that epidemiological studies produce hugely differing prevalence rates from 0.5% to 26% (Green,Wong, Atkins, Taylor, & Feinleib, 1999; Taylor & Hemsley, 1995) of all children.

Despite attempts at standardising criteria, crosscultural studies on the rating of symptoms of ADHD show major and significant differences between raters from different countries (Mann et al., 1992), rating of children from different cultures (Sonuga-Barke, Minocha, Taylor, & Sandberg, 1993), and even within cultures (for example, rates of diagnosis of ADHD have been shown to vary by a factor of 10 from county to county within the same state in the United States (Rappley, Gardiner, Jetton, & Howang, 1995)).

There are high rates of comorbidity between ADHD and conduct, anxiety, depression, and other disorders, with about three quarters of children diagnosed with ADHD also fulfilling criteria for another psychiatric disorder (Biederman, Newcorn,&Sprich, 1991). Such high rates of comorbidity suggest that the concept of ADHD is inadequate to explain clinical reality (Van Praag, 1996).

Neuroimaging research is often cited as "proof" of a biological deficit in those with ADHD, however, after almost 25 years and over 30 studies, researchers have yet to do a simple comparison of unmedicated children diagnosed with ADHD with an age matched control group (Leo & Cohen, 2003). The studies have shown nonspecific and inconsistent changes in some children in some studies. However, sample sizes have been small and in none of the studies were the brains considered clinically abnormal (Hynd & Hooper, 1995); nor has any specific abnormality been convincingly demonstrated (Baumeister & Hawkins, 2001). Most worryingly, animal studies suggest that any differences observed in these studies could well be due to the effects of medication that most children in these studies had taken (Breggin, 1999, 2001; Moll, Hause, Ruther, Rothenberger, & Huether, 2001; Sproson, Chantrey, Hollis, Marsden, & Fonel, 2001). Even a U.S. 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). Research on possible environmental causes of ADHD type behaviors has largely been ignored, despite mounting evidence that psychosocial factors such as exposure to trauma and abuse can cause them (Ford et al., 1999, 2000).

With regards the claim that ADHD is a genetic condition that is strongly heritable, the evidence is open to interpretation (Joseph, 2000). ADHD shares common genetics with conduct disorder and other externalising behaviors, and so if there is a heritable component it is not specific to ADHD(Timimi, 2002).

EFFICACY OF DRUG TREATMENT

The relentless growth in the practice of diagnosis of childhood and adolescent psychiatric disorders has also led to a relentless increase in the amount of psychotropic medication being prescribed to children and adolescents. The amount of psychotropic medication prescribed to children in the United States increased nearly threefold between 1987 and 1996, with over 6% of boys between the ages of 6 and 14 taking psychostimulants in 1996 (Olfson, Marcus,Weismann, & Jensen, 2002), a figure that is likely to be much higher now. There has also been a large increase in prescriptions of psychostimulants to preschoolers (aged 2-4 years; Zito et al., 2000). One study in Virginia found that in two school districts, 17% ofWhite boys at primary school were taking psychostimulants (LeFever, Dawson, & Morrow, 1999). Yet in the international consensus statement (Barkley et al., 2002) the authors still believe that less than half of those with ADHD are receiving treatment. Many of the authors of the consensus statement are well-known advocates of drug treatment for children with ADHD and it is notable that in the statement they do not declare their financial interests and/or their links with pharmaceutical companies.

Despite claims for the miraculous effects of stimulants they are not a specific treatment for ADHD, because they are well known to have similar effects on otherwise normal children and other children regardless of diagnosis (Breggin, 2002; Rapoport et al., 1978). A recent meta-analysis of randomised controlled trials of methylphenidate found that the trials were of poor quality, there was strong evidence of publication bias, short-term effects were inconsistent across different rating scales, side effects were frequent and problematic and long-term effects beyond 4 weeks of treatment were not demonstrated (Schachter, Pham, King, Langford, & Moher, 2001).

The authors of the consensus statement (Barkley et al., 2002) claim that untreated ADHD leads to significant impairment and harm for the afflicted individual; not only do the authors conflate a statistical association with cause but other evidence suggests that drug treatment has at best an inconsequential effect on long-term outcome (Joughin & Zwi, 1999; Zwi, Ramchandani, & Joughlin, 2000).

