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ADHD U.S.A. - Is Rise in ADHD Treatment Truly Justified?

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Monday, November 18, 2013
pic of ADHD stop sign

Ask anyone about what they think about Attention Deficit Hyperactivity Disorder, or ADHD, and you are likely to elicit a variety of opinions. In my office, I have heard everything from “ADHD is a scam” to “but doctor, my son MUST have ADHD – the saliva test I sent to Dr so-and-so in Arizona proves it!” Of course these are not actual quotes from parents but my colleagues and I have experienced very similar reactions when attempting to discuss this topic. And no, there is no FDA-approved saliva test for ADHD. Sorry!

Contrary to popular belief, ADHD is anything but a simple disorder that is "fixed" with a pill. Rather, ADHD is a complex, neuropsychiatric disorder of the brain and its diagnosis is poorly understood not only by the public but also by trained medical professionals. Just how many kids are currently diagnosed with ADHD? The short answer is that this number is a moving target and appears to be steadily increasing, at least according to the Centers for Disease Control, or CDC. When I was in medical school, I was taught that ADHD affects between 3% and 5% of children. However, a 2007 CDC article titled ADHD Throughout the Years demonstrates a clear increase in reported cases of ADHD. In fact, the CDC even produced this map of ADHD rates across the United States, with some states reporting rates of ADHD above 15%. More recent articles, including this 2013 Time Magazine article, suggest the current average rate of ADHD is 11%, a 300% to 400% increase compared to what I was taught in medical school (and, ahem, I'm not all that old!)

So why are the reported rates of ADHD climbing at such a rapid pace? The short answer is that nobody is completely sure. Having said this, the CDC article cited above reports: 

It is not possible to tell whether this increase [in the rate of ADHD] represents a change in the number of children who have ADHD, or a change in the number of children who were diagnosed. Perhaps related, the number of FDA-approved ADHD medications increased noticeably since the 1990s, after the introduction of long-acting formulations.

I take little comfort in the fact that the CDC appears to suggest that ADHD rates have dramatically increased as a result of expensive new medications being brought to market. In fact, one of the biggest mistakes I see healthcare practitioners make is to diagnose ADHD by treating a child with a stimulant medication to see if the child’s focus and attention improve. This approach to diagnosing ADHD is fundamentally flawed, as many studies have shown that taking amphetamines by anyone, with or without ADHD, will improve one's ability to focus and maintain attention. Along these lines, the NBC news article 'Go Pills:' A War on Drugs by Jon Bonné shows how pilots used to be given amphetamines to help them focus during missions. The Time Magazine article Faking it: Why Nearly 1 in 4 Adults Who Seek Treatment Don't Have ADHD speaks for itself. 

Unfortunately, the notion of ADHD medications as performance enhancing brain drugs has really caught on. Increasing evidence is coming out that amphetamines and other ADHD drugs are being widely abused by college students to help "cram" for tests, as highlighted by Alan Schwarz's 2013 New York Times article Drowned in a Sea of Prescriptions. In his article, Mr. Schwarz made the point that the prescribing of ADHD stimulant drugs to college-age adults has doubled in the past four years. Can these medications help students' raise their test scores? Perhaps. But this is no different than athletes taking steroids or blood-doping to enhance their performance on game day, in my opinion.

So what is the proper way to diagnosis ADHD? So-called rating scales are one commonly used approach. These scales are simply questionnaires filled out by parents, teachers, and sometimes patients themselves. Although these ADHD rating scales may provide useful information, they are easily exaggerated or even altogether faked, as highlighted in the article Detection of Feigned ADHD in College Students, co-authored by my esteemed colleague Dr. John Ranseen. Unfortunately, in my experience these ADHD rating scales that are so easily faked are all too often used as the sole basis for an ADHD diagnosis.

I hope it is clear that we have a problem on our hands regarding ADHD misdiagnosis and, based on the rising numbers of ADHD prescriptions written, dare I say an over-diagnosis of this complex neuropsychiatric disorder. In my opinion, a true 360-degree approach is the only way to consistently and reliably make an accurate diagnosis of ADHD. I believe rating scales do have a place in diagnosing ADHD, but alone such rating scales are woefully inadequate. Rather, these scales should be given in concert with other, more objective diagnostic tools as part of a full evaluation. Examples of such methods include direct classroom observation by a mental health specialist as well as utilizing the FDA cleared Quotient® ADHD testing system, which is reported to be over 90% accurate in diagnosing ADHD even without other measures such as classroom observation and behavioral rating scales.  Another advantage of this testing system is that a pilot study published in September, 2013 indicates this test is very good at detecting ADHD fakers.

In summary, my 360 team and I see an alarming trend in the increased diagnosis of ADHD as well as abuse of ADHD medications as performance enhancing agents for students seeking to gain an advantage in the classroom or even abusing it to get 'high'. I believe that if physicians and mental health providers adopt a more holistic approach to diagnosing ADHD rather than simply relying on self-report or responses to questionnaires, then and only then will we see a reversal in this disturbing trend.

-Dr. Tim