ADHD is not a Symptom: Why Managed Medication is Proper Treatment

        

            On his website, www.ddcdrsaul.com, Dr. Richard Saul proudly displays a paragraph that begins, “ADHD is not a disease but a symptom.” The suggestion that Attention Deficit-Hyperactive Disorder is simply a symptom of another disease or disorder, and not a true disorder in itself, downplays the impairment millions of people face in their daily lives. The argument against ADHD as a disease, on Saul’s part, seems to come from his apparent dislike of rising stimulant use numbers for the treatment of ADHD symptoms in the United States (Saul, 2014). Saul claims, in an opinion piece he wrote for TIME, that ADHD is not a real disease since he finds that lifestyle changes he suggests to patients in his clinic resolve some cases of ADHD (Saul, 2014). Saul asserts that the lifestyle suggestions he makes to patients, such as exercise, sleep, and having “passionate” activities to do, will treat all cases of ADHD, and that most, if not all ADHD cases, are actually other health problems mistaken for the disorder.

 Some of the fixes for hyperactive symptoms Saul argues for, however, are common treatment practices typical of Cognitive Behavioral Therapy (CBT), an effective psychoeducational treatment for the management and reduction of ADHD symptoms. CBT focuses on managing health, creating routines (learning “skills”), and possibly changing profession or personal lifestyle to one that focuses on constant engagement, which facilitates hyperactive symptoms for the better. For example, a desk worker with ADHD may shift to a position that facilitates movement, expression, and expressiveness if the patient and clinician decide that those activities may reduce his symptoms to manageable levels. Saul seems to prefer a behaviorist approach to treating ADHD, and appears to believe that classifying ADHD as a disease forces people to seek medication for treatment, rather than behavioral or psychoeducational training.

            The main catalyst of his argument for behavioral treatment of ADHD in place of medicinal treatment is the high misdiagnosis rate of ADHD (Saul, 2014). However, Saul seems to avoid the possibility of ADHD diagnosed with comorbid disorders, and instead claims that hyperactivity and inattentive behavior is the symptom of other disorders. The comorbidity rate of ADHD is relatively high, with an estimated 67% of childhood ADHD cases having at least one comorbid disorder (Larson, Russ, Kahn, & Halfon, 2007). Saul suggests that since he can treat disorders that have inattentive or hyperactive symptoms with behavioral therapy, when those disorders were initially misdiagnosed as ADHD, that ADHD is not a real disease or disorder, but a commonly misdiagnosed symptom. However, the 67% rate of diagnosis in the Larson, Russ, Kahn, & Halfon (2007) study shows 33% of the remaining ADHD cases are ‘pure,’ meaning that no comorbid disorders or disabilities aside from ADHD are diagnosed or present for the child. In addition, out of those diagnosed with ADHD and comorbid disorder(s), 33% had at least one comorbid disorder, which was likely to be a learning disability (46.1%), conduct disorder (27.4%), or anxiety (17.8%) (Larson, Russ, Kahn, & Halfon, 2007). Childhood ADHD patients may receive non-medical treatment for comorbid disorders through in-school educational help or talk/behavioral therapies, as Larson, Russ, Kahn, & Halfon (2007) suggest, but also require careful monitoring and treatment of ADHD symptoms to stabilize the child and place them on a positive developmental trajectory.

However, these findings also create a confirmation bias for Saul’s belief that ADHD is simply a symptom of other disorders. Saul’s preferred behavioral therapies function as treatment for the most likely comorbid disorders of ADHD as well as pure ADHD. As a result, he would find the symptoms of ADHD disappearing as he treats what he believes to be the ‘primary’ disorder that is ‘misdiagnosed’ as ADHD. However, not every diagnosed case of ADHD is a misdiagnosis, and not every diagnosed case of ADHD comes with a comorbid disorder. ADHD symptoms, hyperactivity and inattentiveness, may be shared with other disorders, and it is the clinicians job to carefully diagnose based on diagnostic criteria of impairment in order to differentiate between a pure diagnosis, a misdiagnosis, or a diagnosis with comorbid disorders.

