http://www.quackwatch.org/11Ind/breggin.htmlSome Notes on ADHD and
Peter R. Breggin's Unfair Attack on Ritalin
Stephen Barrett, M.D.
Attention-Deficit/Hyperactivity Disorder (ADHD) is a commonly diagnosed childhood disorder with core symptoms that include inappropriate levels of attention, concentration, activity and distractibility. Although its cause is unknown, considerable progress has been made in managing it. Scientific studies have found that the single most effective treatment is medication with a stimulant drug, of which the most commonly used has been methylphenidate (Ritalin). Behavioral approaches that include helping parents and teachers to deal with the child's behavior are also important, but they are not a substitute for medication in most cases.
These views are strongly supported in publications of the American Academy of Pediatrics [1,2], American Academy of Child and Adolescent Psychiatry [3], American Medical Association [4], American Psychiatric Association [5,6], National Institutes of Health [7,8], United States Surgeon General [9], and an international consensus of experts [10]-- all of which reflect solid agreement within the scientific community.
In stark contrast, psychiatrist Peter Breggin claims that ADHD is not a genuine diagnosis and that the drugs used to treat it do far more harm than good. In line with these views, he has written books [11,12], testified at government hearings [13], and served as a consultant in several lawsuits. He would like you to believe that his clinical experiences and investigations have enabled him to reach a level of insight that is greater than that of the majority of mental health professionals. This article describes why I consider him untrustworthy.
Breggin's Background
Peter R. Breggin, M.D., is a Harvard College graduate who obtained his medical degree from Case Western Reserve Medical School in 1962. After training in psychiatry at Harvard and State University of New York Upstate Medical Center (Syracuse), he worked for two years at the National Institute of Mental Health. Since 1968, he has practiced psychiatry in the Washington, D.C. metropolitan area [14]. Breggin describes his private practice as "psychotherapy for individuals, couples, and families, including children," with "subspecialties" in "the adverse effects of medications, electroshock, and psychosurgery" and "forensic psychiatry and patient rights." [15] His online resumé states that he has testified as an expert in about 40 cases, many of which involved psychiatric drugs, FDA regulations, and product liability [15]. His 18 books, most written for the general public, attack psychosurgery, electroconvulsive therapy ("shock treatments"), Prozac, Ritalin, and the use of psychiatric drugs in general.
In 1972, Breggin founded The International Center for the Study of Psychiatry and Psychology (ICSPP), a nonprofit organization "concerned with the impact of mental health theory and practices upon individual well-being, personal freedom, and family and community values." [15] ICSPP's 2000 federal tax report states that its primary purpose is to gather and distribute information about the "hazards of bio-medical model of psychiatry." [16] Other information I found on the Internet states that ICSPP had one part time employee [17] and less than $25,000 in annual income throughout most of its existence [16]. Breggin also launched Ethical Human Sciences and Services, a journal that began publication in 1999. He has also been listed on the advisory board of Network Against Coercive Psychiatry, an anti-psychiatry organization whose home page asserts that the "mental health establishment has conned the American people."
Breggin's Web site states that he "has been informing the professions, media and the public about the potential dangers of drugs, electroshock, psychosurgery, involuntary treatment, and the biological theories of psychiatry for over three decades." [14] The back cover of his Ritalin Fact Book describes him as "the conscience of psychiatry." [12] I believe it would be more accurate to characterize him as a harmful nuisance whose views can undermine trust in the medical profession and frighten people away from helpful treatment.
A Bit of Puffery?
Breggin's resumé and other biographical reports describe him as a Diplomate of the National Board of Medical Examiners; a "Specialist in Psychiatry" recognized by the State of Maryland, Department of Mental Health and Hygiene, Board of Physician Quality Assurance; a Diplomate of the American Board of Forensic Medicine; and a Fellow of the American College of Forensic Examiners. He also states that he is (or has been) on the editorial board of six peer-reviewed journals and has published more than 25 articles in peer-reviewed scientific journals. Although these accomplishments might sound impressive, they actually are much less than they might seem.
* Breggin is not certified by the American Board of Psychiatry and Neurology, which is the recognized agency for certifying psychiatrists.
* Having completed three years of psychiatric training, Breggin is entitled to call himself a psychiatrist or a "specialist in psychiatry." Until 1996, the Maryland Board of Quality Assurance maintained a list of "identified" specialists. Anyone who completed an approved training program was eligible for listing. No special examination or additional qualifications were required.
