264: Who Really Decided Your Child Needs ADHD Medication?

One doctor in rural Georgia was quoted in the New York Times explaining why he prescribed Adderall and Concerto, not because children had real ADHD, but to help them in “financially strapped subpar schools”. In his words, I don't have a whole lot of choice. We've decided as a society that it's too expensive to modify the environment, so we have to modify the kids.

Hi, I'm Adrian in suburban Chicagoland, and this is Your Parenting Mojo with Jen Lumanlan. Jen is working on a series of episodes based on the challenges you are having with your child. From toothbrushing to sibling fighting to the endless resistance to whatever you ask, Jen will look across all the evidence from thousands of scientific papers across a whole range of topics related to parenting and child development to help you see solutions to the issue you're facing that hadn't seemed possible before. If you'd like a personalized answer to your challenge, just make a video if possible, or an audio clip if not, that's less than one minute long that describes what's happening and email it to support@yourparentingmojo.com and listen out for your episode soon.

Hello and welcome to the Your Parenting Mojo podcast. Today we begin a mini-series within our extended series on mental health focused on ADHD across three episodes I have planned so far, although I'd say there may well end up being more. In this first episode we're going to introduce the medical model of ADHD, which positions ADHD as a chronic highly heritable brain disorder. I actually ended up splitting this into two parts because it got too long for one episode, so here we're going to start out with what Dr. Russell Barkley says ADHD is. He's a leading researcher in the field. We'll look at how it's diagnosed, the problems with the diagnostic process, including the cultural values baked into the criteria. We'll look at the financial conflicts of interest that Barkley and other influential researchers have had with pharmaceutical companies and we'll examine why diagnosis rates vary so much across states and how school accountability policies drive at least part of some of those differences. We'll hear about some pretty scary life outcomes for people with ADHD and the drug company ads designed to terrify parents into medicating kids. In the next part we'll dig into whether ADHD really is a chronic lifelong condition because it turns out that for up to 64 percent of people symptoms fluctuate enough that they move in and out of the diagnostic category. We'll look at whose perspective counts in diagnosis, kids or parents, and what the medication actually does and doesn't do for kids and their learning. We'll hear from kids about what it's like to be on these drugs and then we'll look at the history of how ADHD became a disorder, the values that are embedded in Dr. Barkley's framework, and some potentially alternate pathways for those negative outcomes that give us very different ideas about how to support people with ADHD. And then in our third episode we're going to look at more neuro-affirming ways to support people with ADHD which starts with focusing on their strengths and listening to them about their experiences rather than having researchers who mostly don't have ADHD assuming that they know best what people with ADHD should do. So as I started looking at this whole topic it very quickly became clear that Dr. Russell Barkley was the go-to person to talk to about this. He's the editor of the almost 900-page book Attention Deficit Hyperactivity Disorder, a handbook for diagnosis and treatment that I have read in its entirety. From here on I'm just going to refer to it as the big handbook. Dr. Barkley has conducted well-respected work on ADHD throughout his career. He's published dozens of books and hundreds of papers. And I realized as I was thinking through what this episode would be like and reading his books, one of which is called The Defiant Child, that I disagreed with some aspects of his ideas. So I reached out to him and asked if I could interview him. I made sure to explain that I disagree with some aspects of his framing but I would treat him respectfully. He declined to participate with the reason that he's now retired and no longer gives interviews, which of course is his right.

