COMMENTARY

ADD and Stimulant Use: An Epidemic of Modernity

Michael E. Ruff, MD, FAAP

Disclosures

February 06, 2007

Success to Excess?

During my 14 years as a general pediatrician, I have always had a special interest in learning problems and attentional dysfunction. Stimulant medications have been a blessing, and I continue to use them in my practice for carefully chosen patients with great success. Over the past few years, however, I have become far more conflicted about the increased use of medication and about what has and has not been written in the mainstream pediatric literature on the phenomenology of attention-deficit/hyperactivity disorder (ADD). My professional vexation reached an epoch of sorts recently when I read an article stating that the popular television sitcom, "The Gilmore Girls," had hired dialogue coaches to help the actors speak faster so they could hold their targeted "tween" audience's attention more effectively.[1,2] The next morning I sat down with my mail before office hours. I chuckled under my breath because almost everything I received had something to do with ADD. There was a magazine entitled The ADHD Podium (sponsored by Shire and Adderall), which contained an article on how to use the DSM-IV criteria to diagnose and treat preschool children with ADHD. Next was a brochure and videotape from the University of Florida and Lilly (Strattera) on how to diagnose ADD in adults. Additionally, there were several faxes and letters offering to teach me more about the genetics, neurochemistry, and pharmacotherapeutics of ADD via dinner meetings and phone conferences. Finally, there were 3 magazines of different genres for my waiting room, all of which contained cover ads for Strattera boldly proclaiming: "Welcome to Ordinary" (via medication). By the time I was ready to pitch most of this in the trash and begin to see patients, my initial amusement had been replaced by bemusement. . . was my contemplation correct that the stimulant story had morphed from success to excess? Undoubtedly, the effectiveness of stimulant medication with heterogenous groups of individuals with academic and behavioral problems has encouraged wider boundaries in diagnosing ADD.[3] Do the small cadre of influential academicians who do the vast majority of research and invited commentary want community pediatricians to conceptualize this as a genetically determined phenomenon and largely ignore the critical sociocultural underpinnings of this phenomenon? Is the pharmaceutical industry seducing us into subsuming broader diagnostic categories for ADD and thus expand their markets?

The belief that ADD is a biologically based condition is promulgated in the pediatric and psychiatric literature.[4,5,6] This is the premise on which the prolific researcher, Dr. Joseph Biederman, has based over 95% of his published articles.[7] Many articles make reference to or examine ADD concordance in twins, neurochemical differences, mapping of loci, and structural brain differences seen on PET scan or functional MRIs. While ADD has a biologic substrate, the environmental contribution has been understated. For example, research on the structural differences in children's brains with ADD has been purported to support the biological basis of ADD,[8] and yet individuals with posttraumatic stress disorder (PTSD) also have significant structural differences in their brains compared with controls.[9,10,11,12] Therefore, one cannot conclusively distinguish between genetic and environmental etiologies when examining these structural differences. Gene-mapping studies have yet to yield any single loci or chromosomal region that is found consistently in the majority of individuals with executive dysfunction.[13] The concordance rate for ADD has been quoted as approximately 40% in fraternal twins and 80% in identical twins.[14,15] If 1 parent has ADD, a child is purported to be 3 times more likely to have ADD and 10 times more likely if both parents have it.[16] Yet, the dogmatic studies that make so much of the neurobiological contribution of ADD suffer from methodologic weakness that makes it difficult to separate out the effects of family heredity from family environment.[17] In other words, the apple may not fall far from the tree. . . but, if the tree subsists with suboptimal soil and moisture, it will not produce good fruit. Research has shown, for example, that mothers who are intrusive, overstimulating, and isolated, with fewer emotional supports, are more likely to have children that are viewed by teachers and care providers as hyperactive and distractible between ages 3 and 8.[18] In the words of Dr. Lawrence Diller, "Unfortunately researchers appear to be more interested in the environment of synapse than the environment of the child."[19]

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