The Selling of Attention Deficit Disorder

The New York Times

“This is a concoction to justify the giving out of medication at unprecedented and unjustifiable levels,” Keith Conners, a psychologist and early advocate for recognition of A.D.H.D., said of the rising rates of diagnosis of the disorder.Karsten Moran for The New York Times

By 
DECEMBER 14, 2013 

After more than 50 years leading the fight to legitimize attention deficit hyperactivity disorder, Keith Conners could be celebrating.

Severely hyperactive and impulsive children, once shunned as bad seeds, are now recognized as having a real neurological problem. Doctors and parents have largely accepted drugs like Adderall and Concerta to temper the traits of classic A.D.H.D., helping youngsters succeed in school and beyond.

But Dr. Conners did not feel triumphant this fall as he addressed a group of fellow A.D.H.D. specialists in Washington. He noted that recent data from the Centers for Disease Control and Prevention show that the diagnosis had been made in 15 percent of high school-age children, and that the number of children on medication for the disorder had soared to 3.5 million from 600,000 in 1990. He questioned the rising rates of diagnosis and called them “a national disaster of dangerous proportions.”

“The numbers make it look like an epidemic. Well, it’s not. It’s preposterous,” Dr. Conners, a psychologist and professor emeritus at Duke University, said in a subsequent interview. “This is a concoction to justify the giving out of medication at unprecedented and unjustifiable levels.”

billion

Sales of prescription stimulants have more than quintupled since 2002.

The rise of A.D.H.D. diagnoses and prescriptions for stimulants over the years coincided with a remarkably successful two-decade campaign by pharmaceutical companies to publicize the syndrome and promote the pills to doctors, educators and parents. With the children’s market booming, the industry is now employing similar marketing techniques as it focuses on adult A.D.H.D., which could become even more profitable.

Few dispute that classic A.D.H.D., historically estimated to affect 5 percent of children, is a legitimate disability that impedes success at school, work and personal life. Medication often assuages the severe impulsiveness and inability to concentrate, allowing a person’s underlying drive and intelligence to emerge.

But even some of the field’s longtime advocates say the zeal to find and treat every A.D.H.D. child has led to too many people with scant symptoms receiving the diagnosis and medication. The disorder is now the second most frequent long-term diagnosis made in children, narrowly trailing asthma, according to a New York Times analysis of C.D.C. data.

Behind that growth has been drug company marketing that has stretched the image of classic A.D.H.D. to include relatively normal behavior like carelessness and impatience, and has often overstated the pills’ benefits. Advertising on television and in popular magazines like People and Good Housekeeping has cast common childhood forgetfulness and poor grades as grounds for medication that, among other benefits, can result in “schoolwork that matches his intelligence” and ease family tension.

A 2002 ad for Adderall showed a mother playing with her son and saying, “Thanks for taking out the garbage.”

The Food and Drug Administration has cited every major A.D.H.D. drug — stimulants like Adderall, Concerta, Focalin and Vyvanse, and nonstimulants like Intuniv and Strattera — for false and misleading advertising since 2000, some multiple times.

Sources of information that would seem neutral also delivered messages from the pharmaceutical industry. Doctors paid by drug companies have published research and delivered presentations that encourage physicians to make diagnoses more often that discredit growing concerns about overdiagnosis.

Many doctors have portrayed the medications as benign — “safer than aspirin,” some say — even though they can have significant side effects and are regulated in the same class as morphine and oxycodone because of their potential for abuse and addiction. Patient advocacy groups tried to get the government to loosen regulation of stimulants while having sizable portions of their operating budgets covered by pharmaceutical interests.

VIDEO

How Drug Companies
Sell A.D.H.D.

What makes A.D.H.D. ads so effective? Dr. Aaron Kesselheim, a Harvard professor, analyzes several ads and discusses how many of them play on parents’ common fears about their children.

Poh Si Teng and Alan Schwarz

 

Companies even try to speak to youngsters directly. Shire — the longtime market leader, with several A.D.H.D. medications including Adderall — recently subsidized 50,000 copies of a comic book that tries to demystify the disorder and uses superheroes to tell children, “Medicines may make it easier to pay attention and control your behavior!”

Profits for the A.D.H.D. drug industry have soared. Sales of stimulant medication in 2012 were nearly $9 billion, more than five times the $1.7 billion a decade before, according to the data company IMS Health.

Even Roger Griggs, the pharmaceutical executive who introduced Adderall in 1994, said he strongly opposes marketing stimulants to the general public because of their dangers. He calls them “nuclear bombs,” warranted only under extreme circumstances and when carefully overseen by a physician.

Psychiatric breakdown and suicidal thoughts are the most rare and extreme results of stimulant addiction, but those horror stories are far outnumbered by people who, seeking to study or work longer hours, cannot sleep for days, lose their appetite or hallucinate. More can simply become habituated to the pills and feel they cannot cope without them.

Tom Casola, the Shire vice president who oversees the A.D.H.D. division, said in an interview that the company aims to provide effective treatment for those with the disorder, and that ultimately doctors were responsible for proper evaluations and prescriptions. He added that he understood some of the concerns voiced by the Food and Drug Administration and others about aggressive ads, and said that materials that run afoul of guidelines are replaced.

“Shire — and I think the vast majority of pharmaceutical companies — intend to market in a way that’s responsible and in a way that is compliant with the regulations,” Mr. Casola said. “Again, I like to think we come at it from a higher order. We are dealing with patients’ health.”

A spokesman for Janssen Pharmaceuticals, which makes Concerta, said in an email, “Over the years, we worked with clinicians, parents and advocacy groups to help educate health care practitioners and caregivers about diagnosis and treatment of A.D.H.D., including safe and effective use of medication.”

Now targeting adults, Shire and two patient advocacy groups have recruited celebrities like the Maroon 5 musician Adam Levine for their marketing campaign,“It’s Your A.D.H.D. – Own It.” Online quizzes sponsored by drug companies are designed to encourage people to pursue treatment. A medical education video sponsored by Shire portrays a physician making a diagnosis of the disorder in an adult in a six-minute conversation, after which the doctor recommends medication.

Like most psychiatric conditions, A.D.H.D. has no definitive test, and most experts in the field agree that its symptoms are open to interpretation by patients, parents and doctors. The American Psychiatric Association, which receives significant financing from drug companies, has gradually loosened the official criteria for the disorder to include common childhood behavior like “makes careless mistakes” or “often has difficulty waiting his or her turn.”

