I was planning to write an overview of the recent controversy in this area concerning frequency of childhood ADHD diagnosis and treatment with stimulant medication. Â This very lively exchange of expert and personal views was touched off by a New York Times article citing a Centers for Disease Control and Prevention telephone survey of many thousands of parents. Â However the latest issue of one of my favorite magazines scooped me. Â I can say it no better than the two-page article in Scientific American, Are doctors diagnosing too many kids with ADHD? by Editors Scott Lilienfeld and Hal Arkowitz. Â It’s the most comprehensive presentation of good science concerning the important issues.
The evidence pro and con about both over and under diagnosis, and over- and under-medication treatment of ADHD in children is summarized. The authors report that the scientific results suggest childhood ADHD is actually under-treated, since about a third of diagnosed cases don’t receive stimulant prescriptions. And yet, due to 1] geographical pockets of overprescription, and 2] an increasing number of people without major attentional problems using stimulants, like college students trying to stay awake to study [and risking addiction], the authors also infer a kernel of truth to the perception of overprescription and overuse. Unfortunately good studies often lead to contradictory interpretations, due to differently asked questions and different methodology.
Most of my experience is with adult ADHD folks, not children or college students. Those who believe childhood ADHD is over diagnosed and excessively treated with stimulants cite Dr Phil and the recent NYTimes article based on the CDC’s unreported and unanalyzed raw data from thousands of telephone interviews with parents across the country. Dr Phil’s statement is a personal opinion, not science, and telephone survey information is often unrepresentative of actual facts, to wit telephone polling of “likely voters”. No valid and reliable inferences about actual diagnostic or prescriptive patterns can be drawn from this information, leaving plenty of room for continuing differing opinions.
In many decades of working with ADHD adults as a clinical psychologist [certainly not a representative sample of the larger population], I have come across only two cases of inappropriate use of stimulant medications. ADHD is an extreme variation of standard patterns and dimensions of habits and functioning, like obesity and anorexia, use of tobacco, diabetes, and hypertension. Such diagnoses are regularly redefined and differently treated by healers when changing scientific information and cultural perspectives are considered, so we can surely expect continued variations in the definitions, distributions and treatment of ADHD. For now, I’ll continue to follow my variation of Dan Ariely’s adage: when we have incontrovertible data, let’s go with the data; when there’s no definitive data, let’s use my ideas. I suggest human and humane focus on supporting whatever seems regularly to work, to help and support myself and others carrying the blessings and the burdens of whatever adult ADHD is.
By Bob Dick, PhD, Guest Blogger
You raise an excellent point that different research findings often contradict each other because of their different methodology. And I would like to add on to this.
ADHD is a disorder for which criteria are – only – specified in the DSM. According to the current consensus, those involve inattention, impulsivity and hyperactivity. It’s a dichotomy; you either meet the criteria or you don’t. It’s black and white – but in the clinical practice unfortunately not so; a lot of symptoms are atypical/NOS and a conclusive decision is often made after psychodiagnostic research. But the fact of the matter is that test results don’t matter at all for an ADHD-diagnosis. My point is that:
1. Typical neuropsychological domains for testing include attention, inhibition and (working)memory. ‘Good/bad’ results aren’t specifically a tribute to ADHD.
2. These neuropsychological tests are typically developed for disorders involving some for of organic, acquired brain injury. So normgroups that come with these tests don’t represent ADHD symptoms, or other psychiatric disorders for that matter.
3. Lack of ecological validity: tests are taken in a structural manner in a stimulus poor environment. This situation doesn’t reflect the patients daily life in which his symptoms are obstructive.
I think this ‘confusion’ amongst professionals – and a few other things – attributes for more then some false positive and false negative ADHD cases – thus stringing up actual incidence numbers.
Always reading with pleasure, from the Netherlands.
Thanks, Daniel. I’ll let Dr. Bob respond to your comments.
