Tuesday, January 28, 2014

Pathological Altruism

Pathological Altruism is the first book I have come across (thanks to an anonymous commenter on my blog) that deals broadly with a subject that has been near and dear to my heart. I have been writing about its manifestations in families for almost thirty years.

Pathological altruism is defined as actions designed by someone to help others at one’s own expense that, in the long run, harm not only the giver but the recipient as well. I first thought about it way back in 1985 as I was writing my first book, which was eventually published in 1988.

My ideas stemmed from the writings of family systems therapy pioneer Mara Selvini Palazzoli and her group in the book Paradox and Counterparadox. She described how children are willing to sacrifice their own well being in order to stabilize emotionally dysregulated parents and to preserve family homeostasis - the rules upon which family interactions are regulated and made predictable.

I noted that this sort of self-sacrifice led to a paradox, which I called the altruistic paradox. I got braver later on and re-named it with the moniker I originally had in mind, the Mother Theresa Paradox. Although the altruistic actions of family members would calm things down in the short haul, in the long run they would backfire. This happened for a number of reasons. 

First, such acting out would usually prevent family members from actually discussing mutual dilemmas and intrapsychic conflicts with one another in a way in which problems might be resolved.

Second, in cases in which parents would overly sacrifice themselves for their children in order to follow the homeostatic rules within the family of origin they themselves had grown up in, they would prevent their children from developing skills such as frustration tolerance that would allow their children to eventually function independently. The kids would never seem to grow up. I believe that refusing to grow up eventually becomes their choice and is also, in fact, a major act of self-sacrifice in a culture which values independence.

Third, an imbalance between giving and receiving in which the former is considered a virtue and the latter a vice creates a situation in which group members all become frustrated because no one is willing to receive what the others have to give!

The altruistic behavior within the group is described and explained by evolutionary biologists using the concept of kin selection.

The book Pathological Altruism is an edited collection that includes many different perspectives from a wide range of academics. Although I disagreed with many of the chapter authors, I am certainly delighted that this topic is being tackled, and I was indeed thrilled when the reader told me about the book's existence. As the editors of the book say in their introduction, perhaps pathological altruism has been so little discussed for pathologically altruistic reasons.

As the book illustrates, the concept of pathological altruism certainly can provide powerful answers to such questions as why some people become "co-dependent," why the most difficult patients to treat on a cancer ward are often former cancer ward nurses, and why some people seem to be victimized by criminals far more than the average Joe.

Some of the authors question whether pure altruism even exists – maybe all behavior is performed in order to make one's self feel better, not the other guy. If it does exist, how can we even know that it is pathological?

We can never be certain about the motives behind any human action, as people can be dishonest about that not only with others but with themselves. And maybe they sometimes do not understand their own motives, or they are under the sway of genetically determined processes over which they have no control. As Joseph Miller was quoted as saying, “It is orders of magnitude more difficult to study internal than external stimuli.”

In the book's discussions about making determinations of the motives behind the behavior of another person, one major omission is a pattern that I think is perhaps the most important. While many of the authors wrote about how apparently altruistic behavior can be used to mask covert or hidden selfish intentions, none of them discussed the opposite: how apparently selfish behavior can be used to mask covert or hidden altruistic intentions. For illustrations of how and why this happens, see my posts, The Language of Love from 4/17/10, and my two posts on dysfunctional family roles, Part I and Part II.

I did find much to admire in the writings of many of the authors, but in general I found that a lot of them make the same kinds of errors in thinking that I have brought up in this blog. For instance, they often have very simplistic understanding of what heritability means, or what the differences seen on fMRI scans between various people while doing certain tasks mean. They far overstate genetic influences on behavior.

On a related issue, as author Joachim I. Krueger points out in Chapter 30, there is a tendency of many of the authors to ignore social psychological influences, and think that a lot of the motivation behind pathologically altruistic behavior stems from one’s own internal predispositions rather than from being reactive to environmental contingencies.

These two errors come together in discussions by some of the authors of the "five factor" model for personality. These factors represent behavioral tendencies that may stem mostly from genetic predispositions. Someone may naturally be more agreeable than most others, for instance, and if all environments were the same in regards to the consequences of being agreeable, such a person would be more likely to be agreeable than someone without this genetic predisposition.