The idea that a pill might ease troubles and tension has proved seductive to worried parents, rushed doctors and others.

“Pharma pushed as far as they could, but you can’t just blame the virus,” said Dr. Lawrence Diller, a behavioral pediatrician in Walnut Creek, Calif. “You have to have a susceptible host for the epidemic to take hold. There’s something they know about us that they utilize and exploit.”

Selling to Doctors

Modern marketing of stimulants began with the name Adderall itself. Mr. Griggs bought a small pharmaceutical company that produced a weight-loss pill named Obetrol. Suspecting that it might treat a relatively unappreciated condition then called attention deficit disorder, and found in about 3 to 5 percent of children, he took “A.D.D.” and fiddled with snappy suffixes. He cast a word with the widest net.

All.

For A.D.D.

A.D.D. for All.

Adderall.

“It was meant to be kind of an inclusive thing,” Mr. Griggs recalled.

Roger Griggs, who introduced Adderall in 1994 before ads portraying medication as a way to improve grades and behavior were allowed, said, “There’s no way on God’s green earth we would ever promote” stimulants directly to consumers.Karsten Moran for The New York Times

 

Adderall quickly established itself as a competitor of the field’s most popular drug, Ritalin. Shire, realizing the drug’s potential, bought Mr. Griggs’s company for $186 million and spent millions more to market the pill to doctors. After all, patients can buy only what their physicians buy into.

As is typical among pharmaceutical companies, Shire gathered hundreds of doctors at meetings at which a physician paid by the company explained a new drug’s value.

Such a meeting was held for Shire’s long-acting version of Adderall, Adderall XR, in April 2002, and included a presentation that to many critics, exemplifies how questionable A.D.H.D. messages are delivered.

Dr. William W. Dodson, a psychiatrist from Denver, stood before 70 doctors at the Ritz-Carlton Hotel and Spa in Pasadena, Calif., and clicked through slides that encouraged them to “educate the patient on the lifelong nature of the disorder and the benefits of lifelong treatment.” But that assertion was not supported by science, as studies then and now have shown that perhaps half of A.D.H.D. children are not impaired as adults, and that little is known about the risks or efficacy of long-term medication use.

The PowerPoint document, obtained by The Times, asserted that stimulants were not “drugs of abuse” because people who overdose “feel nothing” or “feel bad.” Yet these drugs are classified by the government among the most abusable substances in medicine, largely because of their effects on concentration and mood. Overdosing can cause severe heart problems and psychotic behavior.

Slides described side effects of Adderall XR as “generally mild,” despite clinical trials showing notable rates of insomnia, significant appetite suppression and mood swings, as well as rare instances of hallucinations. Those side effects increase significantly among patients who take more pills than prescribed.

Another slide warned that later in life, children with A.D.H.D. faced “job failure or underemployment,” “fatal car wrecks,” “criminal involvement,” “unwanted pregnancy” and venereal diseases, but did not mention that studies had not assessed whether stimulants decreased those risks.

Slides that Dr. William W. Dodson, a psychiatrist, presented during a gathering of 70 doctors in 2002 encouraged lifelong treatment for A.D.H.D. Studies have shown that many children with the disorder are not impaired as adults.

 

Dr. Conners of Duke, in the audience that day, said the message was typical for such gatherings sponsored by pharmaceutical companies: Their drugs were harmless, and any traces of A.D.H.D. symptoms (which can be caused by a number of issues, including lack of sleep and family discord) should be treated with stimulant medication.

In an interview last month, Dr. Dodson said he makes a new diagnosis in about 300 patients a year and, because he disagrees with studies showing that many A.D.H.D. children are not impaired as adults, always recommends their taking stimulants for the rest of their lives.

He said that concern about abuse and side effects is “incredibly overblown,” and that his longtime work for drug companies does not influence his opinions. He said he received about $2,000 for the 2002 talk for Shire. He earned $45,500 in speaking fees from pharmaceutical companies in 2010 to 2011, according to ProPublica, which tracks such payments.

“If people want help, my job is to make sure they get it,” Dr. Dodson said. Regarding people concerned about prescribing physicians being paid by drug companies, he added: “They like a good conspiracy theory. I don’t let it slow me down.”

Many of the scientific studies cited by drug company speakers involved Dr. Joseph Biederman, a prominent child psychiatrist at Harvard University and Massachusetts General Hospital. In 2008, a Senate investigation revealed that Dr. Biederman’s research on many psychiatric conditions had been substantially financed by drug companies, including Shire. Those companies also paid him $1.6 million in speaking and consulting fees. He has denied that the payments influenced his research.

Dr. Conners called Dr. Biederman “unequivocally the most published psychopharmacology maven for A.D.H.D.,” one who is well known for embracing stimulants and dismissing detractors. Findings from Dr. Biederman’s dozens of studies on the disorder and specific brands of stimulants have filled the posters and pamphlets of pharmaceutical companies that financed the work.

Those findings typically delivered three messages: The disorder was underdiagnosed; stimulants were effective and safe; and unmedicated A.D.H.D. led to significant risks for academic failure, drug dependence, car accidents and brushes with the law.

Dr. Biederman was frequently quoted about the benefits of stimulants in interviews and company news releases. In 2006, for example, he told Reuters Health, “If a child is brilliant but is doing just O.K. in school, that child may need treatment, which would result in their performing brilliantly at school.”

This year, Dr. Biederman told the medical newsletter Medscape regarding medication for those with A.D.H.D., “Don’t leave home without it.”

Dr. Biederman did not respond to requests for an interview.

Most of Dr. Biederman’s critics said that they believed his primary motivation was always to help children with legitimate A.D.H.D. and that risks of untreated A.D.H.D. can be significant. What concerned them was how Dr. Biederman’s high-profile and unwavering promotion of stimulants armed drug companies with the published science needed to create powerful advertisements — many of which cast medications as benign solutions to childhood behavior falling far short of legitimate A.D.H.D.

“He gave them credibility,” said Richard M. Scheffler, a professor of health economics and public policy at the University of California, Berkeley, who has written extensively on stimulants. “He didn’t have a balance. He became totally convinced that it’s a good thing and can be more widely used.”

