Widening the definition of attention deficit hyperactivity disorder (ADHD) has led to an overdiagnosis of the condition, causing many people, especially children, to receive needless and potentially harmful medical treatment, according to a research analysis published online Wednesday in the journal BMJ (British Medical Journal).
The expansion of the definition of the disorder also threatens to create a skepticism about ADHD diagnoses that may harm people who have severe cases and “who unquestionably need sensitive, skilled specialist help and support,” warn the Australian and Dutch authors of the analysis.
ADHD is a disorder characterized by severe and frequent episodes of inattention hyperactivity or impulsivity. It’s most commonly diagnosed in early childhood, but can continue through adolescence and into adulthood.
Earlier this year, the Centers for Disease Control and Prevention reported that 6.4 million U.S. children between the ages of 4 and 17 — or about 11 percent of all school-aged children in the country — had received a diagnosis of ADHD. Those statistics stunned many health professionals. The rate of ADHD had been previously estimated at 3 to 7 percent of all children.
Some of that rise may be due to clinicians becoming better at recognizing and diagnosing ADHD, acknowledge the authors of the BMJ paper. But research shows, they quickly add, that 86 percent of children diagnosed with ADHD in the United States have “mild” or “moderate” forms of the disorder. Less than 14 percent have severe ADHD.
“Severe cases of ADHD are obvious, but in mild and moderate cases — which constitute the bulk of all ADHD diagnoses — subjective opinions of clinicians differ,” the authors point out.
Evidence of this subjectivity — and how it can lead to overdiagnosis — can be seen in the unsettling finding that children whose birthdays fall in the latter part of the school year (who are, therefore, younger than many of their peers) are more likely to be diagnosed with ADHD than children born earlier in the year.
Unwanted side effects
In the United States, about 87 percent of children diagnosed with ADHD are prescribed a medication, mostly methylphenidates (such as Ritalin) and amphetamines (such as Adderall). Yet, as the authors of the BMJ paper point out, these drugs were developed for the treatment of severe, not mild or moderate, symptoms.
ADHD drugs are linked to serious side effects, including liver toxicity, weight loss, sleep problems, mood swings, and even thoughts of suicide. They can also interfere with growth.
In addition, children who are diagnosed with ADHD are at greater risk of being stigmatized and socially excluded. “Teacher and parent expectations of academic achievements are also low,” the authors of the BMJ paper note, “and these are associated with actual lower achievement scores.”
A loosening of diagnostic criteria
An important contributor to the expanding definition of ADHD — and the subsequent rise in the prevalence of the condition — has been the Diagnostic and Statistical Manual of Mental Disorders (DSM), sometimes referred to as the “bible” of psychiatry. With each new edition, the DSM has loosened its criteria for ADHD, leading to a subsequent jump in the number of children who receive a diagnosis.
The latest edition — DSM-5, which was released earlier this year — is no exception to this trend. It has widened the definition of ADHD in several ways, by including, for example, more behaviors that qualify as symptoms and by increasing the maximum age of the onset of symptoms from 7 to 12 years.
“These changes are a cause for concern because they increase the risk of confusing ADHD with normal development processes, such as pubertal restlessness and distractibility,” write the authors of the BMJ paper.
Other researchers have estimated that the prevalence of ADHD will rise more than 15 percent as a result of the diagnostic changes in the DSM-5.
Financial conflicts
Some 78 percent of the medical experts who participated in developing the DSM-5 guidelines for ADHD and other disruptive behavior disorders had financial conflicts of interest through ties to the pharmaceutical industry, report the authors of the BMJ paper.
“Whether this affected decisions regarding changes to ADHD criteria is unknown,” they add.
It’s been estimated that between $320 and $500 million is spent annually in the U.S. on medications for people inappropriately diagnosed with ADHD.
Answers remain elusive
“Despite extensive research into factors contributing to ADHD etiology, we are no closer to understanding the cause or causes of this disorder,” conclude the BMJ authors. “Social factors such as political environment, education funding, and disability services may contribute to seeking a diagnosis of ADHD and are under-researched.”
Until the causes of the disorder are more fully understood, the authors of the paper call for clinicians to use a six-step approach to diagnosing and treating the disease — an approach that refers children to a developmental pediatrician or psychiatrist for medications only after all other diagnostic possibilities and treatment options have been exhausted.
The paper can be downloaded and read at the BMJ website. Its authors are Rae Thomas, a senior research fellow at Bond University in Queensland, Australia; Dr. Geoffrey Mitchell, a professor of general practice and palliative care at the University of Queensland; and Laura Batstra, a psychologist and researcher at the University of Groningen in the Netherlands.
