Since 1980 Hyperkinetic Disorder, a rarely diagnosed and treated childhood condition, has been transformed into Attention Deficit Hyperactivity Disorder - the world’s most common childhood psychiatric disorder. In 2021, global sales of ADHD ‘medications’ are anticipated to total US$22.5 Billion.
Although the majority occur in the USA, sales are substantial and growing in most developed nations. This growth is likely to continue and new markets in developing nations are expected to help global sales to double by 2030.[1]
These sales estimates only include the revenue earned by ADHD drug manufacturers (i.e. Pfizer, Novartis, Eli Lilly, GlaxoSmithKline, Mallinckrodt Pharmaceuticals, Johnson & Johnson, UCB, Hisamitsu Pharmaceutical, and Purdue and others.)[1] They do not include the retail margin. They also do not include the billions earned by 'experts' who diagnose, research and otherwise derive income from ADHD.
The successful promotion of ADHD as a common and treatable medical condition (i.e. illness) has driven these remarkable sales. This ‘medicalisation’ has occurred despite the fact that numerous non-medical factors have been shown to drive ADHD treatment rates.
Other factors that have been associated with higher rates of ADHD diagnosis and medication use include gender, ethnicity of students and teachers[3], divorce[4], poverty[5], parenting styles[6], low maternal education, lone parenthood and the receipt of social welfare[7], sexual abuse[8], sleep deprivation[9], perinatal issues[10], artificial food additives[11], mobile phone use[12], clinician speciality[13], postcode and regulatory capture.
Obviously being younger than your classmates is not an illness. Neither is being a boy, or a child from a split marriage, or any of the multiple other non-medical factors that increase a child’s likelihood of being ‘treated’ for ADHD.
Put simply despite the success of the Industry in medicalising childhood behaviours, the argument that ‘ADHD is a medical condition’ doesn’t stack-up.
A far more plausible explanation is that ADHD is an Industry, motivated to maximise profits, just like any other industry. In fact, with US$22,500,000,000 in annual drug sales, and countless other billions received for diagnosing and promoting the ‘disorder’, it is ridiculous to argue that ADHD is not an Industry.
The Industry is a combination of for-profit actors (e.g. drug manufacturers, ‘ADHD specialist’ clinicians), paid (e.g. researchers and universities) and not-for-profit actors (e.g. patient support groups) who collectively promote the increased ‘recognition and treatment of the disorder’.
Sometimes the lines between the for-profit, paid, and not-for-profit actors are blurred. For example ADHD patient support groups, like CHADD in the U.S.A. and ADHD Australia have the nominated intention of enhancing the welfare of individuals with ADHD, however, they have close relationships with the for-profit sector. This is not to imply that all proponents of ADHD medication use by children are motivated by profit or other forms of self-interest. Some are undoubtedly well-intentioned and naively believe they are helping children.
Nonetheless these organisations are often controlled or heavily influenced by clinicians who derive much or all of their income from diagnosing, prescribing, researching or promoting ADHD and have received direct financial support from the pharmaceutical industry.[14]
In a similar vein, in 2009 the current Chair of the Board of ADHD Australia, Professor Michael Kohn, described an article in Sydney’s Daily Telegraph detailing extreme reactions to ADHD such as psychotic episodes and suicidal ideation as ‘the latest in a series of articles blaspheming the use of Ritalin’.[17]
There are countless examples of not-for-profit ADHD support groups making optimistic, unsubstantiated claims about the scientific certainty of an ADHD diagnosis and/or the safety and efficacy of ADHD treatments.[18] In contrast pharmaceutical companies are limited by law from making claims about their products that are completely false.
However, when support groups exaggerate the benefits and deny the risks of medications, they increase drug company sales and profits without exposing the drug companies to any legal liability.
Similarly, the for-profit ADHD Industry has benefitted from the uncritical publication of false claims of breakthrough discoveries by ADHD experts who purporting to have discovered the biological/genetic basis of ADHD.
One of the biggest and most powerful deceptions ever in regard to ADHD occurred in September 2010 when the world media buzzed with the news that a group of British researchers had found the Holy Grail for proponents of ADHD, by proving its genetic basis.[19][20]
One of the researchers, Professor Anita Thapar of Cardiff University, proclaimed emphatically ‘now we can say with confidence that ADHD is a genetic disease’.[21]
Thapar’s claim was nonsense, but by the time critics had identified the flaws in the research, the media circus had moved on and tens of millions of people around the globe had read, seen or heard the unchallenged proclamation that ‘ADHD is a genetic disease’.[22]
While pharmaceutical companies have received billions in fines for dishonestly marketing other psychotropic medications in the USA[23], it has been rare for the drug manufacturers to blatantly lie about ADHD medications. However, there has been a systematic and sustained effort by pharmaceutical companies and other elements of the ADHD Industry that have strategically and often dishonestly marketed amphetamines and other similarly dangerous drugs for use by children.