The potential long-term adverse effects of giving psychotropic drugs to children need to cause us more concern than the authors of the consensus statement will allow. Stimulants are potentially addictive drugs with cardiovascular, nervous, digestive, endocrine, and psychiatric side effects (Breggin, 2001, 2002). At a psychological level the use of drug treatment scripts a potentially life-long story of disability and deficit that physically healthy children may end up believing. Children may view drug treatment as a punishment for naughty behaviour and may be absorbing the message that they are not able to control or learn to control their own behavior. Drug treatment may also distance all concerned from finding more effective, long-lasting strategies (Cohen et al., 2002). The child and their carers may be unnecessarily cultured into the attitude of a "pill for life's problems."

A CULTURAL PERSPECTIVE ON ADHD

Why has ADHD become so popular now resulting in spiralling rates of diagnosis of ADHD and prescription of psychostimulants in the Western world? This question requires us to examine the cultural nature of how we construct what we deem to be normal and abnormal childhoods and child rearing methods. Although the immaturity of children is a biological fact, the ways in which this immaturity is understood and made meaningful is a fact of culture (Prout & James, 1997). Differences between cultures and within cultures over time mean that what are considered as desirable practices in one culture are often seen as abusive in another.

In contemporary, Western society children are viewed as individuals who have rights and need to express their opinions as well as being potentially vulnerable and needing protection by the state when parents are deemed not to be adequate. At the same time there has been a growing debate and belief that childhood in modern, Western society has suffered a strange death (Hendrick, 1997). Many contemporary observers are concerned about the increase in violence, drug and alcohol abuse, depression, and suicide amongst a generation perceived to have been given the best of everything. Some commentators believe we are witnessing the end of the innocence of childhood, for example, through the greater sexualization and commercialization of childhood interests. It is claimed that childhood is disappearing, through media, such as television, as children have near complete access to the world of adult information leading to a collapse of the moral authority of adults (Postman, 1983). Coupled with this fear that the boundary between childhood and adulthood is disappearing is a growing sense that children themselves are a risk with some children coming to be viewed as too dangerous for society and needing to be controlled, reshaped and changed (Stephens, 1995).

Thus, in the last few decades of the twentieth century in Western culture, the task of child rearing has become loaded with anxiety.On the one hand, parents and teachers feeling the pressure from the breakdown of adult authority discourse, feel they must act to control unruly children; on the other hand they feel inhibited from doing so for fear of the consequences now that people are aware that families can be ruined and careers destroyed should the state decide to intervene. This cultural anxiety has provided the ideal social context for growth of popularity of the concept of ADHD (Timimi, 2002). The concept of ADHD has helped shift focus away from these social dilemmas and onto the individual child. It has been in the best interests of the pharmaceutical industry to facilitate this change in focus. Drug company strategy for expanding markets for drug treatment of children is not confined to direct drug promotion but includes illness promotion (e.g. funding for parent support groups such as CHADD)and influencing research activities (Breggin, 2001; Jureidini & Mansfield, 2001). Thus the current "epidemic" of ADHD in the West can be understood as a symptom of a profound change in our cultural expectations of children coupled with an unwitting alliance between drug companies and some doctors, that serves to culturally legitimize the practice of dispensing performance enhancing substances in a crude attempt to quell our current anxieties about children's (particularly boys) development (Carey, 2002; DeGrandpre, 1999; Diller, 1998).

In their consensus statement (Barkley et al., 2002), the authors are at pains to point out that it is not the child's, the parent's or the teacher's fault. However, trying to understand the origins and meaning of behaviors labelled, as ADHD does not need to imply blame.What it does require is an attempt to positively engage with the interpersonal realities of human life. This can be done through individualized family counseling and educational approaches (Breggin, 2000), as well as using multiple perspectives to empower children, parents, teachers, and others (Timimi, 2002).

CONCLUSION

The authors of the consensus statement (Barkley et al., 2002) sell themselves short in stating that questioning the current practice concerning diagnosis and treatment of ADHD is like declaring the earth is flat. It is regrettable that they wish to close down debate prematurely and in a way not becoming of academics. The evidence shows that the debate is far from over.