Of course, we all operate within many different environments, each of which is constantly subject to change due to the operation of a literally infinite number of variables. People who are agreeable, if they see that such behavior will lead to adverse consequences, will not be so likely to be agreeable than they would be if left purely to their own devices. When an fMRI scan is done, for instance, that is a measure of the brain’s reactivity within only one of a myriad of other contextual possibilities. In other words, context is everything.

Motivated people can easily defy their own natural inclinations when they see that it is in their or their family's interests to do so. In fact, if there's one thing I have learned in doing psychotherapy for close to 40 years, it is that people can construct a very complicated false self, as first discussed by psychoanalysts Jung and Winnecott, in which they completely submerge many of their own strong inclinations. 

In chapter 29 by Marc Hauser, he points out that from an evolutionary standpoint, it may be advantageous for a person to appear tougher, sexier, or more caring than they actually are. Primatologists have long known about the prevalence of and advantages of being able to deceive other members of one's own species. Hauser also talks about what I refer to as the Actor's Paradox: The act of deception is more convincing if the actors can convince themselves that they really are the character they are playing.

Paradoxically, the tendency of humans to use deception in the act of sacrificing oneself for the sake of their kin group may itself have a very powerful genetic component. This genetic tendency is probably far more powerful that any genetic influences on the five factors, if I had to guess.

The logical error of genetic determinism can be illustrated with an article that was cited by chapter 21 author John W. Traphagan (Freeman, J.B. et. al., “Culture shapes a mesolimbic response to signals of dominance and subordination that associates with behavior,” Neuroimage 47 (2009) 351-359). The brains of Japanese and Americans were scanned while the subjects reacted to photographs of people acting in dominant and subordinate ways, with the nationality of the subjects in the photographs being ambiguous. Statistically significant differences on the scans emerged.

It seems to me that it is highly unlikely that the distribution of genes creating each of the five factors of personality would be hugely different in Japanese or Americans, so this study shows that cultural training affects brain function during certain tasks. It probably does not reflect genetic differences to any significant degree. Of course, if this was a study done by psychiatrists, who always declare differences to be abnormalities, being Japanese would be called a disease!

Of course, it could be that the distribution of genes does vary markedly in different populations. But I doubt it. In Chapter 22, Joan Y. Chiao et. al. opine that empathy and altruism differ in different cultures because of such discrepancies in gene distribution. They chart different countries that vary on the balance between individuality versus collectivism within their cultures versus the percentage of different alleles (versions) of a gene that affects serotonin. 

Although a few seemingly highly collectivist cultures had significantly more of one allele than the other, in fact almost all of the countries had a very similar distribution. In fact, the USA and Brazil, rated vastly different on the individualism-collectivism scale (10% versus 70%), had almost exactly the same allele distribution. 

One wonders if perhaps there might be other more collectivist countries that were not included on the graph that would have been outliers in the opposite direction. This reminds me of a famous old study that showed heart attacks were more common in countries in which there was a higher fat intake in the average diet – a study which for some reason completely left out France. The French eat a lot of fat and have a relatively low incidence of heart attacks.

Some of the chapters in the book seemed to me to be overly academic or discuss arguments that seem to boil down to semantics. The book is probably not meant for lay readers. However, despite all of these reservations, the book has enough great stuff in it for me to recommend it to anyone with an interest in this fascinating subject.  

Tuesday, January 21, 2014

Corruption at Child and Adolescent Psychiatric Hospitals

I have been discussing the huge rise in diagnoses of pediatric bipolar disorder spurred on by Harvard psychiatrist Joseph Biederman and many others (not to mention the huge rise in diagnoses of bipolar disorder in adults), for a long time in this blog. While there are rare children who present with bipolar disorder, they are few and far between, and they are obviously psychotic. Most children getting the diagnosis now don’t even come close.

Not only have the big pharmaceutical companies benefitted from this, but it has also been a big financial boon for the for-profit psychiatric hospitals that have child and adolescent units, and the corrupt child psychiatrists who admit patients into them.

Of course, critics of psychiatry seem to think that it is only psychiatrists who are subject to greed, corruption, and excess. Not people running investment and banking firms, "alternative" medicine websites, auto repair shops, oil companies, or the for-profit prison system prosecuting a racist and phony war on drugs. Not even Congressmen! Just psychiatrists. 

Wolf of Wall Street, anyone? Nope. It's just the Wolf of Roxbury Drive (also known as Couch Canyon in Beverly Hills).

Anyway, the following graphic displays the incredible upsurge in hospital admissions for this alleged disorder between 1997 and 2010.