As with many other areas in medicine and psychiatry some ‘ADHD specialists’ become Key Opinion Leaders, who are supported with pharmaceutical industry funding.[24] Many of these Key Opinion Leaders have made outrageous unsubstantiated claims about the science supporting an ADHD diagnosis and the safety and efficacy of the ‘medications’ that the drug manufacturer can’t legally make.
By sponsoring those who provide misinformation the drug manufacturers outsource their lying and therefore avoid fines and sanctions.
While information on the prescribing patterns of individual clinicians is scant, the little that exists indicates that most prescribing is done by a minority of potential prescribers who derive a significant proportion of their income from specialising in ADHD.
For example in 2015 (the latest year for which data is publicly available) in Western Australia there were 419 clinicians authorised to prescribe stimulant medication. Of these the top 27 prescribed to more than two thirds of the total number of patients, with one psychiatrist prescribing to 2,074 patients, (9.6% of the total ADHD stimulant cohort).[25] We will never know how much this ‘ADHD expert’ made, but it is likely to have been a very healthy income.
In contrast, it is very difficult to make an income from specialising in not diagnosing a condition are therefore most sceptical clinicians have limited opportunity to develop ADHD expertise.
Similarly, it has been my experience that researchers with a critical perspective have limited opportunities to find research funding. As a result those with a critical perspective typically rely on publicly available information and have little capacity to conduct resource intensive original research into important underexplored issues like the long term safety and efficacy of ADHD medications.
In contrast the ADHD Industry is multi-layered, coordinated, well-resourced, strategic and professional; whereas critics are generally poorly-resourced, uncoordinated amateurs.
Predictably the ADHD Industry is winning the contest. It is very likely it will continue to win and global drug sales will continue to grow rapidly.
Conclusion - The massive growth in global ‘medication’ sales is an obvious indicator of the impressive success of the ADHD Industry. It has transformed what were previously regarded as normal if annoying childhood behaviours (e.g. fidgeting, playing loudly, avoiding homework) into the diagnostic criteria of a perceived ‘illness’.
Even more remarkably it has convinced millions of time poor, gullible, parents that the responsible way to parent is to give their child a daily amphetamine habit.
None of this should come as a surprise. History has taught us time and time again that when governments acquiesce to industry (and in the case of ADHD they almost always have) we should expect industry to do whatever it can to increase sales and maximise profits. Until there is a widespread understanding that ADHD is an Industry and not an Illness, drug manufacturers and their allies will continue to profit and children will continue to pay the price.
by ADHDisBS.com Editor Martin Whitely PhD 29 October 2021
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References [1] Persistence Market Research, Global Market Study on Attention-deficit Hyperactivity Disorder (ADHD) Therapeutics: Increasing Production of Generic ADHD Drugs to Boost Market Growth, April 2021 https://www.persistencemarketresearch.com/market-research/attention-deficit-hyperactivity-disorder-therapeutics-market.asp (accessed 15 June 2020)
[2] Whitely M, Raven M, Timimi S, Jureidini J, Phillimore J, Leo J, Moncrieff J, Landman P, Attention deficit hyperactivity disorder late birthdate effect common in both high and low prescribing international jurisdictions: systematic review, Journal of Child Psychology and Psychiatry, October 2018 https://acamh.onlinelibrary.wiley.com/doi/full/10.1111/jcpp.12991
[3] Schneider, H., & Eisenberg, D. (2006). Who receives a diagnosis of attention‐deficit/hyperactivity disorder in the United States elementary school population? Pediatrics, 117, e601– e609. https://pubmed.ncbi.nlm.nih.gov/16585277/
[4] Hjern A, Weitoft GR, Lindblad F. Social adversity predicts ADHD-medication in school children--a national cohort study. Acta Paediatr. 2010;99(6):920-4. https://onlinelibrary.wiley.com/doi/10.1111/j.1651-2227.2009.01638.x
[5] Russell G, Ford T, Rosenberg R, Kelly S. The association of attention deficit hyperactivity disorder with socioeconomic disadvantage: alternative explanations and evidence. Journal of Child Psychology Psychiatry. 2014;55(5):436-45. https://pubmed.ncbi.nlm.nih.gov/24274762/
[6] Johnston C, Mash EJ, Miller N, Ninowski JE. Parenting in adults with attention-deficit/hyperactivity disorder (ADHD). Clin Psychol Rev. 2012;32(4):215-28. https://pubmed.ncbi.nlm.nih.gov/22459785/
