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The ADHD Diagnostic Bubble

“My hometown has this problem, when they don’t know what is wrong with your child, they say it is ADHD”
(A frustrated mother)

“He will blurt things out; he does not know when it is time to joke around and when it is not… He will ask the silliest questions, like: What if an elephant can stand on mom’s head?” “What if a person comes out of a comic book, what would happen?”
With these words a Floridian mother described the behavior of the child whose story I chose to begin my debate over the inflated ADHD statistic. I perceive this case as a portrait of maternal courage and determination because when the question was:
Should I allow the school official to scare me or stand firm for my son’s well-being?

She opted for the latter and stopped the 30 mgs of Ritalin their pediatrician was prescribing for an alleged ADHD diagnosis that was actually made by the boy’s teacher. The busy physician didn’t hear the mother’s concerns about the worsening of behaviors, after the medication was started and decided to rely on the educator’s judgment. Frustrated but vindicated, the mother said:
“The school wanted him back on Ritalin. His teacher threatened to send him back every day that he misbehaved. I told her: do it!.”

Then she gave the following family history:
“His Dad is exactly like him… my father-in law has depression and on my side of the family, my mother had “manic-depression” and she died 3 weeks ago… my aunt has depression and my brother is a bad case of OCD.”
This boy’s Mental Status Examination showed an above average intelligence and good concentration. His artistic skills are evident in this drawing of a “new Picachu.”
After one sees a talented boy with a clearly elevated mood and a family history loaded with mood problems, the question is:

What kind of rationale could have been followed to diagnose a child like this with ADHD?

There are many possible explanations that I discuss in several sections of this book but a short answer could be:
Yes, even if we identify the elevated mood in the boy depicted above he could qualify for an ADHD label, according with the official diagnostic manual known as the DSM-IV and elaborated under by the American Psychiatric Association (APA).
I know of excellent psychiatrists and pediatricians that will detect the presence of mania in the boy described above and diagnose him as having ADHD and bipolar because the APA says so.
I have treated many children in such situation when they arrive to the inpatient unit with a full-blown episode of mania, psychosis, panic attacks and several other presentations that result from the injurious effects of amphetamines and antidepressants on bipolar individuals. In other cases it is a psychosis with hallucinations exacerbated by Ritalin and other stimulants.
I have a simple rule of thumb that I share with those friends that still have a big number of ADHD children in their practices:

If you diagnose more than two cases of ADHD in any given week you need to review your diagnostic criteria.

This is not to subtract merit to the validity of ADHD as an authentic psychiatric condition but to reinforce my disbelief of the current statistics attributed to this illness. I do not believe in the APA-endorsed statistics because I can not see any reason to explain why this should be the only country with an incidence of ADHD greater than 5% of school-age children. In fact, many developed nations report that ADHD occurs in less than 1% of the school-age population. Not surprisingly more than half of the Ritalin manufactured in the world is sold in USA.
This is one of the reasons I have asked, in several articles published by psychiatric journals, how my opponents could explain that only 1% of the patients I treat have ADHD and the other 99% are doing well?
If the whole idea presented in this book is wrong, it should be expected that a significant part of that 99% of my patients would decompensate, because I have diagnosed many of them as bipolar, obsessive-compulsive, psychotic, social anxiety, etc., and they actually have ADHD. In fact, the opposite is the truth: They are stable and doing well.
Nevertheless, in every single scientific article on the ADHD subject you will read the same chant chorused:
“ADHD is the most common mental health disorder of childhood, affecting 3 to 5% of the school-age children.”

When I see that phrase I can’t help but think of the historical blunder recorded when the Inquisition forced the Italian astronomer Galileo to declare that the Earth (and not the sun) was the center of the universe.
By the way, the National Institute of Mental Health (Consensus Statement, 11-18-98, page 5) acknowledges that other nations have a lower rate of ADHD:

Although the prevalence of ADHD in the United States has been estimated at about 3 to 5 %, a wider range of prevalence has been reported across studies. The reported rate in some other countries is much lower. This indicates a need for a more thorough study of ADHD in different populations and better definition of the disorder.”

