ADHD is the most extensively studied pediatric mental health disorder, yet controversy and public debate over the diagnosis and medication treatment of the disorder continue to exist.1 Questions and concerns are raised by professionals, media commentators, and the public about the possibility of overdiagnosis of ADHD in youths and the possibility of overprescribing stimulant medications. Fueled by sensational media coverage that emphasizes controversy over rationality, the debate can at times become quite heated, leading to a general public assumption that ADHD is overdiagnosed and that stimulant drugs are overused and overprescribed in children and adolescents with and without ADHD.2
Trends in ADHD diagnosis and stimulant treatment
ADHD is a psychiatric disorder with a long history. It was first described by the English pediatrician Sir George Frederick Still in 1902, and initial diagnostic classifications emphasized the symptoms of hyperactivity and impulsivity. The diagnostic terms used to describe children with this disorder changed frequently in the 20th century. With the introduction of DSM-III in 1980, the symptom of inattention gained ascendancy and the condition was officially listed as attention-deficit disorder. DSM-IV contains the diagnosis of ADHD with 3 subtypes: combined, inattentive, and hyperactive-impulsive. Further modifications of the criteria for the disorder are expected when DSM-5 is introduced.
Before 1970, the diagnosis of ADHD was relatively rare for schoolchildren and almost nonexistent for adolescents and adults. Between 1980 and 2007, there was an almost 8-fold increase of ADHD prevalence in the United States compared with rates of 40 years ago. Considering the prevalence of school-administered stimulants as synonymous with the prevalence of ADHD, Safer and colleagues3,4 estimated the prevalence of ADHD in American schoolchildren as 1% in the 1970s, 3% to 5% in the 1980s, and 4% to 5% in the mid to late 1990s. In 2007, using data from the National Survey of Children’s Health, Visser and colleagues5 reported that 7.8% of youths aged 4 to 17 years had a diagnosis of ADHD and 4.3% reported current use of a medication for the disorder.
The rise in prevalence stemmed from a complex confluence of forces and events that came together in the first half of the 1990s and permitted a dramatic expansion of ADHD diagnosis and treatment.6 The growing political strength of children’s welfare advocates and the mental health consumer’s movement associated with decreasing stigma resulted in changes to federally funded special education programs. The Individuals with Disabilities Education Act recognized ADHD as a disability, and children with ADHD became eligible for school accommodations.
Beginning in the 1990s, Congress expanded eligibility criteria for Medicaid, especially for children. This fueled a rapid increase in coverage for psychotropic medications, including stimulants.6 At the same time, scientific knowledge about the longitudinal course of ADHD and its lifetime morbidity, heritability, and neurobiology was rapidly increasing, This provided empiric evidence as well as a scientific and neurobiological rationale for medication intervention.7,8 Also, the managed care psychiatric carve-out health insurance industry sought to rein in the costs associated with psychiatric illness and supported pharmacological interventions for complex psychiatric disorders, including pediatric disorders.
In 1997, Congress passed the FDA Modernization Act, which encouraged the pharmaceutical industry to develop and test drugs for children by extending patent exclusivity. This resulted in a dramatic increase in randomized controlled trials in children that involved stimulant compounds for ADHD and further supported an evidence-based rationale for medication intervention in ADHD. As a result, the prescribing of stimulants for children with ADHD increased 4-fold between 1987 and 1996, with a further increase of 9.5% between 2000 and 2005. Currently, slightly more than 4% of children and adolescents in the United States use ADHD medications.5,9
Doubt and confusion as to where this disorder fits into the general spectrum of illness further feeds the general perception that ADHD is a socially constructed disorder rather than a valid neurobiological disorder.
The rise in stimulant prescribing for youths must be taken in context. Between 1990 and 2005 there was a rapid rise in pediatric prescriptions for many psychiatric medications—not only stimulants. There was a 5-fold increase for antipsychotics between 1993 and 2002, and a 3-fold increase for antidepressants between 1997 and 2002.10,11 Thus, the rise in stimulant prescribing for pediatric ADHD was only part of a larger shift to an emphasis on medication interventions for the treatment of children with early-onset and complex behavioral and mental health disorders.
Public perception of stimulant overprescribing is driven by concerns over the rapid rise in the amount of available stimulants produced in the United States over the past 3 decades. For sale stimulant production quotas are published yearly by the Drug Enforcement Administration.12 The rapid rise in the production quota of for-sale methylphenidate (excluding amphetamine) is seen in the Figure. With the production of more stimulants every year, worries about the increased availability of stimulants for abuse and diversion rise as well. Rising production rates are cited as proof of stimulant overprescribing by physicians and indirect evidence of the overdiagnosis of ADHD among children.2
The extant scientific research suggests a much more complicated and nuanced picture of stimulant prescribing. Comparisons of the prevalence of ADHD among youths aged 4 to 17 years (7.8%) with stimulant prescription rates of between 4.3% and 4.4% do not support the idea of a culture of permissive stimulant overprescribing.5,9 Moreover, recent data from the National Health and Nutrition Examination Survey, a nationally representative probability sample of children aged 8 to 15 years living in the community, indicated an ADHD prevalence rate of 7.8%. However, only 48% of the ADHD sample had received any mental health care over the past 12 months.13
1. Goldman L, Genel M, Bezman R, Slanetz PJ. Diagnosis and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Council on Scientific Affairs, American Medical Association. JAMA. 1998;279:1100-1107.