But fortunately, he has a very active YouTube channel where he explains his ideas pretty thoroughly, so we're going to hear from his videos there instead as we think about what ADHD is and how we should support people who are diagnosed with it. So I do want to be clear up front. I'm not here to tell you that ADHD isn't real or that nobody should ever take medication. I am not anti-medication. If medication helps you or your child and you've made an informed choice about the trade-offs, that's a totally valid decision that I respect. What I'm questioning is the medical model framework itself, the assumption that ADHD is fundamentally a disorder that should be fixed rather than a difference that should be accommodated. Now are we thinking about ADHD in the right way when we frame it as a deficit, something broken that medication usually alone can solve? Because something about that doesn't add up to me. The medical model tells us ADHD is a chronic brain disorder that is highly heritable. It also says that people with ADHD face pretty awful outcomes, reduced life expectancy by 7 to 13 years depending on the data source, higher rates of pretty much every bad thing you can think of from dropping out of school to STDs and poor health. And the solution is medication, ideally started early and continued lifelong. But then when I look at what actually happens, it doesn't always match that story. Kids say medication makes them not themselves and most of them have stopped taking it by adulthood. And when you dig into those scary outcome statistics, it turns out they're mostly about people who aren't consistently treated, so we can't actually tell whether medication would have prevented those outcomes or not. And I will also tell you right now, I don't have all the answers. This is really complicated. The field of research is massive, hundreds of thousands of papers, and I've read hundreds of studies but I don't claim to be an expert on this. Fortunately, there are some experts whose ideas we can draw on and those people are sometimes but not always scientists. We also have to listen to people with ADHD and a lot of them have ideas about how they want to be supported that's quite different from what mainstream research says. We're going to get more into that in our second episode in this mini arc. So, let's in this episode begin to lay out what Russell Barkley says about ADHD and I do want to be fair to his position so we're going to hear from him directly. So how do we actually know if someone has ADHD? Well according to the DSM, that's the Diagnostic and Statistical Manual that psychiatrists use, which we covered in depth in our conversation with Dr. Allan Horwitz. You need to meet certain criteria. So, here's Dr. Barkley with an overview.

18 symptoms that are broken down into two dimensions of behavior. These are the two psychological traits that are not developing on time in people with ADHD. One dimension, which has nine symptoms, is that of inattention. The second dimension, also having nine symptoms, is that known as hyperactive impulsive behavior or essentially what I call disinhibition. For children you have to have at least six of the nine symptoms on either of these lists in order to be diagnosed with ADHD. We lower the criteria somewhat down to five symptoms on each list for anyone 18 years of age and older. They don't need as many of these symptoms to be developmentally inappropriate the way children do. Now important to understand is that each of these symptoms is qualified by the descriptor often, which means the symptom has to occur often or more frequently in order to be endorsed. It can't just be some of the time or occasionally or rarely. That's very important because very few typical people endorse a symptom when the word often is indicated as its frequency in an individual. Only about three to perhaps 10% in some cases of the general population would endorse that item for themselves or for their children. And requiring that at least six or more of those symptoms be developmentally inappropriate further winnows down or decreases the likelihood that someone will be diagnosed. All of that is to say that we're not simply diagnosing normal childhood behavior with the label of a neurodevelopmental disability or a psychiatric disorder.

The criteria are things like often fails to give close attention to details, often has difficulty sustaining attention, and often fidgets or squirms. These symptoms have to have been present for at least six months to a degree that is maladaptive and inconsistent with developmental level. But there are some big problems with how these criteria work. As Dr. Barkley says, the diagnostic criteria rest heavily on that word often that appears in every single criterion. And who decides how often is often? There's no objective measure. One teacher might think a child fidgets often while another teacher thinks the same amount of fidgeting is normal. One parent might think their child often has difficulty sustaining attention while another parent with a different child thinks that's just how kids are. The second issue is related and it comes up in criteria like often leave seat in situations where remaining seated is expected, often runs about or climbs excessively in situations in which it's inappropriate, and often talks excessively. There's a big focus on what's appropriate in a specific situation which turns out to be highly culturally determined. One study looked at parent ratings of kids' ADHD symptoms in the U.S. and Hong Kong as well as the kids' brain activity in a scanner. Most of the kids in Hong Kong whose parents rated their symptoms as high would barely be in the moderate category in the UK. The same behaviors were being judged very differently depending on cultural expectations. At its heart, Barkley sees ADHD as a deficit in executive functioning.

How can we fit this new executive theory of ADHD into the clinical description of ADHD? It's very easy. I'll do it quickly. Executive functioning is one thing represented by the light blue box, self-regulation over time to improve our future. We can split this idea or construct into two dimensions, two broad dimensions of behavior and mental functioning. Inhibition and metacognition, the working memory functions. Now, it can also help if we take each of these major dimensions or mental abilities and carve them up into very specific minor abilities. It helps us to understand the disorder and executive functioning better. I've already described all of these for you in this presentation earlier. There are many kinds of inhibition, motor, verbal, mental, emotional, motivational, and there are kinds of attention, non-verbal working memory, verbal working memory, remembering what you're doing, planning and problem solving, and then the ability to manage emotions once they're expressed. Now, can you see how ADHD would fit in here? ADHD is comprised of two dimensions. There's the inhibition dimension, which we call hyperactive impulsive behavior, but it's really a subset of that executive function dimension. And then there is the inattention symptoms, which are misnamed because they're just a subset of the problem with metacognition, executive attention, if you want to call it that, and all of its components. This is really what ADHD is all about.