[7] Hjern A, Weitoft GR, Lindblad F. Social adversity predicts ADHD-medication in school children--a national cohort study. Acta Paediatr. 2010;99(6):920-4. https://onlinelibrary.wiley.com/doi/10.1111/j.1651-2227.2009.01638.x https://onlinelibrary.wiley.com/doi/10.1111/j.1651-2227.2009.01638.x (accessed 15 June 2020)
[8] Weinstein D, Staffelbach D, Biaggio M. Attention-deficit hyperactivity disorder and posttraumatic stress disorder: differential diagnosis in childhood sexual abuse. Clin Psychol Rev. 2000;20(3):359-78. https://pubmed.ncbi.nlm.nih.gov/10779899/
[9] Thakkar VG. Diagnosing the Wrong Deficit. New York Times. 27 April 2013. https://www.nytimes.com/2013/04/28/opinion/sunday/diagnosing-the-wrong-deficit.html
[10] Schmitt J, Romanos M. Prenatal and perinatal risk factors for attention-deficit/hyperactivity disorder. Arch Pediatr Adolesc Med. 2012;166(11):1074-5. Prenatal and perinatal risk factors for attention-deficit/hyperactivity disorder. https://jamanetwork.com/journals/jamapediatrics/fullarticle/1357759
[11] McCann D, Barrett A, Cooper A, Crumpler D, Dalen L, Grimshaw K, et al. Food additives and hyperactive behaviour in 3-year-old and 8/9-year-old children in the community: a randomised, double-blinded, placebo-controlled trial. Lancet. 2007;370(9598):1560-7. https://europepmc.org/article/med/17825405
[12] Byun YH, Ha M, Kwon HJ, Hong YC, Leem JH, Sakong J, et al. Mobile phone use, blood lead levels, and attention deficit hyperactivity symptoms in children: a longitudinal study. PLoS One. 2013;8(3):e59742. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0059742
[13] Western Australia. Parliament. Legislative Assembly. Attention deficit hyperactivity disorder in Western Australia Perth; 2004. https://www.parliament.wa.gov.au/Parliament/commit.nsf/(Report+Lookup+by+Com+ID)/A8838813E981CEE948257831003E9611/$file/ADD%20final%20report%20pdf%20version.pdf
[14] For an example of this type of collaboration see Businesswire, Ironshore Pharmaceuticals Recognizes ADHD Awareness Month Through Partnership With CHADD -Company to Sponsor “Mornings Matter with ADHD” Webinar Hosted by Internationally Renowned ADHD Expert October 28, 2019 https://www.businesswire.com/news/home/20191028005208/en/Ironshore-Pharmaceuticals-Recognizes-ADHD-Awareness-Month-Through-Partnership-With-CHADD
[15] Ray Moynihan and Alan Cassels, Selling Sickness: How the World’s Biggest Pharmaceutical Companies Are Turning us all into Patients, Nation Books, New York, 2005, p. 67.
[16] Kelly Patricia O’Meara, ‘Putting Power Back in Parental Hands; legislation being considered that would allow parents not schools to decide whether their children need to be medicated as a prerequisite for attending classes’, Washington Post’s Insight Magazine, 26 May 2003.
[17] Medicating our children, Reportage Online, 22 December 2009 http://www.reportageonline.com/2009/12/medicating-our-children/ accessed 29 June 2011] Professor Michael Kohn in response to an article in Sydney’s Daily Telegraph detailing extreme reactions to ADHD medications reported to the TGA, such as psychotic episodes and suicidal ideation. [11. We’re turning our children psychotic with ADHD medication, Kate Sikora, The Daily Telegraph October 13, 2009. http://www.dailytelegraph.com.au/lifestyle/body-soul/were-turning-our-children-psychotic/story-e6frf01r-1225786025127] (accessed 3 July 2011)
[18] Whitely MP. Attention Deficit Hyperactivity Disorder Policy, Practice and Regulatory Capture in Australia 1992–2012 [PhD]. Perth, WA: Curtin University; 2014 pp. 189-192
https://espace.curtin.edu.au/bitstream/handle/20.500.11937/1776/225953_Whitely%202014.pdf?sequence=2
[19] Kelland, K. Study finds first evidence that ADHD is genetic, Reuters, 30 September 2010. https://www.reuters.com/article/us-adhd-genes-idUSTRE68S5UD20100930
[20] Landau, E. (2010) ADHD is a genetic condition, study says, CNN Health, 29 September 2010. Available at https://thechart.blogs.cnn.com/2010/09/29/adhd-is-a-genetic-condition-study-says/
[21] ABC Online News. Study finds genetic link to ADHD, 30 September 2010. Available at https://www.abc.net.au/news/2010-09-30/study-finds-genetic-link-to-adhd/2280292
[22] Martin Whitely, Overprescribing Madness – what’s driving Australia’s mental illness epidemic. Wilkinson Publishing 2021. p.p. 131-133
[23] Tiash Saha, The biggest ever pharmaceutical lawsuits, Pharmaceutical Technologies Website. 25 Jun 2019 (Updated January 31st, 2020). https://www.pharmaceutical-technology.com/features/biggest-pharmaceutical-lawsuits/
[24] Watson, G.L., Arcona, A.P., Antonuccio, D.O. et al. Shooting the Messenger: The Case of ADHD. J Contemp Psychother 44, 43–52 (2014). https://doi.org/10.1007/s10879-013-9244-x (accessed 14 August 2021)
[25] Department of Health, (2016), Western Australian Stimulant Regulatory Scheme 2015 Annual Report, Pharmaceutical Services Branch, Health Protection Group, Department of Health, Western Australia p 15,19, 23,39