What to do about the ADHD epidemic
William B. Carey, M.D.
American Academy of Pediatrics
Section on Developmental and Behavioral Pediatrics
Newsletter, Autumn 2003, Pages 6-7
In the last two decades the United States has experienced a great increase in the diagnosis of Attention Deficit Hyperactivity Disorder (ADHD) and its treatment with stimulants. Much of the public is confused, and now apprehensions are mounting with the extension of the diagnosis and drug use into preschool years. Some of us pediatric moderates are trying to mediate between the conservative defenders of the present imperfect construct and the radical critics who regard the diagnosis as a fraud.
The diagnosis is officially based on the DSM-IV criteria: 6/9 inattention or 6/9 hyperactivity/impulsivity symptoms for 6 or more months, which have been present from before the age of 7 years, with impairment in two or more settings, and not due to other conditions. Other assumptions include the beliefs that these behaviors are clearly distinguishable from normal; involve a neurodevelopmental disability; are not influenced by the environment; and can be adequately diagnosed by brief questionnaires.
The most authoritative review of these issues was the 1998 National Institutes of Health Consensus Conference on the Diagnosis and Treatment of ADHD. Its Consensus Panel concluded that "there is evidence supporting the validity of the disorder," but added that "additional efforts to validate the disorder are needed" and that "a more consistent set of diagnostic procedures and practice guidelines is of utmost importance."
In 2000 the American Academy of Pediatrics published some practice guidelines based on that same imperfect DSM construct. An algorithm recommended that, when confronted with a child having problems with school performance, the physician should think first of ADHD, and then broaden the differential diagnosis only after the child cannot be fitted into the impressionistic, flexible criteria of ADHD. Normal but aversive temperament traits, frustration from learning troubles, adjustment reactions, fatigue, anxiety, depression, etc., all commoner than brain malfunction, are scarcely considered.
There is general agreement that 1-2% of children are readily identifiable by the ICD-10 criteria as "hyperkinetic" with pervasive high activity or inattention, which are the clinical problem itself, not just a predisposition or coincidence. However, that does not account for most of the up to 15% of children given the ADHD diagnosis in the USA.
What are the problems?
As stated in my presentation at the NIH conference and as published in the summary book edited by Jensen and Cooper, the problem resides primarily in the ADHD diagnosis itself and secondarily how it is applied:
1) The current ADHD symptoms are not clearly distinguishable from normal behavior. The DSM system fails to acknowledge the existence of temperament and how it differs.
2) The absence of clear evidence that the ADHD symptoms are related to brain malfunction. They may come from other causes, as mentioned above. Genetic studies do not prove that ADHD is a disorder any more than they do with normal temperamental variations. Chemical testing and brain imaging techniques have not proven anything. The associations demonstrated so far have been inconsistent and are not clear as to cause, association, or consequence of the symptoms. These studies all lack appropriate controls, who must be the same as the subjects in every way except for the dysfunctional behavior.
3) The neglect of the environment and interactions with it as factors in etiology. The environment always matters for behavior. The problem is not all in the brain if the child.
4) Diagnostic questionnaires now in use are highly subjective and impressionistic. Items like "Often talks excessively" assess caregiver perceptions and discomforts, not the child.
5) The most important factors predisposing to dysfunction in school may be low adaptability and cognitive problems rather than high activity or inattention.
6) Lack of evolutionary perspective. The traits not fitting well in the artificial modern school setting may have had survival value and been highly adaptive in earlier times.
7) Small practical usefulness and possible harm from the label. The ADHD diagnosis does not define the specific problems. It may be a barrier to some occupations later.
8) Whether one agrees with the current diagnostic criteria or not, there can be no doubt about its widespread misapplication. Studies show criteria are usually not applied.
9) Nonspecific effects of methylphenidate. Many professional persons and members of the public do not realize that stimulants help most normal children too.
What are the solutions?
1) Better diagnostic system- As the NIH panel advised, improved diagnostic criteria are urgently needed. Distinctions must be made between "hyperkinetic" children, who are truly pervasively overactive or inattentive, and those primarily having other problems.
2) Better research- Despite the confidence of ADHD spokespersons, such as was expressed in the 2002 statement of the self-appointed International Consensus Committee on ADHD, much is uncertain. Critics of present ADHD construct and its application are not just dealing in "mythologies" and "fairy tales," as they say.
3) Better education of professionals and public. Both need more information on basic matters such as the broad range of normal behavioral variations and the nonspecificity of stimulants. Much of the problem today comes from unrealistic expectations of caregivers for high performance and conformity and their pressure on physicians to prescribe drugs.
4) Better evaluations- The clinician should consider the full differential diagnosis at first, not just after being unable to fit the child into the highly flexible criteria of ADHD. School problems require comprehensive exams including psychoeducational testing and evaluation of child’s temperament and adjustment. Assessments must be detailed, broad, and dimensional and should include children’s strengths.
5) Better treatment- It should be designed to fit the child’s specific strengths and problems with greater reliance on psychosocial and educational interventions. Behavioral controls can be learned. An aversive temperament cannot be extinguished by behavior modification but can be successfully accommodated by alternative management.
6) Better monitoring of the aggressive advertising by the drug companies to the public and to physicians. Any unethical physician conflicts of interest should be eliminated.
7) A better system than is now provided by insurance companies and managed care for compensating physicians who need to take more time to do adequate evaluations.
8) Better regulation of medical diagnosing and insistence on medication by teachers.
American Academy of Pediatrics: Clinical practice guidelines: Diagnosis and evaluation of the child with Attention Deficit /Hyperactivity Disorder. Pediatrics105:1158-70;2000.
Carey WB: Is ADHD a valid disorder? In Jensen, Cooper (Eds.) 2002 (see below).
Diller LH: Running on Ritalin. New York. Bantam Books. 1998.
Jensen PS, Cooper J (Eds.): Attention Deficit Hyperactivity Disorder: State of the Science; Best Practices. Kingston, NJ: Civic Research Institute. 2002.