Building a Message

Drug companies used the research of Dr. Biederman and others to create compelling messages for doctors. “Adderall XR Improves Academic Performance,” an ad in a psychiatry journal declared in 2003, leveraging two Biederman studies financed by Shire. A Concerta ad barely mentioned A.D.H.D., but said the medication would “allow your patients to experience life’s successes every day.”

Some studies had shown that stimulant medication helped some elementary school children with carefully evaluated A.D.H.D. to improve scores in reading and math tests, primarily by helping them concentrate. The concern, some doctors said, is that long-term, wider academic benefits have not been proved — and that ads suggesting they have can tempt doctors, perhaps subconsciously, to prescribe drugs with risks to healthy children merely to improve their grades or self-esteem.

Advertising Disorder

Drug companies have shifted marketing for A.D.H.D. medication through the years. Most recently, problems like divorce and auto accidents have been used to appeal to adults. Ads in the 1990s advertised improved grades at school as a central benefit. Early ads focused on depression and “the problem child.”

Source: Various medical journals and consumer magazines

 

“There are decades of research into how advertising influences doctors’ prescribing practices,” said Dr. Aaron Kesselheim of Brigham and Women’s Hospital in Boston, who specializes in pharmaceutical ethics. “Even though they’ll tell you that they’re giving patients unbiased, evidence-based information, in fact they’re more likely to tell you what the drug company told them, whether it’s the benefits of the drugs or the risks of those drugs.”

Drug company advertising also meant good business for medical journals – the same journals that published papers supporting the use of the drugs. The most prominent publication in the field, The Journal of the American Academy of Child & Adolescent Psychiatry, went from no ads for A.D.H.D. medications from 1990 to 1993 to about 100 pages per year a decade later. Almost every full-page color ad was for an A.D.H.D. drug.

As is legal and common in pharmaceutical marketing, stimulants’ possible side effects like insomnia, irritability and psychotic episodes were printed in small type and dominated by other messages. One Adderall XR brochure included the recording of a man’s voice reassuring doctors: “Amphetamines have been used medically for nearly 70 years. That’s a legacy of safety you can count on.” He did not mention any side effects.

Drug companies used sales representatives to promote the drugs in person. Brian Lutz, a Shire salesman for Adderall XR from 2004 to 2009, said he met with 75 psychiatrists in his Oakland, Calif., territory at least every two weeks — about 30 to 40 times apiece annually — to show them posters and pamphlets that highlighted the medicine’s benefits for grades and behavior.

If a psychiatrist asked about issues like side effects or abuse, Mr. Lutz said, they were played down. He said he was told to acknowledge risks matter-of-factly for legal reasons, but to refer only to the small print in the package insert or offer Shire’s phone number for more information.

“It was never like, ‘This is a serious side effect, you need to watch out for it,’ ” Mr. Lutz recalled. “You wanted to give them more information because we’re talking about kids here, you know? But it was all very positive.”

A Shire spokeswoman said the company would not comment on any specific employee and added, “Shire sales representatives are trained to deliver fair and balanced presentations that include information regarding the safety of our products.”

Mr. Lutz, now pursuing a master’s degree and hoping to work in mental health, recalled his Shire work with ambivalence. He never lied or was told to lie, he said. He said he still would recommend Adderall XR and similar stimulants for A.D.H.D. children and adults.

What he regrets, he said, “is how we sold these pills like they were cars, when we knew they weren’t just cars.”

Selling to Parents

In September 2005, over a cover that heralded Kirstie Alley’s waistline and Matt Damon’s engagement, subscribers to People magazine saw a wraparound advertisement for Adderall XR. A mother hugged her smiling child holding a sheet of paper with a “B+” written on it.

“Finally!” she said. “Schoolwork that matches his intelligence.”

When federal guidelines were loosened in the late 1990s to allow the marketing of controlled substances like stimulants directly to the public, pharmaceutical companies began targeting perhaps the most impressionable consumers of all: parents, specifically mothers.

A magazine ad for Concerta had a grateful mother saying, “Better test scores at school, more chores done at home, an independence I try to encourage, a smile I can always count on.” A 2009 ad for Intuniv, Shire’s nonstimulant treatment for A.D.H.D., showed a child in a monster suit taking off his hairy mask to reveal his adorable smiling self. “There’s a great kid in there,” the text read.

“There’s no way in God’s green earth we would ever promote” a controlled substance like Adderall directly to consumers, Mr. Griggs said as he was shown several advertisements. “You’re talking about a product that’s having a major impact on brain chemistry. Parents are very susceptible to this type of stuff.”

The Food and Drug Administration has repeatedly instructed drug companies to withdraw such ads for being false and misleading, or exaggerating the effects of the medication. Many studies, often sponsored by pharmaceutical companies, have determined that untreated A.D.H.D. was associated with later-life problems. But no science determined that stimulant treatment has the overarching benefits suggested in those ads, the F.D.A. has pointed out in numerous warning letters to manufacturers since 2000.

Shire agreed last February to pay $57.5 million in fines to resolve allegations of improper sales and advertising of several drugs, including Vyvanse, Adderall XR and Daytrana, a patch that delivers stimulant medication through the skin. Mr. Casola of Shire declined to comment on the settlement because it was not fully resolved.

He added that the company’s current promotional materials emphasize how its medications provide “symptom control” rather than turn monsters into children who take out the garbage. He pointed to a Shire brochure and web page that more candidly than ever discuss side effects and the dangers of sharing medication with others.

However, many critics said that the most questionable advertising helped build a market that is now virtually self-sustaining. Drug companies also communicated with parents through sources who appeared independent, from support groups to teachers.

The primary A.D.H.D. patient advocacy group, Children and Adults with Attention-Deficit/Hyperactivity Disorder, or Chadd, was founded in 1987 to gain greater respect for the condition and its treatment with Ritalin, the primary drug available at the time. Start-up funding was provided by Ciba-Geigy Pharmaceuticals, Ritalin’s primary manufacturer. Further drug company support helped create public service announcements and pamphlets, some of which tried to dispel concerns about Ritalin; one Chadd “fact sheet” conflicted with 60 years of science in claiming, “Psychostimulant drugs are not addictive.”

The program from the 2000 annual convention of the patient advocacy group Chadd thanked its 11 primary sponsors, all drug companies.

 

A 1995 documentary on PBS detailed how Chadd did not disclose its relationship with drug companies to either the Drug Enforcement Administration, which it was then lobbying to ease government regulation of stimulants, or the Department of Education, with which it collaborated on an A.D.H.D. educational video.