And in his videos, Barkley repeatedly compares ADHD to diabetes. He says it's a chronic condition that needs ongoing treatment. Just like you wouldn't expect someone with diabetes to take insulin for a few years and then be cured, he argues you shouldn't expect ADHD medication to fix someone's brain so they can stop taking it.

If you view ADHD the way we view other chronic medical conditions, let's take diabetes as an example I like to use. Why would taking insulin for a few years in childhood and then stopping lead to longer term changes or improvements in the diabetic? It wouldn't. We all know that it's perfectly common sense to realize that once you stop a treatment that's needed to manage your symptoms, the symptoms are coming back. And if we follow you over time, you're going to become more and more like people who were never treated.

But in a different video, he talks about how stimulant medications enhance brain development that taking them is associated with brain growth in deficient regions.

This paper continues the same theme that I described a couple months ago in a longer video on neuroprotection from stimulant medications. In that video I talked about how there were more than 30 studies, rarely mentioned in the mainstream media by the way, more than 30 studies talking about how taking stimulant medication for several years or more was associated with improved brain growth and development in people with ADHD. Most of that research was done with children, but there were a couple of studies of adults that found the same thing, suggesting that staying on medication for several years or longer, particularly with the stimulants, might be associated with promoting brain growth in those areas of the brain that have been associated with ADHD and have been found to be smaller, less functional, and less connected with other brain regions than in typically developing individuals.

He makes the same set of contradicting assertions in other places as well. Here's a fun one, which comes from a series of episodes he recorded responding to Paul Tuft's New York Times article from last year and denying that stimulants repair ADHD brains.

Finally, he says that the premise that medications are being prescribed these days is also founded on the assumption that medications we give repair those brain deficits. That is just utter bull crap. There is no evidence in history that that is why we were doing this. No one at the time that I knew of ever asserted that giving stimulants to ADHD children would repair their brains. We all understood that these were temporary improvements in managing symptoms, and that as the medication washed out, the individual's behavior and probably their brain returned back to its baseline pre-treatment state.

And then in the very next video in this series...

The 33 studies out there that I've talked about on this channel that result in neuroprotection, which is simply a fancy term for if you stay on stimulant medication for several years, we see improved growth in ADHD-related brain structures from the use of that medication. This is not a one-off finding. It has been found repeatedly, including in several large recent studies that I talked about on this channel.

So wait, if the medication helps the brain develop and grow, why do you need to keep taking it forever? If diabetes medication helped your pancreas to grow new beta cells so you could produce more insulin, you might actually be able to stop the medication at some point, right? Now I expect Barkley would say, well, the brain changes are partial, not full repair, so you still need ongoing treatment. But that kind of weakens the diabetes analogy that he chose. The whole reason the diabetes comparison works is that insulin doesn't fix your pancreas. If ADHD medication actually promotes brain growth, the analogy breaks down. You can't have it both ways. Seeing ADHD as a chronic condition requiring lifetime management is at the heart of the medical model, which also portrays ADHD as a highly heritable condition. Studies of genetically identical twins suggest that genes account for somewhere between 76 and 91% of ADHD. That's really high. It's higher than a lot of physical conditions. The idea is that ADHD runs in families because it's passed down genetically. If you have ADHD, there's a good chance your kids will too. And that genetic basis is supposed to tell us this is a real biological condition, not something caused by parenting or the child's environment. The number of symptoms you need for a diagnosis has also changed over time. The DSM-4, which was released in nineteen ninety-four, required six symptoms. The two thousand three updates to the DSM-5 dropped it to five symptoms for adults, and Barclay thinks it should be four.

And it also matters what diagnostic criteria you use. We use the old DSM-4 criteria, which didn't make any adjustments of the symptoms for adults. It was six out of nine symptoms on either symptom list that got you into the disorder category. As you know, DSM-5 said that you only needed five symptoms to have ADHD if you were an adult. By the way, as I've said in other videos, that number should really be four, but the DSM committee didn't want to drop it that far.

