ADHD is a brain disorder that can be treated
With each instalment of their $10-million, unscientific, “review of the evidence,” we hope that our medical colleagues will be moved to act and demand that the Therapeutics Initiative be de-funded again.
This time, the Initiative’s unnamed group of “75 experts and primarycare physicians” took aim at the treatment of attention deficit hyperactivity disorder (ADHD), cherry-picking research and grossly misrepresenting the evidence to support their nefarious claims and prejudices.
Reading the Initiative’s assertion that “teachers, parents and physicians are medicalizing a social rather than a medical problem” was a real blast from the past ... reminiscent of blaming mothers for schizophrenia and labelling wounded warriors with PTSD as having LMF — that’s Low Moral Fibre.
The debate concerning whether it’s safe and appropriate to treat ADHD is the psychiatry equivalent of the childhood vaccination debate. In both cases, the science is abundant and unequivocal. The decision not to vaccinate poses a personal risk to the child but also has societal implications, putting vulnerable children who cannot be vaccinated at risk.
Likewise, there is an abundance of high-quality evidence demonstrating that ADHD is a brain disorder and that a failure to diagnose and treat ADHD can have serious personal and societal implications.
ADHD is a neuro-developmental disorder that affects up to eight per cent of children and four per cent of adults. While it was once considered a childhood disorder, with enhanced brain imaging research we now know that at least half of adults who had childhood ADHD continue to experience significant symptoms and functional impairment.
The Therapeutics Initiative suggests ADHD is nothing more than a “social” issue, or a normal variant of childhood behaviour associated with starting school too early. Yet there is an abundance of replicated research evidence proving that children and adults with ADHD have widespread brain structure and size differences that are directly correlated with the symptoms of ADHD. It is also the most inheritable psychiatric disorder.
The diagnosis of ADHD may include symptoms of inattention, hyperactivity, and impulsivity, but also includes an inability to meet age-appropriate functional demands at home, school, or work.
ADHD is not associated with intellectual impairment, but children with ADHD often struggle academically and socially because of the delayed development of critical brain areas. In school, they are told they are not living up to their potential, but often they receive a blunter assessment: you’re lazy, disruptive and frustrating.
Inattentive kids are forgetful, lose their belongings and fail to complete tasks. They struggle to focus on topics or activities they find boring, which is why ADHD was once called “the math disorder.” They read later than their peers, and adults with ADHD often report that, due to an inability to focus, they have never been able to read anything longer than a newspaper article.
Hyperactive kids are disruptive; they can’t sit still or work and play co-operatively. Impulsive kids can’t wait their turn, they’re intrusive and they have more serious accidents. Many children with ADHD are irritable and have explosive tempers. As a result, they struggle to make and keep friends, impacting their self-esteem which may ultimately hinder their success in adult life.
Compared with their peers without ADHD, adolescents with untreated ADHD are less likely to complete high school or post-secondary education, more likely to abuse illicit substances, have more driving infractions and serious accidents, and are more likely to have an unwanted pregnancy or a sexually transmitted disease. As adults, those with ADHD are more likely to be incarcerated, divorced and cause a fatal car accident. Those are costly personal and societal issues.
The increased use of ADHD medication in B.C. is heartening because it suggests that more children are being diagnosed and treated. However, with only four per cent of B.C. children receiving treatment, ADHD is still under-diagnosed and often goes untreated.
Not every person with ADHD requires medication. Talk therapy and education about ADHD are considered important first-line interventions. Accommodations at school, allowing more time for projects and tests, as an example, can be invaluable. However, large review studies have demonstrated that those types of interventions have inconsistent effects on ADHD symptoms compared to medication treatments. If skills building and support are insufficient, ADHD medications are among the most effective treatments in all of medicine and for most patients, they are very well tolerated. Because we prescribe them for children, they’re also among the most well-researched treatments in medicine. We also have a wealth of clinical experience, because we have been prescribing them for ADHD for more than 80 years.
Treatment for any disorder comes with risks, and every patient (or their parents) must weight those risks against the potential benefits. Parents must receive information regarding the pros and cons of any treatment from their health care provider and make an informed decision that makes sense for their child and their family.
It is the responsibility of every family doctor, pediatrician, and psychiatrist in B.C. to know the research evidence regarding the safety and effectiveness of ADHD treatments and offer that information to patients/ parents, so they can make an informed choice. Likewise, the B.C. government has a responsibility to ensure that they only fund programs that improve the care British Columbians receive. The Therapeutics Initiative are doing a disservice to children and youth in B.C. and Canada by presenting clinicians with biased and inaccurate information.
Doctors who read the research and actually treat patients believe that, much like the individual and societal value of vaccinations, the evidence for ADHD is unequivocal: it is a brain disorder that impacts a child’s development and achievement and negatively impacts society. Gratifyingly, for most of our patients, appropriately treating their ADHD is beneficial for their entire family.
The fact that the Therapeutics Initiative cloaks their opinions as “science” is appalling. Their newsletter would never be published in a peer review journal and yet it has now reached clinicians, and, therefore families, across Canada. Their unnamed experts are unlikely pediatricians or child psychiatrists, which seriously undermines their ability to provide credible evidence-based guidelines for treating children and youth with ADHD.
Despite the mountains of evidence and 80-plus years of treatment experience, the Therapeutics Initiative opines that ADHD is merely a “social problem” and not a medical one. The scientific evidence shows us that it is both.
Drs. Diane McIntosh, BSc Pharmacy, MD, FRCPC, psychiatrist and clinical assistant professor, UBC; Derryck Smith, MD, FRCPC, psychiatrist and professor emeritus, UBC; Don Duncan, MD, FRCPC, psychiatrist and clinical assistant professor, UBC, clinical director, B.C. Interior ADHD Clinic; Dorothy Reddy, BSc, MD, FRCPC, research fellow, psychiatrist; Julia Hunter, BSc, MSc, MD, FRCPC, psychiatrist.