Unfortunately, fraudulent practices in child and adolescent psychiatric units are nothing new. Only the phony diagnoses have changed. In the 1980’s and 1990’s, adolescents with behavioral disturbances were kept in hospitals run by National Medical Enterprises (NME) (now Tenet), Charter (now Magellan), and some others for months at a time – until their insurance benefits ran out. They were then abruptly discharged.

Then, as now, parents were assured that their parenting, chaotic lifestyles, and/or marital problems had nothing at all to do with the behavior problems their children were having. After all, if the hospitals told the truth, parents might take their children out of the hospital in protest. 

Back then, the hospital said the culprit behind what we used to call juvenile delinquency was obviously heavy metal music!

I’m not kidding.

The hospital chains were eventually prosecuted by the United States Justice Department for billing fraud and abuse, as well as for making false diagnoses and even for false imprisonment. This is why the firms reorganized and changed their names.  

So they needed a new way to make money fraudulently, and the Biedermans of the world were happy to oblige them with false diagnoses of bipolar disorder and of course ADHD - or both.

One of my former trainees, now a colleague, told an interesting personal anecdote about a hospital with an adolescent unit, although this concerned a young adult patient with borderline personality disorder (BPD). The doctor planned a brief hospitalization for the girl in order to stabilize her, and - following the way I trained him - soon told her he was going to discharge her. Hospitalization tends to make patients with BPD worse rather than better if they are kept there longer than just briefly.

The hospital literally went behind his back and spoke with the girls parents. They told them that they were concerned that my colleague’s discharge plan was premature and was going to harm their daughter!

As soon as my colleague found out about this, he resigned from the hospital staff. I trained him well.

Of course, being an ethical psychiatrist can get you into trouble. The child and adolescent psychiatry department at the University of Tennessee Health Sciences Center, when I first came there in 1992, was heavily into "structural" family therapy and not just drugging children. It's leader, David Pruitt, had been trained by the family systems therapy pioneer Salvador Minuchin himself. 

Many years later, the department opened a new psychiatric ward at LeBonheur Children's Hospital. Only trouble was, our department's philosophy was to only hospitalize children who actually needed to be in the hospital. There were not enough patients to make the unit a viable concern, so the hospital closed it. So now, children who actually need inpatient care are completely at the mercy of the private chains.

Here are some news stories about the NME scandal:

The trouble began in 1991 when the Texas attorney general sued NME for alleged overbilling practices at its psychiatric facilities in that state. Allegations of wrongdoing were compounded that year, as individual patients began to accuse NME of having held them in psychiatric facilities against their will, only releasing them when their insurance coverage was exhausted. 

Eventually, more than 130 patient suits would be filed. Further, in the summer of 1992, 19 insurance companies, including Metropolitan Life, Aetna, Prudential, and Mutual of Omaha--some of the biggest providers in the country--filed suit accusing NME of an elaborate program of insurance fraud, beginning as early as 1988, whereby NME admitted tens of thousands of patients who did not need inpatient care, paying illegal kickbacks to referring physicians, fabricating trumped-up diagnoses, and charging exorbitant fees to treat them. At its peak, the cost of the fraud was estimated at $750 million.

 In August 1993, 600 FBI and other federal agents raided NME's headquarters and 11 of its psychiatric facilities, seizing hundreds of documents as part of an investigation into possible criminal misconduct. To his credit, Barbakow insisted on full cooperation with the investigations.

The scandals significantly damaged NME's finances as well as its reputation, as operating profits from the psychiatric division fell from $234 million in 1991 to just $3 million in 1993. As for the cost of putting the past behind, by the end of 1993 settlements with only a few of the insurance companies in question had already topped $125 million. Moreover, after spending nearly $65 million in legal fees, NME pled guilty to felony federal charges in 1994 and agreed to pay $379 million to the Justice Department and the Department of Health and Human Services, the largest settlement in history between the U.S. government and a healthcare provider.

From Uow:

In its first incarnation during the 1980s and 1990s the company was called National Medical Enterprises (NME). It was involved in a massive scandal defrauding Medicare by buying patients for up to US $2000 each from anyone who could persuade them to come to hospital. The company had contracts with bounty hunters and even pleaded guilty to kidnapping a patients. It bought patients from Canada.