Chadd subsequently became more open in disclosing its backers. The program for its 2000 annual convention, for example, thanked by name its 11 primary sponsors, all drug companies. According to Chadd records, Shire paid the group a total of $3 million from 2006 to 2009 to have Chadd’s bimonthly magazine, Attention, distributed to doctors’ offices nationwide.

Chadd records show that the group has historically received about $1 million a year, one-third of its annual revenue, from pharmaceutical company grants and advertising. Regarding his company’s support, Mr. Casola said, “I think it is fair to call it a marketing expense, but it’s an arm’s-length relationship.”

“We don’t control what they do,” he said. “We do support them. We do support broadly what they are trying to do in the marketplace — in society maybe is a better way to say it.”

Advocates Answer

The chief executive of Chadd, Ruth Hughes, said in an interview that most disease-awareness groups receive similar pharmaceutical support. She said drug companies did not influence the group’s positions and activities, and noted that Chadd receives about $800,000 a year from the C.D.C. as well.

“One pharma company wanted to get Chadd volunteers to work at their booth to sort of get peer counseling, and we said no, won’t do that, not going there,” Dr. Hughes said, adding, “It would be seen as an endorsement.”

A.D.H.D. patient advocates often say that many parents resist having their child evaluated because of the stigma of mental illness and the perceived risks of medication. To combat this, groups have published lists of “Famous People With A.D.H.D.” to reassure parents of the good company their children could join with a diagnosis. One, in circulation since the mid-1990s and now posted on thepsychcentral.com information portal beside two ads for Strattera, includes Thomas Edison, Abraham Lincoln, Galileo and Socrates.

The idea of unleashing children’s potential is attractive to teachers and school administrators, who can be lured by A.D.H.D. drugs’ ability to subdue some of their most rambunctious and underachieving students. Some have provided parents with pamphlets to explain the disorder and the promise of stimulants.

Susan Parry, with her son, Andy, 30. When Andy was a boy, Mrs. Parry felt pressured to put him on stimulants.Rick Scibelli Jr. for The New York Times

 

Susan Parry, who raised three boys in a top public school system on Mercer Island, outside Seattle, in the 1990s, said teachers pushed her into having her feisty son Andy evaluated for A.D.H.D. She said one teacher told her that her own twins were thriving on Ritalin.

Mrs. Parry still has the pamphlet given to her by the school psychologist, which states: “Parents should be aware that these medicines do not ‘drug’ or ‘alter’ the brain of the child. They make the child ‘normal.’ ” She and her husband, Michael, put Andy on Ritalin. The Parrys later noticed that on the back of the pamphlet, in small type, was the logo of Ciba-Geigy. A school official told them in a letter, which they provided to The Times, that the materials had been given to the district by a Ciba representative.

“They couldn’t advertise to the general public yet,” said Michael Parry, adding that his son never had A.D.H.D. and after three years was taken off Ritalin because of sleep problems and heart palpitations. “But somebody came up with this idea, which was genius. I definitely felt seduced and enticed. I’d say baited.”

Although proper A.D.H.D. diagnoses and medication have helped millions of children lead more productive lives, concerns remain that questionable diagnoses carry unappreciated costs.

“They were telling me, ‘Honey, there’s something wrong with your brain and this little pill’s going to fix everything,’ ” said Micaela Kimball, who received the diagnosis in 1997 as a high school freshman in Ithaca, N.Y., and is now a freelance writer in Boston. “It changed my whole self-image, and it took me years to get out from under that.”

Today, 1 in 7 children receives a diagnosis of the disorder by the age of 18. As these teenagers graduate into adulthood, drug companies are looking to keep their business.

The New Frontier: Adults

The studio audience roared with excitement two years ago as Ty Pennington, host of “The Revolution” on ABC, demonstrated how having adult A.D.H.D. felt to him. He staged two people struggling to play Ping-Pong with several balls at once while reciting the alphabet backward, as a crowd clapped and laughed. Then things got serious.

The television host Ty Pennington has been featured in advertisements in which adult A.D.H.D. has been marketed by pharmaceutical companies.Michael Buckner/Getty Images

 

A psychiatrist on the program said that “the prison population is full of people with undiagnosed A.D.H.D.” He told viewers, “Go get this diagnosis” so “you can skyrocket.” He said that stimulant medication was effective and “safer than aspirin.”

No one mentioned that Mr. Pennington had been a paid spokesman for Shire from 2006 to 2008. His Adderall XR video testimonials – the medication “literally changed my life” and “gave me confidence,” he said in a 2008 ad — had drawn an F.D.A. reprimand for overstating Adderall’s effects while omitting all risks.

Mr. Pennington said through a spokeswoman: “I am not a medical expert. I am a television host.”

Many experts agree that the disorder was dismissed for too long as affecting only children. Estimates of the prevalence of adult A.D.H.D. in the United States — derived through research often backed by pharmaceutical companies — have typically ranged from 3 to 5 percent. Given that adults far outnumber children, this suggests that the adult market could be twice as large.

Because many doctors and potential patients did not think adults could have A.D.H.D., drug companies sold the concept of the disorder as much as their medications for it.

“The fastest-growing segment of the market now is the new adults who were never diagnosed,” Angus Russell told Bloomberg TV in 2011 when he was Shire’s chief executive. Nearly 16 million prescriptions for A.D.H.D. medications were written for people ages 20 to 39 in 2012, close to triple the 5.6 million just five years before, according to IMS Health. No data show how many patients those prescriptions represent, but some experts have estimated two million.

Foreseeing the market back in 2004, Shire sponsored a booklet that according to its cover would “help clinicians recognize and diagnose adults with A.D.H.D.” Its author was Dr. Dodson, who had delivered the presentation at the Adderall XR launch two years before. Rather than citing the widely accepted estimate of 3 to 5 percent, the booklet offered a much higher figure.

“About 10 percent of adults have A.D.H.D., which means you’re probably already treating patients with A.D.H.D. even though you don’t know it,” the first paragraph ended. But the two studies cited for that 10 percent figure, from 1995and 1996, involved only children; no credible national study before or since has estimated an adult prevalence as high as 10 percent.

Dr. Dodson said he used the 10 percent figure because, despite several studies estimating adult rates as far lower, “once a child has A.D.H.D., he does for life. It doesn’t go away with age.”

