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Topic: Doctors Diagnosing Too Many Kids with ADHD?
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Jerry P. Becker

Posts: 13,815
Registered: 12/3/04
Doctors Diagnosing Too Many Kids with ADHD?
Posted: May 19, 2013 8:50 PM
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From Scientific American, Wednesday, May 1, 2013.
See
http://www.scientificamerican.com/article.cfm?id=are-doctors-diagnosing-too-many-kids-adhd&WT.mc_id=SA_WR_20130508
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NOTE: There are many comments following the article at the website.
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Doctors Diagnosing Too Many Kids with ADHD?

Some boys may be labeled incorrectly with the
condition, but undertreatment may be the bigger
problem

By Scott O. Lilienfeld and Hal Arkowitz

A German children's book from 1845 by Heinrich
Hoffman featured "Fidgety Philip," a boy who was
so restless he would writhe and tilt wildly in
his chair at the dinner table. Once, using the
tablecloth as an anchor, he dragged all the
dishes onto the floor. Yet it was not until 1902
that a British pediatrician, George Frederic
Still, described what we now recognize as
attention-deficit hyperactivity disorder (ADHD).
Since Still's day, the disorder has gone by a
host of names, including organic drivenness,
hyperkinetic syndrome, attention-deficit disorder
and now ADHD.

Despite this lengthy history, the diagnosis and
treatment of ADHD in today's children could
hardly be more controversial. On his television
show in 2004, Phil McGraw ("Dr. Phil") opined
that ADHD is "so overdiagnosed," and a survey in
2005 by psychologists Jill Norvilitis of the
University at Buffalo, S.U.N.Y., and Ping Fang of
Capitol Normal University in Beijing revealed
that in the U.S., 82 percent of teachers and 68
percent of undergraduates agreed that "ADHD is
overdiagnosed today." According to many critics,
such overdiagnosis raises the specter of
medicalizing largely normal behavior and relying
too heavily on pills rather than skills-such as
teaching children better ways of coping with
stress.

Yet although data point to at least some
overdiagnosis, at least in boys, the extent of
this problem is unclear. In fact, the evidence,
with notable exceptions, appears to be stronger
for the undertreatment than overtreatment of ADHD.

Medicalizing Normality

The American Psychiatric Association's diagnostic
manual of the past 19 years, the DSM-IV, outlines
three sets of indicators for ADHD: inattention (a
child is easily distracted), hyperactivity (he or
she may fidget a lot, for example), and
impulsivity (the child may blurt out answers too
quickly). A child must display at least six of
the nine listed symptoms for at least half a year
across these categories. In addition, at least
some problems must be present before the age of
seven and produce impairment in at least two
different settings, such as school or home.
Studies suggest that about 5 percent of
school-age children have ADHD; the disorder is
diagnosed in about three times as many boys as
girls.

Many scholars have alleged that ADHD is massively
overdiagnosed, reflecting a "medicalization" of
largely normative childhood difficulties, such as
jitteriness, boredom and impatience.
Nevertheless, it makes little sense to refer to
the overdiagnosis of ADHD unless there is an
objective cutoff score for its presence. Data
suggest, however, that a bright dividing line
does not exist. In a study published in 2011
psychologists David Marcus, now at Washington
State University, and Tammy Barry of the
University of Southern Mississippi measured ADHD
symptoms in a large sample of third graders.
Their analyses demonstrated that ADHD differs in
degree, not in kind, from normality.

Yet many well-recognized medical conditions, such
as hypertension and type 2 diabetes, are also
extremes on a continuum that stretches across the
population. Hence, the more relevant question is
whether doctors are routinely diagnosing kids
with ADHD who do not meet the levels of symptoms
specified by the DSM-IV.

Some studies hint that such misdiagnosis does
occur, although its magnitude is unclear. In 1993
Albert Cotugno, a practicing psychologist in
Massachusetts, reported that only 22 percent of
92 children referred to an ADHD clinic actually
met criteria for ADHD following an evaluation,
indicating that many children referred for
treatment do not have the disorder as formally
defined. Nevertheless, these results are not
conclusive, because it is unknown how many of the
youth received an official diagnosis, and the
sample came from only one clinic.