Copyright (c) 2004 Plenum Publishing Corporation

Critique or Misrepresentation? A Reply to Timimi et al.
Russell A. Barkley, College of Health Professions, Medical University of South Carolina, Charleston, South Carolina, USA, and 20 Coendorsers
Clinical Child and Family Psychology Review, Vol. 7, No. 1, March 2004

In rebuttal to Timimi et al., we show that their critique is not a form of reasonable scientific debate with informed, constructive criticism, but merely a misrepresentation of the existing scientific literature on ADHD apparently designed to convince the scientifically uninformed of its nonexistence and of the misuse of medications for its management.We show their argument to be based on faulty logic, selective citation, misreprensentation of individual studies, ignorance of the vast literature on ADHD, and innuendo that maligns the integrity of scientists studying the disorder. Our original International Consensus Statement on ADHD remains untarnished by this faux critique - indeed it was intended to refute just such unsupported and unsupportable criticism that often appears in the popular media.

We thank the Editors for this opportunity to reply to the critique by Timimi et al. (2003) of the International Consensus Statement Barkley et al., 2002. Space is limited, and so we must be direct. Like much criticism of ADHD and its investigators that has appeared in lay publications, this critique misconstrues our motives, misrepresents the scientific literature on ADHD, engages in faulty logic concerning the basis for viewing conditions as disorders, selectively cites a few reports in support of their assertions while ignoring a much larger body of research opposing them, and uses innuendo to malign the integrity of scientists whose research supports the existence of this disorder.

Contrary to Timimi et al., we can find no compelling evidence in scientific journals or scientific meetings that the validity of the disorder has been "shaken by criticism." Indeed, with as many as 20 or more papers related to ADHD per month published in scientific journals internationally, the genuineness of ADHD as a disorder appears to be alive, well, and on solid-scientific ground, continuing to usefully drive programmatic research. Any "debate" over the legitimacy of ADHD as a valid disorder exists only in some segments of the popular media, not in the scientific community. That is why our sizeable group produced the Consensus Statement. Drawn largely from the membership of the International Society for Research in Child and Adolescent Psychopathology, which has no commercial or vested interests, the signers clearly represent the largest single group of mainstream scientists studying ADHD ever assembled for a common cause. Our aim, clearly stated in our introduction, was to confront misrepresentation of the disorder in the popular media using the status of the science on ADHD to refute it. It was not, as these critics disingenuously claim, "to forestall debate," to act "completely counter to the spirit and practice of science," or "to close down debate prematurely and in a way not becoming of academics," or other such assertions. All such misrepresentations are straw men bearing no resemblance to our stated intentions.

Given the ease with which Timimi et al. dismiss ADHD as a legitimate disorder, we can rightly ask "How would they know?" What specific standards or criteria have they applied to the wealth of scientific literature on ADHD that permit such a conclusion? Specifically, just how do they distinguish valid disorders from mere problems in living, the consequences of "cultural anxiety," or parents "loaded with anxiety" in their child-rearing? Apparently, they have no such standards for none are set forth against which to judge the merits of their argument. We made our dual standards obvious: (1) valid disorders are failures or severe deficiencies in psychological adaptations (functional mental mechanisms) that are universal to humans and (2) the failures or deficiencies result in harm (increased morbidity, mortality, or impairment in major life activities) (Wakefield, 1997, 1999). And we provided more than 400 references to scientific studies that attest to ADHD meeting these standards-we could have cited five times as much.

Our critics can site but three reviews (not experimental research) and two studies by Ford et al. that they claim raise issues about the validity or etiologies of ADHD. Tellingly, even the studies by Ford et al. are misrepresented as to their findings and conclusions. Those studies do not show that ADHD arises from child maltreatment and trauma exposure but that histories of such circumstances may be present to a greater than expected degree in ADHD, especially where ODD may also be present. Here is what Ford et al. (2000) actually concluded: "The finding that ADHD was associated with lesser likelihood of having experienced maltreatment than ODD and the absence of an increased risk for accident/illness trauma in ADHD(compared to adjustment disorder), is consistent with studies indicating that biological and nontraumatic parent/family factors are critical in the etiology and treatment of ADHD (emphasis added)." (p. 213) And further on, they state: "Another limitation is the study's cross-sectional design, which does not permit the detection and clarification of crucial causal and temporal relationships linking trauma, PTSD symptoms, and the disruptive behavior disorders." Yet that is what Timimi et al. tried to assert. Thus, where we stand accused of implying cause from correlational evidence, it is our critics who have been caught doing so.