2. LeFever GB, Arcona AP, Antonuccio DO. ADHD among American schoolchildren: evidence of overdiagnosis and overuse of medication. Sci Rev Ment Health Pract. 2003;2:49-60.
3. Safer DJ, Malever M. Stimulant treatment in Maryland public schools. Pediatrics. 2000;106:533-539.
4. Safer DJ, Zito JM, Fine EM. Increased methylphenidate usage for attention deficit disorder in the 1990s. Pediatrics. 1996;98(6, pt 1):1084-1088.
5. Visser SN, Lesesne CA, Perou R. National estimates and factors associated with medication treatment for childhood attention-deficit/hyperactivity disorder. Pediatrics. 2007;119(suppl 1):S99-S106.
6. Mayes R, Bagwell C, Erkulwater J. ADHD and the rise in stimulant use among children. Harvard Rev Psychiatry. 2008;16:151-166.
7. Barkley RA. Attention-Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment. 3rd ed. New York: Guilford Press; 2006.
8. Solanto MV. Neuropsychopharmacological mechanisms of stimulant drug action in attention-deficit hyperactivity disorder: a review and integration. Behav Brain Res. 1998;94:127-152.
9. Castle L, Aubert RE, Verbrugge RR, et al. Trends in medication treatment for ADHD. J Atten Disord. 2007;10:335-342.
10. Olfson M, Marcus SC, Weissman MM, Jensen PS. National trends in the use of psychotropic medications by children. J Am Acad Child Adolesc Psychiatry. 2002;41:514-521.
11. Vitiello B, Zuvekas SH, Norquist GS. National estimates of antidepressant medication use among U.S. children, 1997-2002. J Am Acad Child Adolesc Psychiatry. 2006;45:271-279.
12. Drug Enforcement Administration, US Department of Justice. Controlled Substances: Proposed Aggregate Production Quotas for 2008. http://www.deadiversion.usdoj.gov/fed_regs/quotas/2008/fr1107.htm. Accessed July 7, 2011.
13. Merikangas KR, He JP, Brody D, et al. Prevalence and treatment of mental disorders among US children in the 2001-2004 NHANES. Pediatrics. 2010;125:75-81.
14. Centers for Disease Control and Prevention. Mental health in the United States. Prevalence of diagnosis and medication treatment for attention-deficit/hyperactivity disorder—2003. MMWR. 2005;54:842-847.
15. Angold A, Erkanli A, Egger HL, Costello EJ. Stimulant treatment for children: a community perspective. J Am Acad Child Adolesc Psychiatry. 2000;39:975-984.
16. Kollins SH. Abuse liability of medications used to treat attention-deficit/hyperactivity disorder (ADHD). Am J Addict. 2007;16(suppl 1):35-42; quiz 43-44.
17. Wilens TE, Adler LA, Adams J, et al. Misuse and diversion of stimulants prescribed for ADHD: a systematic review of the literature. J Am Acad Child Adolesc Psychiatry. 2008;47:21-31.
18. Kollins SH. A qualitative review of issues arising in the use of psycho-stimulant medications in patients with ADHD and co-morbid substance use disorders. Curr Med Res Opin. 2008;24:1345-1357.
19. Biederman J, Monuteaux MC, Mick E, et al. Young adult outcome of attention deficit hyperactivity disorder: a controlled 10-year follow-up study. Psychol Med. 2006;36:167-179.
20. Pappadopulos E, Jensen PS, Chait AR, et al. Medication adherence in the MTA: saliva methylphenidate samples versus parent report and mediating effect of concomitant behavioral treatment. J Am Acad Child Adolesc Psychiatry. 2009;48:501-510.
21. Volkow ND, Ding YS, Fowler JS, et al. Is methylphenidate like cocaine? Studies on their pharmacokinetics and distribution in the human brain. Arch Gen Psychiatry. 1995;52:456-463.
22. Kollins SH. ADHD, substance use disorders, and psychostimulant treatment: current literature and treatment guidelines. J Atten Disord. 2008;12:115-125.
23. Dulcan M. Practice parameters for the assessment and treatment of children, adolescents, and adults with of attention-deficit/hyperactivity disorder. American Academy of Child Adolescent Psychiatry. J Am Acad Child Adolesc Psychiatry. 1997;36(10 suppl):85S-121S.
24. King RA. Practice parameters for the psychiatric assessment of children and adolescents. American Academy of Child Adolescent Psychiatry. J Am Acad Child Adolesc Psychiatry. 1997;36(10 suppl):4S-20S.