On a broad scope, Saul seems to argue that various health complications produce the symptoms of ADHD, and that should remove ADHD as a true disease from diagnostic handbooks. However, evidence of ‘pure’ childhood ADHD exists from Larson, Russ, Kahn, and Halfon (2007), and a recent longitudinal study by Moffitt and colleagues suggests that ‘pure’ adult ADHD also exists.

Evidence of adult-onset ADHD bolsters an even stronger argument against Saul’s denial of ADHD as a disease. A study based in New Zealand by Moffitt, et al. (2015) followed a birth cohort of 1,037 children born in Dunedin, New Zealand until age 38. The participants in this study were evaluated at age three for ADHD, and were reevaluated for symptoms at ages 11, 13, and 15 to determine ADHD diagnosis in childhood/adolescence using the DSM-III. Researchers evaluated patient adult ADHD symptoms at age 38 using the DSM-V, which uses broader diagnostic criteria than the DSM-III. The results reveal that 90% of the adult ADHD cases diagnosed had no previous diagnosis or symptomatic evidence of ADHD in childhood or adolescence (Moffitt, et al., 2015). Additionally, of the comorbid disorders and other mental health symptoms evaluated by researchers less than half of the adult ADHD group had a comorbid disorder of any kind, and the childhood ADHD group had far less than half with a comorbid diagnosis (31.7%) (Moffitt, et al., 2015). These findings suggest not only that adult onset ADHD possibly be classified as its own disorder, but also that childhood ADHD is a disorder in itself that can manifest without comorbid disorders in tow. Empirical evidence addresses the problematic distinctions Saul finds with the current DSM classification, which refers to adult ADHD as a continuation of childhood ADHD, but with fewer symptomatic criteria than childhood ADHD diagnosis. However, if the slackening of criteria from six symptoms of impairment in childhood to five symptoms of impairment in adulthood had any sort of distorting effect on results, then the number of adult ADHD cases diagnosed would be higher than the childhood condition (Moffitt, et al., 2015). This reasoning refutes the notion by Saul that slackening criteria allows any single person to get a diagnosis for simple human tendencies of inattention or hyperactivity. However, it does not address his assertion that medication treatment is ineffective and frivolous. So, for those children with ADHD what is the most effective treatment, and is behavioral treatment the most effective treatment, as Saul suggests?

            There is empirical evidence to suggest that stimulant medication is effective at treating ADHD, and bolsters the effectiveness of behavioral therapy. In the Multimodal Treatment Study of Children with ADHD (MTA), the first longitudinal multimethod study of treatment effects on children with ADHD, 579 children, from ages 7-9.9 years participated in a 14-month trial to determine personal, family, and school outcomes of medicinal, behavioral, combined, and community treatments (The MTA Cooperative Group, 1999).

 Each study group went through a different treatment over the course of 14 months. The medicinal treatment group went through randomized and controlled titration cycles to determine proper stimulant medication type and dose for treatment period. Researchers carefully monitored taking of stimulant medication during the treatment period, and did frequent pill counts. The behavioral condition completed rigorous at home, in school, out of school (summer camp), and in lab behavioral therapies over the course of the 14-months aimed at reducing and managing ADHD symptoms. The combined treatment group received carefully monitored stimulant medication treatment and intensive behavioral therapy that combined treatment schedules of the medication management and behavioral therapy groups. Finally, the community treatment group received a diagnostic screening for ADHD and any comorbid disorders. If a patient in the community group received an ADHD diagnosis, researchers referred the patient to a community ADHD clinic. The community group functioned as a generalizable ‘control’ group for the other treatments, and was comparable to the typical process of ADHD diagnosis and referral (The MTA Cooperative Group, 1999).

The initial findings of this study suggest that medication treatment for ADHD is the most effective at reducing inattentive and hyperactivity-impulsivity symptoms according to parent and teacher reports (The MTA Cooperative Group, 1999). In addition, the findings of The MTA Cooperative Group (1999) suggest that combined-type treatment, a mix of medication and behavioral therapy, shows superior improvement of ADHD symptoms than behavioral therapy alone. These findings suggest that Saul’s argument for behavior therapy is partially inaccurate by providing evidence of the superior outcomes in a 14-month longitudinal trial of medication treatment for ADHD, as well as medication enhanced behavioral therapy (combined treatment), over behavioral therapy.

