Childhood psychiatric disorders have become an issue of grave concern, especially in the US. Up till the late 1950s, behavioral problems among children were reported or diagnosed to limited extent and even when they were diagnosed, children were almost never placed on psychiatric medication. However, in the 1960s, doctors began to consider it reasonable to prescribe psycho stimulants such as Ritalin/methylphenidate for ameliorate symptoms with minimal levels brain dysfunction . By 1999, nearly 6% of school age population in the US was diagnosed with ADHD, with 90% of the patients being treated with Ritalin . Today, these symptoms are identified as Attention Deficit Hyperactivity Disorder or ADHD and over 5 to 6 million American children are diagnosed the disorder and prescribed with drug treatment annually . The growing incidence of diagnosis and drug treatment of ADHD has led to calls for an in-depth public and professional review on how the disorder is approached. While over diagnosis is not supported by evidence or research, reports have been growing steadily in several communities. Identifying a more effective method of diagnosis and prescribing psycho stimulants only when necessary can lead to improved care for children suffering from ADHD.
ADHD DIAGNOSIS DEFINED
ADHD is not a common psychological disorder, as is often assumed given its growing incidence today. In fact, the diagnosis of ADHD requires a patient to be, what is known as, a statistical rarity, with a high degree of developmental deviance. In simpler terms, while several children display the symptoms of ADHDH such as hyperactivity, inattention and impulsiveness, a child would need to exhibit these traits in extremity in order to qualify as being a statistical rarity. A child suffering from ADHD would display two standards deviations away from the mean to be diagnosed as having the disorder. If the above mentioned measurements are put in place, it is estimated that about 3% to 5% of children would be afflicted by the disorder. However, this estimate too is considered to be liberal as it does not take into account several other factors that would affect proper diagnosis. For example, the symptoms being exhibited by the child would need to be persistent, pervasive, impairing and not attributed to any other conditions. Should all these factors be taken into consideration, ADHD may affect as few as 1% to 3% of kids .
However, ADHD is generally classified as a biological disorder and hence, experts argue that it is inappropriate to mark a 3% to 5% prevalence as no natural limit can be defined. At the same time, pathognomonic biological markers for the disorders are non-existent while assessment methods and tools are poorly defined . Hence, it is often stated that it is impossible to know exactly how many children suffer from ADHD at a given point in time . Till the time that a biological marker is decided upon and gold standard diagnostic procedure defined, ADHD may as well be over diagnosed and continue to be so.
CAUSES OF OVER-DIAGNOSIS OR MISDIAGNOSIS
In addition to the lack of biological markers and diagnosis procedure mentioned earlier, there are several other factors that may be contributing to ADD and ADHDH being over-diagnosed or misdiagnosed among children.
1. Children potentially suffering from ADHD are often assessed by healthcare professionals who are not trained enough to be able to effectively diagnose the disorder. While standardized tools for assessment are available and their manufacturers take great care to control their usage, they often get used by social workers, pediatricians and general practitioners with limited or no diagnostic training or the knowledge of testing instruments.
2. As there is no standard diagnostic procedure for ADHD, there is a large spectrum of practices prevalent. Hence, child diagnosed with the disorder may have been evaluated for a mere 15 minutes, which is hardly enough time to observe his or her behavior or collect comprehensive data related to factors leading to effective diagnosis. For a diagnosis to be correct, the healthcare provider would need to take into consideration the involvement of parents, teachers as well as previous doctors consulted, take feedback in the form of face to face interviews, questionnaires as well as other tools of measurement. Failure to dedicate sufficient time, effort and attention when diagnosing a child may lead to misdiagnosis.
3. There has been increasing pressure on public schools to ensure that children with learning disabilities receive appropriate services that will enable them to accomplish educational or academic success. Since the ‘No Child left Behind Act’ was signed by president Bush in 2001, schools have become all the more responsible for detecting early childhood disorders such as ADHD. It has become a common practice for teachers to refer low performing children to general practitioners for ADHD medication well before they can be screened by a qualified diagnostician. As more general practitioners screen potention ADHD children, the chance of over diagnosis increases.
RETINALIN USE IN ADHD
Up until 1960, the number of children being medicated for ADHD was minimal; however, the figures increased six folds between 1960 and 1975. Prominent psychologists warned about the effects of increasing use of psycho stimulants in children as well as the decreasing interest shown by parents and teachers to alternative treatment methods . However, the growth in Ritalin use trends in the 1980s and 1990s was shocking even for those who advised caution. There was a 700% jump in the global use of psychostimulants, 90% of which were being used in the US. Today, 5 to 6 million US kids take drug treatment for ADHD per year . As per these statistics, drug treatment for ADHD among US children has increased by 100 folds over the past 5 decades and it still continues to rise. The DEA measured Ritalin use between the years 1997 to 1999 revealing some states to be using Ritalin 30 times more than others while certain communities consumed it up to 100 times more than others .
