ADHD Does not Exist

Richard Saul

• Publisher: Harper
• Year: 2014
• ISBN:
  9780062266750
• Topic: Psychologie
• Subtopic: Trouble déficitaire de l'attention (TDA-TDAH)

In this groundbreaking and controversial book, behavioral neurologist Dr. Richard Saul draws on five decades of experience treating thousands of patients labeled with Attention Deficit and Hyperactivity Disorder—one of the fastest growing and widely diagnosed conditions today—to argue that ADHD is actually a cluster of symptoms stemming from over 20 other conditions and disorders.

According to recent data from the Centers for Disease Control and Prevention, an estimated 6.4 million children between the ages of four and seventeen have been diagnosed with attention deficit hyperactivity disorder. While many skeptics believe that ADHD is a fabrication of drug companies and the medical establishment, the symptoms of attention-deficit and hyperactivity are all too real for millions of individuals who often cannot function without treatment. If ADHD does not exist, then what is causing these debilitating symptoms?

Over the course of half a century, physician Richard Saul has worked with thousands of patients demonstrating symptoms of ADHD. Based on his experience, he offers a shocking conclusion: ADHD is not a condition on its own, but rather a symptom complex caused by over twenty separate conditions—from poor eyesight and giftedness to bipolar disorder and depression—each requiring its own specific treatment. Drawing on in-depth scientific research and real-life stories from his numerous patients, ADHD Does not Exist synthesizes Dr. Saul's findings, and offers and clear advice for everyone seeking answers.

PART I

THE BIRTH OF A CRISIS

CHAPTER 1

Where We Are and How We Got Here

Imagine a person who is somewhat distracted or impulsive in nature. Someone close to them—a friend, parent, family member, or educator—recommends that they undergo a professional evaluation. They make an appointment with a family doctor or one they found within their health insurance network. If that doctor is like most physicians practicing today, he or she will ask the patient some general questions about their symptoms. More thorough physicians might ask the patient to fill out some forms—one possibly specific to ADHD (like the Vanderbilt Assessment Scale1)—but even assessments like these are becoming increasingly rare in practice. The doctor would then compare the patient’s responses to this list of symptoms, provided by the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders:2

Inattention

• Fails to pay close attention to details (for example, careless mistakes in schoolwork)

• Has difficulty sustaining attention in tasks

• Does not seem to listen when spoken to directly

• Does not follow through on instructions (for example, for schoolwork, chores)

• Has difficulty organizing tasks/activities

• Avoids, dislikes, or is reluctant to engage in tasks requiring sustained mental effort (for example, schoolwork)

• Loses things necessary for specific tasks (such as homework assignments)

• Easily distracted by external stimuli

• Forgetful in daily activities

Hyperactivity-Impulsivity

• Fidgets with hands/feet

• Leaves seat in situations where remaining seated is expected

• Runs about or climbs excessively in situations in which this is considered inappropriate (this often manifests as restlessness in adolescents/adults)

• Has difficulty engaging in leisure activities quietly

• Often on the go or acts as if driven by a motor

• Talks excessively

• Blurts out answers

• Has difficulty awaiting turns

• Interrupts or intrudes on others (for example, in conversations)

There are eighteen symptoms in total, but to meet criteria for the diagnosis, the patient would have only needed to display five symptoms from one or both of the categories. And, as easy as that, possibly in a matter of minutes, they went from being distracted or impulsive to having a classified “disorder.”

If you (or your child) have been diagnosed with ADHD, it most likely happened under circumstances similar to those above. It may have been a surreal moment, or perhaps it was an expected one. It may have seemed too quick of a judgment to be true, or perhaps you were grateful for an explanation that answered all of your (or your child’s) problems, but as we’ll see later, there are no shortcuts to finding the source of ADHD symptoms. For an evaluation to be effective, it must be thorough.

You’ll notice that the symptoms above are split into two categories: inattention and hyperactivity-impulsivity. Those diagnosed with ADHD fall into one of three subtypes:

predominantly inattentive type,

predominantly hyperactive-impulsive type,

or combined type.

According to the DSM, features associated with the symptoms include temper tantrums, stubbornness, volatile mood, rejection by peers, and poor self-esteem. I don’t have to convince you that the checklist above is highly prone to subjectivity. What level of disorganization is considered “too disorganized”? How much talking is “excessive”? Indeed, one could easily argue that the loose criteria above have led to an overstatement of attention deficit and hyperactivity in the population, associated, in turn, with a low threshold for diagnosis. Quite alarmingly, with the recent introduction of the DSM-V, that threshold for diagnosis of ADHD has dropped even further.

The ease and carelessness with which ADHD is diagnosed is nothing short of jarring, but like so many wrongs, the ADHD diagnosis took time to reach its current state of prevalence, steadily sneaking up to the cliff we see today. This chapter is about where we are now with regard to the diagnosis of ADHD, and how we got here. We will discover how our understanding of ADHD has evolved over time and why this presents a problem for individuals and society today.

A BRIEF HISTORY OF ADHD

THE STORY OF FIDGETY PHILIP

Let me see if Philip can

Be a little gentleman

Let me see, if he is able

To sit still for once at the table. . .

But fidgety Phil,

He won’t sit still;

He wriggles and giggles,

And then, I declare

Swings backwards and forwards

And tilts up his chair. . . .