It seems obvious that top experts recognize a need to improve the ways we use to diagnose ADHD but nobody wants to take the first step in changing what is being taught in American academic centers about ADHD and mood disorders. That change is necessary because the academics are obligated to follow guidelines, similar to what Federal Judges have to do when applying mandatory sentences in certain types of cases. In other words, if DSM-IV states that children who exhibit defiant behavior should be diagnosed with Oppositional-Defiant Disorder (ODD), that is exactly what they have to do.
Hundreds of youths and their parents know from personal experience that current parameters to diagnose children with mental illness are obsolete and confusing but the establishment persist in its mistakes. This is why I keep copies of the evaluations I have done on children previously diagnosed as Conduct Disorder or Oppositional-Defiant Disorders (with names deleted) and they are available to anybody who questions this pronouncement:
How could these diagnoses have validity if not even one child, out of hundreds, persisted showing disordered conduct, after I detected the real illness and was treated with the appropriate medication.

Why nobody comes forward and tries to discuss my findings I can not understand, but I provide more details on this subject in the chapter “There Is No Such Thing as ODD.”
At this point, I want to introduce the official definition of the word prevalence because I am obligated to use it many times. Several medical dictionaries define it as:
“The number of cases of a disease existing in a given population at a specific period of time or at a particular moment in time.”
With that in mind, take a look at a report from “U.S. News & World Report” (11-23-98) on a long and expensive study conducted by the National Institute of Mental Health to determine the effectiveness of Ritalin alone vs. Ritalin combined with psychosocial interventions. The lead investigators in this study are highly regarded researchers but they also seem to have fallen into the generalized mistake of labeling children with mood disorders as ADHD.
I am 100% sure they misdiagnosed some of their volunteer patients because they report data on children who have ADHD and Conduct Disorder as well as ADHD and Oppositional-Defiant Disorder and we know that ODD and CD are in fact diagnostic disguises for other conditions. I have conclusive evidence (already published in psychiatric journals and reproduced in this book) demonstrating that when ADHD is diagnosed in the same person also labeled with CD or ODD, and exhibits clear mood problems, the real illness is not ADHD.

Now look carefully at what the NIMH’s document mentioned above says under “Introduction,” page 5:
“Attention deficit hyperactivity disorder (ADHD) is the most commonly diagnosed behavioral disorder of childhood, estimated to affect 3 to 5 % of school-age children.”

If we interpret this statement following the definition of prevalence presented above, how many individuals in the USA should have ADHD?

The 2000 census counted 281,421,906 people living in this country and 20% (more than 50 million) of that population represents school-age children, the number of American children with ADHD should be close to two million. However, I am not the only one questioning the real number of children with ADHD. One of the best textbooks of Psychiatry (Kaplan & Sadock, 9th edition, 2003, page 1223) reports that in the USA there is a wide range of fluctuation on statistics about this condition. It also says that the incidence (defined as the number of new cases) of ADHD in Great Britain is less than one percent.
Furthermore, considering that many studies have demonstrated the high number of children who have been misdiagnosed as ADHD, I can not help but wonder what the researchers are going to do with the thousands of books and research studies that were based on faulty ADHD statistics?
This issue actually represents a Pandora Box of astronomical proportions that many are afraid to open. Just imagine the nightmare that will arise from the admission that more than half of research studies in pediatric psychiatry are meaningless because they used samples contaminated with wrongly diagnosed patients.
To put it in simple words, many children with mood disorders, anxiety, OCD, PTSD, psychosis, sexual abuse and neglect, etc., were mislabeled with ADHD to participate in research investigations whose outcomes are now used as the “law of the land".
A sad example will be the so-called “Multimodal Treatment Study of Children with Attention-Deficit Hyperactivity Disorder, also know as the MTA.” Despite the reputation and qualifications of the lead investigators in this study, which are highly regarded researchers, the outcomes are irrelevant and ill-founded. That is the case because they also have fallen into the generalized mistake of labeling children with mood disorders as ADHD and defining them as having Oppositional-Defiant Disorder or Conduct Disorder, which have proven to be invalid diagnosis in my data.
To give you an idea of how “lost in space” this study was, look to what the journal Clinical Psychiatry News, (January 2001) reported in reference to the MTA findings:
Medications were effective for children with ADHD but not for those with “ODD symptoms.”