Timimi et al. challenge the view of ADHD as a legitimate disorder on several grounds, none of which are logical or scientifically defensible. While professing no explicit standards against which real disorders are to be judged, the critique does imply what their grounds for dismissal might be. To them genuine disorders: (1) cannot exist without some "medical test" being available for their diagnosis; (2) cannot change in having their defining features revised or improved upon across their history; (3) cannot vary in prevalence across segments of society, countries, or geographic regions; (4) cannot have other disorders coexist with them (comorbidity); (5) must have a distinct and specific neurobiological lesion identifiable as their etiology; and (6) cannot share heritability or other contributing factors that may overlap with other disorders. Applying all these criteria as the standard for defining disorders would rule out all currently known psychiatric disorders as being valid not to mention numerous medical ones as well, including Alzheimer's and Parkinsons disease, multiple sclerosis, cancer, HIV/AIDS, seizure disorders, sickle cell anemia, etc. None of these disorders could withstand comparison to such a set of criteria for concluding a disorder to be valid. Such unscientific challenges to the validity of ADHD are not just misguided but harmful because they can serve to misinform policy-makers and the public and thereby restrict, reduce, or eliminate access to services for them. We address each briefly below:

Certainly the fields of medicine, psychiatry, pediatrics, and clinical psychology, among others, strive to develop accurate, reliable, objective tests for disorders where they may be possible. And surely some clinicians need to do a better job of evaluating and treating those who seek services from them. Yet the absence of such tests or the occasional clinical misdiagnosis or mismanagement of disorders is not evidence against the existence of a disorder. If this inappropriate standard were true, then all major mental and developmental disorders, including schizophrenia, bipolar disorder, Tourette's syndrome, mental retardation, autism, to name just a few, and many medical disorders (see above) could not be considered as valid disorders.

Just because definitions of ADHD have been refined and improved across the history of the disorder provides no logical justification against it being a disorder. How could this be so if science is an enterprise of test, re-fine, then test again? If disorders had to be defined precisely and accurately when first they appear in history and could not undergo change with subsequent revision and refinement then there would be no disorders. For no disorders of which we are aware in either medicine or mental health have been de-fined precisely and unchanginglywhenfirst recognized. Such a standard clearly ignores the Darwinian self-corrective process that is the scientific enterprise-proposing, testing, and refining based on the evidence so obtained. We can and should expect the DSM-V diagnostic criteria for ADHD to be somewhat different from those in DSM-IV (e.g., greater developmental sensitivity to different ages). This will arise purely from science being a selfcorrecting enterprise. It would not provide evidence against the disorder.

This is a nonstarter that overlooks the reality that different definitions applied at different stages in the history of a disorder may yield differing prevalence figures, as would be expected. It also ignores the real likelihood that disorders vary as a function of demographic parameters such as geographic location, population density, sex, nutrition, prenatal care, access to medical care, exposure to biological hazards, etc. If this assertion of Timimi et al. were true, then the variations frequently noted in the geographic and demographic distributions of cancers, sickle cell disease, or multiple sclerosis, or mental disorders such as psychosis or Tourette's Syndrome, to choose but a few, are prima facie evidence against their being valid disorders when judged against this implied standard. That different countries and cultures may manifest different levels of prevalence or severity of a disorder raises good reasons to study those differences for what they may yield about refining its nature and causes yet they would hardly invalidate the existence of a disorder. Here Timimi et al., true to pattern, once more misrepresent their references. The paper by Rappley et al. (1995) is cited as evidence for intrastate variability of disorder (Michigan) when it was in fact about intrastate variations in prescribing patterns as its title clearly shows. Prescribing patterns may vary for many legitimate reasons, including the very real contemporary problem of grossly uneven access to care across segments of society, and do not directly indicate a disorders actual prevalence within the population.

Because ADHD coexists with other disorders, it is said, "the concept of ADHD is inadequate to explain clinical reality," whatever that may mean. As a standard for judging the status of a disorder, this makes no sense. Nearly all of the mental disorders and many medical ones can co-occur with others yet remain separable and genuine disorders. Again, what science strives to do is study such patterns of coexistence for what they may have to say about how disorders relate, develop, and even contribute to each other and why. That does not invalidate the disorder.

