The ADHD Debate

An attempt for some common ground

Posted Jan 06, 2014

There has been an awful lot of debate lately about the diagnosis of Attention Deficit Hyperactivity Disorder (ADHD) brought on by a thought-provoking article in the New York Times (NYT) by Alan Schwartz followed by a number of interesting and challenging blog posts here at Psychology Today by Allen Frances, Marilyn Wedge, Robert Berezin and others here as well as from many other sites.

In all the rhetoric, it is important to point out that there may be more common ground, at least between most commenters, than folks might think. Whether it is the NYT article or the blog entry by Dr. Frances, there is almost always at least some fine print acknowledging that ADHD exists and that at least some people deserve the diagnosis. On the other side, even the most ardent supporters of ADHD and its treatment acknowledge that overdiagnosis can be a problem, medications can be misused, and the long-term impact of our treatments are not studied as well as they could be. Thus, we are talking about those kids (and now adults) in the middle: the ones who struggle with focus and activity to the point that it causes problems but who aren’t the kids who anybody could easily recognize as literally bouncing off walls.

This observation brings us to the essence of the problem, which is that attention span and activity level are complex dimensional constructs with no clear boundary between normal and abnormal either on the surface level or even possibly when it comes to the underlying neurobiological processes in the brain. Diagnosing someone with ADHD is a little like diagnosing someone as being too tall, except that you don’t get to use a ruler. 

A lack of clear cut-offs points or specific biological “thing” to point at on an MRI scan, however, in no way makes ADHD not real. Apply that logic, and everything from most types of pain to autism to hypertension should be called into question too. Remember, we are talking about the human brain here. Yet despite the brain’s astonishing complexity, progress is being made to understand the causes—yes, causes—of ADHD. The level of evidence that genetic factors play a huge role in ADHD and that the behaviors reflect significant and measurable changes in brain structure and function is simply overwhelming. To deny this fact requires someone to simply write-off and dismiss massive amounts of research data that comes from hundreds of publicly funded scientific studies, not from the pharmaceutical companies, as the New York Time article mistakenly implies. 

One convenient way to dismiss these studies is to basically view researchers as corrupt mouthpieces of the drug companies. As the Schwartz article points out, the influence of the pharmaceutical industry is huge and we as psychiatrists would be quite naïve to think that their marketing effects everyone except us. As one of the only professions that actually receives training in the mechanisms through which our beliefs and ideas can be undermined by other forces, we of all people should know better.

At the same time, those pointing fingers also need to keep in mind that there are a lot more ways to introduce a bias or conflict of interest than a speakers’ bureau.  Yes, receiving money to talk about ADHD from a drug company will introduce bias, but going on the talk circuit about how evil the pharmaceutical industry has become, or writing a book about why ADHD does not exist (or the fuzzy boundary between traits and illness for that matter), or being trained to do one type of treatment but not another, creates a conflict too.  Perhaps the ultimate hypocrisy are those elected officials who preach to physicians about how brainwashed they have become from drug companies and then accept massive political donations. 

All of us, I think, could do with a bit less stone throwing and bit more honest introspection.

In closing, I would respectfully suggest a few considerations from folks who come from either sides of the issue.

For those who are inclined to doubt ADHD as a valid entity…

  1. Keep in mind that because something is subtle or difficult to measure does not make it unreal.
  2. Consider the possibility that at least some of the hundreds of studies of ADHD are not biased from the pharmaceutical industry.
  3. Know that most parents of children with significant attention problems and hyperactivity are doing a pretty good job and that you may not look so good either if the same child was in your house.

For those people, especially my fellow physicians, inclined to dismiss all ADHD critics as the lunatic fringe….

  1. Understand that we are not immune to the influence of money, prestige, or even the embarrassment of not being right all the time.
  2. Stay aware of the possibility that someone who is not entirely correct in one area might be somewhat correct in another.
  3. Be humble in our acknowledgement of the immense amount of really important things that we still do not understand when it comes to the brain.

I hope this small effort may serve to bridge many concerned and well-meaning people together. Nobody wants to see kids suffering needlessly. Neither does anyone want to see children being plastered with medications they don’t need.  It is time to get to work.

@copyright by David Rettew, MD

Image courtesy of David Castillo Dominici and

David Rettew is author of Child Temperament: New Thinking About the Boundary Between Traits and Illness and a child psychiatrist in the psychiatry and pediatrics departments at the University of Vermont College of Medicine.

Follow him at @PediPsych and like PediPsych on Facebook.