Now that might not sound like a big deal, but if we change the cutoff from six symptoms to five or five to four, we're changing who gets diagnosed. We're changing who is told that they have a About 10 to 15 key contributors to the DSM and some committees of researchers made these decisions. Not people with ADHD, not the general public, not even most clinicians who actually diagnose patients. And those decisions determine who gets diagnosed, who gets medication, who gets accommodations at school or at work, who is told that they have this disorder. Barclay is actually against any sort of reorganizing of our society to better support neurodivergent people. And one of the reasons that he gives for that is that it's impossible to say who should decide what changes should be made. As he describes in another excerpt of a video from the coverage on Paul Tuff's New York Times article, Tuff is the individual that Barclay is referring to in this clip.

What's different in this article and that I find rather disturbing is the idea that the individual is recommending that we change the entire societal landscape around people with ADHD in order to accommodate their disorder. Meaning that everybody else in the world, all employment, all schools, all colleges, all environments, they all need to be changed to make sure that the individual with ADHD isn't going to be impaired in them. It's that kind of broad scale environmental engineering that to me is simply another example of the utopianism that I found in the Economist article as well. Because how do you do that on a societal level? And at what cost? And who gets to decide what those environmental changes are going to be? So no, we're not going to change societies for a five to eight percent prevalence rate of a disorder so that the other 92 percent or more of individuals are affected and inconvenienced for the benefit of those individuals. That just doesn't make any sense.

Here's the thing, someone always decides. And when it comes to ADHD, a relatively small group of powerful psychiatrists has been making really consequential decisions that change who get diagnosed and who gets medication for decades. So, Barkley's actually fine with someone deciding as long as he's part of that group. I also want to look at the values that are embedded in these diagnostic criteria. He writes that in a society that values controlled, well-channeled activity levels, sustained attention, reasonably regulated emotional reactions, moderate degrees of sociability, curiosity in healthy but channeled ways, and predictable regularity of habits that lead to easy caretaking, an infant or child who is seriously deviant or negative in these areas is destined to have great difficulties in social and familial adjustment no matter what the parents are like. My goodness, he is describing really specific cultural values, controlled activity, sustained attention, regulated emotions, predictable habits. And then he says a child who doesn't fit these values is destined for difficulties. And instead of examining our cultural values to see if they serve kids with ADHD, or any kids at all in fact, we should change the kids with ADHD so they fit in better, either with medication or by shaping their behavior. Barkley's written extensively about what he calls deviant children who exhibit oppositional behavior. In his manual for clinicians on parent training, one of the primary goals is to improve child compliance with commands, directives, and rules given by the parents, and so reduce the extent of parent-child conflicts. He gives an example. A parent tells a child to get ready for bed while the child is watching a favorite TV program. The child resists.

Barkley says the child's success at escaping from the command, even if only temporarily, negatively reinforces his or her oppositional behavior, meaning they're more likely to do it again. The solution is behavior modification for the child. No mention of adjusting the evening schedule, no suggestion the parent might sit with the child, finish the program together, and then transition gently. Because after all, wouldn't you resist if someone told you to get ready for bed in the middle of your favorite TV show? But where children are seen as defiant if they don't immediately obey, the problem is framed as a child's non-compliance rather than the parent's unreasonable request. And look what happens when parents don't follow through with the training program. Barkley writes that often legitimate reasons exist for what he calls parental non-compliance. These might be family stress, the parent isn't motivated for training. In some cases, he says training may be temporarily discontinued while the family stress event is managed, or the parent is provided with a different intervention aimed at the stressor. So parents get understanding and flexibility when they can't comply, but kids get behavior modification. So while we're looking at these challenges with Dr. Barkley's research and approach, I want to follow the money. And I do want to be careful here because I'm not saying anyone's research is automatically invalid because of who funds it.

