ADHD proven to be a genetic disorder! Well, maybe not.

Medical News Today recently ran a headline stating “ADHD Is A Genetic Neurodevelopmental Disorder, Scientists Reveal.” They drew this headline from a recent study published in The Lancet, which analyzed the DNA of 366 children diagnosed with ADHD against a much larger control group. The study in The Lancet concluded that 15% of the ADHD sample had chunks of DNA missing or duplicated compared to 7% of the control group. This is a significant result, suggesting a probable genetic predisposition for some children with problems with inattention and impulsivity.

But it hardly justifies the headline nor the statement by Professor Anita Thapar, lead investigator of the study:

“Now we can say with confidence that ADHD is a genetic disease and that the brains of children with this condition develop differently to those of other children.”

In fact, if one looks closely at the numbers, a more accurate headline begins to take shape: “85% of ADHD cases found to have no genetic basis.” Admittedly, this is an over-simplification, as there may be other, hitherto undiscovered genetic markers implicated in impulsivity and inattention. However, if you consider the fact that the investigators in most studies of ADHD are more rigorous in their election process than clinicians, who often diagnose and prescribe stimulants for “subclinical” cases, the percentage of nongenetic impulsive/inattentive behavior is probably far higher than 85%. Not to mention that the headline and Professor Anita Thapar’s conclusion ignore the complex interaction between environment and heredity at the heart of nearly all psychological diagnoses. The fact that 7% of the “normal” population have the same genetic markers and no diagnostically significant symptoms suggests that DNA abnormalities are just pieces in a larger puzzle.

The problem is that spin in medical journals has a huge effect on clinical practice. You can be sure that pharmaceutical reps have incorporated the headlines, rather than the numbers, into their talking points. And how many pediatricians and psychiatrists look past these headlines to the nuanced results? CHADD, the largest ADHD patient advocacy group (largely funded by drug companies), now states in its website, without referencing specific studies:

“There is little question that heredity makes the largest contribution to the expression of [ADHD] in the population. “

The belief that ADHD is determined by genes invariably means that a child will be treated with stimulant medication rather than therapy. You don’t use words against a brain abnormality. The numbers bear this out. Global sales of ADHD drugs increase 8% year on year and are forecast to reach $4.3 billion by 2012. For the parent who consults with a doctor about a child’s impulsive behavior, caveat emptor.

The Limits of Neuroscience

When I set about becoming a writer in my twenties, I felt I needed to understand the nuts and bolts of language. I compiled lists of words and learned their etymologies. I broke down the sentence structure of books I admired in the hope of discovering a particle physics behind their greatness. One day I came upon Tolstoy’s response to an accusation that he used language in an ordinary way. “You don’t need beautiful bricks,” he wrote, “to build a beautiful building.”

When I entered the field of psychology, I felt I needed to understand the inner workings of the brain. The 1990s promised that we were edging ever closer to Freud’s dream of uncovering a “nerve” basis of the psyche. The DMH demanded “evidence-based practice,” looking to a reductive medical model imported from the physical sciences. In county clinics, I watched psychiatrists educate patients by referring to diagrams of the brain, pointing out how ADHD arises out of deficits in frontal-lobe processing and PTSD from dissociation of limbic areas from higher cortical regions. I struggled to memorise the specialisations of brain areas. I learned about myelination and action potential and absorbed Daniel Siegel’s definition of mental health as brain integration.

But psychotherapy seemed to me to happen on a different dimension. Consider the case of a 20 year old client who came to me with “presenting problems” of ADHD and a strange phobia toward motes of dust. He demanded to know exactly what was wrong with his brain and how I could fix it. It turned out that behind the urgency of his desire for a “brain” explanation was a fear that his symptoms proved that he had been cursed by God for his thoughts and behavior. If only his problems could be understood as physical instead of moral. My client lived at home, under the rule of a father who followed a dogmatic religion and discharged his anger by violently punishing family members for violations of biblical rules. My client’s greater difficulty turned out to involve separating out his anger at his abusive father from the much-valued spiritual beliefs he had inherited from him. His phobias and impulsiveness persisted, but as we felt our way toward a larger understanding of who he was, they mattered less. Patients often initially ask for concrete brain-oriented explanations, but they tend after awhile to reject attempts to wrap a species template over their unique adaptations to the world. The natural course of therapy seems less reductive than expansive, moving from symptoms to meaning to narratives of the self in relation to the world. If our subjective experience boils down to chemicals squirting through the brain, why this fundamental human quest for expansive explanations?