From my perspective that outcome ratifies my theory because those “ODD” children could not respond to medication for ADHD because they did not have it.
But if you still have doubts about what I state in this book take a look at the outcome of a short study I conducted in Phoenix, AZ. It was a review of the diagnostic accuracy in children referred from the community to two inpatient units, one for children and another for adolescents. It shows the following:

From May 1999 until January 2000, 84 patients, ages four to 17 years and a half, were admitted to my care. They were referred to the hospital by their psychiatrists. Four of them came from two Indian Reservations.

In this Managed Care environment, we do not have to explain that hospitalization was the last resource after long attempts to control their symptoms or behavior in the outpatient setting.

As you can imagine, 43 of the 84 children and youths were on stimulants when they arrived at the hospital. Nine were on antidepressants, despite having clear signs of an elevated mood.

For 7 patients the referring psychiatrist did not include the diagnosis of Sexual Abuses of a Child, even though such history had been previously documented. In nine other cases the missing diagnosis was of substance abuse.

When the children were evaluated by me, four of the “violent ADHD” had their diagnoses changed to Intermittent Explosive Disorder (IED), a condition that gets worse on stimulants like Ritalin and the amphetamines.

I should explain that if these numbers do not add to the total of 84 it’s because in several cases a particular patient carried more than one diagnosis. But the really astonishing finding is that 64% of those patients arrived at the hospital with a wrong diagnosis and, consequently were on the wrong medication. Children in full state of mania (racing thoughts, grandiose demeanor, aggressive or “dare devil” behavior, insomnia, etc.) were still receiving amphetamines. A few others were having hallucinations (“hearing voices”) while being “medicated” with stimulants.

I feel comfortable stating that my diagnoses were correct because, once hospitalized and re-diagnosed with treatment changes, all these patients got better. Not surprisingly, some of the letters inserted in the chapter “What Parents Have to Say” come from this experience. One of them, the mother of a 9-year- old boy had said to his previous psychiatrists:
“Doctor, I am Bipolar and I take lithium. I think that my sons got what I have.”

That boy ended up in the hospital because his psychiatrist, instead of listening to her, handed out a Ritalin prescription with this pronouncement:
“He is too young to be Bipolar and we have to increase his medication.”

I know this is the reality in many pediatric psychiatric hospitals but, unfortunately, as Larry David says, every day I have to “curb my enthusiasm” because nothing is going to change in the near future. Most psychiatric researchers may ignore these findings with this comment “This is not scientific data.”
Because this might occur, here is a second set of data that should help you to make up your mind about who could represent the truth in this debate.
During a five-month period I treated 645 patients in a Southern state on an outpatient basis but in the same age group as the inpatient sample. This is the outcome:

Almost half (48%) of the patients that had been evaluated and/or treated with medications and psychotherapy carried a wrong diagnosis. Very few, 2.5%, had never been treated with psychiatric medications.

Like the inpatient group, several children also said, “nobody asked before”. Some of them were talking about auditory hallucinations, but unfortunately two were referring to sexual abuse. You will find more details in the chapter “The Perfunctory MSE”.

Finally, the last set of patients to be discussed is categorized as youths incarcerated due to “unruly” or “incorrigible” behavior.
I found that almost 100% of those diagnosed with the popular combination ADHD, CD and ODD had a mood disorder, anxiety, psychosis or IED. Clinicians kept combining these 3 diagnoses even though DSM-IV clearly states that Conduct Disorder (CD) and Oppositional-Defiant Disorder (ODD) should not be diagnosed together.
The set of patients in correctional settings is discussed in more detail in the chapter “A Human Touch Behind Bars.” Here I will only say that 56% of the youths had a wrong diagnosis, repeated many times, despite multiple evaluations by several psychiatrists in the community. If you wonder how something like this could happen in a country with such sophisticated medical technology, here is a clue:

Less than 1% of the youths in the correctional system I surveyed had been diagnosed as having a mood disorder when they living in their community of origin.