LACK OF RESEARCH AND EVIDENCE
While there has been escalating concern on the subject of over diagnosis of ADHD and the use of psychostimulants among children, there is still a great lack of substantial evidence or research to make a definitive case against current practices. Previous studies such as those conducted by Safer (Safer, 2000; Safer & Krager, 1988, 1989, 1994; Safer & Malever, 2000; Safer et al., 1996) that were deemed to be the most reliable of the data currently available as they fail to take into consideration several factors that affect the outcome of research and data analysis. These factors are:
a) Data Source – Safer relied mainly on data collected off school records or samples taken from Medicaid, estimating that the records missed 20% of children receiving medication for ADHD. However, the number children taking medication only at home has increased as long-term drug treatment has increased. School records underestimate ADHD drug treatment among children by up to 50% in the late 1990, while the rate had increased to 75% by the year 2002. Hence, the data source used by these studies cannot be deemed to be accurate.
b) Sample Size – The Jensen study of 1999 attempted to cover a wider base and took community specific samples . However, the study covered a mere 1,285 children of which only 66 ADHD cases were identified, making a total of 5% while other studies estimated the percentage to be around 16% to 26%. The discrepancies between findings are far too great for any one study to be considered anywhere near accurate.
c) Known Risk Factors – Factors such as race and gender in addition to age have been known to influence the prevalence and treatment of ADHD, yet, both the above studies failed to take such factors into consideration during their research. While Safer in 1999 presented data relating to elementary school boys from Baltimore County, Jensen’s 1999 study included children and adolescents aged between 9 to 17 year, thus excluding the age group where the disorder is most prominently diagnosed, i.e.: 6 to 9 years of age. Such exclusions lead to distortion of the data used to decipher the prevalence of ADHD and further affects its treatment.
d) Time Factor – Jensen’s study used data collected in 1992 whereas Safer and Malevar’s 2000 study took Ritalin use statistics from the mid 1990s. In both cases, considering the fast paced growth of ADHD diagnosis and Ritalin use, the data may be grossly out dated for use today. Further, Safer’s study covers only Ritalin administered through schools. It did not include other psychostimulants as well as medication that were being administered only at home. Hence, the 4% prevalence of ADHD deduced from these studies may be highly under-estimated.
e) Data Interpretation – From the points mentioned earlier, it is clear that the two most prominent studies on ADHD over-diagnosis left much to be demanded in terms of data accuracy and reliability of findings. Further, neither of the researchers were able to undeniably refute the case of ADHD over-diagnosis. Safer went on to state that if the trends prevailing at the time of his study continued, then the concerns of over-diagnosis and over-treatment may be justified.
EVIDENCE IN FAVOR OF ADHD OVER-DIAGNOSIS
A study conducted by LeFever and colleagues in 1999 among the school districts of Baltimore and Maryland found that in school ADHD treatment between the two economically, racially and socially divided district remained the same. While 17% of white male students were receiving medication, the highest rate, only 3% of black females made up the lowest rate , further revealing that the treatment ratio in the two districts was around 3 times more than the national estimate of the prevalence of the disorder. While LeFever included parental feedback in his 2002 study, the incidence of ADHD prevalence doubled with 17% of all elementary students, among which 22% were white boys, were diagnosed with ADHD. This study reveals that school data on the disorder were grossly under-recorded. A follow up study further showed that, as of 2002, only 25% of ADHD cases had been recorded in school data . This study clearly shows that the data being used to deduce the national prevalence rate for ADHD does not take into account a majority of children who have been diagnosed with the disorder and are being treated at home. As such, devising a more comprehensive method for collecting data is needed to better understand the extent of ADHD over-diagnosis and over treatment among children
CONCLUSION
The rate of ADHD cases being diagnosed among children has been growing at an alarming pace, raising concerns whether the disorder is being diagnosed effectively. Also, with majority of diagnosed children being prescribed with psychostimulants, it is also being debated whether this should be considered taking ‘the easy way out’, leading to parents and teachers not attempting to control symptoms through other treatments such as psychotherapy and support groups. While experts have argued that the prevalence and treatment of ADHD is controlled, the studies that this assumption relies on are outdated and have far too many loop holes to be considered reliable. At the same time, several studies exist that reveal that available data relating to ADHD prevalence may show gross underestimation of the diagnosis and medication of the disorder. As such, calls for a more organized and clear procedure for diagnosis of ADD and ADHD are well placed. Further, setting a minimum criterion for a child to qualify for psychostimulant treatment need to be brought into place while treatments that do not rely on medication need to be promoted in order to curtail the growth of the disorder.
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