But I do think that we should know about financial relationships. The American Academy of Child and Adolescent Psychiatry reports that Russell Barkley receives or has received research support, acted as a consultant, and or served on a speaker's bureau for Eli Lilly and Company, Shire Pharmaceuticals Group, PLC, and McNeil Pediatrics. And these are some of the biggest ADHD medication manufacturers. According to journalist Allan Schwartz, who wrote the book ADHD Nation, Barkley accepted five or six figure sums yearly for industry-sponsored work and was at his prime what Schwartz calls a one-man ADHD public relations powerhouse. His findings, Schwartz writes, were not necessarily false, but they were phrased and wielded to persuade doctors and parents to get any child, even suspected of ADHD, diagnosed and medicated or face the consequences. And Barkley is not alone here. Dr. Joseph Biederman, another highly influential ADHD researcher, received over 1.6 million dollars from pharmaceutical companies between two thousand and two thousand seven for consulting and advisory services and being on their speaker's bureau, which basically means giving favorable presentations about the drug company's products to other doctors. But he only reported two hundred thousand of that to his employers, Harvard University and Massachusetts General Hospital. This all came out during a deposition in a lawsuit against Johnson & Johnson in two thousand nine. What's particularly striking is how Biederman described his own work. In documents from that lawsuit, his research center at Harvard reported work that, “facilitated drug development for ADHD”. So he would do studies to show things like parent reports are sufficient for detecting efficacy in studies of long-acting medications.

So if the parent says it works, the doctor can keep prescribing, even if they don't have any information from the child's teacher, when the ADHD symptoms are supposed to be present in at least two environments. He also described how, by demonstrating the validity of adult ADHD diagnoses, this and other work has led to a more widespread acceptance of the diagnosis, including acceptance by the FDA, which previously doubted its validity but which has now given pharmaceutical company Eli Lilly an adult ADHD indication, meaning you can prescribe, for Strattera. In other words, his research opened up new markets for ADHD drugs. And Biederman made claims that went well beyond what the science supported. He told Reuters Health in two thousand six, if a child is brilliant but is doing just okay in school, that child may need treatment, which would result in their performing brilliantly at school. He published a study claiming the drug pemmeline is well tolerated and effective in adolescents and may be a particularly useful ADHD treatment, despite noting elsewhere that pemmeline appeared to cause fatal liver damage. In one paper, he wrote, family studies of ADHD have shown that the relatives of ADHD children are at a high risk for ADHD, comorbid psychiatric disorders, school failure, learning disability, and impairments in intellectual functioning. The implication is the ADHD child's entire family should also be diagnosed and medicated. Biederman and his colleagues were punished by Harvard and Massachusetts General Hospital for lying about their income. And the punishment? They had to refrain from working with drug companies for a year and undergo ethics training. That's it.

His work was too big for them to want to do anything else about it. Biederman died in twenty-twenty three, but his work is still alive and well. 26 of the 35 chapters in the Big Handbook, which is the gold standard for clinicians on ADHD, cite his research. And Barkley and Biederman are far from alone, of course. Prolific researcher Dr. Stephen Farrarone wrote a two thousand seven paper called The Scientific Foundation for Understanding Attention Deficit Hyperactivity Disorder as a Valid Psychiatric Disorder, in which he argues that “inaccurate beliefs about the diagnostic validity of ADHD hinder the clinical care of the many ADHD patients and parents who have misgivings about seeking and accepting treatment, was sponsored in part by McNeil Consumer, which makes Concetta”. So Farrarone and these other individuals are known as Key Opinion Leaders, or KOLs, and they're paid by the drug companies as long as they speak positively about the company's products. We heard more about them in the conversation on depression with Bob Whitaker. And the KOLs do have to be very positive. It's common for KOLs to be fired if they speak in anything less than glowing terms about the drugs they're paid to represent. Even Keith Connors, who developed the rating scale that was ultimately used to form the criteria for an ADHD diagnosis, was fired by Eli Lilly after he hedged in front of an audience on whether its product Strattera was as effective as Ritalin. Allan Schwartz describes how our very own Dr. Barkley has essentially created a new diagnostic category called Sluggish Cognitive Tempo, which is a syndrome apparently marked by daydreaming, lethargy, and slowed thinking or behavior. He's devised a Connors-like symptom checklist for doctors to diagnose adults, and he worked a chapter on it into the big handbook to give it even more legitimacy, even though the condition has never been recognized by the American Psychiatric Association. And Eli Lilly has already enlisted Barkley and others to investigate how Strattera will treat Sluggish Cognitive Tempo.

