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Sharon Collins, M.D.
Pediatrician, Cedar Rapids, Iowa |
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YES
At recent congressional hearings, all groups agreed that doctors should be more thorough in diagnoses before prescribing drugs for ADHD.
The reported prevalence of ADHD rose from 900,000 in 1990 to two million in 1995. In Cedar Rapids, children diagnosed with ADHD have doubled, to 8%. This is too huge to be explained by an environ-
mental cause or better diagnoses.
The driving force behind the overdiagnosis is a system that is out of control. Teachers want compliant, well-behaved children. Parents eager to see children succeed take them to mental-health professionals who are quick to diagnose ADHD and seek drug treatment. Under an insurance system that favors drugs over therapy, ADHD is an easy label to apply to undesired behavior; drugs are a quick fix.
The average diagnostic visit with a psychiatrist is 20 minutes. Psychologists probably spend more time, but they are also too quick to recommend drugs. Children come to pediatricians not for an opinion but for a prescription.
I saw a 13-year-old who began on methylphenidate (Ritalin, Ciba) and was switched to paroxetine, imipramine, and dextroamphetamine. No one had questioned this.
Children who are creative, have a different learning style, or are oppositional, angry, or depressed all have been diagnosed as having ADHD. Many of these problems can be found only by talking with patients at length.
Today, there are a million children taking methylphenidate in the U.S, a sixfold increase since 1990, when three tons of the drug was made. In 1994 it was 8.4 tons, says a U.N. agency, of which 90% was used domestically. Are our children suffering an epidemic of ADHD not seen elsewhere?
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Martha Bridge Denckla, M.D.
Director, Cognitive Neurology, Johns Hopkins
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NO
It is not the children who have changed, but the world around them. No one can say ADHD is overdiagnosed, because the criteria keep changing. The criteria in DSM-IV are different than in DSM-III-R and DSM-III. The new criteria give far more latitude for the diagnosis.
DSM-IV says an ADHD diagnosis must be based on symptoms from two lists, inattention and hyperactivity-impulsivity. From each list, six or more symptoms are required in a manner that significantly impairs the child.The key phrase is significant impairment. Many children diagnosed with ADHD are impaired relative to some current demand, creating a dilemma for a physician who is asked to help a child to succeed in a given environment.
We are seeing more children pushed over the threshold into an ADHD diagnosis because of shifting criteria for significant impairment. Those who don’t do their homework, forget their books, or daydream are labeled with ADHD, when the problem is more complex. Though they may have biologically based weaknesses in self-control and behavior, in other environments they might not be as limited.
Children with ADHD are more dependent than their peers on controls from parents and society. But teachers are stretched to the limit and parents spend less time with their children. The lack of support lets “full-blown” ADHD develop where it may have lain dormant.
Success with methylphenidate requires that the doctor, parents, and school work together to gauge its effects. But many parents stop giving the child the drug, and adolescents often won’t take it. Methylphe-nidate is a relatively weak drug, but one that makes people more available for treatment. The drug is not the concern, but the follow-up.
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