Neuroimaging research on ADHD can tell us nothing about its biological bases because the crucial comparison of unmedicated ADHD children to age matched controls has not been done. The Neuroimaging findings could be the result of medication treatment. Unfortunate for this position is that such a study has been done (Castellanos et al., 2002) and its results were very much in keeping with other previous neuroimaging studies of ADHD in which group differences were obtained. More importantly it was able to demonstrate that such differences are persistent over time as shown in serial scans. That this study used both never-medicated and medicated ADHD children and found comparable differences from normal for each ADHD group refutes this point by Timimi et al. So does an earlier study on deficient neuronal inhibition assessed via transcranial stimulation of the motor region using stimulant naive children (Moll, Henreich, Trott, Wirth, & Rothenberger, 2000).

Critics of ADHD may wish to view the evidence for its striking pattern of genetic heritability as being "open to interpretation" but that does not make it so. No one cognizant of the current scientific literature doubts the consistency of findings in this area of research. It has repeatedly shown ADHD and its symptoms to be among the most genetically influenced psychiatric conditions across multiple studies in multiple countries (see Levy & Hay, 2001; and our original references). These studies involved hundreds or even thousands of identical and fraternal twin pairs. Others involved comparisons of siblings reared together to those reared apart or comparisons of biological versus adoptive families of ADHD children. All these different methods supported the strong level of heritability of this disorder and its defining symptoms. Indeed, there exist no studies that would refute this clear pattern of results. The fact that other disorders may share some genetic susceptibility with ADHD is hardly an indictment against it as a valid disorder-such shared genetic vulnerabilities are found in other mental and medical disorders as well.

Though it was a very minor point in our statement, Timimi et al. aim much of their criticism at the rise in medication use for the management of ADHD as if such an increase alone were de facto evidence of something scandalous or reprehensible taking place in our professions. Interestingly, they ignore the rise in empirically based behavioral, psychosocial, and special educational treatments that have occurred simultaneously, though these can, often in combination with medication, effectively assist with the reduction in symptoms and impairments for many children. Their logic would extend to these psychosocial forms of treatment as well. If the identification and care of psychiatrically ill children improves in any way from some earlier historical bench mark, our critics imply, then this is explicit evidence that something is dramatically wrong with the mental health profession. Obviously this ignores the fact that this is precisely what takes place from efforts to address public mental health problems. True to form, our critics cite the only outlier study of prevalent stimulant use; that being the one done by Lefever et al. (1999) in the Norfolk, VA area that claimed to have found an exceptionally high level of stimulant prescribing relative to other regions and large databases. Other more numerous studies showing considerably lower prescribing rates go unmentioned though they are clearly from larger databases and are likely more representative of U.S. patterns. What the critics do not know is that a subsequent study just completed has been unable to replicate the earlier Lefever et al. results for that same region and finds a prescribing prevalence closer to 3%, in keeping with other studies of other regions (Hathaway, personal communication, September, 2003). The reasons for such a gross disparity of results deserve investigation. The more obvious and sensible interpretation for the rise in medication use is that it has occurred because of the increasing evidence for the safety and effectiveness of some medications for the symptomatic management of the disorder, the increased recognition that girls, teens, and adults can also have this disorder, changes in special education regulations, and the rise in public awareness about the disorder, among other legitimate factors.

Finally, there is the scientifically flimsy "cultural perspective" offered up by these critics as a competing theory for the origins of ADHD in contrast to the neuropsychological, neurological, and genetic ones that have substantial support in the science on this disorder. Thus, ADHD is said to originate in the "collapse of the moral authority of adults" (unexplained), anxieties in contemporary child rearing (also unexplained), and drug company strategies to expand markets to children using unwitting ADHD scientists in their campaign (innuendo). No evidence is offered to support any of these assertions though they are presented as undeniable facts based solely on citations of politically motivated editorials and highly biased trade books. Fortunately, we have reached a state in the mental health sciences where sufficient data are available on disorders like ADHD such that all ideas about it no longer get prizes. Theories and hypotheses about the origins of ADHD must have consequences to be useful; that is, they must be testable against the sizeable and increasing body of scientific findings available on it for consistency with that database. When this is done, the vague pontifications of these critics do not square with the available data.

