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Child psychiatrist on ADHD: Overdiagnosed, stimulants overprescribed


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Winston Chung, a brilliant young child psychiatrist, debunks the fad for drug treatment of ADHD.


Misperceptions about ADHD

Winston Chung MD September 01 2011


It's back-to-school time again and parents and non-parents alike are calling for treatment of ADHD symptoms.


The CDC recently reported that the percentage of children in the US ever diagnosed with attention deficit hyperactivity disorder (ADHD) increased from 7 percent to 9 percent from 1998-2000 through 2007-2009.



I'm not arguing with the fact that there are individuals who are properly diagnosed with ADHD and receive great benefits from treatment, but I see more children and adults who are misdiagnosed with ADHD and treated with stimulants. Here are some misperceptions about ADHD and stimulant use that I believe contribute to this trend:


  • -There is a gold-standard, highly reproducible screen or test for ADHD.

From flashy brain scans to an hour-long interview, clinicians diagnose ADHD in a number of different ways, but there is no single radiological, blood or psychometric test to definitively diagnose ADHD.


According to the American Academy of Child and Adolescent Psychiatry ADHD Practice Parameter:


The evaluation of the preschooler, child, or adolescent for ADHD should consist of clinical interviews with the parent and patient, obtaining information about the patient's school or day care functioning, evaluation for comorbid psychiatric disorders, and review of the patient's medical, social, and family histories.

I would add formal psychoeducational testing to screen for learning problems or language disorders to the AACAP parameter, but every clinician is different and diagnostic variability may contribute to overdiagnosis and misdiagnosis. Some clinicians claim to diagnose ADHD with costly brain scans, using brilliant images to coax funds from desperate families. Others don't care if you memorize the DSM-IV criteria for ADHD and recite them as your symptoms in a 45-minute interview, they will give you the diagnosis and your stimulant as long as you pay their fee. The variability between clinicians and diagnostic processes may have contributed to results from a study suggesting that almost a million children in America have been misdiagnosed with ADHD.


  • -If one performs better or is a 'different person' on stimulants, she or he must have ADHD.

....We consider the use of performance enhancing drugs in sports to be unethical, so how do we feel about the growing demand for cognitive enhancement in an increasingly competitive world? Is it a coincidence that 5-hour energy, Red Bull, and energy-infused vitamin liquids and teas seem to be ubiquitous?


[see http://www.hatts.ca/adderall-abuse-among-college-students]


The use of stimulants without prescriptions is increasing on college campuses and I have seen several first year law and medical school students who routinely claim to have ADHD symptoms, but stop coming to see me when I offer non-stimulant treatments. Older professors, attempting to fight the cognitive decline that may come with aging, are seeking stimulant treatment. It's one thing to seek out cognitive enhancement and another to have a disruptive, neurobehavioral syndrome like ADHD. Until the use of cognitive enhancers is universally accepted, adults seeking cognitive enhancement will present with symptoms of ADHD, leading to misdiagnosis if symptoms are falsely represented.


  • -There are long-term benefits to treating ADHD with stimulants.

The MTA was the seminal study that set the tone for intensive medication management as the commonly accepted first-line treatment for ADHD. The NIMH summarized results from the 8-year follow-up of the MTA study:


The eight-year follow-up revealed no differences in symptoms or functioning among the youths assigned to the different treatment groups as children. This result suggests that the type or intensity of a one-year treatment for ADHD in childhood does not predict future functioning.


A majority (61.5 percent) of the children who were medicated at the end of the 14-month trial had stopped taking medication by the eight-year follow-up, suggesting that medication treatment may lose appeal with families over time. The reasons for this decline are under investigation, but they nevertheless signal the need for alternative treatments.


Children who were no longer taking medication at the eight-year follow-up were generally functioning as well as children who were still medicated, raising questions about whether medication treatment beyond two years continues to be beneficial or needed by all.


  • -ADHD is a purely biological disorder.

Xavier Catellanos, M.D., is former chief of the ADHD research unit at the NIMH, and is considered an expert when it comes to neuroanatomical correlates associated with ADHD. In a PBS interview, he said, "We don't have an objective way of definitively saying, 'This person has ADHD, or does not,' in part, because we don't really understand what it is."