The booklet later quotes a patient of his named Scarlett reassuring doctors: “If you give me a drink or a drug, I’ll abuse it, but not this medication. I don’t consider it a drug. Drugs get abused. Medication helps people have satisfying lives.”

Shire’s 2008 print campaign for adult A.D.H.D. portrayed a gloomy future to prospective patients. One ad showed a happy couple’s wedding photo with the bride airbrushed out and “DIVORCED” stamped on it. “The consequences may be serious,” the ad said, citing a study by Dr. Biederman supported in part by Shire. Although Dr. Biederman’s study showed a higher rate of divorce among adults with the disorder, it did not assess whether stimulant treatment significantly deterred such consequences.

Questionable Quizzes

Adults searching for information on A.D.H.D. encounter websites with short quizzes that can encourage normal people to think they might have it. Many such tests are sponsored by drug companies in ways hidden or easily missed.

“Could you have A.D.H.D.?” beckons one quiz, sponsored by Shire, on the website everydayhealth.com. Six questions ask how often someone has trouble in matters like “getting things in order,” “remembering appointments” or “getting started” on projects.

A user who splits answers evenly between “rarely” and “sometimes” receives the result “A.D.H.D. Possible.” Five answers of “sometimes” and one “often” tell the user, “A.D.H.D. May Be Likely.”

In a nationwide telephone poll conducted by The Times in early December, 1,106 adults took the quiz. Almost half scored in the range that would have told them A.D.H.D. may be possible or likely.

About 570,000 people took the EverydayHealth test after a 2011 advertisementstarring Mr. Levine of Maroon 5 sponsored by Shire, Chadd and another advocacy group, according to the website Medical Marketing & Media. A similar test on the website for Concerta prompted L2ThinkTank.com, which assesses pharmaceutical marketing, to award the campaign its top rating, “Genius.”

John Grohol, a Boston-area psychologist who licensed the test to EverydayHealth, said such screening tools do not make a diagnosis; they merely “give you a little push into looking into” whether you have A.D.H.D. Other doctors countered that, given many studies showing that doctors are strongly influenced by their patients’ image of what ails them, such tests invite too many patients and doctors to see the disorder where it is not.

Online Test Asks Whether You Could Have A.D.H.D., Too

A web page sponsored by the drug maker Shire features this quiz, which encourages adults with what many would consider common behavior to think they might have A.D.H.D. In a Times poll of 1,106 American adults asking the same questions by telephone, nearly half got a result of “A.D.H.D. Possible” or “A.D.H.D. May Be Likely.” Only 5 percent said they had received an A.D.H.D. diagnosis from a medical professional.

Try this six-question quiz to see how you score — then see how you compare with other Americans.

1. How often do you have trouble wrapping up the final details of a project once the challenging parts have been done?
  • Never
  • Rarely
  • Sometimes
  • Often
  • Very Often

 

“I think it is misleading,” said Dr. Tyrone Williams, a psychiatrist in Cambridge, Mass. “I do think that there are some people out there who are really suffering and find out that maybe it’s treatable. But these symptoms can be a bazillion things. Sometimes the answers are so simple and they don’t require prescriptions – like ‘How about eight hours of sleep, Mom, because four hours doesn’t cut it?’ And then all their A.D.H.D. symptoms magically disappear.”

Because studies have shown that A.D.H.D. can run in families, drug companies use the children’s market to grow the adult one. A pamphlet published in 2008 by Janssen, Concerta’s manufacturer — headlined “Like Parent, Like Child?” — claimed that “A.D.H.D. is a highly heritable disorder” despite studies showing that the vast majority of parents of A.D.H.D. children do not qualify for a diagnosis themselves.

A current Shire manual for therapists illustrates the genetic issue with a family tree: three grandparents with the disorder, all six of their children with it, and seven of eight grandchildren, too.

Insurance plans, increasingly reluctant to pay for specialists like psychiatrists, are leaving many A.D.H.D. evaluations to primary-care physicians with little to no training in the disorder. If those doctors choose to learn about the diagnostic process, they can turn to web-based continuing-education courses, programs often subsidized by drug companies.

A recent course titled “Unmasking A.D.H.D. in Adults,” on the website Medscape and sponsored by Shire, featured an instructional video of a primary-care physician listening to a college professor detail his work-related sleep problems. After three minutes he described some attention issues he had as a child, then revealed that his son was recently found to have the disorder and was thriving in college on medication.

Six minutes into their encounter, the doctor said: “If you have A.D.H.D., which I believe you do, family members often respond well to similar medications. Would you consider giving that a try?”

The psychiatrist who oversaw the course, Dr. David Goodman of Johns Hopkins and the Adult Attention Deficit Disorder Center of Maryland, said that he was paid several thousand dollars to oversee the course by Medscape, not Shire directly, and that such income did not influence his decisions with patients. But as he reviewed the video in September, Dr. Goodman reconsidered its message to untrained doctors about how quickly the disorder can be assessed and said, “That was not an acceptable way to evaluate and conclude that the patient has A.D.H.D.”

A Shire spokeswoman declined to comment on the video and the company’s sponsorship of it.

Mr. Casola said Shire remains committed to raising awareness of A.D.H.D. Shire spent $1 million in the first three quarters of 2013, according to company documents, to support A.D.H.D. conferences to educate doctors. One this autumn found J. Russell Ramsay, a psychologist at the University of Pennsylvania’s medical school, who also serves as a consultant and speaker for Shire, reading aloud one of his slides to the audience: “A.D.H.D. – It’s Everywhere You Want to Be.”

“We are a commercial organization trying to bring health care treatments to patients,” Mr. Casola said. “I think, on balance, we are helping people.”

A version of this article appears in print on December 15, 2013, on page A1 of the New York edition with the headline: The Se

Nearly 25 Years of Fathering — and All I’ve Got Are These 3 Lousy Tips

 

Jim Higley

Bobblehead Dad; Author; Speaker; Parenting Columnist; Radio Host; Cancer Warrior

Posted: 12/03/2013

I haven’t read many parenting books. And I know, that’s a little surprising for a guy who spends most of his time talking and writing about being a dad.

So, if you chose to read no further, I understand. It’s pitiful. I know.

But what I lack in reading and scholarly research, I’ve compensated for with a lot of observations, conversations with professionals and good old-fashioned trial-and-error. A little over 24 years of it. One of the things I’ve learned is that being an effective dad requires strong communications with your child. If you can nail that part of the dad job, the rest comes much easier.

