The Over-diagnosis and Over-treatment of ADHD
(April 1, 2014)
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!
1. The Journal of the American Medical Association, JAMA. 2014;311(6):565. doi:10.1001/jama.2014.244.
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
4. Centers for Disease Control
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.
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 Children, By ALAN SCHWARZ, New York Times, February 18, 2014
American Academy of Pediatrics Guidelines or Should we be Diagnosing 4 year olds with ADHD?
(December 31, 2012)
In October 2012 the American Academy of Pediatrics* issued new guidelines for the diagnosis and treatment of ADHD. While most of the guidelines are relatively straight forward the one area of controversy is the recommendation that children as young as age 4 can be diagnosed and treated for ADHD (lowering the threshold age for diagnosis from 6 to 4). The Academy appears to be trying to balance early intervention with caution as Academy guidelines include a number of criteria that physicians should heed before diagnosing a younger child:
• All of the DSM IV criteria should be clearly met including the presence of significant impairment in more than one setting.
• Information should be obtained from more than just parents, i.e., teachers and other professionals.
• Alternative or co-existing conditions or problems should be considered and ruled out: learning problems and other developmental
disorders; emotional and behavioral problems including anxiety and depression; and physical illnesses, e.g., sleep apnea.
However, even with these cautions the lowering of the age threshold is cause for concern. First, significant changes can occur in younger children in 6-12 month periods. What might appear to be overactive behavior, poor attention, or impulsivity may be well within the normal range of development, for a 4 year old. Second, the impact of family environment (stress, conflict, etc) is not fully considered. Family disruption can significantly affect children and younger children are particularly prone to acting out emotional distress. Moreover, assessing family functioning is often not in the purview of most physicians. Third, the assumption inherent in the guidelines is that physicians will adhere to DSM IV criteria, and carefully assess for ADHD symptoms while also carefully ruling out alternative diagnoses. Given the time pressures on physicians this assumption may not be always warranted.
Therefore, it would seem more prudent for professionals working with younger children who exhibit ADHD like symptoms to follow the Academy’s recommendation that behavioral therapy is the first line intervention in treating younger children with ADHD like symptoms. Moreover, an even more conservative approach would be to defer diagnosis and utilize behaviorally focused family behavioral treatment to address the specific concerns that parents have raised about their child’s behavior. This approach not only allows for treatment of parental concerns, but also provides a forum where more thorough assessment (particularly of familial issues, but also of other concerns) can take place. Finally, a recent summary** of treatment for preschoolers with ADHD like symptoms concludes that parent training programs, ones that emphasize the use of positive reinforcement and the strengthening parent-child relationship, are the most appropriate treatment intervention. Thus, it would seem that the most appropriate intervention for younger children (those under age 6) who present with ADHD like symptoms would be a behavioral focused treatment which also includes assessment of other concerns (family stresses, developmental problems, health problems).
In conclusion, early diagnosis is not wrongheaded. Clearly, if the generally accepted assumption that ADHD is a genetic disorder is correct, there are younger children with ADHD. The problem is that diagnostic methods are not sufficiently precise to differentiate ADHD from normal developmental challenges, in younger children. Therefore, a more conservative approach appears warranted.
**http://www.effectivehealthcare.ahrq.gov/ehc/products/191/818/CER44-ADHD_20111021.pdf (Attention Deficit Hyperactivity Disorder: Effectiveness of Treatment in At-Risk Preschoolers; Long-Term Effectiveness in All Ages; and Variability in Prevalence, Diagnosis, and Treatment. Prepared for: Agency for Healthcare Research and Quality U.S. Department of Health and Human Services, 540 Gaither Road, Rockville, MD 20850. www.ahrq.gov).
How to Best Assess ADHD: Is psychological testing necessary?
September 7, 2012
Controversy continues regarding the most appropriate method for diagnosing ADHD. Many clinicians continue to utilize the detailed interviewing coupled with clinical rating scales. This approach is recommended by Russell Barkley, PhD, and flows from Barkley’s understanding of ADHD. Some psychologists, particularly those who refer to themselves as neuropsychologists advocate extent testing to make a diagnosis of ADHD. These psychologists utilize a variety of tests to make a diagnosis. Recently, they have begun to utilize tests of Executive Functioning (relatively new tests that examine high order cognitive skills).
In trying to respond to this debate the most reasonable strategy is to determine if there is any research to support one approach over the other. Recently, a study by Block et al, the Journal of Neuropsychiatry and Clinical Neurosicence, examined whether tests of executive functioning were useful in diagnosing ADHD. The authors concluded that tests of EF do not make a clinically significant contribution to the diagnostic process. While one study does not a definitive answer make, this research offers additional support for the argument that extensive psychological testing does not assist in diagnosing ADHD.