ADHD AssessmentADHD Treatment

The Over-diagnosis and Over-treatment of ADHD

There has been a significant increase in both the diagnosis of ADHD and the use of stimulant (and other medications) to treat ADHD. A number of recent studies have highlighted this trend. A recent study noted in the Journal of the American Medical Association (1) reported a 40% increase in the rate of diagnosis of ADHD, from 2003 to 2011. A 2012 study in the Journal of Academic Pediatrics (2) reported that the number of physician outpatient visits in which ADHD was diagnosed increased 66% from 2000 to 2010. Finally, a 2014 study of prescription patterns (3) also showed a notable increase in the rate of ADHD diagnosis in the period of 4 years; specifically for boys the rate of ADHD diagnosis in that time period increased from 7.9% to 9.3%. Moreover, these are only a few of the studies that have shown increases in the rate of ADHD diagnosis. Data from the Centers for Disease Control (4) indicates that the rate of diagnosis of ADHD increased by 42% from 2003 to 2011. Specifically, the CDC reported that as of 2011, 11% of all U.S. children, as reported by parents, have received a diagnosis of ADHD.

These findings have raised serious concerns about the over-diagnosis of ADHD. If one examines earlier research on ADHD the prevalence (rate of diagnosis in the population) for ADHD, has historically been estimated to be in the 3-7% range, as little as 10 years ago (5). While some may attribute the increases in diagnosis to better awareness and improved diagnostics it is far more likely that ADHD is now being over diagnosed.

In conjunction with the sizeable increase in the over diagnosis of ADHD there has been a substantial increase in the use of prescription medications. The studies cited above (1,2,3) note a significant increase in the use of prescription medication (particularly stimulants) for the treatment of ADHD. For example, The Express Scripts Report (3) notes that the use of ADHD medications increased 35.5% from 2008 to 2012.

Multiple articles in the popular press have cited concerns about the proliferation of prescriptions for ADHD, particularly for stimulant medications. Concerns have been raised about the overuse of these medications, particularly the use of ADHD medications as performance enhancing drugs (which I previously discussed in this blog in 2012).

Increasingly, leading experts in the field, appear to be more and more concerned about the over-diagnosis and over-treatment of ADHD. In an article, “The Selling of ADHD,” (an article that should fall into the “must read category” for anyone with an interest in ADHD) Alan Schwartz (New York Times, December, 14, 2013) thoroughly examines and discusses these concerns (6). Schwartz cites experts such as Keith Connors , PhD., who expressed significant concerns that ADHD is being significantly over-diagnosed. This article also highlights how pharmaceutical companies have worked to market ADHD medications, minimize their risks, and lower the bar for the diagnosis of ADHD.

The over-diagnosis of ADHD raises multiple concerns. First, individuals are exposed to unnecessary medication based treatment, and the associated risks/side-effects of the prescribed medication. On a purely anecdotal level, most clinicians (myself included) can identify children and teenagers who have had problematic reactions to medication, ranging from appetite and weight loss, to increased anxiety, to increased aggression. Second, the over-focus on diagnosing and treating ADHD can result in an overly narrow focus on the child/individual and on specific symptoms (attention, academic achievement) and shift the focus away from other issues and concerns (anxiety, depression, family problems, to mention just a few) that are at the heart of the child’s or teenager’s difficulties. Again, most clinicians can identify families where the parents preferred to focus on the child’s symptoms and view those symptoms as a medical problem, rather than address obvious family issues that were negatively impacting the child. Third, the over-diagnosis of ADHD dilutes the meaning of the diagnosis. Many clinicians (myself included) remain convinced that ADHD is a real disorder which causes serious difficulties. However, by not adhering to diagnostic criteria the diagnosis is at risk of becoming meaningless and is increasingly likely to be dismissed as having little utility.

The solution to the problem is deceptively simple. First, professional who diagnose ADHD must adhere to rigorous diagnostic criteria and not quickly diagnosis ADHD. Second, alternative explanations of problems need to be carefully considered. As Kevin Murphy, Ph.D., has sagely noted in discussing ADHD adults, ADHD is not an excuse for not achieving at the level that one hoped/expected to achieve at (7) . This argument can also be made for high school and college students who are not achieving at levels they or their parents expect. There are many explanations for difficulties with attention and concentration, poor frustration and impulse control problems, and underachievement. Possible explanations range from specific learning disabilities, to anxiety and depression, to family stresses and problems. Third, professionals assessing ADHD need to be competent. A recent N.Y. Times article, again by Alan Schwartz, (8) described a new 3 day workshop training physicians to diagnose ADHD, and noted, that many physicians are not sufficiently well trained to diagnose ADHD. This problem is not limited to physicians. Fourth, we need to recognize that there are broader social factors that influence how we think about various problems. The wave of advertisements for medication have clearly shifted how American consumers think about their problems, and the treatment options they are likely to consider. The N.Y. times article on the “Selling of ADHD” (6) clearly highlights the influence of pharmaceutical companies in influencing the way ADHD is conceptualized, assessed and treated.

In conclusion when one is evaluating for ADHD it is important to remember that multiple factors and forces may be encouraging a diagnosis of ADHD, but such a diagnosis should not be made unless it is clearly warranted!

References

1. The Journal of the American Medical Association, JAMA. 2014;311(6):565. doi:10.1001/jama.2014.244.

http://jama.jamanetwork.com/article.aspx?articleID=1829696&utm_source=Silverchair%20Information%20Systems&utm_medium=email&utm_campaign=MASTER:JAMALatestIssueTOCNotification02/11/2014

2. Academic Pediatrics
Volume 12, Issue 2 , Pages 110-116, March 2012

3. AN EXPRESS SCRIPTS REPORT MARCH 2014, U.S. MEDICATION TRENDS for Attention Deficit Hyperactivity Disorder, at http://lab.express-scripts.com/wp-content/uploads/2014/03/ADHD_March2014_ExpressScripts.pdf

4. Centers for Disease Control

http://www.cdc.gov/ncbddd/adhd/features/key-findings-adhd72013.html

5.  Russell Barkley, Ph.D.

On his website, http://www.russellbarkley.org/factsheets/adhd-facts.pdf,   Barkley asserts that 3-7% of the population has ADHD.  He cites multiple studies to support this estimate, in his most recent Handbook on ADHD,  Attention Deficit Hyperactivity Disorder, Barkley, R. A. (2006). N.Y., Guilford Press.

6.  The Selling of ADHD, Alan Schwartz, in the New York Times, December 14, 2013.

http://www.nytimes.com/2013/12/15/health/the-selling-of-attention-deficit-disorder.html?_r=0

7. Kevin Murphy, PhD in :

ADHD in Adults: What the Science Says, Russell A. Barkley, Kevin R. Murphy, and Mariellen Fischer, Guilford Press, 2007.

Out of the fog: treatment options and coping strategies for adult attention deficit disorder, Kevin R. Murphy, Suzanne LeVert, Hyperion, 1995

8. Doctors Train to Spot Signs of A.D.H.D. in ChildrenBy ALAN SCHWARZ, New York Times, February 18, 2014

http://www.nytimes.com/2014/02/19/health/doctors-train-to-evaluate-anxiety-cases-in-children.html

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