Saving Normal

Mental health and what is normal.

How Parents Can Protect Kids From the ADHD Epidemic

Advice from the master

Keith Conners can be considered the father of ADHD. He did the early studies, helped work out the definition, developed the most widely used diagnostic tools, and did research that led to treatment guidelines. He knows as much about ADHD as anyone on the planet.

In a recent great New York Times article, Keith shared his deep misgivings that ADHD is now being wildly overdiagnosed and inappropriately treated with excessive medication.

This false epidemic of ADHD was triggered by three events that occurred almost simultaneously about 15 years ago.

1. Drug companies used their political mucle to gain the unprecedented right to advertise directly to consumers—and then used misleading marketing to convince parents and teachers that ADHD was everywhere.

2. They brought to market new and expensive drugs for ADHD.

3. A multi-center NIMH study gave the impression that drugs were much more effective than therapy and drugs for ADHD (a finding that didn't hold up on follow up).

Drug companies were given the means, the motive, and the message to disease-monger ADHD and blow it up out of all proportion. They succeded beyond all expectations in achieving a triumph of clever advertising over common sense. Rates of ADHD have tripled and drug company revenues have multiplied by a factor of twenty—now approaching an astounding ten billion dollars per year.

Fortunately, the press and the public are beginning to catch on. And luckily, we have the master to provide advice to parents on how to protect their kids from all this unneeded medication. Keith writes:

"Parents and teachers are understandably confused about the latest flaps around the diagnosis and prevalence of ADHD. On one hand, they hear that more than 10% of all kids (and almost 20% of teenage boys) have ADHD. On the other, skeptics say it does not exist at all or is simply the naughtiness of ordinary childhood.

Both extremes are wrong. The high numbers do not reflect clinically meaningful ADHD. But the idea that ADHD should never be diagnosed and treated misses the clinical reality that some kids have an early onset of severely impairing symptoms that do require diagnosis and do respond well to treatment.

The ridiculous epidemic-like level is most surely a mistaken exaggeration caused by careless neglect of differential diagnosis. Doctors are prescribing stimulant drugs for a hodgepodge of childhood disorders and for basically normal kids who happen to be on the active and distractable side of the spectrum.

What is the true rate? You can't find it using the usual broad brush phone survey methods used in large scale national studies—these capture many false positive cases and provide no more than a screening upper limit.

An accurate assessment of ADHD requires comprehensive and repeated interviews of the kid and parents; gathering information from teachers; a differential diagnosis that also considers comorbid conditions; and an evaluation of whether the symptoms and behaviors are severe and persitent enough to be considered clinically significant—and much more.

The results of a study done with this rigor were startling. The true prevalence of ADHD appears to be between 2-3%, and most of the cases being treated with stimulant drugs failed to meet DSM diagnostic criteria. Stimulant drugs were both over-prescribed (given to children not meeting DSM criteria) and under-prescribed (not given to children who met rigorous DSM criteria). Many of the children who were treated as if they had ADHD instead met criteria for Oppositional Defiant Disorder, a condition well-treated by behavioral and parent training methods—not stimulant drugs.

What, therefore, should the public conclude about the “diagnosis” of ADHD?

First, there is no doubt that 2% or 3% of children and adolescents suffer from a serious and treatable disorder, for whom medication or CBT or both is required to avoid the serious lifetime impairments.

Second, no child should be diagnosed with ADHD without a thorough clinical assessment that includes self-report by the child or adolescent, a family psychiatric history, and developmental history of the child. Reports from teachers are essential and represent one of the most neglected sources of information in ordinary pediatric practice. Treatment almost always requires working together on school-related problems.

Third, it is apparent that the DSMs are part of the diagnostic problem, providing definitions that are too loose and insufficient guidance to the practitioner on how to make a proper diagnosis.

Finally, the public should be skeptical both of the diagnostic enthusiasts who see ADHD everywhere and the diagnostic nihilists who see it nowhere.

What should parents do when they suspect their child may need treatment?

First, remember that most medication is prescribed by pediatricians, and these days many do not specialize in developmental behavior problems. Those who do have a specialty are more likely to have the time and experience to recognize and treat real ADHD. They will give advice on other therapies in addition to medication.

Even some specialists (like child psychiatrists or child psychologists) lack the background or training for ADHD or may have biases that fail to account for the particular needs of the child. So don’t hesitate to check credentials and look for those who have a record of extensive care of ADHD. Ask what tests or procedures are being used to identify ADHD, and do not accept cursory, brief examinations that do not involve a complete picture of family environment, school, and development from an early age.

Although medication can sometimes provide dramatic initial relief from a serious situation, additional help with school, peer, and home problems is almost always needed.

ADHD can be a frequently changing, up-and-down experience for a child and family. Make sure that your doctor or therapist follows the situation regularly, and adjusts the treatment as needed in order to maintain gains or deal with new problems as they arise. This applies to both medication dosage and behavioral or cognitive treatments.

Parents need to understand that severe, chronic ADHD can be a mind-numbing experience that can wear any family out—never accept a neighbor’s view that you are the cause of the problem. To avoid burnout, get all the help and support and once in a while try to take a vacation away from the stress of raising a lovable but difficult ADHD child.

If you are wondering whether your child has ADHD, The National Resource Center has trained staff to answer your questions at 1-800-233-4050. For help in your area, contact the National Dissemination Center for Children with Disabilities by logging on to http://www.nichcy.org/ or calling 1-800-695-0285. These sources can also put you in touch with CHADD, a national organization of parents of ADHD which is likely to have meetings in your area and will supply all of the literature you need to understand the facts about ADHD.

If your child is already being treated with medication, but still has significant handicaps in dealing with peers, with school adjustment and learning, or with dealing with problems within the family, it may be time to seek out additional help. Ask yourself these questions:

Is the medication being checked and adjusted frequently for necessity and adverse reactions? Have you received help on specific methods for homework and in-class school behavior? Does your child receive help in social skills and peer behavior? Does your physician seek out reports from school teachers as well as from you?

If any of these answers are “no,” then you should discuss these issues with your physician, and if not satisfied with the answers, consider getting second or third opinions.

Finally, as your child moves towards adolescence or young adulthood, many additional issues will have to be faced, so adjustments in a treatment plan will surely be needed. As many as half of children with ADHD continue with significant problems in learning, work, or social problems as they move to young adulthood and need continued treatment. But adolescents and young adults are also the group where over-medicating is most common. Careful re-evaluation for your child may be required. New forms of help in school or college or the workplace, as well as alertness to possible over-medication, will be mandatory. Be mindful that drug companies are now directing their misleading, high pressure sales pitch to the adult ADHD market."

Wow, what great advice. Thanks so much, Keith. Just a couple of closing thoughts: Parents need to be super informed and should feel free to ask lots of questions and expect clear answers. Treatment shouldnt be started casually or stopped casually. Get lots of advice both ways

And wouldn't it be nice if we stopped wasting billions of dollars on unnecessary drugs and instead paid for smaller class sizes and more gym teachers.

Allen Frances, M.D., was chair of the DSM-IV Task Force and is currently professor emeritus at Duke.

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