Attention deficit hyperactivity disorder is an example of bad medicine

Whitely’s commentary on Levy’s (2014) article ‘DSM-5, ICD-11, RDoC and ADHD diagnosis’ is welcome. In contrast, Levy’s article does what adherents to the faith that our psychiatric diagnoses have a basis in our biology often do, which is promise that we are on our way to finding these putative biological underpinnings without offering any evidence to support this. Levy admits that the Diagnostic and Statistical Manual of Mental Disorders/International Statistical Classification of Diseases and Related Health Problems (DSM/ICD) approach has failed to improve reliability or our ability to predict treatment response. This is a welcome admission, although she understandably avoids delving into the thorny, but important, territory of validity. What is tiresome is that these admissions are usually only made when we have a ‘new kid on the block’, which in this case is the Research Domain Criteria (RDoC) from The National Institute of Mental Health in the United States. The brave new world of RDoC promises us psychiatric classification that matches diagnoses to putative biological features/mechanisms. Haven’t we been here before? Isn’t that one of the things DSM criteria was supposed to help us achieve?

Given that spending for research on the biological underpinnings of mental disorders dwarfs other mental health research, we are entitled to ask what insights such endeavours have delivered into the cause or treatment of mental disorders. As Levy and others confirm, decades of brain and gene based research has delivered nothing of any scientific or clinical value. Indeed, existing research mainly points to causal associations with real-life contexts and experiences and in treatment to the centrality of the therapeutic relationship, with the technical approach of matching treatment to diagnosis having a clinically insignificant impact on outcomes (Bracken et al., 2012). Typical of those who wish to uphold the faith, Levy looks towards the RDoC to solve the problem of the lack of biological evidence, but can only offer the reader a promise of ‘jam tomorrow’. Surely, the possibility that the reason that we cannot find obvious biological correlates is because there are none must at least be considered. A properly scientific (rather than faith based) approach would be to assume that the behaviours we label attention deficit hyperactivity disorder (ADHD) have no direct genetic/biological until proven otherwise.

Whitely in his timely critique explains why Levy might have been reluctant to explore the territory of validity. He gives examples that illustrate many of the problems around validity. For example, Diagnostic and Statistical Manual of Mental Disorders–Fourth Edition (DSM-IV) guidelines note that ADHD behaviours may be minimal or absent in a number of settings such as when the person is under close supervision, a novel setting or engaged in especially interesting activities. He argues that even if a genetic basis for certain behavioural characteristics were found (and as he points out with a telling example we are a long way from that), we still have to run the ‘so what’ test and ask why such behaviours should be treated as disorders rather than differences. Deciding where to draw the line between what we consider part of the ‘ordinary’ spectrum of behaviours and what we decide is ‘pathological’ is more dependent on cultural than scientific processes. I have previously argued (Timimi, 2005; Timimi and Leo, 2009) that the rapid expansion in the use of culturally constructed diagnoses like ADHD, together with giving children powerful stimulant medications to control their behaviour, is a damning indictment of the position of children in neo-liberal cultures, rather than an indication of scientific progress. The continuing absence of biological support, together with the avoidance of engagement with questions of validity, leads me to believe that this assertion remains relevant.

Time for a rethink

Critiques like Whitely’s matter ultimately to the children and families that get saddled with the ADHD label and particularly those who end up taking stimulants. How often do practitioners discuss the potential effects of stigmatisation? Is it explained to parents and children that, as it stands, a diagnosis of ADHD is simply a description, cannot function as an explanation and is based on subjective opinion of the diagnoser? When it comes to medication, practitioners and patients are all too often left in the dark as international guidelines have much to say about starting stimulants, but little to say on how long you should use them for or how you would stop them. The latest paper looking at long-term outcomes following treatment with stimulants (Currie et al., 2013) concurs with other naturalistic studies, finding that long-term exposure to stimulants does not improve outcomes and may in fact lead to poorer academic performance and an increase in other psychiatric problems.

I agree with Whitely’s position. It is time to face up to the reality that ADHD is a prime example of bad medicine that is putting children at greater risk of negative outcomes. It is time to drop our reliance on such faith-based pseudoscience.

See Debate by Whitely, 2015, 49(6): 497–498.