Roger Sperry, who won the Nobel prize for his work with split-brain patients, provides the most credible hypothesis. In his view, feelings, ideas, values and other mental states are emergent properties of the physical brain, irreducible entities that depend on but cannot be explained in terms of their interacting parts. Furthermore, these mental states exercise a controlling influence over the physical components that give rise to them. In this model, “mind is in the driver’s seat in the brain, in command over matter.”

The notion of the whole exerting “downward causality” on its parts is best understood as happening in two mutually influencing dimensions. Imagine a rolling wheel. Its molecules obey all the usual laws of molecular physics. But if we consider the fate of those molecules through space and time, the rolling wheel is a more important controlling factor. Furthermore, we could no more predict the rolling wheel by considering its molecules than we can understand the meaning of this sentence by examining the individual words and letters that comprise it or understand a person’s thoughts, feelings and ideals by analysing the play of neurons in his brain. This is not to say that medication, which intervenes on the level of the brain, has no place in treatment, only that it will never make the kinds of higher-order changes that emerge when two minds connect in the service of one — not until we invent a pill that understands people.

Deconstructing the ADHD "epidemic"

• In 2000, The American Academy of Pediatrics stated that ADHD is an epidemic.
• 8% of school-aged children were reported to have an ADHD diagnosis by their parent in 2003.
• Diagnosis of ADHD increased an average of 3% per year from 1997 to 2006.
• The production of stimulant medications Adderall and Dexedrine increased by 4,516%, while the production of Ritalin also increased by 375% from 1993 -2003 (U.S.D.E.A., 2003).

A few years ago, the Ecuadorian mother of a boy I was treating told me that her son's teacher wanted her son tested for ADHD for talking out in class. My client's mother wanted to know more about "this ADHD." I brought out the DSM IV statistical manual of mental disorders and showed her the entry for ADHD, which describes multiple "behavioral" symptoms of inattention and impulsivity, using phrases such as "often does not seem to listen when spoken to directly," "often blurts out answers before questions have been finished" or "often has trouble waiting one's turn."

The mother seemed to be in a state of culture shock. "This is a definition of children," she said.

The mainstream scientific response to this mother would be that ADHD is a spectrum disorder pathological only at the far-end of the continuum. But when we are close to placing 10 percent of our children at the far end of this continuum, one begins to suspect that the diagnostic criteria for the disorder is overly inclusive or that it is simply being misdiagnosed -- or both.

To understand the true origins of our current ADHD "epidemic," we need to look at the medical history of ADHD as it dovetailed with the rising influence of the pharmaceutical industry. Hyperactivity was originally associated with brain damage. In 1940, scientists discovered that amphetamines improved the behavior of brain-damaged hyperactive children. The 50s and 60s witnessed the explosive growth of the pharmaceutical industry and the deployment of increasingly sophisticated marketing techniques. By 1970, what had been thought of as a hyperactivity brain-damage syndrome morphed into a developmental neurological disorder and got the new name Minimal Brain Dysfunction. Drug companies had already cooked up 31 amphetamine preparations, were now producing billions of pills a year and funding expensive research studies. By 1997 we had an even less stigmatizing name, Attention Deficit Hyperactivity Disorder, with a new type (inattentive) and an extension of the age-range into adulthood. By the new millennium, mainstream science firmly decided that ADHD is a hereditary neurological disorder best treated with stimulants.

If we consider the history of ADHD, we cannot help but note an expansion of the criteria defining the illness running parallel to the discovery, and later the marketing, of an amphetamine treatment. Since doctors are not constrained even by the DSM's loosened protocols, there is little doubt that children on the unimpaired area of the spectrum receive the diagnosis. This expansion of market-share for the drug-companies should come as no surprise. They had the perfect pitch, true or not, for over-worked, guilt-ridden parents. "You are not to blame. Your son simply has an hereditary neurological disorder best treated with stimulants." And who doesn't feel at fault for their child's misbehavior?

Drug companies continue to push the message hard. They now spend 20 to 30 thousand dollars per American physician on junkets, free meals, trips, trainings, cash rewards to "high-prescribers" and free samples. It is now nearly impossible to find a researcher who advocates stimulants for ADHD who is not on a drug-company's payroll. The most famous case involved Harvard psychiatrist and stimulant-treatment guru Joseph Biederman, who admitted to congressional investigators that he had failed to report 1.6 million in payments from drug companies. Even the brilliant Dr. Russell A. Barkley, who wrote the book on executive function and ADHD, acknowledged receiving 24 percent of his income in 2007 as a speaker/consultant for Eli Lilly Co., Shire and Novartic, the makers of Strattera, Vyvanse and Ritalin respectively. It is hard to imagine how these researchers can remain objective when their self-interest leans toward a particular finding.