There is no evidence to show that ADHD arises from any such unsupportable cultural perspectives as claimed by these critics. Indeed, studies of twins are an excellent means of testing such environmental hypotheses about disorders. Modern statistics can be applied to such data sets that can discern the extent to which variation in the population in certain traits or disorders can be attributed to common, shared, or rearing environment, to unique events that occur only to the affected family member, or to genetics. The hypotheses of our critics clearly fall within the common or shared environmental variation tested in such twin studies. To date, all twin studies have found no significant contribution of shared environment to the symptom expression of ADHD. They do find a small but significant contribution of unique environmental events (some or all of which can be due to biohazards experienced by the child as well as unique social influences from outside the home). But they consistently find a substantial genetic contribution to ADHD within the population. These numerous studies, and many other lines of evidence, directly refute the nonexpert folk wisdom offered by these critics as to the origins of ADHD. In fact, hundreds of studies finding differences between ADHD and community control children not to mention the numerous crosscultural studies on the prevalence of ADHD would be evidence against their vaguely framed hypothesis. For their hypothesis asserts that there is nothing unusual about these children in any way-it is all to be found in parental child-rearing and some amorphous concept called "cultural anxiety" prevalent in the United States or western world. Such views are at worst a continuation of the past 50 years of parent bashing stemming from psychoanalytic, radical behavioral, and poppsychology perspectives on children's mental disorders (see Harris, 1997; Pinker, 2002 for discussions). These are historical dead ends in understanding child psychopathology. At best this hypothesis is a form of scientific buck-passing for it can generate no useful understanding of disorders, predictions that can drive informative programmatic research, or insights into effective treatments. All one need do, apparently, is "engage with the interpersonal realities of human life" using the untested methods of Peter Breggin. Such unscientific views and treatments are unpersuasive when judged against the abundant scientific evidence. As we urged in our initial statement, such views deserve to be ignored in the popular media.

Copyright (c) 2004 Plenum Publishing Corporation

My personal comments on the International Consensus Statement on ADHD excerpted from The Parental Intelligence Report on 'ADHD' May 2003.

Powerful stuff, indeed.

Now, I'd expect Dr. Valentine and Dr. Baughman and their supporters to know all about this statement, yet they seemingly remain adamant in their point of view, that 'ADHD' does not exist. Why is that?

Possibly, its because the 'International Consensus Statement on ADHD' is a red herring.

Here we have SEVENTY-FIVE "prominent medical doctors and researchers in AD/HD" and, despite all their PhDs and what have you, none of them can tell the difference between a disease and a diagnosis!!

Unfortunately for Dr. Barkley and his cohorts, I CAN. So can Dr. Valentine. So can Dr. Baughman. So can anyone who won't be intimidated by the apparent 'authority' of the International Consensus Statement into leaping before they look.

How many times does the term 'ADHD' appear in Dr. Barkley's statement?

I counted twenty-five.

How many times are the diagnostic criteria for 'ADHD' presented in the statement?

A big fat zero!

Twenty-five references to 'ADHD' and not one of those uses of the term 'ADHD' is validated by the presentation of legitimate diagnostic criteria.

Why doesn't Dr. Barkley want to talk to us about his 'diagnostic criteria'? Why doesn't he want to tell us exactly HOW he and other members of his profession decide that somebody 'has ADHD'?

Dr. Barkley, it seems, would rather we accept that 'ADHD' is what HE says it is because he says that's what it IS!

Then he can roll out his 'cause and effect relationships' and his 'research results' and all his 'facts and figures' without the inconvenience of having to deal with obvious questions like, "Why should I take your word for that?" or "How do I know you're not making that up?"

Perhaps Dr. Barkley doesn't want to talk to us in his International Consensus Statement about his 'diagnostic criteria' for 'ADHD' for the simple reason that he doesn't want us to have all the pieces of the jigsaw in the same place. We might just put them all together and find that the picture we get is different to the one on the box!

A lot of people are already there.

I, myself, observed earlier that the 'diagnostic criteria' for 'ADHD' as published in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) are "so vague and subjective they would surely be in constant danger of an interpretation to suit just about ANY conceivable purpose".