That’s a significant contrast with the scenario that many investigators have reported in adult-population jails. In that setting almost everybody agrees that there is an overrepresentation of psychiatric diagnosis (other than ADHD), when compared with people in the community.
What could be the explanation for such difference between incarcerated youths and jailed adults?
Wouldn’t it be reasonable to think that the “today’s emotionally-distressed adult inmate” was once a child with emotional problems? That is an answer that I can’t wait to hear but also that I don’t foresee coming in a near future.
Meanwhile, I try to join efforts with parents and patients to deal with this archaic psychiatric establishment that runs the show in our professional setting.
The only positive signs, so far, come from the publication of new papers reporting the presence of mood disorders in children. But there is also a continue flow of discouraging news, like this one:

The December 2000 issue of “Psychiatric News” (page 42) brought a report entitled “Study to Assess Ritalin Use in Preschoolers with ADHD.” It talks about a research project to investigate the effect of methylphenidate (Ritalin, Concerta, Metadate and Focalin’s generic name) in children under the age of 6.
As doctors should know, the FDA has approved Ritalin only for children over 6, but pediatricians and psychiatrists have been prescribing it for practically any age. This new study appears to be already condemned to result in another disappointment for the clinicians on my side of the controversy because, despite the fact that very talented people are going to participate in it, I think it will be “more of the same” since they are already talking about “extremely high scores on the ADHD symptoms.” My concern with their methodology is that to estimate those scores they are using tools that are not specific for ADHD. Some of these rating scales mix together symptoms of mood disorders, anxiety, PTSD, OCD with those usually attributed to ADHD, which leads me to suspect that those “severe” ADHD cases are not going to be real ADHD but in fact missed cases of “something else.”

Because I understand how disrespectful this could sound to the researchers involved in the above-mentioned project I want to clarify that it is not my intention to hurt or to offend anybody and especially those that have made significant contribution to psychiatry. To one of them, in particular, I am grateful for granting me the opportunity to enter into a very good fellowship program in child psychiatry. But the fact is that even the “Grandfather of psychiatry,” Sigmund Freud was wrong multiple times and we all can make mistakes.
Just consider this: I found a vignette supposed to describe a “textbook case” of ADHD in a book written (in the 90s) by a world famous ADHD authority in which he confuses manic-depressive illness with ADHD. He even reports clear mood swings in his patient and a family history of bipolar disorder but ends diagnosing ADHD. It is very possible that this researcher would diagnose (in 2005) that person as having a mood problem if conducting the evaluation these days. Similar change in theoretical orientation would be a blessing for the outstanding researchers responsible for the MTA mentioned above. This study is revered by clinicians, journalists and researchers as if it were a revealed truth from God when the fact is that it has multiple weaknesses. One of them, already mentioned above, was the inclusion of children with diagnoses of ODD and CD in conjunction with ADHD.
In my experience, such diagnostic mélange 99% of the time indicates “none of the above” and that explains why Ritalin didn’t work in the patients who had dual diagnosis of ADHD and ODD. My question to this group of devoted and famous researchers, on this particular matter, is:

Why to even think that amphetamines could change the behavior of a child who is defiant and oppositional toward authority figures?

Trying to understand such beliefs, a famous psychologist and researcher, Dr. Michael Manos once told me that children with ADHD become aggressive and defiant secondary to chronic frustration and, in fact, that theory sounds like a reasonable explanation for some of the impulsive aggression. On the other hand, when we look at the conduct of a 4 year old boy killing rabbits and birds and laughing about it, to attribute such a bizarre behavior to ADHD appears to me as a high dose of denial of those reluctant to diagnose serious mental illness in children.

By the same token, it would be equally difficult to use Dr. Manos’ rationale to explain the extreme reaction of another child who “destroyed his room” (his mother’s words) because he was grounded for refusing to go to sleep at midnight.
Furthermore, why children who are able to show remorse, and most of time are compassionate and caring, would be intentionally “bad” at other times?
I strongly believe that when they show inappropriate behavior we should search for a reason that could explain it instead of looking for “the right punishment.” Unfortunately, the child-blaming label of Oppositional-Defiant Disorder (ODD) diagnosis is based on the opposite premise.
I regret to oppose those who have taught many generations of psychiatrists and psychologist but my obligation to patients and their parents stands above personal sympathies. Besides, to accept the validity of ODD and Conduct Disorder as real diagnoses would betray my clinical and research findings.
I have hundreds of patients who are functioning at their maximum after ODD/CD were replaced by the correct diagnosis, and this data is available to anybody who want to see it, but to conclude I am going to reproduce a letter published by the scientific newspaper NeuroPsychiatry (May 2001):

I disagree with a comment included in the report about the Multimodal Treatment Study of Children with ADHD (February, cover story). The writer said that the trial “sparked controversy in some quarters when its initial findings, published in December 1999, were misinterpreted as a blanket endorsement of pharmacotherapy over behavioral therapy.”