Even more sinister is how pharmaceutical companies have begun to infiltrate patient advocacy groups. CHADD, the largest ADHD patient advocacy group in America, receives almost 26 percent of its funding from drug-companies. CHADD appears to be a neutral patient-centric organization offering information, support groups, classes for parents, conferences, even a free "CHADD discount prescription card," but in part also functions as a conduit of information between the drug-companies and the public, going so far as to produce with Ciba-Geigy money a public service announcement advocating the Ciba-Geigy product Ritalin.

In part due to CHADD lobbying efforts, the Department of Education in 1991 issued a memorandum mandating that students with ADHD receive special education and/or related services. Many believe that the DOE memorandum was responsible for the explosion of ADHD diagnoses in the 1990s, as frustrated, easily blamed teachers now became major referral sources.

So here we are in 2010. We have a research establishment at least partially co-opted by the pharmaceutical industry, reluctant to question assumptions about the hereditary nature of ADHD and the long-term effects of stimulants. We have a sizable number of pediatricians and psychiatrists paid to receive pharmaceutical company talking points. And due to the work of CHADD and other seemingly neutral groups, we have a population of parents and teachers open to interpreting impulsive behavior and spaceyness as symptoms of a brain disease.

It is my guess that only a small percentage of children are correctly diagnosed with ADHD -- meaning they have biologically driven delays in frontal lobe development that prevents them from thinking before acting. Many of the misdiagnosed are probably mistreated children, as the behavioral symptoms of trauma and neglect are almost identical to ADHD. The well-known trauma researcher Jennifer Freyd, Phd. recently published a study indicating that teachers, responsible for the majority of ADHD referrals in the US, frequently identify children suffering from maltreatment and neglect as exhibiting ADHD symptomatology. The study goes on to warn that "we have a responsibility to investigate whether we are medicating abused or neglected children for misdiagnosed ADHD." The rest are no doubt children who lie in the mid-range of the spectrum, difficult, fidgety children with maybe more of a present-tense bias to their temperament, but unimpaired.

The Death of a Nonprofit

I had been working for the last few years as a therapist at BHS Hollywood Family Recovery, treating "dual-diagnosis" clients in an outpatient drug program. BHS had been in trouble since the economy tanked in August, with County contracts gradually drying up during the course of the year.

After several rounds of layoffs, the CEO Henry van Oudheusdenhad, MSW, sent out a global email describing the millions lost in the last month. He ended the letter with an assurance that we will all band together and move forward as one. A few days later, Henry showed up to meet with our group at Hollywood. He looked haggard and stressed, and he perspired when he talked, which was his way. He was a heated guy. He talked breathlessly about how difficult this is, his love for this program, and how he didn't want to lose the program altogether but that it would be "reset" at ten percent of its current capacity. Then he went on, oddly, to praise the strength and flexibility of BHS even in the face of great adversity. Afterward, he spoke with each employee separately. He told some to pack up immediately and asked others to stay a few weeks to help transition clients to other agencies, which we all knew would be impossible.

BHS Hollywood recovery is in the heart of Hollywood, on Sunset and Highland, just across from Hollywood High School. We got gang-bangers with neck tattoos, fallen porn stars, Hollywood hopefuls who had come to LA to be closer to their dream, not to achieve it. The ones who ended up in therapy tended to have histories of horrendous child-abuse, which left them prone to emotional storms and an incoherent understanding of the past and the future -- Addiction's ideal habitat. I grew attached to my clients, which seemed to help them, and some got over their addictions and got better. It was a good feeling when that happened. Others "went out," or relapsed. I thought "went out" was a strange way of putting it at first, but I came to appreciate its descriptive power. When you call a client and get a message that his phone is no longer in service, you know that he has sold it along with his watch and his computer, that he has disconnected himself from the grid and gone out.

Ex-addicts run BHS. One of the top executives is supposed to have walked Sunset Strip during her using days. They are known collectively as "Corporate" and operate out of a grim stucco-sprayed structure in Gardena, also known as "Corporate." I remember my first corporate Christmas party. On the walls a few plastic Santas competed half-heartedly with giant matching wooden "scrawls" of the Twelve Steps and the Twelve Traditions. A line of BHS employees -- most of them ex-addicts -- snaked around those walls toward another room. In that room, Corporate stood behind a table in white aprons, ladling out "barbecued" turkey and mashed potatoes. Most of us were embarrassed and a little spooked to be fed, literally, by Corporate.