* To become licensed in the United States, every physician must pass an examination given by the National Board of Medical Examiners or an equivalent examination by a state licensing board. Thus being a "diplomate" of the National Board of Medical Examiners means nothing more than the fact that the doctor has passed a standard licensing exam. Most resumés I have seen do not list this credential.
* The American Board of Forensic Examiners is not recognized by the American Board of Medical Specialties (ABMS), which is the recognized standard-setting organization. ABMS offers subspecialty certification in forensic psychiatry and forensic pathology, neither of which Breggin has achieved.
* Only one of the six journals with which Breggin has been affiliated is significant enough to be listed in MEDLINE, the National Library of Medicine's principal online database.
* On September 5, 2002, I found that Breggin had 33 citations listed in MEDLINE. None of these publications appears to be a research report. Eight were letters to the editor, two were books, and most of the rest were expressions of his opinion on various psychiatric topics.
ADHD: The Prevailing Scientific Viewpoint
The prevailing scientific viewpoint is that ADHD should be regarded as a neuropsychiatric disorder, that it differs from simply rambunctious behavior, and that medication has been thoroughly studied and found to be helpful in managing the problem. The American Psychiatric Association has published a list of criteria that should be used in making the diagnosis [4]. As its name implies, ADHD is characterized by two sets of symptoms, inattention and hyperactivity. Although these usually occur together, one may be present to qualify for a diagnosis.
In 1997, largely in response to Breggin's writings, the American Medical Association Council on Scientific Affairs issued a report on ADHD that was approved by the AMA's House of Delegates. The report concluded:
Diagnostic criteria for ADHD are based on extensive empirical research and, if applied appropriately, lead to the diagnosis of a syndrome with high interrater reliability, good face validity, and high predictability of course and medication responsiveness. The criteria of what constitutes ADHD in children have broadened, and there is a growing appreciation of the persistence of ADHD into adolescence and adulthood. As a result, more children (especially girls), adolescents, and adults are being diagnosed and treated with stimulant medication, and children are being treated for longer periods of time. Epidemiologic studies using standardized diagnostic criteria suggest that 3% to 6% of the school-aged population (elementary through high school) may suffer from ADHD, although the percentage of US youth being treated for ADHD is at most at the lower end of this prevalence range. Pharmacotherapy, particularly use of stimulants, has been extensively studied and generally provides significant short-term symptomatic and academic improvement. There is little evidence that stimulant abuse or diversion is currently a major problem, particularly among those with ADHD, although recent trends suggest that this could increase with the expanding production and use of stimulants.
Although some children are being diagnosed as having ADHD with insufficient evaluation and in some cases stimulant medication is prescribed when treatment alternatives exist, there is little evidence of widespread overdiagnosis or misdiagnosis of ADHD or of widespread overprescription of methylphenidate by physicians [3].
ADHD: What Breggin Says
The Ritalin Fact Book makes many claims that clash with the prevailing scientific viewpoint. Among other things, it exaggerates the problem of misdiagnosis, misrepresents what medication is likely to do, greatly exaggerates what non-drug treatment can accomplish, misrepresents the results of a scientific study, uses an out-of-context quote to attack the credibility of other professionals, and exaggerates the extent of side effects. Here are my responses to several such passages in the book:
What Breggin Says My Comments
Page 3: "Many children diagnosed with ADHD and treated with stimulants have relatively benign problems. Often they simply daydream in the classroom or dislike school a little more often than other children. Or they may be a little bit more active and energetic than most." Although misdiagnosis obviously can occur, Breggin presents no data showing that this is a major problem or that it is likely to happen when skilled professionals conduct the evaluations.
"Some children with ADHD are very angry, out of control, and difficult to be around. When children have these more serious behavioral or emotional problems, stimulant medication is likely to worsen their mental condition and behavior." This advice is extraordinarily irresponsible. The fact that stimulant medication can calm many hyperactive children has been known for more than 60 years and has been demonstrated by many well designed clinical studies. Breggin has published no clinical study and provides no data to back his claim.
Page 3: "Even the most difficult and out-of-control children can be helped by informed adult intervention without resort to drugs." On pages 161-174, Breggin supports this statement with passages about a nurse he met during a train ride and two experienced teachers who told him how they dealt with children that were considered hyperactive. The techniques they described are standard ones that would work with mildly disturbed children and might help but would not be sufficient to control truly hyperactive children. Breggin assumes that the descriptions were accurate, concludes that the techniques would work for all hyperactive children, and treats this anecdotal evidence as more important than well-designed studies in which children have been formally diagnosed and their behavior carefully monitored.