It already paid him one hundred eighteen thousand dollars between two thousand nine and two thousand twelve for consulting and speaking engagements. And the conflicts extend beyond individual researchers to major advocacy organizations. The organization Children and Adults with Attention Deficit Hyperactivity Disorder, commonly known as CHAD, grew from a niche organization into a powerful lobbying force. It persuaded Congress to classify ADHD as an official learning disability, to be covered under educational and government-assisted programs, and that stimulants should be reclassified from Schedule II to Schedule III controlled substances, which means greater access and less regulation. A PBS documentary uncovered that the manufacturer of Ritalin had given CHAD close to a million dollars since nineteen eight-nine, and CHAD hadn't disclosed this funding. Parents, doctors, and government officials had no idea that CHAD was advocating for expanded use of Ritalin while being bankrolled by the company that sold Ritalin. So the drug company's fingerprints are everywhere in the research and diagnosis of ADHD. And this brings us to how many people are getting diagnosed. Well, Barkley says ADHD affects about 5 to 7% of kids and 3 to 5% of adults worldwide. That 5% global prevalence in kids is a pretty commonly cited number, and it comes from a paper co-authored by our old friend Joseph Biederman. But let's look at the other authors on that paper as well. One of them is on the Speakers Bureau and is a consultant for four drug companies and sits on Eli Lilly's advisory board. A third author is the medical director at Eli Lilly Brazil. And the studying received funding from, guess who? Eli Lilly.

But the paper tells us, and I'm reading directly here, “there was no involvement of any funding source in the study design, data collection, analysis, interpretation of data, and writing of this article or in the decision to submit the article for publication”. So we're supposed to believe that Eli Lilly and the other 11 drug companies mentioned in the disclosures had no interest at all in the idea that 5% of the global population has a condition that should be treated with their pills every day for the rest of the patient's life. So ADHD is supposedly a biological disorder caused mostly by genes, which means a global prevalence level is sort of expected. We'd also expect lower diagnosis rates in places where healthcare infrastructure isn't as robust. But if the overall prevalence rate is 5%, why does that seem to provide a floor level of diagnosis here in the states of California, Nevada, and Utah, while rates in states like North Carolina, Tennessee, and Ohio are two to three times the supposed global prevalence rate? What's up with that? When researchers Stephen Hinshaw and Richard Scheffler examined several hypotheses related to these differences, they found there may have been small impacts from different racial and economic situations in the different states, different training of doctors and healthcare policies, different cultural values. But it turned out that the biggest impact was from school policies. So North Carolina was among the first states to implement school accountability laws. After no child left behind started in two thousand three, diagnosis rates among kids aged 8 to 13 living in low-income homes shot up from 10% to 15.3% in states without previous accountability laws. And there were two main reasons for this. First, children diagnosed with ADHD could be placed in special education classes where they might get more services that could raise their test scores. And second, in some areas, those children didn't have to be counted in the district's overall test score average. And where they weren't doing well in school before, they'd been dragging down the school's average.

One doctor in rural Georgia was quoted in the New York Times explaining why he prescribed Adderall and Concerto, not because children had real ADHD, but to help them in “financially strapped subpar schools”. In his words, I don't have a whole lot of choice. We've decided as a society that it's too expensive to modify the environment. So we have to modify the kids. I also want to look at how easy it is to get a diagnosis. So in his chapter in the big handbook on the Psychological Assessment of Children, Dr. Barkley describes what a proper assessment process is supposed to look like. It should gather information in a parental interview on demographic information, major parental concerns, a review of major developmental domains and childhood disorders and other learning disabilities. There should be a child interview, but we shouldn't really trust what the child says about their own behavior. And we're going to hear more about that in our next episode. There should be a teacher interview and then a variety of behavior scales should be used to assess children's behavior, impairment, peer relationships, parents' marital discord, parental stress and distress, and other potential diagnoses to rule out before landing on ADHD. Because ADHD is supposed to be a diagnosis that's only made once you rule everything else out. There should be a direct behavioral observation, although Dr. Barkley says this rarely happens because insurance won't cover it. Dr. Stephen Hinshaw, author of The ADHD Explosion, says the reality is that most assessment of ADHD is done by general pediatricians who lack the training and also the time in a 15-minute office visit to conduct an adequate evaluation. Because of this, he says “a large percentage of children receiving stimulant medication do not, in fact, even have a viable diagnosis of ADHD”. For decades, clinicians used a child's response to stimulant medication as a way to make a diagnosis. The thinking was that stimulants had a calming effect on hyperactive kids. So, if the pill calmed your child down, that proved they were hyperactive. The medication wouldn't work if your child wasn't hyperactive.