After the recession, Corporate preached about increasing productivity, which meant more billable hours. The two therapists at BHS Hollywood were already seeing up to twenty clients a week and the chemical dependency counselors 30 or 40. We were being asked to sacrifice quality for quantity but didn't fully feel the pressure because of that word "productivity." It was hard to see talking intimately to people as a "product." Halfway through the year, corporate sent out a mass email with the headline, "BHS is going green!" This turned out to mean that Corporate would no longer supply plastic plates and cups. I wondered how Corporate could quantify treatment and yet be so misty and euphemistic about cost-cutting.

Around the same time, Corporate started "letting people go." Before the recession, people only got "let go" at BHS if they "went out." After the recession, every month brought rumors of sweeps. They're going to be closing a facility or firing 10 percent of the staff, we would hear. And then people would disappear. One day a co-worker just stopped showing up and we learned after the fact that he had been let go last week, along with thirty other employees at 6 separate facilities. In August, Corporate instituted furloughs one Friday a month. In September, a rumor began to float that Hollywood was on the cutting block. We were a small site with relatively expensive rent -- not cost-effective, expendable. It was just a matter of time.

When the blow came, the receptionist and most of the chemical dependency staff were "let go" immediately. Ex-addicts with felony convictions, they would not find new jobs in this economy and were looking at unemployment and welfare. The program director, myself and the remaining CD counselor were given a month "to transition" clients either to BHS' Boyle Heights facility or to another agency. The problem was Boyle Heights could only take a fraction of our clients, and most of the other agencies had either closed down or were full. We were a county-contracted agency with the usual government make-work that goes along with that, but we also helped a lot of people no one else would touch and formed strong bonds with them. Three of my clients began to talk about suicide. A few others "went out." Some left my office in tears or anger. I thought about my clients constantly during that last month but had no words to inspire security. On my last day, Corporate assured me that my clients would "be taken care of," but not one had been placed anywhere.

A few days before I left, I had a dream that I was smoking crystal meth with a client. Having been "let go," did I identify with "going out?" Or did I simply share my client's desire to extinguish emotions that had no solution or object? After all, who even to blame for this catastrophe? Corporate for their callous kow-towing to the bottom-line? California for cutting services to those whose minds and bodies most depend on them? The media for not attending to the plight of people at street level. My greatest fear is that our disappearance will seem to make no difference. Our clients might "go out" or kill themselves, but who will notice?

The evolution of two psychoanalytic words

I've been thinking recently about "repression," and "projection" and how they've entered into contemporary talk and taken on interesting new meanings. Freud used the word "repression" to describe the involuntary process of excluding unacceptable impulses from consciousness. He used the word "projection" to describe one way people do this -- by disavowing these impulses and ascribing them to another person. In certain psychoanalytic circles, people still try to use these words in a neutral, clinical way, but in ordinary circles they have a blaming feel. When we call someone "repressed," we hold him responsible. The suggestion is that a repressed person somehow /chooses/ not to be aware of something that would make him more spontaneous and alive if he would just loosen up a little. The unintentional nature of repression is just an annoying aspect of a process that we see as fundamentally intentional. How can repression be intentional and also a little bit unintentional? It seems impossible, yet this is clearly how we view it.

"You're projecting" has an even more blatantly accusatory ring to it. The word "project" derives from the Latin "pro-" meaning "forward" and "jacere" "to throw" -- literally, "to throw forward." Although Freud et al described "projection" as an unconscious process, its roots suggest otherwise, and its contemporary meaning has returned to thoe roots. As with "repression," the word continues to be haunted by Freud's "unconscious" reformulation. This makes the accusation of projection all the more frustrating. The phase "you're just projecting" has a mind-bending, catch-22ish sting to it. One projects deliberately but also without meaning to -- so denial is futile.

Freud's structural model of the mind was a little like the Pagan model of the heavens, consisting of several anthropomorphic entities -- Id, Ego and Super Ego -- battling it out and producing irrational behavior in their human subjects. It makes sense that opposing motives will co-exist in a mind conceived as a territory ruled by opposing forces. The problem is that most of us now are monotheists when it comes to the mind. We believe in a unitary self. How does a unitary self exclude information from itself? The answer is that the unitary self is multi-dimensional, much like a sub-atomic particle, which behaves simultaneously like a particle and a wave. When we speak of projection and repression now -- we see these phenomena less as a battle between forces of exclusion and forces of awareness than as dual states of being, where we both know and don't know simultaneously. Clinicians have struggled to find new phrases to capture this paradox. British psychoanalyst Christopher Bollas has coined the phrase the "unthought known." Robert Stolorow speaks of the "preconscious." Daniel Stern prefers the term "implicit knowing." But nothing captures better the feeling of acting with knowledge and yet without as when we misuse the words "repression" and "projection" in ordinary speech.