Idea of New Attention Disorder Spurs Research, and Debate
By http://www.nytimes.com/2014/04/12/health/idea-of-new-attention-disorder-spurs-research-and-debate.html?partner=rss&emc=rss&_r=2
With more than six
million American children having received a diagnosis of attention deficit
hyperactivity disorder, concern has been rising that the condition is being
significantly misdiagnosed and overtreated with prescription medications.
Yet now some powerful
figures in mental health are claiming to have identified a new disorder that
could vastly expand the ranks of young people treated for attention problems.
Called sluggish cognitive tempo, the condition is said to be characterized by
lethargy, daydreaming and slow mental processing. By some researchers’
estimates, it is present in perhaps two million children.
Experts pushing for
more research into sluggish cognitive tempo say it is gaining momentum toward
recognition as a legitimate disorder — and, as such, a candidate for
pharmacological treatment. Some of the condition’s researchers have helped Eli
Lilly investigate how its flagship A.D.H.D. drug might treat it.
The Journal of
Abnormal Child Psychology devoted 136 pages of its January issue to papers
describing the illness, with the lead paper claiming that the question of its
existence “seems to be laid to rest as of this issue.” The psychologist Russell
Barkley of the Medical University of South Carolina, for 30 years one of
A.D.H.D.’s most influential and visible proponents, has claimed in research
papers andlectures that sluggish cognitive tempo
“has become the new attention disorder.”
In an interview, Keith
McBurnett, a professor of psychiatry at the University of California, San
Francisco, and co-author of several papers on sluggish cognitive tempo, said:
“When you start talking about things like daydreaming, mind-wandering, those
types of behaviors, someone who has a son or daughter who does this excessively
says, ‘I know about this from my own experience.’ They know what you’re talking
about.”
Yet some experts,
including Dr. McBurnett and some members of the journal’s editorial board, say
that there is no consensus on the new disorder’s specific symptoms, let alone
scientific validity. They warn that the concept’s promotion without vastly more
scientific rigor could expose children to unwarranted diagnoses and
prescription medications — problems that A.D.H.D. already faces.
“We’re seeing a fad in
evolution: Just as A.D.H.D. has been the diagnosis du jour for 15 years or so,
this is the beginning of another,” said Dr. Allen Frances, an emeritus
professor of psychiatry at Duke University. “This is a public health experiment
on millions of kids.”
Though the concept of
sluggish cognitive tempo, or S.C.T., has been researched sporadically since the
1980s, it has never been recognized in the Diagnostic and Statistical Manual of
Mental Disorders, which codifies conditions recognized by the American
Psychiatric Association. The editor in chief of The Journal of Abnormal Child
Psychology, Charlotte Johnston, said in an email that recent renewed interest
in the condition is what led the journal to devote most of one issue to
“highlight areas in which further study is needed.”
Dr. Barkley declined
repeated requests for interviews about his work and statements regarding
sluggish cognitive tempo. Several of the field’s other key researchers, Stephen
P. Becker of Cincinnati Children’s Hospital Medical Center, Benjamin B. Lahey
of the University of Chicago and Stephen A. Marshall of Ohio University, also
declined to comment on their work.
Papers have proposed that a recognition of sluggish cognitive
tempo could help resolve some longstanding confusion about A.D.H.D., which
despite having hyperactivity in its name includes about two million children
who are not hyperactive, merely inattentive. Some researchers propose that
about half of those children would be better classified as having sluggish
cognitive tempo, with perhaps one million additional children, who do not meet
A.D.H.D.’s criteria now, having the new disorder, too.
“These
children are not the ones giving adults much trouble, so they’re easy to miss,”
Dr. McBurnett said. “They’re the daydreamy ones, the ones with work that’s not
turned in, leaving names off of papers or skipping questions, things like that,
that impinge on grades or performance. So anything we can do to understand
what’s going on with these kids is a good thing.”
But
Dr. McBurnett added that sluggish cognitive tempo remained many years from any
scientific consensus: “We haven’t even agreed on the symptom list — that’s how
early on we are in the process.”
Steve
S. Lee, an associate professor of psychology at the University of California,
Los Angeles, who serves on the editorial board of The Journal of Abnormal Child
Psychology, said in an interview that he was conflicted over the journal’s
emphasis on sluggish cognitive tempo. He expressed concern that A.D.H.D. had
already grown to encompass too many children with common youthful behavior, or
whose problems are derived not from a neurological disorder but from inadequate
sleep, a different learning disability or other sources.
About two-thirds of children with an A.D.H.D. diagnosis take
daily medication such as Adderall or Concerta, which often quells severe
impulsiveness and inattention but also carries risks for insomnia, appetite
suppression and, among teenagers and adults, abuse or addiction.
“The scientist part of me
says we need to pursue knowledge, but we know that people will start saying
their kids have it, and doctors will start diagnosing it and prescribing for it
long before we know whether it’s real,” Dr. Lee said. “A.D.H.D. has become a
public health, societal question, and it’s a fair question to ask of S.C.T. We
better pump the brakes more diligently.”
Dr.
McBurnett recently conducted a clinical trial funded and overseen by Eli Lilly
that investigated whether proposed symptoms of sluggish cognitive tempo could
be treated with Strattera, the company’s primary A.D.H.D. drug. (One of
Strattera’s selling points is that it is not a stimulant like Adderall and
Concerta, medications more susceptible to abuse.) His study, published in The Journal of Child and
Adolescent Psychopharmacology, concluded, “This is the first study to report
significant effects of any medication on S.C.T.”
An Eli Lilly spokeswoman said in an email, “Sluggish cognitive
tempo is one of many conditions that Lilly scientists continue to study to help
satisfy unmet medical needs around the world.”
Representatives
of the drug companies that make the best-selling medications for A.D.H.D. —
Shire (extended-release Adderall and Vyvanse), Novartis (Focalin) and Janssen
(Concerta) — said they are not currently conducting research into sluggish
cognitive tempo. However, because the new condition shares so many symptoms
with A.D.H.D., these products might easily be repositioned to serve the new
market.
Dr. Barkley, who has said that “S.C.T. is a newly recognized
disorder,” also has financial ties to Eli Lilly; he received $118,000 from 2009
to 2012 for consulting and speaking engagements, according topropublica.org. While detailing sluggish
cognitive tempo in The Journal of Psychiatric Practice, Dr. Barkley stated that
Strattera’s performance on sluggish cognitive tempo symptoms was “an exciting
finding.” Dr. Barkley has also published a symptom checklist for mental health
professionals to identify adults with the condition; the forms are available
for $131.75 apiece from Guilford Press, which funds some of his
research.
Dr.
Barkley, who edits sluggish
cognitive tempo’s Wikipedia page, declined a request to discuss his financial
interests in the condition’s acceptance.
“I
have no doubt there are kids who meet the criteria for this thing, but nothing
is more irrelevant,” Dr. Frances said. “The enthusiasts here are thinking of
missed patients. What about the mislabeled kids who are called patients when
there’s nothing wrong with them? They are not considering what is happening in
the real world.”
Parents Warned: Don't Use Ritalin
Hyperactive
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