Clearer, but less dramatic, evidence for
overdiagnosis comes from a 2012 study in which
psychologist Katrin Bruchmüller of the University
of Basel and her colleagues found that when given
hypothetical vignettes of children who fell short
of the DSM-IV diagnosis, about 17 percent of the
1,000 mental health professionals surveyed
mistakenly diagnosed the kids with ADHD. These
errors were especially frequent for boys, perhaps
because boys more often fit clinicians'
stereotypes of ADHD children. (In contrast, some
researchers conjecture that ADHD is
underdiagnosed in girls, who often have subtler
symptoms, such as daydreaming and spaciness.)

Pill Pushers?

Published reports of using stimulants for ADHD
date to 1938. But in 1944 chemist Leandro
Panizzon, working for Ciba, the predecessor of
Novartis, synthesized a stimulant drug that he
named in honor of his wife, Marguerite, whose
nickname was Rita. Ritalin (methylphenidate) and
other stimulants, such as Adderall, Concerta and
Vyvanse, are now standard treatments; Strattera,
a nonstimulant, is also widely used. About 80
percent of children diagnosed with ADHD display
improvements in attention and impulse control
while on the drugs but not after their effects
wear off. Still, stimulants sometimes have side
effects, such as insomnia, mild weight loss and a
slight stunting of height. Behavioral treatments,
which reward children for remaining seated,
maintaining attention or engaging in other
appropriate activities, are also effective in
many cases.

Many media sources report that stimulants have
been widely prescribed for children without ADHD.
As Dutch pharmacologist Willemijn Meijer of
PHARMO Institute in Utrecht and his colleagues
observed in a 2009 review, stimulant
prescriptions for children in the U.S. rose from
2.8 to 4.4 percent between 2000 and 2005. Yet
most data suggest that ADHD is undertreated, at
least if one assumes that children with this
diagnosis should receive stimulants. Psychiatrist
Peter Jensen, then at Columbia University, noted
in a 2000 article that data from the mid-1990s
demonstrated that although about three million
children in the U.S. met criteria for ADHD, only
two million received a stimulant prescription
from a doctor.

The perception that stimulants are overprescribed
and overused probably has a kernel of truth,
however. Data collected in 1999 by psychologist
Gretchen LeFever, then at Eastern Virginia
Medical School, point to geographical pockets of
overprescription. In southern Virginia, 8 to 10
percent of children in the second through fifth
grades received stimulant treatment compared with
the 5 percent of children in that region who
would be expected to meet criteria for ADHD.
Moreover, increasing numbers of individuals with
few or no attentional problems-such as college
students trying to stay awake and alert to
study-are using stimulants, according to ongoing
studies. Although the long-term harms of such
stimulants among students are unclear, they carry
a risk of addiction.

A Peek at the Future

The new edition of the diagnostic manual, DSM-5
(due out in May), is expected to specify a lower
proportion of total symptoms for an ADHD
diagnosis than its predecessor and to increase
the age of onset to 12 years. In a commentary in
2012 psychologist Laura Batstra of the University
of Groningen in the Netherlands and psychiatrist
Allen Frances of Duke University expressed
concerns that these modifications will result in
erroneous increases in ADHD diagnoses. Whether or
not their forecast is correct, this next chapter
of ADHD diagnosis will almost surely usher in a
new flurry of controversy regarding the
classification and treatment of the disorder.
--------------------------------------
This article was originally published with the
title Are Doctors Diagnosing Too Many Kids with
ADHD?.
--------------------------------------------
ABOUT THE AUTHOR(S) -- SCOTT O. LILIENFELD and
HAL ARKOWITZ serve on the board of advisers for
Scientific American Mind. Lilienfeld is a
psychology professor at Emory University, and
Arkowitz is an associate professor of psychology
at the University of Arizona.
Send suggestions for column topics to editors@SciAmMind.com
(Further Reading)
Is ADHD Diagnosed in Accord with Diagnostic
Criteria? Overdiagnosis and Influence of Client
Gender on Diagnosis. Katrin Bruchmüller, Jürgen
Margraf and Silvia Schneider in Journal of
Consulting and Clinical Psychology, Vol. 80, No.
1, pages 128-138; February 2012. [See
http://psycnet.apa.org/index.cfm?fa=buy.optionToBuy&id=2011-30100-001
]
**********************************************
--
Jerry P. Becker
Dept. of Curriculum & Instruction
Southern Illinois University
625 Wham Drive
Mail Code 4610
Carbondale, IL 62901-4610
Phone: (618) 453-4241 [O]
(618) 457-8903 [H]
Fax: (618) 453-4244
E-mail: jbecker@siu.edu



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