Clinical psychologist Dr. David Keirsey makes the following observations in his article "The Great A.D.D. Hoax":

". the essay on attention deficit in the DSM-IV is so poorly written that it's a wonder anybody takes it seriously."

"The other problem with the idea of attention deficit is that the medics apparently believe it is caused by its symptoms. For sure the medics have got it backwards, and some of us are surprised that they haven't noticed such an obvious error. Even though medical practitioners aren't scientists they ought to know better than that. It's preposterous to say that the symptoms of attention deficit cause the deficit of attention."

The Great A.D.D. Hoax
by David Keirsey
http://keirsey.com/addhoax.html

Then there's this:

"If nothing else, scrutinize the diagnostic criteria. Who doesn't know a child -- for that matter an adult -- who "has difficulty sustaining attention, doesn't seem to listen when spoken to directly, loses things necessary for tasks, fidgets, or is on the go constantly?"

For that matter who hasn't been that child at some point?

Couple such subjective diagnostic criteria with the fact boys outnumber girls with the condition by nine to one, and ask yourself whether the ADHD-diagnosis is not inadvertently targeting typical male exuberance."

Good news: abnormal behaviour is a disease
North Shore News (Vancouver, B.C.), Sept. 6, 1999
http://www.nsnews.com/issues99/w090699/mercer.html

Dr. Fred Baughman again:

"They made a list of the most common symptoms of emotional discomfiture of children; those which bother teachers and parents most, and - in a stroke that could not be more devoid of science or Hippocratic motive - termed them a 'disease.' Twenty five years of research, not deserving of the term 'research', has failed to validate ADD/ADHD as a disease."

ADHD Fraud - the official website of Fred A. Baughman Jr., MD (Neurologist, Pediatric Neurology)
http://www.adhdfraud.org/

Psychiatrist Al Parides:

"The DSM is also a masterpiece of deception. Shrouded in the rhetoric of "science", every human emotion, experience, habit and activity is listed as a symptom of a mental "disorder"."

The Great Waste
ttp://psychfraud.freedommag.org/page04a.htm

Now you know what the term 'ADHD' in Dr. Barkley's 'International Consensus Statement' REALLY represents. Anything he wants it to!

In fact, you could replace the word 'ADHD' with the name of any other 'disease' whose methods of diagnosis have likewise not first been validated and what the Statement says would make just as much sense.

Try 'Allgemein Krankheit Syndrome Disorder' (or 'AKSD'); that's one of my personal favourites - doesn't it have just a simply excellent medical sound to it? If you read the International Consensus Statement again with the word 'AKSD' substituted for each one of the twenty-five instances of 'ADHD', you'll find that - because you haven't been told how Allgemein Krankheit Syndrome Disorder is diagnosed (just as you haven't been told how 'ADHD' is diagnosed) - you would have to simply take it on trust that the characteristics and effects attributed to it are fact not fiction. It would be impossible for you to do otherwise.

In other words, if I was Dr. Russell Barkley and I told you, for example, that "All of the major medical associations and government health agencies recognize AKSD as a genuine disorder because the scientific evidence indicating it is so is overwhelming"; or "there is no doubt that AKSD leads to impairments in major life activities, including social relations, education, family functioning, occupational functioning, self-sufficiency, and adherence to social rules, norms, and laws." - you'd be absolutely none the wiser.

What Dr. Barkley and his 74 other "prominent medical doctors and researchers in AD/HD" have come up with is, in the final analysis, merely an assortment of unsubstantiated claims. Because they have failed to validate the diagnostic criteria (nor can they, in my opinion), their case for 'ADHD' as presented in the International Consensus Statement is worthless to anyone interested in the facts.

'Allgemein Krankheit', by the way, is German for general or universal illness - which is, more or less, what Dr. Barkley seems to have been talking about in his Statement.

If you haven't read The Parental Intelligence Report on 'ADHD', from which the above is extracted, the complete text can be found at http://www.adhd-report.com

If you're not clear about the point I'm making, here's another attempt to explain it:

In the matter of the International Consensus Statement and his response to Sami Timimi's Critique, Russell Barkley has failed (or, rather, not attempted) to properly precede his argument by demonstrating beyond reasonable doubt in scientifically controlled conditions that those behaviours which he claims are the 'symptoms' of a 'disease' called 'ADHD' are intrinsically pathological - that is, that they are actually indicative of malfunction. He has not done that, even despite the fact that those behaviours constitute the foundation of all his assertions regarding the nature, causes, attributes and effects of the alleged 'disease'.