Thanks for your thoughtful comment, DC. I agree and feel the diagnostic categories professionals create, use and change after some years often have relatively unclear standards and often try to put into words the ineffable, trying to measure the immeasurable. I sure understand the utility of such systems for statistical/public health purposes, for giving clinicians some guidance in our thinking, and for insurance companies to delimit payments to policy holders ( what that industry labels “Losses” in their financial statements). Many diagnoses have been little used, for instance certain Personality Disorders,while others are interpreted very differently by clinicians with different training and perspective, like ADHD. It’s also true that many clinicians actually treat clients phenomenologically, according to what seems to work, rather than focusing on diagnosis. Despite the drawbacks, I think that without some attempt at systematic order and reliability, diagnoses would be even less meaningful and useful than they seem to be. Dr Bob
I do wish for clarity around ‘appropriate’ and so on.
Is disinterest in schooling a sign of sanity?
E, I too think that sometimes often a student’s disinterest in standard teaching and content reflects the inability of mass public education to individualize most pupil’s education. Dr Bob
Can ADHD be treated without medication?
In my experience, yes, but I’ll be interested to hear what Dr. Bob thinks about this.
The general consensus I’ve seen among professionals is that yes, it can. Unfortunately, there’s very little ou there in the form of good WAYS to do so…
Absolutely. However the research indicates to me that stimulant medication for genuine ADHD kids usually results in significant improvement in attention, focus and achievement. At best, it seems to me that some children might have sufficient improvement if good psychological approaches were used, and that most stimulant medication treatment of ADHD needs to be followed with appropriate psychological approaches, like coaching, self-image improvement, and meditation/self-hypnosis. In my experience, many kids and adults are able to benefit from the psychological approaches only after receiving appropriate medication. Unfortunately good help from either modality is very often simply not available or affordable. Dr Bob
First I would like to say I enjoy your posts and have referred both clients and clinicians alike to your site. Here’s my two cents regarding over diagnosis, over medication and under-treatment. First, I have a specialty in trauma treatment (disclosure statement :)) and I work with adoescents primarily but have seen quite a few adults who at one time or another received a diagnosis of ADD/ADHD and experienced no improvement with medication or therapy. I am shocked to find after taking an extensive psycho-social history to find that a great deal of these folks report traumas (discrete single event or chronic maltreatment/abuse/neglect etc)- some of which is revealed over time during the course of treatment. What I have seen clinically now seems to be reported more and more in the press – the significant overlap of symptoms of ADHD and the manner in which PTSD and most significantly complex developmental PTSD presents itself. We need more trauma informed assessments and treatments for children (and adults). Is it really any wonder that medications and certain treatments have failed for this population? I should also note that another diagnosis thrown at this population has been bi-polar disorder…
Thanks for sharing your experience. The overall inaccuracy of diagnosis — the haste in which it is made, the lack of thorough case histories — is another important issue.
Thanks JH, It seems true to me too, that emotional deprivation and/or abuse of every sort is very often part of a clint’s back round in many, many otherwise labeled disorders, in both children and adults. Recent brain research suggests that such history may impact brain development in very signficant negative ways. Recent research also suggests that the brain is not necessarily so permanent and unchangeable an organ as we had thought. Dr Bob
Yes, Bob.
” Unfortunately good help from either modality is very often simply not available or affordable. ” Dr Bob
Therein lies the crux of the matter.
And indeed where mental illness in general is concerned.
Agreed! Dr Bob
Academic difficulties are also frequent. The symptoms are especially difficult to define because it is hard to draw a line at where normal levels of inattention, hyperactivity, and impulsivity end and clinically significant levels requiring intervention begin. To be diagnosed with ADHD, symptoms must be observed in two different settings for six months or more and to a degree that is greater than other children of the same age.
I wish the people who make the diagnosis so freely and frequently would observe those guidelines.
Thanx VW for your reminders. My expertise is with adults, and the symptoms can show up in any venue of life, including work. I think of school as work for children, and scholastic difficulties can be due to many other problems, and to an interaction with things like specific learning disabilities. I wish excellent diagnostic evaluations done by an experienced expert to rule out other issues were available for understanding these complexities in children, and they usually aren’t. According to the research, there are pockets of over-diagnosis in the US, however rampant over-diagnosis seems to me more a function of loud political interpretations of the preliminary data by a minority or professionals. Dr Bob