But in nineteen seventy-eight Judith Rappaport at the National Institute of Mental Health gave stimulants to kids who didn't have ADHD and found they had the same effects. Improved attention, less motor activity. The stimulants do the same thing to everyone's brain and this really should not have been a massive shock since the U.S. military has known this for decades. Stimulants were heavily used in desert storm, Vietnam, World War II to boost vigilance and endurance and to reduce the effects of fatigue. Even researchers who support the medical model of ADHD, like Stephen Farrarone, now say that medication response should never be used as a diagnostic tool. Diagnostic guidelines are clear that stimulant response does not diagnose ADHD, but in a busy primary care practice, some pediatricians who don't have the time or the tools to go through the complete diagnostic process will use a quick stimulant trial as part of deciding whether the child really has ADHD. Kind of a let's try this and see if it helps. And that's a generous interpretation. It's also widely reported that kids needing extra help or their parents go to the family doctor and say, oh my child needs help focusing, and they walk out with a prescription. Now we get to the scary part of the ADHD research. Barkley presents data showing that people with ADHD face significantly worse outcomes across pretty much every domain you can imagine, all of which leads to a reduced life expectancy.

They reported that males with ADHD had a life expectancy that was projected to be 6.8 years less than males in the general population. Females, interestingly enough, had a predicted life expectancy of about 8.6 years less. So in other words, females had a shorter life expectancy than males, which is sort of the inverse of the population, as well as what we would have expected would be the opposite given that males engage in more risk-taking, especially males with ADHD than females. And we know that accidental injuries are one of the chief causes of early mortality in individuals with ADHD.

Barkley's own research has found up to a 13-year lower life expectancy for people whose ADHD persists into adulthood. That is huge. That's on par with the reduction in life expectancy associated with smoking. So what's driving this? According to Barkley's analysis is a whole host of things. Lower education and income, more alcohol use and smoking, less sleep, more driving infractions, higher rates of suicide, about three times higher for kids with ADHD, more car crashes and accidents, higher rates of substance use disorders, higher rates of obesity and type 2 diabetes, higher rates of cardiovascular disease. And outcomes are particularly grim for women and girls with ADHD who are five times more likely to be victims of physical intimate partner violence than girls without ADHD. 30% versus 6% Women with ADHD have higher rates of self-harm, suicidal behavior, depression, anxiety, and eating disorders than men with ADHD. On his YouTube channel, Barkley reviewed a study out of the UK which corroborated this finding.

They're finding a significant difference and that females have a shorter life expectancy. That is worth pursuing because it is counterintuitive. If risk taking and inhibition are the predictive factor, then it should have been more males. That is, males should have had a shorter life expectancy than females. So something's going on here, whether it's related to early teen pregnancy, whether it's related to sexual victimization in the females, which we know is higher in females with ADHD. I'm not sure what's going on here. We know that intimate partner violence is greater and also reported as higher in females than males, so maybe that's going on here too. So these factors need further exploration.

So Barkley's hypothesis about why girls and women have a lower life expectancy all involve two people. Teen pregnancy usually involves two people. Sexual victimization and intimate partner violence always involves two people. I'm sure he would argue that medicating the girl with ADHD will mean she makes better life choices, but why is there no analysis of the other partner's role in this? We wouldn't have sexual victimization and intimate partner violence without a usually male partner taking those actions. I would argue that addressing these issues would have benefits far beyond people with ADHD. The single biggest factor accounting for 31% of the reduced life expectancy is something Barkley calls behavioral disinhibition.

What we found is that the single biggest background factor in predicting life expectancy was the extent of behavioral disinhibition, impulsivity. That has been found repeatedly in studies in health psychology. It is the number one predictor of life expectancy in the human population, death by all causes.

Behavioral disinhibition is basically impulsivity, difficulty controlling your behavior. And according to Barkley, you have to treat that with medication before you can address any of the other factors.