I believe the results were correctly understood, and after evaluating more than 2000 children over the past four and a half years, I am convinced that “true” ADHD children do well on medication alone. Therapy actually helps mostly the family and educators than the child.

Like diabetes, ADHD is a biological condition and requires a medication that remedies the “chemical imbalance.” Type II diabetes can be corrected with diet and weight reduction but Type 1 requires insulin. The same is true with ADHD: The “pure” variety requires medication, but patients with co-morbidity need some other type of intervention, besides the pharmacological one.

On the other hand, many investigators are overlooking a scary truth that nobody wants to acknowledge: Most children diagnosed as having ADHD are actually affected by a condition falling within the realm of the bipolar spectrum disorders. These children are labeled as having ADHD plus conduct disorder, or ADHD plus oppositional-defiant disorder, or ADHD plus anxiety. (DSM-IV prohibits the diagnosis of oppositional-defiant disorder if the child meets the criteria for Conduct Disorder.)

I surveyed 450 children in Arizona and 618 in Tennessee with bipolar spectrum disorders and found that between 45 and 56% of them had been misdiagnosed, in some cases for as long as 5 years. Several other clinicians have found the same, but we have no voice. Even people, like Dr. Janet Wozniak, with her impressive Harvard Medical School credentials, cannot get the point across; instead, researchers are still saying that ADHD is more common than mood disorders. Children are being placed in jail or residential treatment centers because their elevated mood and lack of insight is viewed as “oppositional-defiant” behavior. Once again, the victim is taking the blame.

Manuel Mota-Castillo, MD

Another child & adolescent psychiatrist, Dr. Irene Abramovich, who practices in West Hartford, Connecticut, sent the following letter to the same publication, Neuropsychiatry:

I would like to join Manuel Mota-Castillo, MD, in his evaluation of the current controversy concerning attention-deficit/hyperactivity disorder (ADHD) and bipolar disorder (May, “Letters").

It has become customary in my practice to see a couple of children a week with florid bipolar disorder who have been treated for a nonexistent ADHD by their pediatricians or, even worse, by one of our colleagues. Not infrequently, I see adults with the same presentation who wobbled through life trying different remedies for ADHD, not finding any help and gradually losing their grip on life because they had been treated for the wrong condition. Unfortunately – and Dr. Mota-Castillo is right again - the voices of Drs. Janet Wozniak and Joseph Biederman are not heard.

I believe that several factors contribute to this sad picture. For one, pediatricians wrongly feel competent to diagnose and treat any psychiatric condition despite their lack of appropriate training. The American Society of Clinical Psychopharmacology inappropriately lowered the bar, welcoming any physician (with or without psychiatric training) to be a prescriber of psychotropic medications and totally ignoring the dangers of misdiagnosis.

Second, psychiatrists trained solely in the tradition of developmental pathology and the psychoanalytic approach has a very difficult time accepting the reality of biological psychiatry. As a consultant for a special board of education, I frequently find myself in a difficult position when my diagnosis of bipolar disorder or psychotic disorder causes a furious reaction from my colleagues who had been treating the child for a couple of years for “ADHD” and ignoring the fact that their therapy and stimulants were, at best, not helpful. It is becoming a difficult moral dilemma for me: how to divulge the truth to parents without undermining the reputation of guild and at the same saving the face of the treating psychiatrist after his or her major diagnostic blunder.

The third part–and probably the most hopeless—concerns the lack of appropriate education for pediatric fellows: Who is to teach if the teachers themselves are not equipped with appropriate diagnostic tools and knowledge? I would like to share my experience with residents and fellows, but it is not possible in the conservative milieu in which we live. So, in the absence of a better solution, I can only continue to collect more and more knowledge about the interplay between ADHD and the great chameleon, bipolar disorder, and try to help as many of my patients as I can in the solitude of my private practice.

Irene Abramovich, MD, Ph.D.

This letter came as a healing balm for those who, at times, feel like we are fighting alone against an establishment that would never change. In fact, the reality is that truth always wins. Sometimes it takes decades or even centuries but, in the end, rightness would defeat wrongs.

(Drs. Mota and Abramovich letters reprinted with permission from Neuropsychiatry)

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