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A CRITIQUE of attention deficit hyperactivity disorder saying the disorder is overdiagnosed and overtreated has polarised Australian specialists.
The analysis by two Australian doctors and a Dutch colleague, published in the BMJ and subtitled “Are we helping or harming?”, said Australian data on prescribing rates for ADHD medication showed an increase of 72.9% between 2000 and 2011. (1)
The authors wrote that there were no definitions for mild or moderate ADHD in the latest Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and a broadening of the diagnostic criteria in the manual was likely to increase overdiagnosis.
“We argue that the overdiagnosis of ADHD resides within the clinical subjectivity of impairment”, they wrote.
The broadening of the diagnostic criteria in DSM-5 “risks resulting in a diagnosis of ADHD being regarded with scepticism to the harm of those with severe problems who unquestionably need sensitive, skilled specialist help and support”.
Dr Daryl Efron, paediatrician at the Royal Childrens Hospital and senior research fellow at Murdoch Childrens Research Institute in Melbourne, said the authors provided no supporting evidence that ADHD was overdiagnosed.
He told MJA InSight the best recent Australian data suggested that nationally about 1% of boys and 0.5% of girls were on medications for ADHD, compared to a prevalence of about 5%. (2)
He said data from his group showed that 81% of children diagnosed with ADHD by paediatricians, the main doctors who managed the condition, were treated with medications.
“Many would argue that it’s good that more kids are accessing diagnosis and effective treatment leading to improved function”, Dr Efron said. However, there should never be a rush to either diagnose ADHD or to begin medication, he said.
The BMJ analysis canvassed a range of issues from criteria for ADHD, drivers of overdiagnosis including shifting definitions and commercial influence, and the effectiveness of treatment.
It outlined potential harms of overdiagnosis, including medication costs, adverse events and psychological harms, and suggested a stepped diagnostic and care approach.
Professor Jon Jureidini, professor of psychiatry at the University of Adelaide, told MJA InSight he did not think making a diagnosis of ADHD was a helpful exercise.
It was more helpful to meet the family to find a better explanation for the problem, whether it was a language disorder, or marital disharmony, or deafness, and then treat that problem rather than diagnose ADHD, Professor Jureidini said.
“There is no doubt that you can reliably identify kids who are overactive, inattentive and impulsive but that is a final common pathway of many different sets of circumstances”, he said.
“There is always a more compelling and more treatable explanation than dumbing down the understanding by calling it ADHD.”
Professor Jureidini, coauthor of the NHMRC Clinical Practice Points on the Diagnosis, Assessment and Management of ADHD in Children and Adolescents, said stepped diagnosis and care was an excellent approach to mental health in children and adolescents in general. (3)
However, Associate Professor Michael Kohn, of the department of adolescent medicine at the Children’s Hospital, Westmead, who also coauthored the NHMRC clinical practice points, said the BMJ analysis was biased and the authors had not presented primary evidence to substantiate their concerns about diagnosis or recommendation for the effectiveness of a stepped care approach.
“ADHD is not overdiagnosed and overtreated in Australia”, he said. “The DSM criteria robustly identify those behaviours predictive of impairment.”
He told MJA InSight the analysis did not include studies comparing clinician rating with objective measures, which were important in considering the reliability of specialist and primary care physicians to accurately diagnose ADHD.
Dr Brad Jongeling, paediatric head of department in the WA Child Development Service and a consultant general and developmental paediatrician, said the BMJ authors’ premise that the DSM-5 change had resulted in a broadening of the diagnosis and carried the risk of increased diagnosis was debatable.
Dr Jongeling said the recommendation of a conservative approach to ADHD was not unreasonable in preschool children and mild impairment cases but moderate and severe impairment “presents a different story”.
He said most parents had already waited 2‒4 years following their initial concern about symptomatology before seeking diagnosis. Further waiting might increase impairment to psychosocial, behavioural, developmental health and emotional function, which medication combined with behavioural treatment might help.