Vast numbers, many of them children did not need hospital admission. The company lied to them and kept them in hospital for the full duration of their insurance all the time providing them with vast amounts of unneeded treatment. All of this was signed for by doctors. The company eventually pleaded guilty to criminal practices in 1994, was forced to sell its specialty hospitals where the fraud occurred, entered into a variety of integrity and compliance agreements and paid in the region of US $1 billion in settlements and compensation to patients

From Business Week  9/12/93:  

On Aug. 26, 600 FBI and other federal agents swooped down on NME's Santa Monica (Calif.) headquarters and 11 of its psychiatric facilities, seizing hundreds of documents. The government hasn't filed charges against NME, but sources close to the investigation say the FBI raid follows a two-year probe into possible criminal misconduct, including widespread overbilling and fraudulent diagnoses to extend patients' hospital stays.

"GOLDEN RULES." Insurers claimed that NME's top management instructed hospital administrators to adopt "intake" goals designed to lure patients into NME hospitals for lengthy and unnecessary treatments. Although the Justice Dept. isn't elaborating, sources say the government is investigating possible illegal marketing and billing practices that are the crux of lawsuits filed last year against NME by 19 insurers, including Prudential, Aetna, and Travelers.

In one internal NME document called "Intake Focus Golden Rules," which was obtained by insurers, hospital administrators declared: "Intake is our most important system--nothing else matters if we don't do that well." To that end, hospital staffers were urged in the document to admit fully half of all patients who came in for an evaluation. Barbakow, a board member since December, 1990, says the document was put out by lower-level managers. NME says it was later recalled when headquarters learned of its existence.

The FBI has also been interviewing former NME patients who are suing the company for false imprisonment. Robert Andrews, a Fort Worth lawyer who is handling 68 such cases, claims NME guide manuals instructed staffers to "push the pain" by convincing parents that if their kids weren't admitted, they might commit suicide. NME says the manual hasn't been used in years.

Dawn McClary is one plaintiff. McClary, now 20, says she spent 20 months from December, 1987, to July, 1989, at NME's Brookhaven Hospital in Dallas after quarreling with her parents about staying out late. After a three-week evaluation, McClary alleges, she was misdiagnosed with a borderline personality disorder and strapped to a wheelchair or her bed for days at a time. McClary's parents were advised she should stay at Brookhaven for five years. But when her insurance policy refused to continue payments, McClary says she was finally released. Total cost to her insurer: $298,000. NME says it's barred by law from discussing patient treatment.

Tuesday, January 14, 2014

The American Psychiatric Association: the Good, the Bad, and the Ugly

On his blog Real Psychiatry, psychiatrist George Dawson, put up a post that was highly critical of the American Psychiatric Association (APA) and its current president, Jeffrey Lieberman. He accused the organization of catering to managed care mismanagement of psychiatric benefits with its focus on collaborative care models. The organization has also been criticized for being in bed with Pharma, although it has taken steps to reduce its dependence of Pharma money. Surprisingly, at long last they even eliminated the very popular Industry-Sponsored Symposia at the Annual Meeting, in which drug companies used free food to attract large audiences to highly biased “educational” presentations by their own hired “experts.”

George Dawson, M.D

I agree with a lot of the criticism. I am particularly annoyed by the way the APA gives lip service to so-called scope of practice issues - which really boil down to whether insurance companies will ever pay psychiatrists (who are physicians first) to do more than write prescriptions - while continuing to basically ignore the issue of psychotherapy disappearing from the practice of psychiatrists all across the United States. The fact that psychiatrists are not taking complete histories any more, which leads to frequent bogus diagnoses and the unnecessary and potentially toxic medicating of children and adults alike, also gets little attention.

This situation leads to the question of whether ethical psychiatrists should boycott the APA. I say no, because I think we need to have more good psychiatrists active in the organization. On Dawson’s blog, I got into the following discussion about this issue in the comment session with psychiatrist James O’Brien:

ME: I wonder if there is any way like-minded people can get together with us to better sound the alarm about this travesty of psychiatric "care." Blogs are easy to ignore.

James O’Brien: This was an excellent article. In response to Dr. Allen's question, the answer is for turkeys to stop paying dues to the American Thanksgiving Association.

ME: If that would make the APA change it's policies or even go away, I'd agree. But since they are probably here to stay, we need people on the inside to at least try to keep its negative tendencies in check.