THE STORY OF JOHNNY HEAD-IN-AIR

As he trudg’d along to school,

It was always Johnny’s rule

To be looking at the sky

And the clouds that floated by;

But what just before him lay,

In his way,

Johnny never thought about;

So that everyone cried out—

“Look at little Johnny there,

Little Johnny Head-in-Air!”

—POEMS WRITTEN IN THE LATE 1800S OR EARLY 1900S3

Some see these poems, most likely written at the turn of the twentieth century, as the earliest accounts of what we know today as attention-deficit/hyperactivity disorder. After all, Philip and Johnny do display elements of the two main symptom categories associated with the disorder called ADHD: inattention and hyperactivity-impulsivity. Today, more than a century after those verses were penned, parents and teachers could easily point to at least one Fidgety Philip/Phyllis or Johnny/Joanna Head-in-Air they know. Nor do Philip or Joanna have to be children; the estimated rate of adults diagnosed with ADHD is 4.4 percent.4 Everyone has a friend, colleague, or family member who has difficulty concentrating or staying on task; many adults self-identify as having “ADD” and make statements like, “Sorry I forgot to call; it’s my ADD again.”

But, as alluded to in the introduction, there’s a big problem here: The diagnosis and treatment of ADHD as we know it today are wrong. The symptoms of attention deficit and hyperactivity can be explained fully by other conditions, from something as simple as poor sleep, to something as complex as bipolar disorder. Fidgety Philip’s table manners could easily have been consequences of early-stage bipolar disorder or Tourette’s syndrome. Vision problems, depression, or a seizure disorder could have explained why Johnny’s head was always “in the air.” Through the historical lens we see that our understanding of distractibility and impulsivity has changed shape over time, and is likely to continue changing.

Symptoms associated with ADHD have likely been part of the human experience since before recorded history. As far as documented accounts of the disorder, Edward Hallowell and John Ratey, in their book Driven to Distraction, point to the 1902 description of a group of twenty children (fifteen boys and five girls) with strong traits of defiance and disinhibition by a physician named George Still.5 Dr. Still pointed out that the children had adequate parenting, and thus may have inherited a biological predisposition to the behavior—highly unconventional thinking at a time when most psychological and behavioral symptoms were attributed to the family environment. The physician-psychologist William James, too, saw a potential neurological basis for such behavior in children. Later, in 1934, Eugene Kahn and Louis Cohen published an article in the New England Journal of Medicine linking hyperactivity and impulsivity to encephalitis infections.

In 1937, Charles Bradley found additional evidence for the biological basis of attention-deficit hyperactivity when he treated children displaying such symptoms with Benzedrine, a stimulant. Soon after, child patients with attention-deficit symptoms were diagnosed with “minimal brain dysfunction,” or MBD, and treated with the stimulants Ritalin and Cylert. The DSM-II, which came out in 1968, labeled the symptom set “hyperkinetic reaction of childhood.”6 Maurice Laufer hypothesized that the syndrome was related to an overactive thalamus (part of the midbrain), an early explanation in a series of similar ones involving excessive activity within the central nervous system.

By the 1970s, it was commonly accepted that hyperactivity, distractibility, and impulsivity tended to cluster together, and that genetic-biological explanations for the symptoms were most apt, though difficult to prove conclusively. The DSM-III (1980) introduced the concept of attention deficit disorder with and without hyperactivity (ADD-H and ADD, respectively). Seven years later, the revised version of the DSM-III (known as the DSM-III-R) changed the label to attention-deficit hyperactivity disorder (ADHD), which remains the current name for the condition.7 The DSM-III-R and DSM-IV (released in 1994) had very similar criteria for ADHD. Studies conducted around the time of each manual’s release were essentially in agreement.8

An additional source of evidence that ADHD should not be diagnosed as a separate disorder is that some mental conditions (many of which are discussed later in this book) share a common genetic link with “ADHD.” Specifically, Harvard University research released in 2013 shows for the first time that some of the same genetic patterns underlie autism, depression, bipolar disorder, schizophrenia, and ADHD.9 The study examined the genetic codes of more than sixty thousand people with and without those conditions—the largest study to date of the genetics of these conditions. The lead researcher calls the findings “just a tip of an iceberg,” suggesting that deeper genetic linkages among multiple disorders are likely to be discovered. While these findings don’t “prove” that ADHD symptoms can always be explained by other diagnoses, they suggest that there is much more overlap among what we call “ADHD” and other conditions than previously thought, lending further support to my argument.

Nevertheless, this long and varied history of ADHD highlights the persistent ambiguity and controversy around the symptoms and their sources, a pattern that has continued into the present day.

THE LATEST CHANGES TO THE DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS

In May 2013, the American Psychiatric Association released the fifth edition of their “bible,” the Diagnostic and Statistical Manual of Mental Disorders.10 Despite the fact that we’ve seen tremendous growth in the number of people diagnosed with ADHD in the past decade, the DSM-V reflects even less strict criteria for ADHD than its predecessor, the DSM-IV. For example, where the DSM-IV required that symptoms should be “more frequent and severe than typically observed in individuals at a comparable level of development,”11 the DSM-V merely suggests that symptoms should be “inconsistent with development level.”12 Similarly, while the DSM-I...