1. BMJ 2013; Online 5 November
2. Aust NZ J Psych 2011; 45: 332-336
3. NHMRC 2013; Clinical Practice Points on the Diagnosis, Assessment and Management of ADHD
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The fact in the second paragraph of the article that the Australian data on prescribing medication for ADHD increased 72.9% between 2000 and 2011 remains undisputed by anyone so far.
What was the population increase during those 11 years ? Far less.
Ritalin, prescribed since 1960, has had adverse effects reported including psychosis . Effects on the developing brain have been questioned .University students request the drug to improve performance . There are reports of the drug being sold to users to inject . Issues of lack of informed consent, lack of information on side-effects , misdiagnosis, and coercive use by schools have been raised.
Another undisputed fact is that using DSM criteria leads to higher rate of diagnosis of ADHD than the ICD-10 criteris for “hyperkinetic disorders”.
What was that Hippocratic oath?
As a general Paediatrician dispensing stimulants to selective children over 3 decades, I would have seen a fair spectrum of behaviours in children. I’ve also attended national and international conferences and tried to imbibe the experience of experts – medical and non-medical – with lives devoted to the question of ADHD. I’m cautious about dose, and proceed carefully. There is no doubt that remarkable turn-arounds in children’s lives occur when they’re are accurately diagnosed and treated. I always wait until serious self-esteem problems are looming in such children; and carefully monitor closely in the first weeks. It certainly isn’t easy for boys with this condition in a female-dominated workplace; but I”ve dealt with excellent female teachers. (One comes to mind, who knew the rules of any sport, and could handle any number of restless boys with a ball in her hand, and a whistle in her mouth: and had done 2 years of Police training before she took up teaching!!). 19 out of 20 adolescents seem to advance to a situation where they don’t need pharmacologic treatment any more; and I strongly suspect this relates to adolescent brain maturation advancing frontal lobe executive function……and hopefully on my watch, is supported by a childhood devoted to habits of vigorous structured physical outlet which continues into adult life.
I agree with Dr. Michael Gliksman that the natural exuberance of boys ( and I add some girls) is a source of inconvenience in a feminised ( and I add a an ineffectual, narrow ) education system, where natural therapies of sport and music and agricultural and mechanical education are too much effort for the teachers sitting on their seats-these teachers prefer to blame the students desire for activity rather blaming the teachers natural tendency to inertia. Perhaps we could treat the teachers with speed to get them up to speed .
ADHD is real, can destroy lives and disrupt families, and yes, can be helped by medication. The vast majority of experts and guidelines reflect this position. The treatment rate using medication of 0.5-1% on a prevalence rate of 5% suggests it is not overtreated, and the recent increase in prescribing rates reflect more that we are getting ‘less bad’ at missing it.
When you talk to real families like Dr J’s and Realworld above who are dealing with this issue (like I do regularly as a GP with a special interest in behavioural / developmental paeds) and can see what positive effect a diagnosis and treatment can bring you can only get very frustrated with the Ritalin bashers screeching ‘we are drugging our kids!’
I am amazed that only one medical practitioner, Dr Jon Jureidini, is ever regularly quoted as the expert on the subject of ADHD throughout the Lifespan.
After travelling to over five Medical Conferences on ADHD over the past three years ( Euthynidis Barcelona, 3rd World Congress in ADHD Milan ,CHADD- Orlando,SanFrancisco and Washington DC and CADDRA Montreal ) one finds virtually no appropriately qualified Australian ADHD experts in attendance. Are there any? Maybe Australia and New Zealand does not ‘have “ADHD throughout the Lifespan”? I think not.
After a brief discussion with Professor Russell Barkley at CHADD San Francisco 2012 , Professor Barkley allowed me to quote him, thus:-
“Philosophically, one could make a case that given the body of evidence of more than ten thousand articles with two thousand of those published just in the past five years, that anyone within a mental health profession who failed to recognise ADHD would be negligent”.
