Problems in Diagnosing and Treating ADD/ADHD - attention deficit disorder, attention deficit-hyperactivity disorder

PUBLIC AND MEDICAL concern regarding the overdiagnosing of attention deficit disorder (ADD) and attention deficit-hyperactivity disorder (ADHD) and the overprescribing of Ritalin hit the mainstream in 2000 with the publication of a study in the Journal of the American Medical Association (JAMA). As early as 1988, researchers Daniel J. Safer and John M. Krager reported in JAMA that there was a doubling of Ritalin use every four to seven years from 1971 to 1987, which was then followed by a decline in response to public concern about excessive use of the drug. They indicated, nonetheless, that there was no cause for concern.

In the 2000 report, an alarming increase in the general use of psychiatric drags for preschoolers was documented for the first time. Some of the findings of that study revealed that the number of preschoolers on antidepressants had risen 200% from 1991 to 1995 (among those enrolled in two state Medicaid programs and a health maintenance program in the Northwest), and there was a twofold to threefold increase in the number of children ages two to four who were taking methylphenidate (the generic form of Ritalin). In addition, the use of clonidine (popularly used for blood pressure) for children had risen substantially.

An editorial by Joseph T. Coyle of Harvard Medical School's Psychiatry Department accompanying the JAMA article points to the salient concerns: Methylphenidate, or Ritalin, carries a warning against its use in children younger than six, and "the validity and reliability of the diagnoses of ADHD [has] not been demonstrated." Moreover, the editorial makes a stunning admission: "There is virtually no clinical research on the consequences of pharmacologic treatment of behavioral disorders in very young children ... it would seem prudent to carry out much more extensive studies to determine the long-term consequences of the use of psychotropic [having an altering effect on the mind] drags at this early stage of childhood."

The lead researcher of the study, Julie Zito, associate professor of pharmacy and medicine at the University of Maryland, summed up the significance of the new findings by saying that "This seems to support the anecdotes that more children are receiving a diagnosis and treatment for attention deficit-hyperactivity disorder in the late 1990s than ever before."

Even psychiatric experts were shaken by the study's results. Steven Hyman, director of the National Institute of Mental Health (NIMH), described himself as "more than shocked" by the findings.

In April, 2000, then-First Lady Hillary Clinton announced a multimillion-dollar government study to examine the consequences of the increase in the number of schoolage children who are prescribed stimulants for ADD/ADHD. Now, as a senator from New York, she acknowledges that physicians may be "too quick to diagnose" these disorders, noting that "Some of these young people have problems that are symptoms of nothing more than childhood or adolescence."

Recognition of this issue within the medical and governmental establishments has been a long time in coming, although there has been no lack of criticism in the press. In 1993, in JAMA's Correspondence section, we criticized a 1992 article by Safer and Krager in which they implicitly condemned a "media blitz" as being responsible, along with threatened lawsuits, for a decline in stimulant treatment in Baltimore County (Md.) elementary and secondary schools. The "blitz" attacked by Safer and Krager was allegedly misleading, full of "anecdotal and unsubstantiated critical allegations concerning Ritalin use and side effects...."

They further decried in this article the fact that parents "fearful of media-reported medication `side effects' and school staff hesitated to refer restless, impulsive, and inattentive students to physicians." Safer and Krager concluded that the "blitz" had little impact on parents whose kids already were receiving Ritalin since, they argued, "Presumably, most of these parents were satisfied with the benefits of the medication...." We pointed out that parental satisfaction was a dubious criterion for supporting Ritalin therapy, for such compliance may reflect only unquestioned trust in physicians and a desire to meet school expectations.

Safer and Krager's response to our criticism stressed the safety of Ritalin medication, ending with the statement: "To suggest that stimulant treatment is widely overprescribed or imprudently prescribed requires contrary evidence." To imply that such evidence did not exist in 1992-93 is to ignore without concern a wealth of reports on excessive use, including Safer and Krager's 1988 findings which indicated that "giving stimulant medication to inattentive but not hyperactive public school students is not an uncommon practice and has in fact become more prevalent of late...." Moreover, how could serious researchers ignore the obvious problems inherent in widespread use of a central nervous system stimulant--such as the exacerbation of Tourette's syndrome--as NIMH has pointed out more than once?