When asked about how ADHD works on the brain, he replied, "We don't yet know what's going on in ADHD." While Dr. Castellano's lab has made great advancements in elucidating the neurobiology of ADHD, the fact of the matter remains that there is no single biological marker or gene that has been unequivocally linked to ADHD.


I have heard clinicians tell parents that ADHD is a purely biological disorder and I consider saying this as malpractice. According to the aforementioned 8-year follow-up of the MTA study, sociodemographic advantage may mean a better prognosis in children treated for ADHD. I have little doubt that prefrontal cortical and/or dopamine dysfunction contribute to cases of ADHD, but patient presentations are heterogeneous and I'm concerned with casting aside a bio-psycho-social formulation in reducing a person into a bundle of neurons and neurotransmitters.


A danger in perceiving ADHD as purely biological is missing the environmental and family dynamic factors that can lead to a young person having difficulty with attention and behavior. I believe that a biological problem might be more acceptable than considering the possibility that inconsistency or a contentious, shared-custody could contribute to symptoms of ADHD in a child of separation or divorce. Clinicians may prefer to approach the biological domain of a child's condition, rather than increasing their capacity to artfully intervene in challenging family dynamics or emotionally provocative situations. In a study published in the Journal of the American Academy of Child and Adolescent Psychiatry, children's perceptions of marital conflict were independently related to inattention and hyperactivity behaviors as rated by parents and teachers after control of all other risk factors.


Lawrence Diller, M.D., practices behavioral/developmental pediatrics in Walnut Creek, California. His latest book is Remembering Ritalin: A Physician and Generation Rx Reflect on Life and Psychiatric Drugs. Here is an excerpt from his op-ed piece, titled The United States of Adderall:


The U.S. is a signatory to a 1972 United Nations treaty monitoring the production and sale of potentially addicting substances. The U.N.'s International Narcotics Control Board (INCB) based in Vienna, monitors the production of legal stimulants worldwide. INCB data shows that in 2009 the U.S., representing 4 percent of the world's population, produced 88 percent of the world's legal Ritalin type drugs. Canada uses a third per capita of prescription stimulants compared to the U.S. - Germany, one eighth, the U.K. one twelfth, Japan, one fiftieth.


These drug production amounts do not separate child from adult use and clearly there has been a surge in adult ADHD/ADD and their use of stimulants in America in the last decade as well. Still the CDC study marks a continued increase in the diagnosis and use of these drugs in children. Is this a good thing or a bad thing?


This is not medical advice. Discuss any decisions about your medical care with a knowledgeable medical practitioner.

"It has become appallingly obvious that our technology has surpassed our humanity." -- Albert Einstein

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Environmental issues! Kids live in soundbites. We all do. When I was a kid, I knew all of my friends phone numbers, addresses. Now, I wonder how many people could remember an emergency contact number if cell phone unavailable. I believe all of those ways that we used our brains back in the olden days helped shape our ability to concentrate, attention, and to learn more.


Biopsychosocial model?? That has completely disintegrated with USA healthcare system. Docs protect their turf/specialty, no interdisciplinary work unless hospitalized or in facility. And many insurers will not cover anything but 'traditional' (per USA) providers and meds. I got off of pain meds by using acupuncture and chiro. Medicare does not cover acupuncture and cutting back on chiro. I pay for a secondary insurance but they pick up only what Medicare covers first. So, if United was still my primary, I could get acupuncture, massage, more chiro, etc. I'm not old enough for Medigap or supplemental plans.

This sucks. I wish every legislator was forced onto Medicare and a low income.

I'm in a gnarly mood.

Sorry, this belongs in RANTS.

Pristiq tapered over 8 months ending Spring 2011 after 18 years of polydrugging that began w/Zoloft for fatigue/general malaise (not mood). CURRENT: 1mg Klonopin qhs (SSRI bruxism), 75mg trazodone qhs, various hormonesLitigation for 11 years for Work-related injury, settled 2004. Involuntary medical retirement in 2001 (age 39). 2012 - brain MRI showing diffuse, chronic cerebrovascular damage/demyelination possibly vasculitis/cerebritis. Dx w/autoimmune polyendocrine failure.<p>2013 - Dx w/CNS Sjogren's Lupus (FANA antibodies first appeared in 1997 but missed by doc).

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