However, the MTA medication management and behavioral therapy conditions do have caveats. The titration cycle for medication, medication selection, and medication management does not represent real life medication dispersal (The MTA Cooperative Group, 1999). The rigorous management of the medications represents the ideal scenario for medication usage and prescription for children diagnosed with ADHD, and would require vast resources in true world settings to maintain long term. Additionally, the CBT condition was a 14-month process with far more follow-ups than are typical in natural treatment courses. Not only did parents complete sessions, but teachers also completed sessions during school days, children met with therapists, and children attended a Summer Treatment Program (The MTA Cooperative Group, 1999). In spite of these caveats within conditions, the study shows evidence that medication and combined treatment strategies are significantly better for ADHD combined-type symptom reduction outcomes than behavioral treatment alone.

Concerning the community treatment condition, which showed the least improvement in ADHD symptom outcomes following study duration, the MTA study reveals that proper medication management and intake is crucially important if on a stimulant medication schedule for ADHD. Children in the community treatment group often received stimulant medication prescriptions, but did not undergo close medication management with oversight by physicians from the community clinic, unlike those in the medication management and combined treatment groups (The MTA cooperative Group, 1999). The evidence implies that the success of stimulant medication treatment for reduction of ADHD symptoms heavily relies on proper intake monitoring and dosing procedures with the help of a physician. Practices conducted within the MTA may resolve problems with over-intake, abuse, and ineffectiveness stressed by Saul in his TIME article.

A follow up moderation-mediation evaluation of the same data set reveals that the combined treatment was more effective than medication treatment for ADHD children with comorbid anxiety, and these results are the same with diagnosed comorbid internalizing anxiety symptoms (The MTA Cooperative Group, 1999). This finding, however, occurs due to the nature of combined treatment strategies, which bolster careful medication strategies to treat ADHD symptoms with behavioral therapy in order to create habits and skills that manage context dependent symptoms elicited by ADHD or anxiety. This follow up analysis also looked at whether or not those in the community care condition received medication for the duration of the community care. Of those given medication in the community care condition, ADHD symptom ratings were significantly more positive than those who did not receive medication for symptom management (The MTA Cooperative Group, 1999). These findings differentiate within group that medication treatment for ADHD is effective in a natural setting, but still shows that unmonitored medication treatment is less effective than careful medication management with a physician. Careful medication management practices, such as those used in the MTA study, alleviate much of the concern Saul puts forward regarding over-prescription and frivolous intake of stimulant medication. However, another follow up study conducted by Molina, et al. (2009) suggests that the treatments conducted lacked long-term efficacy.

Saul argues that long-term stimulant use is the least effective method for treating ADHD. Rather than using medications for other comorbid disorders that need them (e.g. depression and bipolar disorder), Saul argues that behavioral therapies are better in the long term and more effective. However, findings from an 8 year follow up to the original MTA study shows ADHD children’s trajectories at pretreatment were better predictors of outcomes than were the results at the end of the 14-month treatment cycle (Molina, et al., 2009). Additionally, the outcomes of children in all four conditions collapsed to approximately the same level at the eight-year follow-up, suggesting that the strict management of treatment during the initial 14-month cycle was responsible for many of the findings, and that once management was reduced and participants began naturalistic treatment maintenance plans the results faltered (Molina, et al., 2009). That is not to say that medication treatment is ineffective, rather these findings suggest that individual patients must make careful decisions regarding their treatment cycles, which medications work best for them, and communicate with their doctor about what additional treatments to pursue for ADHD symptoms and comorbid disorder management (Molina, et al., 2009). Molina et al. (2009) suggest similar ideas as Saul, but they make an important distinction in regards to whether or not medications are necessary for ADHD treatment. Where Saul calls for complete removal of medication from the treatment of ADHD, Molina, et al. (2009) calls for the careful management and individualized use of medication in tandem with supervision to ensure proper control of symptoms.