James O’Brien: Dr. Allen, I wish that were a possibility, but the APA is dominated by academics on salary who love theory over reality and don't understand or are indifferent (or even hostile) to the economics of private practice. Paying dues to APA and AMA is selling them the rope to hang us with. 85% of doctors realize this about AMA but for some reason, many private practice psychiatrists have trouble dumping APA even though they should be horrified by Lieberman's comments. And BTW, if you enjoy APA CME activities, you can still attend at a higher cost. Frankly, I think they are pretty basic and you can do better if you shop around. Lieberman is doing more damage to psychiatry than Scientology can dream of doing.

ME: Maybe so, but what's the alternative? A small chance of having an impact is still better than no chance at all.

James O’Brien: You have more chance of getting them to pay attention by hurting them in the pocketbook than changing their minds through dialogue. All APA Presidents in recent years are cut from the same cloth. I don't see why APA has to be a monopoly. Psychologists who were sick of their APA formed the Association for Psychological Science which is a superior organization.

ME: Well, we did have Harold Eist a few years ago. Granted, no one like him since. I just don't think there's enough of us to hurt the APA in the pocketbook, frankly. I wish we had an effective alternative to the APA, but right now there isn't one. As to the psychologists, CBT'ers who grossly exaggerate their evidence base, ignore human relationships, and deny funding to other types of psychotherapy outcome studies still dominate clinical psychology, so I don't know how much good that other organization is really doing. I'm certainly open to anyone with new ideas about how to better get the word out.  

At least at the APA annual meeting, opposing voices do have a forum. Mark Zimmerman presented on the evils of symptom checklists and about patients with borderline personality disorder being misdiagnosed as Bipolar. My colleague from Australia, Peter Parry, presents the other side on pediatric bipolar disorder. I presented on the neglect of social psychology by the field. And folks like us get up and challenge nonsense with questions after stupid presentations. We need more people like us at the meetings, not fewer.

The APA is certainly a mixed lot these days. There’s something for everyone to criticize, especially with Lieberman. On one of my issues, time spent with patients, Lieberman was recently quoted in Psychiatric News, the APA’s newspaper for members: “The psychiatrist of the future will likely have less regular face-to-face time with patients (like our colleagues in other medical specialties)…We will have to do more with less.”

Oh, so short changing and mismanagement of patients is something we just have to accept, perhaps because there’s not enough of us to go around? That is outrageous. As I have said before, accepting such a managed care perspective is just like a cardiac surgeon agreeing to only do single bypass surgery on all patients even when triple bypass surgery is called for. 

If there’s a doctor shortage, let’s do something about that. There has not been an increase in post-doctoral residency training slots since the mid nineties. Society doesn’t want to pay for more? Too bad for them. Not our fault. The answer to the doctor shortage is not to short-change the patients we do see.

Then there is the matter of the skyrocketing number of bogus diagnoses of ADHD and treatment with stimulants in both children and adults, a frequent topic on this blog.  As reported by a recent article in the New York Times:

‘Could you have A.D.H.D.?’ beckons one quiz, sponsored by Shire, on the website 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.

These are the questions:
1.     How often do you have trouble wrapping up details on a project, once the challenging parts have been done?
2.     How often do you have difficulties getting things in order when you have to do a task that requires organization?
3.     How often do you have trouble remembering appointments or obligations?
4.     When you have a task that requires a lot of thought, how often do you avoid or delay getting started?
5.     How often do you fidget or squirm with your hands or feet when you have to sit down for a long time.
6.     How often do you feel overly active and compelled to do things, like you were driven by a motor?

As I discussed in my last post, The APA’s own Psychiatric News e-mail alert reported, “The authors speculate that “better detection of underlying ADHD, due to increased health education and awareness efforts,” may be the reason for the increase of ADHD diagnoses among American children.” The more likely explanation - that acting out kids and adult are being saddled with diagnoses made without any evaluation of psychosocial problems - was not mentioned at all.

Still, there are forces in the organization that seem to be paying more attention to things, so good doctors resigning from the organization is counterproductive. The APA has started paying attention to another horrific managed care problem – the response of the industry to the so-called “parity law” passed by the US Congress, which stipulates that insurers must cover mental disorders the same as they cover physical disorders (however bad that coverage is, unfortunately). 

Even Lieberman was alarmed. He was quoted thusly in the 8/16/13 issue of Psychiatric News: “Despite passage of the 2008 legislation, many insurance companies have manipulated its intent and purpose through vague medical necessity standards, lengthy approval processes, bureaucratic delays in service requests, and complicated appeals progress.”  