Pages 36-37: "A 1997 study published in Pediatrics confirms high rates of stimulant-induced depression in 125 children . . . who were given relatively small doses of Ritalin or Dexedrine. Two children on Ritalin and two on Dexedrine developed severe enough adverse effects to be terminated from the study. One eight-year-old became 'over-focused, extra sensitive, and increasingly anxious,' and a five-year old became 'extremely aggressive and tearful' . . . . Side effects from amphetamine (Dexedrine) were higher than those from Ritalin for 'trouble sleeping, irritability, prone to crying, anxiousness, sadness/unhappiness, and nightmares.'" Breggin's description distorts what the study showed. The study, which lasted two weeks, was done to compare the side effects of Ritalin and Dexedrine and to identify which symptoms might be due to the underlying condition rather than to the drugs. The researcher's concluded that overall, both drugs "were well tolerated by most subjects" and that "many symptoms commonly attributed to stimulant medication are actually preexisting characteristics of children with ADHD and improve with stimulant treatment." [18] A 3% dropout rate caused by temporary symptoms is certainly is not reason to avoid use of the medications. What do you think it means that Breggin uses data from a highly favorable study to argue that stimulant drugs should be avoided?
Page 85: "Pronouncements made in public by professional advocates for stimulants paint glowing pictures about the effectiveness of these drugs. But professional reviews and textbooks often present a more conservative picture -- one that hardly justifies exposing children to such great dangers. A review in the American Psychiatric Press Textbook of Psychiatry concluded: 'Stimulants do not produce lasting improvements in aggressivity, conduct disorder, criminality, education achievement, job functioning, marital relationships or long-term adjustments.'" The textbook sentence is quoted out-of-context. The paragraph from which it comes begins: "Treatment outcome studies of ADHD have led to some striking findings. in addition to helping reduce inattention, impulsivity, and hyperactivity, treatment with psychostimulants can lead to enduring improvement in social skills and attitudes toward self." [19] The sentence is part of a long discussion of the benefits, risks, and limitations of various treatment methods. The authors clearly state that stimulant drugs are likely to be useful for the majority of children with ADHD, but that special educational or psychological help may still be needed.
Pages 93-94: "Starting with the first dose, almost any psychiatric drug . . . can worsen the symptoms commonly thought of as ADHD-like. . . . People who persistently use psychiatric drugs legally or illegally for several months or more are likely to become forgetful, overlook details, and lose their focus on difficult tasks. Similarly, they may begin to experience "disinhibition" or "loss of impulse control." The earliest signs are irritability and unexpected outbursts of anger, followed eventually by dangerous expressions of violence. I have seen this pattern develop in dozens of clinical and legal cases involving both adults and children." Breggin, who states on page xvii that he never starts anyone on psychiatric medication, cites no source for this sweeping condemnation other than his own vaguely described observations (mostly with people who come to him because they are dissatisfied with their treatment). All effective medications can produce adverse effects. However, competent prescribers will adjust dosage and/or change medication to produce maximum benefit with minimum or no adverse effects. Millions of people believe they have been helped by psychiatric drugs. Does Breggin think that they, the doctors who prescribe the drugs, and the thousands of researchers who have studied the effects of such drugs are dishonest or are fooling themselves?
In the book's introduction (pages xviii-xx), Breggin attempts to justify his contrary views by portraying himself as privy to unique information.
In addition to more than three decades of clinical work, this book draws upon the years of work required for writing dozens of scientific books and articles; the workshops I have given for professionals and the public; teaching I have done in the past at universities . . . and presentations I have made at national conferences for health professionals and attorneys. . . .
I often hear about newly discovered adverse drug reactions long before most professionals become aware of them. . . .
I have yet another unique source of information and knowledge. For many years I have been a consultant and medical expert in legal actions involving psychiatric drugs, including the stimulants described in this book. . . . .
My most specialized source of information about psychiatric drugs comes from my work as a medical expert in cases against giant pharmaceutical companies that are charged with negligence or fraud in developing or publicizing their products. In this fascinating legal arena, I can gain access to secret "inside information" about psychiatric medications that is literally unavailable to any other physician in the world. . . .
