Is ADD a Sleep Disorder? (5/6/13)
The Newest Epidemic
ADD is now “epidemic” across America. With 13% of adolescents “diagnosed” in national surveys, people want to know just how big a problem ADD is. A recent article by psychiatrist by Vatsal Thakkar in the NY Times argued much of ADD may be misdiagnosed sleep disorders. Himself once diagnosed as suffering from ADD, Thakkar was later discovered to suffer from “atypical narcolepsy” and has improved with stimulants and antidepressants – along with lifestyle changes.
So what’s the truth?
Does Everyone Have ADD?
When John Ratey published his very popular popular book on ADD there was a joke among the marketing team. One member would stand up and say “I have ADD.”
Then the rest would stand up – one by one. All of them.
Distractibility, forgetfulness, inability to finish work on time, minds that go in five directions at once – these “ADD” symptoms are actually common in the population. They are particularly common in people suffering with manic-depression and depression and in people who are sleep deprived.
Why the latter?
Bodies regenerate to survive. We must continuously regenerate to function. We learn or we die.
Sleep deprive most anybody and they get distractible, forgetful, slow, cognitively clueless. They’re tired, dull, sleepy. And they often feel stupid.
Now, don’t just do this in a lab with friendly undergraduates prodding you to stay up all night. Do it societally.
Tell kids they can go to bed whenever they want. Let them take their cellphones into that bed to text all night. Rouse them in the morning, and give them enough money to buy energy drinks so they can caffeinate themselves sufficiently to appear sort-of awake in class.
Voila! A population that “fits” many ADD symptoms.
And a population that 1. Will gain weight – an expected result of partial sleep deprivation 2. Not learn very well – you don’t consolidate memory or cognitively restructure without sleep 3. Be more reckless in behavior – Tom Balkin’s work on this in the military is fairly hair-raising. 4. Not look very pretty or handsome – a great bounty for cosmetic manufacturers and aestheticians.
The physiology is relatively simple – regenerate or die. And kids and adolescents don’t just regenerate – they grow. A lot.
So they need more sleep to grow than they get. A lot more than their stressed, often overworked parents, many of whom try to endure on 6.5 hours or less of sleep. Even older adolescents probably need at least 9 hours on average to learn (including sports skills ) and remain functional. Instead they emulate sleep deprived parents – who need less sleep than the kids.
And that represents an extraordinary “opportunity” – one where lots of folks can make a lot of money.
Who Makes Money From ADD Diagnoses?
The number of “special interests” is surprisingly large. Certainly there are doctors and therapists and ADD “coaches”. They are however, a rather small section of those who really cash in when ADD diagnostic criteria are kept wide:
1. Drug companies. Big Pharma has come to love ADD. Not only can they concoct new, patent protected extended release forms of old drugs that cost many multiples more than the old generics. They benefit further when governments, like that of Florida, ration the number of stimulant pills because of illegal drug use (see below). Somehow, the cheaper generics seem to become unobtainable, though the vastly more expensive patent protected pharmaceuticals remain in supply. Plus there are millions and millions of kids who will “need” stimulants born every year – and their “need” – according to some clinical metrics – may last much of their lives.
2. Educational testing services and educational institutions. Many parents who want their kids to attend “good” colleges will fight to obtain any edge. Getting an ADD diagnosis makes for preferential testing conditions. It also provides legal access to stimulants. Many parents – and their children – are convinced these drugs improve overall school performance (this group tends not to see the profound, sometimes horrible downsides of sleeplessness, recklessness, moodiness, addiction and death.) If diagnosing John and Joanie with ADD means admission to Cornell versus Bucknell, will all parents hesitate?
3. Drug dealers. With so many kids getting diagnoses of ADD, drug dealers can buy from the youngsters and have “real”, non-street drugs to sell. And with kids often “exchanging” drugs with their friends for “recreation”, a new group of addicts soon appear.
4. Sleep diagnosticians. It turns out that kids with sleep apnea may develop the full stigmata of ADD. Treat them with tonsillectomies or CPAP devices and a lot of them – by no means all – get better. And chronic partial sleep deprivation, particularly when it complicates and worsens ADD and depression, can provide sleep labs a lot of business.
How Does This Affect Kids with Severe ADD?
Badly. With the diagnosis so prevalent, their conditions may be derided or neglected. Many also cannot afford medications that might help them.
Why Is It So Hard to Diagnose ADD Properly?
1. With so many interest groups involved, the diagnosis is infected by politics and money – as the fights over DSM-V are bearing out.
2. Most psychiatric diagnoses are phenemonological, and demand complicated and careful history taking, rather than the check lists beloved of Big Pharma and educational testers.
3. ADD is a continuous, rather than a dichotomous variable, much as blood pressure is. Since the symptoms look worse – or are mimicked – when people have sleep deficits, mood disorders, or even stress – people can “move over the line” into the diagnosable ADD category.
4. The need to take into account the whole life of people – their sleep and diet, their parents and school stressors (do they have to do soccer, the chess club, volunteer at the Salvation Army maintain a 5.0 grade average and win the county clarinet competition?) With their specific domains of expertise, doctors and therapists can miss both the forests and the trees.
ADD symptoms can be caused by sleep disorders, like sleep apnea. Sleep disorders can also exacerbate ADD symptoms.
Yet ADD – the amazing distractibility, intractability, impulsiveness, recklessness, forgetfulness, and full blown cognitive inability to learn simple things simply – is not a sleep disorder.
If you foul up normal human regeneration a lot of things fall apart – particularly health and performance. And ADD is just part of that much larger picture.
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