They have also ratched down fees paid by psychiatrists, leading to many of them resigning from some of their provider panels, so the patient is “covered” but cannot find a doctor!

In terms of so-called medical necessity (whether the insurance company will deem a given service as reimbursable), the insurance companies often would not tell doctors – or its customers for that matter – what standards the company was using to make a decision about that. They called it a “trade secret!”

The APA lobbied the federal government hard to stop these unfair practices with some success, resulting in the recently released final rule regarding implementation of the parity law. Insurance companies at least now have to disclose their standards for determining “medical necessity.” Of course, insurance companies will continue to be ingenious at finding ways to deny care.

So maybe there’s hope for the APA yet. Psychiatrists no longer have the luxury of being politically inactive and letting the APA continue to wander in the proverbial wilderness. Any concerned psychiatrists need to join the organization and let their voices be heard.

Tuesday, January 7, 2014

Recognition of the False Epidemic of ADHD by a Major Newspaper - It's About Time

Finally, there has been recognition by at least one major metropolitan newspaper, the New York Times, about the phony “epidemic” of ADHD diagnoses among both adults and children. Not that doctors pushing the disorder would ever admit to it. (News to some: a high percentage of these diagnoses are made by non-psychiatrist physicians such as pediatricians).

An e-mail newsletter from the American Psychiatric Association contained the following story on 12/10/2013:

 “The Centers for Disease and Control and Prevention (CDC) reports that there has been a 42% increase in attention-deficit/hyperactivity disorder (ADHD) diagnoses in children aged 4 to 17 from 2003 to 2011. Data were published in the Journal of the American Academy of Child and Adolescent Psychiatry. The study included 2011 data from a randomized, cross-sectional national survey of more than 95,000 U.S. households known as the National Survey of Children's Health. …The results showed by 2011, 11% of children—or 6.4 million children nationwide—had received a diagnosis of ADHD. Among those with a diagnosis for ADHD, approximately 70% were currently taking medication for the disorder—increasing by 28% from 2007 to 2011. Nearly 1 in 5 high school boys was diagnosed with ADHD, compared with 1 in 11 high school girls. ADHD-diagnosis frequency was most prevalent in Kentucky, at 15 percent, and least prevalent in Nevada, at 4.2 percent.

"The authors
[of the study] speculate that 'better detection of underlying ADHD, due to increased health education and awareness efforts' may be the reason for the increase of ADHD diagnoses among American children."

BETTER RECOGNITION?? REALLY?!?  A story in the New York Times by Alan Schwarz on December 14, 2013 had a far more reasonable explanation.  It said that even the person most responsible for recognition of ADHD in children, Keith Conners, 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.”

Keith Connors, Ph.D.

The Times story continues:
“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.
… 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.”
The story was followed by an editorial on 12/18/13, An Epidemic of Attention Deficit Disorder.  Hooray for the New York Times!!  Some of what it said:
“The hard-sell campaign by drug companies to drive up diagnoses of attention deficit hyperactivity disorder, or A.D.H.D., and sales of drugs to treat it is disturbing. The campaign focused initially on children but is now turning toward adults, who provide a potentially larger market…Many of these children, it appears, had been diagnosed by unskilled doctors based on dubious symptoms…

“Shire, an Irish company that makes Adderall and other A.D.H.D. medications, recently subsidized 50,000 copies of a comic book in which superheroes tell children that “Medicines may make it easier to pay attention and control your behavior!” Advertising on television and in popular magazines has sought to persuade mothers that Adderall cannot only unleash a child’s innate intelligence but make the child more amenable to chores like taking out the garbage…

“The potential dangers should not be ignored. The drugs can lead to addiction, and, in rare cases, psychosis, suicidal thoughts and hallucinations, as well as anxiety, difficulty sleeping and loss of appetite…So many medical professionals benefit from overprescribing that it is difficult to find a neutral source of information. Prominent doctors get paid by drug companies to deliver upbeat messages to their colleagues at forums where they typically exaggerate the effectiveness of the drugs and downplay their side effects. Organizations that advocate on behalf of patients often do so with money supplied by drug companies…

“Curbing the upsurge in diagnoses and unwarranted drug treatments will require more aggressive action by the F.D.A. and the Federal Trade Commission, which share duties in this area. It will also require that doctors and patients recognize that the pills have downsides and should not be prescribed or used routinely to alleviate every case of carelessness, poor grades in school or impulsive behavior.”