25. Bridges J, Fitzgerald L, Meyer J. New workforce roles in health care: exploring the longer-term journey of organisational innovations. J Health Organ Manag. 2007;21:381-392.
26. Sciutto MJ, Eisenberg M. Evaluating the evidence for and against the overdiagnosis of ADHD. J Atten Disord. 2007;11:106-113.
27. Conners CK, March JS, Francis A, et al. Treatment of attention-deficit/hyperactivity disorder: expert consensus guidelines. J Atten Disord. 2001;4(suppl 1):S1-S128.
Yes it is
It does not even exist it is just that these kids are very bad and need to get a disciplined. Some kids believe that since they do not get a spanking that they will get away with anything they feel like it and that is not the way the world works. If a parent truly loves their child then they should discipline them harshly anytime they disobey and I promise that will cure them.
ADHD is over diagnosed
I am writing a paper on the over diagnosis of ADHD right now for my college class. Certain states have up to 11 percent of kids diagnosed with this disorder. It is truly ridiculous. Although I do believe ADHD is a real disorder, the number of children diagnosed with it is unreal.
Adhd is overdiagnosed
I'm a psychiatrist, and I recently started working with children. A lot of the parents are there with "Adhd" children. The reason for the diagnoses?
1. They misbehave often (have you ever tried time-outs or spanking? "No, it's unethical and cruel,)
2. They don't pay attention in class (a majority of these children are just barely old enough to be in school, turning 5 the day or week before school. They simply don't have the intellectual maturity their older classmates have.)
3. (My favorite) They were unable to keep their mouths shut when coming across different things, such as asking why a pregnant lady is so fat, or why someone has weird scars. (This is normal for children, you dolts! Especially in the age group of 4-8, the age group I work with!)
ADHD is over diagnosed much of the time
While there may be some children that have ADHD there are just as many that just need a firm hand of discipline. I think they should test the parents for drugs because it can lead to such a crazy life style children can't be normal in that kind of environment. Many times when parents are on drugs they are trying to get a disability check for their children so they can buy more drugs! Then there are parents that really lack the parental skills to discipline their children. Then there are some children that may actually be ADHD and for those good parents who are doing the right thing it makes it that much harder because your put in a category with all the nut cases!
It's practically mythical.
I have done much research on the subject.
The DSM requires symptoms of ADHD (which, by the way, could be observed in ANY child at various points in his/her life) to be "noted in 2 or more settings". This has been understood to mean both at school and at home.
Schools are then charged with the additional duty to spot ADHD in children. The teachers themselves are not mental health professionals, so are provided guidelines by organizations that are exclusively funded by pharmaceutical companies (in Canada, this is CADDRA and CADDAC).
The financial well being for the school and/or school board is bolstered by more children diagnosed (think Special Education grants). So the teachers are coached or lean towards diagnosing the children more rapidly.
This makes the schools then put pressure on parents (who would otherwise not have had a clue about their child's "ADHD") to bring their child to a doctor to be diagnosed.
Evidence of this school involvement is the fact that about 75-80% of ADHD cases are boys (the vast majority of school-teachers are female and more rapidly rail against boisterous behaviour in boys) and the vast majority of the children who are diagnosed are the youngest 10-20% of the children in their grade.
The doctor's (in Ontario) receive twice as much as remuneration from Ontario Health Insurance, to speak to the parent and child and provide a prescription (15-minute conversation) than he would were he to do a full physical examination of the child (such as to identify nutritional deficiencies, etc that may be causing the unwanted behaviour), which can take much more time.
Kids then get put on Ritalin (or a similar stimulant drug in the same category as cocaine) and as a result, a percentage die, and a percentage commit suicide, and a percentage kill other kids; and this fuels the argument that more attention needs to be put on kids' mental health.
It's a great racket and happening all over the world.
ADHD is a very real and serious problem and overdiagnosis causes problems with those who suffer from the disorder for real.
There are many levels of normal in society. Everyone has a different level of height, intelligence, weight, temperament and so on. Some kids are normal and healthy but just far more active and distractable than average kids. It does not mean they have a disorder.
Look at height as an example. We are all different heights. Most are around average or a bit above or a bit below. Some are tall and some are short but they are still within the realms of normal. Then you have those who have a condition (dwarfism) which means they are seriously out of step with others which affects their daily lives.
Diagnosing active kids with ADHD is like calling all the short people dwarfs. ADHD should only be diagnosed if a serious problem exists.
Yes, it probably is
A diagnosis of ADHD is a convenient outlet for further reasons of explanation of a child's behavior. This condition has no physical basis in nature -- it is merely an observation of what a child exhibits. In the past, this "disease" would have have simply and effectively been handled with a few stern disciplinary measures.
I believe it is.
We live in a world where parents neglect their children, and don't want to take responsibilities. Children are hyper. Remember when you were a kid? Parents nowadays feed their children loads of sugar, watch them bounce off the walls, then go crying to the doctor wondering why their child is so hyper. They are children. They want to jump around, play, get rid of their energy. But parents find it easier just to put them on some medication. Out of mind, out of sight.