Thursday, February 14, 2013

Beyond polemics: science and ethics of ADHD by Illna Singh (critique by Maylen Perez)

Over the past decade or so, there has been an alarming growth in the number of ADHD diagnoses, and, which is more disturbing, the prescription of stimulants for children with this condition. Concurrent with these increases has been a growing concern in the general public about the legitimacy of ADHD as a real disease and the repercussions and ethical issues of giving kids psychotropic drugs.

A hundred years back, this was not a problem. Kids would come to class, be disruptive, not listen, misbehave… and get a whopping smack in the hand or bum with some kind of discipline ruler or other blunt object. The teacher found this behavior to be typical of kids, the parents shook their heads wondering “where did we go wrong?” and life went on. Today, however, there have been striking advances in science that have given us some insight into the factors that contribute to ADHD, tools for recognizing the symptoms of this disease, and yet others for treating it. Or so it seems. Do we indeed have a robust and trustworthy method of detecting ADHD? Can we prove, beyond a doubt that this disease it truly real and not just a series of troublesome personality traits that society has to deal with? Unfortunately, the answer to these questions is not a definite “no”, but it is most certainly not a “yes”.

ADHD or normal behavior? (Source)

In 2008, Illna Singh published Beyond polemics: science and ethics of ADHD. This striking and informative review provides important insights into the state of ADHD research at the moment, the procedures and tools used to diagnose and treat this disease, and the ethical issues surrounding these topics that have mostly been swept under the rug.

As mentioned in the review, two main factors make ADHD difficult to diagnose. First of all, the core symptoms of ADHD (inattention, hyperactivity and impulsiveness) are similar to typical behavior exhibited by normal children. Second of all, ADHD is not diagnosed using the same criteria everywhere. There is the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) with less stringent criteria, and the International Classification of Diseases (ICD-10), with more stringent criteria. Apart from using different criteria, these manuals both use a categorical, rather than a dimensional, system of classification for this disease. Since ADHD has a heterogeneous distribution of symptoms, these categories also confound accurate diagnosis.

These issues with diagnosis have led people to take three different stands on the nature of ADHD and the moral value of using stimulants as treatment. Some people believe ADHD is completely biological and therefore should be treated with medication because it is a real disease that leads to cognitive impairment. There has been little evidence to suggest that dopamine and serotonin are implicated in this disease, but the effect size is small. Others believe that ADHD has both genetic and environmental causes and that medication is pertinent in some cases, but behavioral therapies should also be employed. Still others believe ADHD is wholly environmental and due to some detrimental event(s), and thus should not be treated with medication, but only with other therapies. There are also those people that still doubt ADHD is a real disease and their viewpoint is obviously that nothing should be done for treatment.

It would be very easy if the validity of ADHD as a disease was the only troubling factor for people. If this were the case, we could bring together social scientists, scientists, clinicians, psychologists, etc. to discuss the issues and formulate a more accurate and reliable way of diagnosing this disease. Unfortunately, the use of psychotropic, addictive stimulants, such as amphetamine, to treat ADHD in small children is the biggest concern of all, in my opinion. Not only have these drugs not been tested in kids, but there have not been any long-term longitudinal studies to assess the consequences of this treatment. Even more outrageous is the allegation that pharmaceutical companies that make these stimulants for treatment selectively publish results that make their drug look good, and hide results that suggest any detrimental effects.

Another not-so-small ethical concern revolves around the idea that we are getting better at identifying the factors that may increase a child’s risk of having ADHD. As mentioned in the article, indentifying risk factors would be useful in preventative treatment for the child, but would also bring to light ethical issues of discrimination and bias. I teacher could just as easily ignore and lose patience with a struggling student that is at risk for ADHD, as she could provide extra help for them to compensate for the possible disease. Moreover, the likelihood that ADHD children will develop further psychological problems in adulthood and become criminals may put a social stigma on anyone that is found to have the risk factors for ADHD.

Now, let’s consider the idea that stimulants do not “fix” ADHD, but are merely cognitive enhancers that compensate for the impairments caused by the disease. Should this change our view of its validity as a treatment? Stimulants have also been shown to enhance cognitive function in normal children, so is it valid to just medicate everyone and create a generation of extra smart kids better able to address the confounding environmental and sustainability issues of today? No consensus on these questions has been reached, but efforts to bring together people with different skills and experiences to discuss these issues would definitely help us tackle them more efficiently. Collaborations among scientists, social scientists and ethicists will help us understand what ADHD is, how to better diagnose and treat it, and what the ethical implications of doing so may be.

--Maylen Perez


Want to cite this post?

Perez, M. (2012). Beyond polemics: science and ethics of ADHD by Illna Singh (critique by Maylen Perez). The Neuroethics Blog. Retrieved on , from http://www.theneuroethicsblog.com/2013/02/beyond-polemics-science-and-ethics-of.html

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