Based on my publications and consultations, a series of class-action suits have been brought against Novartis, the manufacturer of Ritalin, charging the company with conspiring with the American Psychiatric Association and the parents' group Children and Adults with Attention Deficit Disorder (CHADD) to fabricate the ADHD diagnosis and foster the overuse of Ritalin.
Research? Unique private communications? Access to "secret" documents? A big conspiracy? As far as I can tell, Breggin has made no systematic clinical reports, and the book provides no relevant "insider information" or alleged facts about any conspiracy. The suits to which he refers were filed during the year 2000 in California, Florida, New Jersey, Puerto Rico, and Texas and were not legitimate. The California and Texas suits were dismissed by the courts for failure to state a proper cause of action [20]. The New Jersey suit was withdrawn after the judge made it clear that he was highly skeptical of plaintiffs' allegations of conspiracy [21], and the others were quietly withdrawn, presumably because the plaintiffs realized they were certain to lose. The final withdrawal took place on August 16, 2001. Yet The Ritalin Fact Book' (publication date July 2002) and Breggin's Web site still portray the suits as legitimate and pending.
Russell A. Barkley, PhD, a university-based psychiatry professor who has specialized in ADHD and related disorders for more than 20 years and has published more than 150 scientific papers, book chapters, and books, reached a parallel conclusion about the first edition of Breggin's Talking Back to Ritalin. In a blistering review, Barkley said:
Literally from its opening pages, this book makes contorted attempts at the appearance of scholarship, replete with quotes, footnotes, and references to scientific papers and other sources. Throughout, any quote is mustered from scientific papers that can be taken out of context to support the author's biases along with every exaggerated fact and figure he can find to support his call to alarm, no matter the credibility (or lack of it) of his sources. However, the flaws of both his research methods and his arguments are evident to any scientist even slightly familiar with the scientific literature on the topics covered here [22].
Barkley also led a team of 75 experts who recently issued a international consensus statement expressing concern about the "inaccurate portrayal of attention deficit hyperactivity disorder (ADHD) in media reports." Although the statement did not name Breggin, it obviously referred to him in the following passage:
Occasional coverage of the disorder casts the story in the form of a sporting event with evenly matched competitors. The views of a handful of non-expert doctors that ADHD does not exist are contrasted against mainstream scientific views that it does, as if both views had equal merit. Such attempts at balance give the public the impression that there is substantial scientific disagreement over whether ADHD is a real medical condition. In fact, there is no such disagreement -- at least no more so than there is over whether smoking causes cancer, for example, or whether a virus causes HIV/AIDS [9].
Breggin's credibility has also been skewered during three legal actions in which judges either excluded his testimony or gave it no credibility. The first two involved dubious claims that a medication had caused severe harm, and the third was a contest between parents about whether or not a child with ADHD should be treated with Ritalin.
This court finds that the evidence of Peter Breggin, as a purported expert, fails nearly all particulars under the standard set forth in Daubert and its progeny. . . . . Simply put, the Court believes that Dr. Breggin's opinions do not rise to the level of an opinion based on "good science." The motion to exclude his testimony as an expert witness should be granted. -- Magistrate Judge B. Waugh Crigler in Lam v. The Upjohn Company, No. 94-0033-H, W. Dist., of VA (Harrisonburg Division, U.S. District Court, 1995)
The court believes not only is this gentleman unqualified to render the opinions that he did, I believe that his bias in this case is blinding. . . . I find that he . . . was not only unprepared, he was mistaken in a lot of the factual basis for which he expressed his opinion. . . . The court is going to strike the testimony of Dr. Breggin, finding that it has no rational basis. -- Judge Hilary J. Caplan in Lightner v. Alessi, No. 94013064/CL174959 (Baltimore City Circuit Court, 1995).
Dr. Breggin's observations are totally without credibility. I can almost declare him, I guess from statements that floor me, to say the he's a fraud or at least approaching that He has made some outrageous statements and written outrageous books and which he says he has now withdrawn and his thinking is different. He's untrained. He's a member of no hospital staff. He has not since medical school participated in any studies to support his conclusions except maybe one. . . . I can't place any credence or credibility in what he has to recommend in this case. -- Judge James W. Rice in Schellinger v. Schellinger, No. 93-FA-939-763 (Milwaukee County Circuit Court, 1997)
The Bottom Line
Peter R. Breggin , M.D., would like you to believe that his personal experience and judgment enable him to out-think and outperform the collective wisdom of the science-based mental health community. Some of the things he describes may reflect genuine problems. However, he is prone to exaggeration and has certainly failed to substantiate his ADHD-related criticisms. The Ritalin Fact Book should be classified as junk science.