A daunting task for sure — especially as kids get older. So, here are my three top tips to help you grease that two-way road to trust-filled communications with your children.

Put It On Ice

You don’t need to react so quickly to every situation. Slow down and think. Erupting like Mt. Vesuvius, spewing words and emotions, doesn’t work. It’s scary and models inappropriate behavior for your children.

Give yourself a little time to think. A minute. Five. With older kids I might wait several hours or even a day.

The key is to plant the seed with your child that the topic is “open” and that you’re going to revisit it with them after the two of you have a chance to mutually think about it.

With little kids who are misbehaving, you can literally pick them up, carry them to their room, and have a firm chat after a couple of minutes of cool-down time. But with older kids, that tactic doesn’t work. Additionally, if you verbally attack an older kid in the heat of the moment, they are likely to feel cornered and trapped. You’re simply inviting them to verbally attack you back.

That’s why (unless someone is at risk of being hurt or hurting someone), I’m now far more likely to say something like, “You know, the way you talk to me is just not working for me. But I’m not going to scream and simply hand you a punishment. I want you to think about it before we talk later this afternoon.”

Kids desperately want respect. Even when they don’t show it towards you. They want to be heard. When you introduce topics with respect and consideration, it makes it much harder for them to continue their cycle of behavior. Try it.

30-Second Rule

Stop lecturing.

And when you feel the urge to lecture, limit it to 30 seconds.

Kids hate lectures. I bet you do, too. If you can’t get 95 percent of your point made in 30 seconds, then you need to think through your message.

When I feel the need to preach to my kids, I introduce it with, “I need 30 seconds to share something with you that’s been on my mind. Is your head in a good place to listen?”

And you know what? Nine times out of 10, my kids tell me to bring it on right then and there.

And you know something else? They listen.

I end my half-minute sermon with something like, “Okay, that’s what I wanted you to know. I want to hear your thoughts later today when you’re ready to talk.”

Sometimes they want to talk right away. Sometimes they noodle and come back on their own. And sometimes I have to bring the subject back up a bit later. But it’s almost always a smoother road to a sincere, open conversation.

Start with 30 seconds. It works.

Stop Solving Everything

This one took me years to figure out. It’s one that is really hard for dads to get good at because we love fixing and solving things.

I’m talking about those times in life when your kids are mad, upset, hurt, frustrated, or angry over a host of things. Mean friends. Unfair coaches. Tough teachers. Annoying siblings. The list is miles long. I know for me, any time I used to hear another problem de jour, I’d reply to it with strategies for fixing it and make it go away.

“Here’s what you need to do with your friends -”

“Next time your coach tells you blah, blah, blah, you should -”

“Well, you should never let your friends tell you -”

And you know what I’ve learned? Kids don’t always want you to tell them what to do. They don’t always need you to strategize. They’re also far more resilient and capable than you give them credit for.

A lot of times, they just want you to be in the zone with them. Empathize. Go deep. Be in the moment. Experience their feelings. I figured this out one day when my 13-year-old daughter was sulking in her bedroom, angry at mean friends. It tore me apart. I didn’t want her to hurt. But at the advice of another wise dad, I tried something new.

I went into her room, laid on the floor, and just stared at the ceiling with her.

And eventually she said, “I hate my friends.”

And I replied, “That must suck to feel that way.”

And what followed was a dad-changing moment. She told me details of what was going on while I just stared at the ceiling. She told me about her hurt and pain. And I just kept reaffirming my love for her, my sadness at the situation, and my understanding of her feelings.

And she was fine with that. She didn’t need me to solve it.

She needed me to experience it with her.

I’m convinced that my actions sent her a far more important message than had I tried to give her an assortment of ideas to fix the specific problem.

***

So there you have it. My top three tips. And just in case you’re thinking, “Taking the easy road, huh?” the truth is all three of these ideas require you to stop, think and really focus on what your child needs. They require conscious parenting.

But slowing down, taking time to think, fine-tuning your message, and acknowledging your child’s emotions are collectively some of the best ways to build strong communications.

Try them out. Modify them to work for your family. The rewards are plentiful.

How Do We Inspire Young Inventors?

MindShift

 | November 25, 2013

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Brightworks School

 

In New Haven, Connecticut, where I live with my husband and two sons, we are lucky to have nearby the Eli Whitney Museum. This place is the opposite of a please don’t touch repository of fine art. It’s an “experimental learning workshop” where kids engage in an essential but increasingly rare activity: they make stuff. Right now, looking around my living room, I can see lots of the stuff made there by my older son: a model ship that can move around in water with the aid of a battery-powered motor he put together; a “camera obscura” that can project a real-world scene onto a wall in a darkened room; a wooden pinball game he designed himself. (You can view an archive of Eli Whitney Museum projects here.)

 

The people who run Eli Whitney call these hands-on projects “experiments.” As they put it: “Experiments are a way of learning things. They require self-guided trial and error, active exploration, and testing by all the senses. Experiments begin with important questions, questions that make you think or that inspire you to create.” This process of exploring, testing and finding out is vital to children’s intellectual and psychological development—but opportunities to engage in it are fewer than they once were. “My friends and I grew up playing around in the garage, fixing our cars,” says Frank Keil, a Yale University psychologist who is in his early 60′s. “Today kids are sealed in a silicon bubble. They don’t know how anything works.”

 

“We scour the country looking for young builders and inventors. They’re getting harder and harder to find.”

Many others have noticed this phenomenon. Engineering professors report that students now enter college without the kind of hands-on expertise they once unfailingly possessed. At the Massachusetts Institute of Technology, “we scour the country looking for young builders and inventors,” says Kim Vandiver, dean for undergraduate research. “They’re getting harder and harder to find.” MIT now offers classes and extracurricular activities devoted to taking things apart and putting them together, an effort to teach students the skills their fathers and grandfathers learned curbside on weekend afternoons.

 

Why should this matter? Some would argue that the digital age has rendered such technical know-how obsolete. Our omnipresent devices work the way we want them to (well, most of the time), with no skill required beyond pushing a button. What’s to be gained by knowing how they work?