Saul expresses several concerns about the safety of stimulant medication use. Specifically, he states that addiction to stimulant medication is a common occurrence and that over time the dosage of the medication must rise dramatically so that the patient receives the same symptom reduction effects. However, the literature on drug dependence suggests that Saul is cherry-picking statistics. Compton and Volkow (2005) state that addiction to stimulant drugs, namely methylphenidate (Adderall), rarely occurs when patients take them following proper medical guidelines and supervision. Addiction to stimulants occurs when the dosage is high enough to cause reinforcement or the rate of onset of action (how quickly the effects of the drug occur) comes quickly and fades rapidly over a short interval (Compton and Volkow, 2005). Stimulant drugs prescribed therapeutically typically come in doses far smaller than that needed to produce reinforcement, which is the brain’s need for the rush of stimulant onset. Additionally, patients taking stimulants for ADHD typically do not ingest them in a manner that results in a rapid rate of onset of action (ingestions that lead to rapid rate of onset of action: snorting, injection, smoking) (Compton and Volkow, 2005). Saul’s anxiety over prescription drug addiction and reinforcement seem to apply only for cases of drug abuse by recreational users who obtain stimulants illegally, rather than for those who actually need stimulants to function without impairment, such as ADHD patients.

Saul’s statements on ADHD diagnosis, classification, and treatment miss the mark when compared to the actual data and results of varying studies. ADHD is a disorder, and may have separate classifications in childhood and adulthood that need further investigation (Moffitt, et al., 2015). Furthermore, empirical evidence shows that ‘pure’ ADHD does manifest in some individuals without comorbid disorders (Larson, Russ, Kahn, & Halfon, 2007). Behavioral treatment alone does not effectively treat all cases of ADHD symptoms, and may be bolstered and show efficacy in treatment effectiveness when conducted with careful monitoring and individualized management of stimulant medication with the assistance of a medical professional (The MTA Cooperative Group, 1999; Molina, et al., 2009). Finally, addiction and reinforcement of stimulant drugs does not typically occur for patients needing therapeutic prescriptions (Compton and Volkow, 2005). Based on this evidence, Saul receives a D+ for his efforts within the TIME opinion piece. While he brings up decent ethical concerns and anecdotal evidence, Sault does not refer to any empirically written pieces to support his argument outside of the statistical data showing that prescriptions and ADHD diagnosis rates are rising in tandem. 

Written by Mitchell Parry for his senior seminar, "ADHD in Focus," at the University of Richmond

References

Compton, W. M., & Volkow, N. D. (2006). Abuse of prescription drugs and the risk of addiction. Drug and Alcohol Dependence, 83, S4-S7. doi:10.1016/j.drugalcdep.2005.10.020

Larson, K., Russ, S. A., Kahn, R. S., & Halfon, N. (2011). Patterns of comorbidity, functioning, and service use for US children with ADHD, 2007. Pediatrics, 127(3), 462-470. doi:10.1542/peds.2010-0165

Moffitt, T. E., Houts, R., Asherson, P., Belsky, D. W., Corcoran, D. L., Hammerle, M., . . . Caspi, A. (2015). Is adult ADHD a childhood-onset neurodevelopmental disorder? Evidence from a four-decade longitudinal cohort study. American Journal of Psychiatry, 172(10), 967-977. doi:10.1176/appi.ajp.2015.14101266

Molina, B. S., Hinshaw, S. P., Swanson, J. M., Arnold, L. E., Vitiello, B., Jensen, P. S., . . . Houck, P. R. (2009). The MTA at 8 years: prospective follow-up of children treated for combined-type ADHD in a multisite study. Journal of the American Academy of Child & Adolescent Psychiatry, 48(5), 484-500. doi:10.1097/chi.0b013e31819c23d0

The MTA Cooperative Group. (1999). A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder. Archives of General Psychiatry, 56(12), 1073-1086. doi:10.1001/archpsyc.56.12.1073

The MTA Cooperative Group. (1999). Moderators and mediators of treatment response for children with attention-deficit/hyperactivity disorder. Archives of General Psychiatry, 56(12), 1088-1096. doi:10.1001/archpsyc.56.12.1088

Saul, R. (2014, March 14). Doctor: ADHD does not exist. Retrieved January 25, 2016, from http://time.com/25370/doctor-adhd-does-not-exist/

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