For Additional Information
* Book Review: Talking Back to Ritalin
* International Consensus Statement on ADHD
* American Academy of Pediatrics
o ADHD and your school-aged child. AAP Parent Page, Oct 2001.
o Understanding ADHD: A Guide for Parents (booklet)
o ADHD: A Complete and Authoritative Guide (book, 2003)
* A trick question: A hoax that turns out to be true: Excellent article by Michael Fumento.
* American Psychiatric Association fact sheet
* New Zealand Guidelines for ADHD Assessment and Treatment
* Dr. Larry Silver's Advice to Parents on ADHD (book)
*
References
1. American Academy of Pediatrics. Clinical Practice Guideline: Diagnosis and evaluation of the child with attention-deficit/hyperactivity disorder. Pediatrics 105:1158-1170, 2000.
2. American Academy of Pediatrics. Clinical Practice Guideline: Treatment of the school-aged child with attention-deficit/hyperactivity disorder. Pediatrics 108:1033-1044, 2001.
3. Practice parameters for the assessment and treatment of attention deficit/hyperactivity disorders. Journal of the American Academy of Child and Adolescent Psychiatry 30:1-3, 1991.
4. Goldman LS and others. Diagnosis and treatment of attention-deficit/hyperactivity disorder in children and adolescents. JAMA 279:1100-1107, 1998.
5. Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR. Washington, DC: American Psychiatric Press, 2000.
6. Attention deficit/hyperactivity disorder. American Psychiatric Association fact sheet, March 2001.
7. Diagnosis and treatment of attention deficit hyperactivity disorder. NIH Consensus Statement 16(2), Nov 16-18, 1998. [Download PDF]
8. Attention deficit hyperactivity disorder. NIH Publication No. 96-3572, printed 1994, reprinted 1996. [Download PDF]
9. Attention deficit/hyperactivity disorder. In Mental Health: A Report of the Surgeon General. Rockville, MD: U.S. Dept. of Health and Human Services, 1999, pp 142-150.
10. Barkley RA and others. International Consensus Statement on ADHD. ADDitude magazine, Jan 2002.
11. Breggin PR. Talking Back to Ritalin: What Doctors Aren't Telling You about Stimulants and ADHD. Cambridge, MA: Perseus Publishing, revised edition, 2001. (Previous edition published in 1998 by Courage Press, Monroe, ME.
12. Breggin PR. The Ritalin Fact Book: What Doctors Won't Tell You about ADHD and Stimulant Drugs. Cambridge, MA: Perseus Publishing, 2002.
13. Breggin PR. Testimony at Hearing on Behavioral Drugs in Schools: Questions and Concerns. Held by the Subcommittee on Oversight and Investigations, Committee on Education and the Workforce, U.S. House of Representatives, Sept 29, 2000.
14. Breggin PR. Psychiatric drug facts: Biography. Accessed Sept 6, 2002.
15. Breggin PR. Peter R. Breggin resume. Accessed Sept 6, 2002.
16. ICSPP. Form 990-EZ for 2000.
17. Schaler JA. Double-think at the ICSPP corral: A rejoinder to Peter R. Breggin, M.D. Psychnews International 4(1), March 1999.
18. Efron D and others. Side effects of methylphenidate and dexamphetamine in children with attention deficit hyperactivity disorder: a double-blind, crossover trial. Pediatrics 100:162-166, 1997.
19. Popper C, West CA. Disorders usually first diagnosed in infancy childhood, or adolescence. In Hales RE and others, editors. The American Psychiatric Press Textbook of Psychiatry, Third Edition. Washington, DC: American Psychiatric Press, pp 825-855.
20. Hausman K. Last of Ritalin-based lawsuits against APA comes to a close. American Psychiatric News, April 5, 2002.
21. Dismissal of New Jersey lawsuit strengthens CHADD's Resolve: New Jersey plaintiffs drop lawsuit after judge criticizes complaint. CHADD press release, Feb 21, 2002.
22. Barkley RA. ADHD, Ritalin, and Conspiracies: Talking Back to Peter Breggin Originally posted to CHADD Web site, 1998.
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This article was revised on September 23, 2002.