 

Actually, a lot. Research in the science of learning shows that hands-on building projects help young people conceptualize ideas and understand issues in greater depth. In anexperiment described in the International Journal of Engineering Education in 2009, for example, one group of eighth-graders was taught about water resources in the traditional way: classroom lectures, handouts and worksheets. Meanwhile, a group of their classmates explored the same subject by designing and constructing a water purification device. The students in the second group learned the material better: they knew more about the importance of clean drinking water and how it is produced, and they engaged in deeper and more complex thinking in response to open-ended questions on water resources and water quality.

 

If we want more young people to choose a profession in one of the group of crucial fields known as STEM—science, technology, engineering and math—we ought to start cultivating these interests and skills early. But the way to do so may not be the kind of highly structured and directed instruction that we usually associate with these subjects. Instead, some educators have begun taking seriously an activity often dismissed as a waste of time: tinkering. Tinkering is the polar opposite of the test-driven, results-oriented approach of No Child Left Behind: it involves a loose process of trying things out, seeing what happens, reflecting and evaluating, and trying again.

 

“Tinkering is the way that real science happens, in all its messy glory,” says Sylvia Martinez, co-author of the new book Invent To Learn: Making, Tinkering, and Engineering in the Classroom. Martinez is one of the leaders of the “makers’ movement,” a nationwide effort to help kids discover the value of getting their hands dirty and their minds engaged. The next generation of scientists—and artists, and inventors, and entrepreneurs—may depend on it.

Single-sex classrooms: Educators, students say the change makes a difference

Winston-Salem Journal

CIT WSJ_1206_WSPADavid Rolfe/Journal

Aligah Alford, center, works on a class assignment as sixth-grade social studies teacher Earnest Hall, standing, right, gives directions to his class at the Winston-Salem Prepatory Academy, Thursday, Dec. 5, 2013. The school instituted single-gender classes this year.

Posted: Tuesday, December 10, 2013 12:00 am

Arika Herron/Winston-Salem Journal

A change at Winston-Salem Preparatory Academy has shaken up classroom dynamics, even pitting boys against girls in the school’s lower grades.

Don’t worry, though, teachers say. It’s all in the spirit of healthy competition, and it’s leading to better classroom performance on all fronts.

It started when the school adopted a single-gender classroom policy for its middle-school core classes. The change was approved in April and implemented this school year. When classes began in August, Winston-Salem Prep’s sixth-, seventh- and eighth-graders were divided into two classes of all boys and two classes of all girls for their math, science, language arts and social studies lessons.

School administrators and teachers were looking for a way to create a classroom where students were more attentive, more engaged and more comfortable participating.

“I was looking to change the culture and environment in the school,” said Janel Sharpe, an eighth-grade science teacher. “I wanted to improve test scores and learning conditions.”

So far, teachers say they’ve gotten all of that and more. Students are more comfortable sharing their ideas and answering questions. And because students are paying better attention, teachers say they’re able to move through material more quickly.

What do you think about single-gender classrooms?

Sixth-grader Lovely Ponce said she likes her all-girl classes. She gets more done, she said, because the new classroom makeup has removed a large distraction — the opposite sex.

“I won’t get distracted by the boys,” she said. “It keeps me from not doing my work.”

Distractions have been removed, but it’s also created a level of healthy competition between the gendered classes that teachers weren’t necessarily expecting, said Carlos Rodriguez, an eighth-grade math teacher. Now, when his boys hear that the girls’ class is ahead in a lesson, they’re more apt to focus and get work done.

“It helps promote more learning,” Rodriguez said.

With single-gender classes, teachers say they’re able to better connect with students.

It’s no secret that boys and girls learn differently. But instead of trying to cater to both in a single lesson, like traditional classrooms, Winston-Salem Prep’s middle-school teachers get to design lessons tailored to boys or girls. Danielle Moore, a sixth-grade language arts teacher, said it lets her choose different poems for the grade’s poetry unit for her boy classes versus her girl classes. During a unit looking at song lyrics, she can choose different songs. Creating two lessons to teach the same topic is extra work, but Moore said it’s worth it for the difference she sees in her students.

“Especially when we’re talking about feelings,” she said. “Girls are not as shy, and guys don’t feel like they have to remain ‘cool.’”

What about socializing with the other gender? Well, students still get to do that in their elective courses. Students are in co-ed classes for such courses as music, art and gym.

But during the core classes — the subjects on which they take standardized assessments at the end of the year, with scores that will be compared to those around the state — it’s all single-gender and it’s all business.

Teachers aren’t the only ones in favor of the move. Students, too, are saying they’re happy with their single-gender classes.

“Some of the boys would play with the girls in class,” said DeAndre Boyd, a sixth-grader. “I don’t want nobody getting distracted or trying to distract me.”

Winston-Salem Prep has struggled with academic performance, falling behind district averages on end-of-grade tests. While students who took the new READY Accountability assessments — statewide exams to test the standards in the new common core curriculum — met the growth targets that measure how much they learned in a single year, the school’s middle school composite score was one of the lowest at just 20 percent.

Teachers are hoping the improved performance they’re seeing in the classroom will translate into improved performance on test scores at the end of the school year, also.

It’s too early to have hard data to look at for comparisons against previous years, but teachers and students alike seem to believe single-gender classrooms have had a positive effect.

It’s one of a handful of schools in the Winston-Salem/Forsyth County Schools system to implement the practice, but the first to do so across entire grades.

At the high school level, Winston-Salem Prep is a magnet school with a college prep theme. Principal Richard Watts said there are no plans right now to implement single-gender classrooms at the high school level.

The Overlooked Secret to Great Performance

The New York Times

BY TONY SCHWARTZ
Ignore exercise, and you will get progressively weaker, and more vulnerable to illness.Matthew Peyton for The New York TimesIgnore exercise, and you will get progressively weaker, and more vulnerable to illness.

Think of a time when you were performing at your best and another occasion when you were performing at your worst. Now, take a few moments to visualize the two occasions in your mind.

The vast difference between these two experiences has nothing to do with your inborn talent or your skills. How much of your capacity you bring to work on any given day depends, to a large degree, on how much energy you’ve got in your tank.

Obvious as that seems, we underestimate how much impact taking care of ourselves — and feeling taken care of — has on our performance.  Unlike machines, which run on a single source of energy, human beings require four types of fuel to perform at their best: physical, emotional, mental and spiritual. Each of these influences one another, and none is sufficient by itself.

Physical energy is the core fuel we require to get things done. Everything we do rests on that foundation, and how we feel is influenced by what we eat and when, how much we exercise, whether or not we renew our energy intermittently through the day and how many hours we sleep.