Professor Barkley is perfectly free, of course, to treat any behaviours as if they're symptoms of disease, and to act accordingly, but he can make no legitimate claim that they are symptoms of disease in the absence of the required validation. By default, that becomes simply a matter of his opinion. The behaviours could not be regarded by any sensible person as symptoms of disease just because Russell Barkley says they are.

Since there has never been any demonstration that the 'diagnosis' of so-called 'ADHD' is inherently legitimate, any statement Professor Barkley makes that he contends to be factual, but which is based upon his assumption that certain behaviours are symptoms of disease when they have not been shown in fact to be symptoms of disease, is meaningless and I, for one, would certainly disregard it.

I appreciate that, because Professor Barkley does not wish to take into consideration any possibility that the 'diagnosis' of 'ADHD' is other than 100% legitimate, he is, of course, convinced that everything he's saying is correct. He couldn't possibly be otherwise in those circumstances. So it's no real surprise that he chooses not to acknowledge that there is a need to validate the alleged 'diagnostic criteria' , nor, despite his superficial deference to the scientific, does he appear motivated by any obligation as a scientist himself to fairly and effectively scrutinise those 'criteria' - he simply assumes, or has decided, that they are legitimate.

They're not. They're a joke.

But, the fact that the alleged 'diagnostic criteria' for so-called 'ADHD' are laughable to begin with is only part of the fiasco. As I now know from what I've learned over the past year and a half, the epithet of 'ADHD' has, for many years, customarily been attached to all sorts of behaviours, many of which merely approximate those listed in the DSM - and they are already vague and subjective, in any case; add to that the casual and careless manner in which what's supposed to be a dangerous brain disease can be 'diagnosed' on a mere whim by any old psychiatrist, psychologist, doctor, teacher, or parent, and even an occasional bloke you met down the pub, and what you have is a complete dog's breakfast that's hardly the stuff 'scientific research' is made of. Who could honestly make any sense of such a mess?

In effect, what Russell Barkley actually means (or thinks he means) whenever he uses the term 'ADHD' is anybody's guess. He has simply failed to understand the inherent fraudulence of that alleged 'diagnosis' upon which he has, sadly, built a magnificent life's work of erroneous perceptions.

In this following paragraph, extracted from the International Consensus Statement on ADHD, for example, he tells me in all seriousness:

"ADHD is not a benign disorder. Follow-up studies of clinical samples suggest that sufferers are far more likely than normal people to drop out of school (32-40%), to rarely complete college (5-10%), to have few or no friends (50-70%), to under perform at work (70-80%), to engage in antisocial activities (40-50%), and to use tobacco or illicit drugs more than normal. Moreover, children growing up with ADHD are more likely to experience teen pregnancy (40%) and sexually transmitted diseases (16%), to speed excessively and have multiple car accidents, to experience depression (20-30%) and personality disorders (18-25%) as adults, and in hundreds of other ways mismanage and endanger their lives."

This is the translation for those of us living in the real world:

"The description of 'ADHD' is usually applied to people who behave in ways that produce undesirable experiences. Follow-up studies of some people described as 'ADHD' suggest that people who drop out of school, fail to complete college, have few or no friends, under perform at work, engage in antisocial activities, and use tobacco or illicit drugs more than normal are more likely to be described as 'ADHD' than people who do not. Moreover, people who experience teen pregnancy and sexually transmitted diseases, who speed excessively and have multiple car accidents, who grow up to experience depression and personality disorders as adults and in hundreds of other ways mismanage and endanger their lives are more likely to be described as 'ADHD' than people who do not."

So, there you go. Of course, this is all only my personal view from where I'm standing, as always - but, wait, what's that I see from here? The earth is flat, the laws of gravity are debatable, and the periodic table in chemistry is a fraud.

And so is 'ADHD'.

ADHD-Report.com: The concerned parents' guide to childrens' attention-deficit hyperactivity disorder (ADHD/ADD)

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