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Problems in Diagnosing and Treating ADD/ADHD.

PUBLIC AND MEDICAL concern regarding the overdiagnosing of attention deficit disorder (ADD) and attention deficit-hyperactivity disorder (ADHD) and the overprescribing of Ritalin hit the mainstream in 2000 with the publication of a study in the Journal of the American Medical Association (JAMA). As early as 1988, researchers Daniel J. Safer and John M. Krager reported in JAMA that there was a doubling of Ritalin use every four to seven years from 1971 to 1987, which was then followed by a decline in response to public concern about excessive use of the drug. They indicated, nonetheless, that there was no cause for concern.

In the 2000 report, an alarming increase in the general use of psychiatric drags for preschoolers was documented for the first time. Some of the findings of that study revealed that the number of preschoolers on antidepressants had risen 200% from 1991 to 1995 (among those enrolled in two state Medicaid programs and a health maintenance program in the Northwest), and there was a twofold to threefold increase in the number of children ages two to four who were taking methylphenidate (the generic form of Ritalin). In addition, the use of clonidine (popularly used for blood pressure) for children had risen substantially.

An editorial by Joseph T. Coyle of Harvard Medical School's Psychiatry Department accompanying the JAMA article points to the salient concerns: Methylphenidate, or Ritalin, carries a warning against its use in children younger than six, and "the validity and reliability of the diagnoses of ADHD [has] not been demonstrated." Moreover, the editorial makes a stunning admission: "There is virtually no clinical research on the consequences of pharmacologic treatment of behavioral disorders in very young children ... it would seem prudent to carry out much more extensive studies to determine the long-term consequences of the use of psychotropic [having an altering effect on the mind] drags at this early stage of childhood."

The lead researcher of the study, Julie Zito, associate professor of pharmacy and medicine at the University of Maryland, summed up the significance of the new findings by saying that "This seems to support the anecdotes that more children are receiving a diagnosis and treatment for attention deficit-hyperactivity disorder in the late 1990s than ever before."

Even psychiatric experts were shaken by the study's results. Steven Hyman, director of the National Institute of Mental Health (NIMH), described himself as "more than shocked" by the findings.

In April, 2000, then-First Lady Hillary Clinton announced a multimillion-dollar government study to examine the consequences of the increase in the number of schoolage children who are prescribed stimulants for ADD/ADHD. Now, as a senator from New York, she acknowledges that physicians may be "too quick to diagnose" these disorders, noting that "Some of these young people have problems that are symptoms of nothing more than childhood or adolescence."

Recognition of this issue within the medical and governmental establishments has been a long time in coming, although there has been no lack of criticism in the press. In 1993, in JAMA's Correspondence section, we criticized a 1992 article by Safer and Krager in which they implicitly condemned a "media blitz" as being responsible, along with threatened lawsuits, for a decline in stimulant treatment in Baltimore County (Md.) elementary and secondary schools. The "blitz" attacked by Safer and Krager was allegedly misleading, full of "anecdotal and unsubstantiated critical allegations concerning Ritalin use and side effects...."

They further decried in this article the fact that parents "fearful of media-reported medication `side effects' and school staff hesitated to refer restless, impulsive, and inattentive students to physicians." Safer and Krager concluded that the "blitz" had little impact on parents whose kids already were receiving Ritalin since, they argued, "Presumably, most of these parents were satisfied with the benefits of the medication...." We pointed out that parental satisfaction was a dubious criterion for supporting Ritalin therapy, for such compliance may reflect only unquestioned trust in physicians and a desire to meet school expectations.

Safer and Krager's response to our criticism stressed the safety of Ritalin medication, ending with the statement: "To suggest that stimulant treatment is widely overprescribed or imprudently prescribed requires contrary evidence." To imply that such evidence did not exist in 1992-93 is to ignore without concern a wealth of reports on excessive use, including Safer and Krager's 1988 findings which indicated that "giving stimulant medication to inattentive but not hyperactive public school students is not an uncommon practice and has in fact become more prevalent of late...." Moreover, how could serious researchers ignore the obvious problems inherent in widespread use of a central nervous system stimulant--such as the exacerbation of Tourette's syndrome--as NIMH has pointed out more than once?

For the authors of the 2000 study, including Safer, to express surprise at and concern over their findings and to conclude that the increased use of Ritalin may be partly due to "pressure to conform to school standards" strains credulity. The geometric increase in Ritalin use by prescription had already been widely publicized. Even the suggested explanation for such an increase, including the drug's universal effect on every recipient's ability to focus, had been articulated by us and others, but had not been taken seriously.

In a discussion with us of the study on public television, Zito acknowledged that the rise in rates of Ritalin prescriptions for young children is surprising in its swiftness. Moreover, she added, this increase "makes it easier for more children to be justified to receive the diagnosis." She pointed out that the results reflect a growing emphasis on "the biological-psychiatric model for management of problems in living and mental disorders."

Ritalin creates new problems

In an op-ed piece in The New York Times (Apr. 1, 2000), author Elizabeth Wurtzel examines concerns over some of the relatively unreported problems with the avalanche of prescribing Ritalin. As the drag proliferates in American society, its illegal use has grown even more rapidly than was the case with earlier stimulants, such as dexedrine and others. She cites a study conducted by psychiatrists at the University of Wisconsin which found that one-fifth of college students interviewed had taken Ritalin without a prescription at least once and that many had taken it to allow them to study without sleep. (It was "a poor man's cocaine," as one student explained it to the Times.) That study, published in the June 1998 Journal of Developmental and Behavioral Pediatrics, pointed out the proliferating effects of the increase in Ritalin prescriptions and argued for severe steps in prescription-monitoring and continuous, systematic assessing of the drug's efficacy.