Yes, this has happened before
Unfortunately we’ve seen stuff like this before. These are psychiatric fads that come and go but in the three decades they’ve gone from being fodder for Woody Allen to being downright harmful.
You see these fads starting with Borderline and Multiple Personality Disorders (Dissociative Disorders) and working their way through ADHD and Autism beginning in the 80s. They all have certain things in common:
1) Pure behavioral diagnostics. There are no physical diagnostics i.e. blood work, DNA, or scans of any kind. You have this disorder because someone says you do and here’s no way to rule it out.
2) The primary source of diagnosis is self appointed “experts” in the field. There are no criteria for expertise, it’s self accredited and self sustaining. The more expertise the practitioner claims, the more diagnosis they make, and the more diagnosis they make the more expertise they claim.
3) Near epidemic explosions in frequency. These disorders go from being rare to being unbelievably common. This circles back to the expertise issue, at first only “experts” can can make the diagnosis that everyone else has been “missing” all along. As the expertise achieves popularity more and more practitioners start claiming expertise.
4) There is a definite social component. For some reason the patients or the families actively seek out the diagnosis. This creates and sustains the epidemic because a feedback loop develops between those seeking diagnosis and the “experts” providing it.
5) Battles over terminology. The vague nature of the disorders and lack of any physical diagnostic instruments create a reliance on “experts” who in turn start broadening criteria. This leads to rapid changes in diagnostic criteria and categories. Dissociative Identity Disorder for instance went from Dual Personality to Multiple Personality to DID to Dissociative Disorders within 10 to 15 years, every new version of the DSM had new terminology. ADHD started out as Hyperactivity. The diagnostic criteria for Autism and changed dramatically since it was first recognized in DSM II.
ADHD was always troubling because the treatment was to dump very powerful medications into childrens brains and bodies at a time when they were in critical stages of development. The very nature of human drug research actually prevented any kind of drug trials with children so these medications, the doses, and the effects were all guesstimates at best with absolutely no medical data. The demand for diagnosis AND treatment from parents and educators was overwhelming.
We know how to recognize these fads when they emerge. The problem is that the consumerism that underlies our entire society makes intervention almost impossible. Once that feedback loop between consumer demand and the expertise to meet that demand hits a critical mass there’s no stopping it.
The other problem is our lack of affordable health care and safety nets for troubled adults and children. In many cases these diagnosis become the only gateway to necessary assistance for individuals and families. Without a diagnosis you can’t help. In this way the fad serves two functions, on one hand it’s self propagating and sustaining, while on the other hand it serves an legitimate function of providing a gateway to services otherwise not available.
ADHD
At least two comments:
1) The DSM was originally formulated to allow researchers to begin to group patients in relatively homogeneous groups to allow studies, both behavioral and biological, to focus on similar subjects. Unfortunately, the biological progress has been slow.
More recently, the expansion and modification of diagnostic categories has been driven, it seems, to allow practitioners to be paid for an increasing population of “patients.”
The influence of Big Pharma not only contributes to these changes but also reduces the value of diagnostic labels for meaningful research.
2) There ARE objective tests for ADHD that have been standardized and validated on large populations of children with adequate controls. They also allow measurement of treatment response.
The original DSM and Tests
I’d say by the mid-80s the DSM was established as a billing code vehicle as well as a grant application gate-keeper. Insurance companies would not pay for treatment of disorders not recognized in the DSM. It’s very hard to get grants, almost impossible to get NIH grants, to study a disorder that’s not in the DSM.
I think the financial structure of our health care system pushed the DSM in a different direction here in the US while the ICD seemed to fair better according to the original intent in Europe.
Lawrence, what tests are you referring to?
Any comment from the researchers on UNDER-diagnosis in girls, which is a real phenomenon?
Dangers of medicating a child with ADHD
After reading this article, the question I keep having is what the actual benefits of a child being put on ADHD medication would be. What is the point when there are so many negative aspects that in fact, might even over power the positives and benefits. Children might struggle with focusing/paying attention in school, but to put a child on medication that could harm the child in the present or future is horrible. ADHD medication should be banned from being prescribed to children, especially knowing that ADHD is often misdiagnosed or exaggerated. It is alarming to hear that a child can in the future experience: liver toxicity, weight loss, have sleep problems, mood swings, and even thoughts of suicide just from a medication that is only to help them focus and help change some of their impulsive tendencies. Although parents need to weigh the options and think of the pros and cons, it is a better idea to help children through therapy or other types of safe treatment. It is truly upsetting that the United states spends an insane amount of money per year on ADHD medication, even though it is either being overly diagnosed, and or dangerous. Our country could be spending that money on treatment for illnesses that people are dying from. To sum up, ADHD medication should not be consumed by children as there are many harmful effects it can play in the end.