Hope the medical professional indemnity insurers and the government purveyors of justice are keeping a very close eye on this quote!
David Nolte , Consultant Pharmacist Practitioner in Sleep Health and ADHD throughout the Lifespan.
ADHD is attracting the wealth of criticism that other psychiatric diagnoses have in the past, prior to the public at large gaining insight into the pervasively detrimental impact of such illnesses on an individual’s global functioning, and their significant others. Stigmatisation is rife within the medical profession itself. We need to approach ADHD and the developmental disorders with objectivity, permitting ourselves an opportunity to achieve greater diagnostic accuracy, and better treatment outcomes. Consider the scorn that was exerted by the medical profession on our pioneers of the past (Helicobacter Pylori research comes to mind). We need to destigmatise ADHD, and sharpen our own skills. Dr Jongeling’s approach is noted, and we thus require ongoing research supporting accurate diagnosis, identifying specific functional deficits and behavioural problems, and supporting these individuals with targeted interventions. Broad brushstrokes, stigma and dogma do not serve these patients well.
My wife and I are parents of a very active and bright 10 year old ADHD boy. We have seen doctors, gps, counsellors, psychologists, family therapists, dealing with our boy for 5-6 years . We are participating in a international study out of Westmead Children’s hospital led by Professor Simon Clarke.
Dr J above is correct. He and his child, like myself and my child, are immersed in the ADHD “spectrum”. I say this because I am convinced ADHD cases also present blooms of other disorders, such as obsessive compulsive disorder, narcissim, depression, rage, anxiety, jealousy, impulsivity, and the list goes on.
Labelling conditions, and the repsonses we provide, has positive and negative impacts. A natural consequence is it creates a tractor beam for supporters and critics driving their own agendas, unfortunately these agendas are rarely based on a sound readings of all the evidence.
ADHD might be over diagnosed. It might be a wiley scheme of Big Pharma, Big Psych and Bad Parents, which is why more evidence based reseach is needed and why my family acitively participates in research. Suggesting ADHD is a myth or is over prescribed dismsses considerable evidence based research and denigrates practitioners, parents and the problem.
The condition is real as is our situation. The greatest progress we have made in helping our child has been with the assistance of low dose medication and regular psychological sessions.
I prefer and ADHD needs evidence over generalisations and accusations
In Europe ADHD is rarely diagnosed. Children are seen as easy or difficult. Here labelling and medicating children has become a growth industry. It also covers up for a flawed education system which does not teach phonetics leaving many students (especially boys) bored and prone to acting up.
Thanks Dr Jureidini – I see it is all my fault.
Well our family dynamics were just fine until #1 came along. Unfortunately he is just like I was at 5 yrs old – the most difficult child any of the paeds/psychologists/child care etc etc had ever seen. My mother loves it – now I have to go through what she went through.
But I see it is not genetic…..I just have the same parental inabilities my parents had (dont worry we checked his ears – I am an ENT surgeon). Unfortunately all the parenting courses, psychologist, paeds, paed pych’s have the same deficiencies – because they did not help talk him out of it.
It is not just a normal boy exuberence. It is that x10. He has zero abnormal behaviour. But just too much of a good thing
Yes it took years to decide to take medication. It is not a cure or solution. But he gets to go to school (with a full time helper – the shool needs, it not him, he tests at the 98 percentile).
So Dr Jureidini you can have him for a week – see if you can “sort him out”. Everyone thinks they can… untill they try.
40yr ago I di not get any medication, just a good belting. I ended up a surgeon. Maybe that explains it.
This article begins badly. To say that it has polarises Australian specialists is to elevate the problem by inferring that it is being argued from a point of being well informed
There are some salient points which have been ignored. The first is the general assumption that children “grow out” of ADHD as they mature. This has not been put to the test in any meaningful way except to show that the presentation of ADHD symptoms in adults differs from that of children. Circumstantial evidence may point to the veracity of this assertion but quantification is not there!