What's important here, you've got to treat the behavioral inhibition problems before you tackle these other first order risk factors, or you're probably not going to get anywhere in those change programs. So treatment with ADHD treatments, particularly with medications, could be used to reduce this background risk factor. And then we can get on with helping people change all these lifestyle and other factors, but they're probably not going to work if the inhibition is not recognized and treated as well.

It's a grim picture. You're only hearing short snippets of his work here. When I heard him talk about this stuff for an hour straight in the certified ADHD professional intensive course that I did, I would have been terrified if I had a kid with ADHD. His rhetoric is really outstanding. It's not just about trouble paying attention in school. It affects your whole kid's life. It can literally shorten your kid's life. And that brings us to his proposed solution. For Barkley, remember, who is adequately compensated by the pharmaceutical companies, the evidence is clear. Stimulant medication works.

Even if the drugs don't improve achievement, which it appears they do over the long run, they do improve work completed, which results in better grades. They do improve behavior in school. They do improve peer relationships in school. They do result in reduced punishment of the individual in school, among other things that these medications do in that environment. And by the way, aren't those good things in their own right? Must they translate to improved achievement to be a worthwhile basis for giving medication? To say otherwise is absurd.

The overall message of the medical model is that ADHD is a serious chronic biological disorder. It's highly genetically inherited. It's like diabetes. You need ongoing treatment. If it's left untreated, it leads to devastating outcomes. But we have a treatment that works, stimulant medication, and people should start it early and stay on it. The drug company manufacturers pick up on the research that Dr. Barkley, Biedermann, and their colleagues conduct, and use it to create ads to scare parents on the one hand, and tell them about the great outcomes they'll have when they do medicate their child. Journalist Allan Schwartz's book, ADHD Nation, shows and describes several drug company ads. Sometimes they try the carrot approach. One shows a mother and a young son playing. Schwartz describes it like this. The headline read, thanks to Adderall XR, David's mom is learning a whole new language. That language included phrases like, I'm proud of you, good job on your homework, let's play a game, and thanks for taking out the garbage. Adderall XR suddenly wasn't just a medicine for an ADHD child, it was for his mother too, to make her child less of a pain, to provide her parental satisfaction of a job well done." And if the carrot doesn't work, there's always the stick. One ad for Adderall XR warned that many kids with ADHD can also have conduct disorder, a condition linked with bullying, physical cruelty, use of weapons, and other behaviors that can put them in trouble with the law. Another ad said that young people with ADHD who didn't take medication regularly had four times as many serious injuries and three times as many car accidents. However, it went on, ADHD may be successfully treated.

Today's ADHD medications, like Adderall XR, have come a long way in providing better symptom control. Schwartz says that, it stands to reason that being impulsive can lead to injuries, and that distractibility doesn't make for great driving. But there was one problem. The implication that Adderall XR's symptom control would lower the risks for injuries or accidents was by no means supported by science. As for Shires invoking the grim consequences of conduct disorder, the American Psychiatric Association's official term for chronic violent anti-authority aggression, Adderall XR not only had never been shown to address that behavior, the company hadn't even looked at it. Nevertheless, the parents got the message. Give your child Adderall or else he could become a car-crashing felonious psychopath. The FDA sent warning letters to Shire and other manufacturers who pulled similar stunts, and the companies took the ads off the air. But they'd already done their work. So far, the medical model of ADHD paints a really compelling picture. A serious, lifelong brain disorder demanding early, ongoing medication to dodge devastating outcomes. But as we've heard from Barkley himself via these clips, contradictions can emerge, like meds supposedly creating brain growth yet requiring indefinite use. What that word often means for diagnosis and whose problems we're really looking at. We've seen how differences in diagnosis rates can be driven by school policy, and how big pharma's money has driven increased medication rates. In our next episode, we'll look more closely at this idea of ADHD being a lifelong disorder, because, as I mentioned at the beginning, turns out for a majority of people diagnosed with ADHD in childhood, symptoms fluctuate enough that at times they no longer qualify for a diagnosis. We'll look at how ADHD shows up or doesn't in different environments, and we'll also consider some alternate pathways for the negative outcomes that Dr. Barkley finds that can give us new ways to support people with ADHD.

If you'd like Jen to address the challenge you're having in parenting, just email your one-minute video or audio clip to support@yourparentingmojo.com and listen out for your episode soon.