Ritalin, according to Wurtzel, has been a gateway drug for many with whom she has interacted at Narcotics Anonymous meetings, where mothers have admitted stealing Ritalin prescribed for their kids, and Wurtzel's own experience was chopping up Ritalin pills and snorting them through her "nostrils almost continuously."

Reacting to concerns about overdiagnosis and overmedicating of allegedly hyperactive children, in May, 2000, the American Academy of Pediatrics released its first recommendations for diagnosing ADHD in schoolage children. The Academy wants strict adherence to the diagnostic criteria specified by the American Psychiatric Association in its Diagnostic and Statistic Manual of Mental Disorders IV (DSM-IV). The Academy now claims that up to 12% of all children may suffer from ADHD. It further indicates that existing diagnostic tests were ineffective, including lead screening, tests for generalized resistance to thyroid hormone, and brain image studies.

A Reuters report makes clear some of the rising problems in the diagnosis and treatment of ADHD. It maintains that "surveys of pediatricians and family physicians across the United States have shown wide variations in diagnostic criteria and treatment methods" for dealing with ADHD.

Indeed, how could it be otherwise, given that the diagnostic criteria for ADD/ADHD in DSM-IV are utterly subjective and nonspecific. It includes "symptoms" of "inattention" and "hyperactivity-impulsivity," such as the following: "often does not seem to listen when spoken to directly"; "often has difficulty organizing tasks and activities"; "often has difficulty playing or engaging in leisure activities quietly"; and "often talks excessively."

Moreover, if the general criteria are insufficient for diagnosing ADD/ADHD, the diagnostician may cite an individual as having "attention deficit-hyperactivity disorder not otherwise specified." This is described by the manual as being a category "for disorders with prominent symptoms of inattention or hyperactivity-impulsivity that do not meet criteria for Attention Deficit-Hyperactivity Disorder." There is no further elaboration provided by the manual.

Yet, the mental health community has been conspicuously slow in even recognizing that there may be a problem with diagnoses and prescriptions. The mammoth 1999 government publication, Mental Health: A Report of the Surgeon General, belittles concern regarding overdiagnosis ("Indeed, fewer children are being treated for ADHD than suffer from it") and overprescribing of stimulant therapy, while allowing that there may be some "inappropriate diagnosis and treatment." The report notes no contraindications for the stimulant except to caution parents regarding their children's combining methylphenidate with clonidine and recommending that there should at some point be "reevaluation" to ascertain whether "stimulant treatment is still indicated." There is no examination in the report of the younger and younger age groups diagnosed with ADD/ADHD and treated with Ritalin.

Added to the standard concerns regarding a lifelong stigma of a psychiatric diagnosis and the introduction of drags and the drag culture into the lives of so many children is this significant one: Ritalin specifically carries a warning proscribing use of the drag for children under six.

The Food and Drug Administration announced in 2000 that it will design studies to provide safe and accurate pediatric dosage information for labeling on drags that are used for children, and the National Institute of Mental Health indicated that it will subsidize studies to determine the safety of "psychotropic medication" on preschoolers who have been diagnosed with ADD or ADHD. This is a laudable, if tardy, start to protect our youngest citizens, but, as The New York Times argued in a March, 2000, editorial, these efforts will not confront the problems of indiscriminate diagnosing and treatment of ADD/ ADHD in children.

The question always remains, "What is to be done with unruly or misbehaving children," the largest portion of those labeled as having ADHD. Lawrence Diller, who practices behavioral pediatrics in California, articulated the frustration of many within and without the mental health field in an op-ed piece in The Washington Post [Feb. 2, 2000]. He pointed out that many parents are at the far end of frustration as a large portion of these kids have "extremely tense or chaotic family lives." Moreover, "the absence of any definitive research on the value and safety of psychiatric drugs for children is compounded by the minimal efforts made to address the environment these children are placed in."

Perhaps the most frightening developments are the impending trials at six sites, including Johns Hopkins University, in a study of preschool ADHD treatment of the effects of Ritalin on about 200 children from three to six years of age. It is hard to determine whether it is more shocking that, without testing, youngsters are given such serious drugs in early years of neurological development or that such testing on these children is beginning. Thus, we have the headline in the Jan. 2, 2001, Washington Post "Health" Magazine: "Scandal! They Haven't Tested Ritalin on the Children It's Prescribed for!; Scandal! They're Going to Test Ritalin on the Children It's Prescribed for!"

The difficulties in finding a panacea for entrenched, maladaptive behavior in children do not provide sufficient justification for plunging into a nationwide pharmacopoeia for solutions. As Diller concluded, "I'm not against using medication in children. I just believe in the rule: first do no harm."

Richard E. Vatz, Associate Psychology Editor of USA Today, is professor of rhetoric and communication, Towson (Md.) University.

Lee S. Weinberg, Associate Psychology Editor of USA Today, is an associate professor in the Graduate School of Public and International Affairs, University of Pittsburgh (Pa.).
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Title Annotation:attention deficit disorder, attention deficit-hyperactivity disorder
Publication:USA Today (Magazine)
Geographic Code:1USA
Date:Mar 1, 2001
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