Go without eating for five or six hours, for example, and you’re depriving the brain of its ravenous need for glucose. Work continuously for multiple hours without a break, and you’re progressively depleting your capacity to remain calm and collected under pressure. Ignore exercise, and you will get progressively weaker, and more vulnerable to illness.

No single behavior in our lives matters more than sleep, because without enough of it — a minimum of seven to eight hours for 97 percent of us — the toll shows up in every aspect of our lives. Even small amounts of sleep deprivation take a toll, for example, on vigilance on a task, our mental agility on tasks, our mood and even our motivation.

The second fuel in our lives is emotional. We assume we’re rational beings, but it turns out we’re run largely by our emotions, for better and for worse. Think again about how you feel when you’re performing at your best. We’ve asked this question to tens of thousands of people over the years and the adjectives people describe are always the same: energized, excited, happy, positive, engaged and in the flow.

Put simply, we perform best when we’re feeling high positive emotions, and we perform less well as our feelings move in the direction of anger, frustration, impatience and fear — all of which are also draining, and antagonizing to others. Just being aware that negative emotions undermine us can be a powerful impetus to address them.

Psychologists like Roy Baumeister have long written about our “negativity bias” — the default inclination to focus more on what is wrong in our lives than what’s right. While we’re wired to be vigilant to threat, it’s also possible to consciously cultivate positive emotions.

Taking time to appreciate one’s bounty and express gratitude all serve this end. So, too, does spending time with people we care about deeply, which helps explain why having a close friend at work has a powerful and positive impact on engagement and performance at work.

The mental fuel we require to perform at our best is focus, and more so than ever in a world of infinite distractions. Control of our attention — the capacity to put our focus where we want it to be — makes it possible not just to get the right work done, but also to intentionally shape our experience. Attention, like any other muscle, gets stronger when we train it — which helps explain why practices like mindfulness are suddenly generating so much interest in organizations

The fourth fuel that influences our performance is the sense of purpose we bring to our work. Is there any doubt that we feel more positive — and bring more passion and focus to what we do — when we believe what we’re doing really matters? Paradoxically, the more we invest in adding value to others, the better we feel about ourselves.

Just as we underestimate how much these sources of fuel influence our performance, so do the organizations for which we work. Few companies or leaders I’ve encountered systematically focus on, and invest in, how their employees feel, even though doing so would serve their bottom line.

The 2012 Global Workforce Study conducted by the consulting firm Towers Watson measured the relationship between engagement — the willingness of employees to invest discretionary effort at work — and financial results. The key for the most highly engaged employees turned out to be their ability to maintain their energy and enthusiasm at work.

The differentiating factor among companies with the most highly engaged employees was an environment that supported people’s physical, emotional and social well-being. Companies that did this least well had an average operating margin of 10 percent. Companies that best supported employees had an average operating margin of 27 percent.

It’s a dual challenge. Organizations stand to improve performance by helping their employees feel better every day. We perform better and more sustainably when we take better care of ourselves.

Far From My Tree

Motherlode - Adventures in Parenting


By SUE ROBINS

My eldest son is 20 years old, lives in a house crammed with seven scrabbly roommates, works part time in a restaurant kitchen, doesn’t drive, is a vegetarian, and has homemade tattoos etched into his thighs.

He’s firmly a musician – a drummer in a loud punk band, and he loves nothing more than to tour across North America, playing gigs in sketchy houses in Oakland, Calif., and south Chicago.

He appears to have only one pair of pants – dirty, black cutoff jeans, and his shirts are also of the ripped-off-arms variety. I’m not sure who has been ripping up all his clothes. Maybe there’s a wild dog living in his house.

I’m both proud of and horrified for my boy. His jaw is squarely set, and he’s acutely committed to what he wants to do. And that is to tour with his band in their black-panel van, crisscrossing borders, dodging death in dubious neighborhoods, sleeping on strangers’ couches, and eating vegetarian burritos.

As my children traveled through their teenage years, I emphasized to them: Find your passion and follow it. What I really meant was: Find your passion, but do it in the way I did it. That is, go to college first, get a liberal arts degree, meander through your 20s, and then supplement your undergraduate degree with graduate studies. All while wearing clean, intact clothing.

But what if, as Andrew Solomon so eloquently addresses in his masterpiece, “Far From the Tree,” your child ends up so very different from you? I read “Far From the Tree” because it speaks of children with disabilities (and my youngest son has Down syndrome), but I gained a deeper knowledge of all children who stray from their parents. If we face reality squarely, and give our children the space to be who they want to be, every single child should be different from his parents, and should be allowed and even encouraged to fall far from our trees.

My oldest boy does not show up to family events in his collared shirt and pressed pants. In fact, he rarely shows up at all. He doesn’t respond to calls from grandparents, although he will send thank you texts for birthday gifts, so he still has a sliver of decorum. He’s proudly anti-establishment, and my current lifestyle with my husband (and his stepfather) – living in the suburbs and driving a BMW – clearly disgusts him.

I watch my friends’ children embarking on their second year of college, most of them still living at home with their parents. They are clean-cut, unfailingly polite, sit quietly at dinner parties and patiently dole out answers to questions from adults. Inevitably, someone asks me, “What’s your son doing?” and then I feel a strange mix of pride and apology. “He’s living his life,” I say. “But what graduate program? What path is he taking?” “He’s not in a program,” I say. “He’s working and playing in a band.” They take a deep gulp of wine and look down at their expensive shoes.

I read a biography of Dave Grohl, the former drummer for Nirvana. In it, Mr. Grohl’s mother – a teacher herself – agreed to let him drop out of high school so he could tour with his band. She said that he was good at a lot of things, but school was not one of them. Clearly Mr. Grohl’s path did not include the traditional, go-to-college-get-a-job trajectory.

My son is teaching me that there isn’t just one way to live life. Yes, I wish he would go to college so he doesn’t live below the poverty line and reside in a house of squalor.

But that’s what I want for him. That’s not what he wants for himself. He is not the male version of me. He’s a musician, and the creative life means a guaranteed amount of struggle and heartache. Every time we meet for lunch, I tell him that I love him, and that I’m proud of him.

Even if my boy’s path never rises out of moshing in the basements of America, that’s got to be O.K., too. There are no conditions placed on unconditional love.