See Sawyer, 2000 for baseline data to which, in Australia, constant reference is made; see Das et al http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0031500 for current data for adults. In statistical terms , they would not appear to be in disagreement.
While the authors of the critique can find no definitions for mild or moderate ADHD, there is much circumstantial evidence to suggest that in terms of Quality of Life and Burden of Disease, these terms may have little relevance as ADHD appears, not to be so much a debilitating disorder in itself, as to be a catalyst for adverse responses under stress. Studies in addictive behaviours, poor driving behaviour, financial mismanagement etc, all point to an underlying problem of untreated ADHD as being of critical importance. They are therefore correct in calling upon the issue of clinical subjectivity. In such case, they must then critically evaluate the results of failure to treat children as evidenced by the flow-on effects in adulthood. Maybe our Jails may not have so many ADHD inmates if this recognition were to occur.
Where are we at in diagnosing the ‘Why’? And if you say it is because we have a better diagnosing system – then I might suggest that many people managed to sort themselves out by the time they get older without needing help. Please read the two links below to add to our thinking. Dr. Leon Eisenberg, was prominent figure in the field of child psychiatry. As described by the British Medical Journal, Dr. Eisenberg ‘tranformed child psychiatry by advocating research into developmental problems”. Eisenberg said. “The genetic predisposition to ADHD is completely overrated.” Instead, child psychiatrists should more thoroughly determine the psychological reasons that can lead to behavioral problems, Eisenberg said, adding with a sigh: “Prescribe a pill for it very quickly.” On a related note, in August 2012 Der Spiegel, Harvard psychologist Dr. Jerome Kaganwas was critical of “fuzzy diagnostic practices” and the over-prescription of drugs such as Ritalin for behavioral problems in children, 90% of diagnosed ADHD kids don’t have an abnormal dopamine metabolism. In the 1960s, mental disorders were virtually unknown among children. Today, official sources claim that one child in eight in the United States is mentally ill. Kagan said; “Let’s go back 50 years. We have a 7-year-old child who is bored in school and disrupts classes. Back then, he was called lazy. Today, he is said to suffer from ADHD”. That’s why the numbers have soared.
http://www.snopes.com/politics/quotes/adhd.asp
http://www.spiegel.de/international/world/child-psychologist-jerome-kaga…
The natural exuberance of boys is a source of inconvenience in a feminised educational setting and of difficulty in a world where both parents work. Is the gender imbalance in diagnosis and ‘treatment’ of ADHD little more than the medicalisation of misandrist notions of ‘normal’? (I can feel an article coming on…).
As a Psychiatrist I have long been concerned about the overdiagnosis of ADHD. The condition does exist but it is far less common than current diagnosis trends imply due to diagnosis being based on the symptoms without regard to the note in DSM-IV requiring the exclusion of other causes of the same symptoms. However, having worked in a couple of public Child & Adolescent Psychiatry units recently, I am also concerned that in the public system there is an equally important over-focus on family dynamics and family therapy, so that genuine cases of ADHD, early onset Bipolar Disorder, and Major Depression, are being missed. This is partly because the few Psychiatrists only see the cases the less expensive Case Workers – Nurses, Psychologists , and Social Workers – think they need a medical opinion on.
This debate will never advance the cause of helping children in Australia. Rather than focus on yes/no questions like is it overdiagnosed, we should be focusing on how best to help children who have neurodevelopmental disorders. These are disorders that are biologically based, impacting on the development, behaviour and mental health of children.
The public heatlh system does not easily recognise and support these problems, as they are serviced almost entirely in outpatient and community settings. The Not-for-profit sector’s contributions are ad-hoc, whilst the private (Medicare based) systems favour short consultations and reactive care.
I would suggest that how we deliver health services is the major determinant of the mess we are in at the moment, and questions such as these are only distractions. Our new society, Neurodevelopmental and Behavioural Paediatric Society of Australasia, will hopefully address more fundamental issues.