Overdiagnosis, overtreatment and overshadowing

ADHD, A GROWING CONCERN

Attention deficit hyperactivity disorder (ADHD) is one of the most common reasons children are referred to mental health professionals (Brown, 2000). Stangely, Early intervention approaches have rarely been implemented for the prevention of ADHD. And since ADHD is conceptualized as a lifespan disorder, one realizes that stimulants do not cure the disease but only treat the symptoms, leading to long-term use of the drugs.

When people use the term overdiagnosis, they typically refer to children who are diagnosed with ADHD but should not be, i.e. the false positives. However, overdiagnosis is only one side of the coin of poor diagnoses. There will also be children who warrant the diagnosis but go unidentified or undiagnosed, i.e. the false negatives.

FALSE POSITIVE : OVERDIAGNOSIS & OVERTREATMENT & OVERSHADOW

The overdiagnosis is the diagnosis of a condition or disease more often than it is actually present.

A recent spike in diagnoses of ADHD and other mental disorders has fueled an unprecedented reliance on pharmaceutical medications to treat children, with long-term effects that remain unknown. The rate of new ADHD diagnoses in the Western world is reaching epidemic levels.

During the 90s, a rapid increase of stimulant use was noticed in several western countries. In the US, the prevalence of stimulant use increased from three to seven fold among children under 18 years of age between 1987 and 19961. Another US study by Castle et al., estimated that the prevalence of ADHD medication among children aged 0–19 increased from 2.8% in 2000 to 4.4% in 2005. They also concluded that the prevalence in adults doubled from 0.4% to 0.8% in between 2000 and 2005. Treatment rates grew more rapidly for adults than for children and more rapidly for women than for men2. The prescription of stimulant medication, which is very frequently used to treat ADHD, has significantly increased over the past decade (Ghodse, 1999; Olfson, Marcus, Weissman, & Jensen, 2002). A recent U.S. Centers for Disease Control and Prevention report estimating that one in 10 American children – a total of 5.4 million – has been handed that label (dec. 2010).

Quebec kids popped 32 million Ritalin pills in 2010 according to numbers compiled by health care research firm IMS Brogan 3,4,5. That’s a 10% jump from last year and part of an ongoing trend in the province. In fact, Quebec accounts for 35% of the Ritalin pills distributed in Canada and for 44% of all prescriptions written for the drug.

The Ritalin familly drugs have now become noticed by students, professionals, athletes and teenagers. They are looked at by these people as “smart drugs”, cognitive enhancers, performance enhancers.

Does this involved what I’ve come to think of as the ADHD Industrial Complex, made up not only of the powerful pharmaceutical industry, but an emerging, lucrative and mostly unregulated industry of non-drug alternatives.

FALSE POSITIVE : MISDIAGNOSIS

A misdiagnosis is an incorrect diagnosis.

With the increased use of medication and broader definitions for diagnoses like Attention Deficit Disorder (ADD) and Attention Deficit/Hyperactivity Disorder (ADHD), kids and adults who were previously just ‘acting up’ now have a label and what we call a ‘black hole diagnosis’. Often, « The bad-behaviour label is just used by people who don’t have a clue. » It is not uncommon to hear of the misdiagnosis of ADHD, wherein a child’s behaviors are attributed to ADHD when in actuality they are caused by or related to some other condition or trait (e.g., Perry, 1998).

Many times parents and teachers do not feel like dealing with a child that is out of control. Diagnosis and treatment is a quick fix to change any negative behavior. A positive diagnosis is seen as an aid to general parenting. It solves the problem of an unruly child. The problem is that treatment usually takes one form and that is to medicate them. It is much easier when a problem child just stops being a problem. This solves the problem for parents that do not have the time to parent and teachers that feel they do not have the time to teach. What it does not do is address the underlying problem that the child has. It is a form of medicalisation.

In a recent U.S. Study, almost one million children in the United States are potentially misdiagnosed with Attention Deficit-Hyperactivity Disorder (ADHD) because they were the youngest and least mature in their kindergarten classes. « The youngest kindergartners were 60 per cent more likely to be diagnosed with ADHD than the oldest children in the same grade. Similarly, when that group of classmates reached the fifth and eighth grades, the youngest were more than twice as likely to be prescribed stimulants. But these ‘symptoms’ may merely reflect emotional or intellectual immaturity among the youngest students »6. A child that is easily distracted, fidgety and interruptive in school might not have a clinical case of attention-deficit hyperactivity disorder (ADHD), but might rather just be ‘acting’ his or her age. Younger children may be mistakenly diagnosed as having ADHD, when in fact they are simply less mature : similar students have significantly different diagnosis rates depending on when their birthday falls in relation to the school year. Some 4.5 million U.S. children under the age of 18 have been diagnosed with ADHD. And approximately 2.5 million children take stimulant medication to counteract the symptoms of the disorder. Some 20 percent of those kids might have been misdiagnosed due to their relatively young age in the classroom7.

FALSE NEGATIVE : UNDERDIAGNOSIS & UNDERTREATMENT

The underdiagnosis is a failure to recognize or correctly diagnose a disease or condition especially in a significant proportion of patients.

ADHD is under-identified and under-treated as an underlying factor for prolonged poor health in the adult population (Biederman, Faraone, Monuteaux, Bober, & Cadogen, 2004). Wender, Wolf, and Wasserstein (2001) have concluded that ADHD is probably the most undiagnosed psychiatric disorder in adults. Furthermore, a new study, published in Archives of Pediatrics & Adolescent Medicine, found that 8.7 percent of children in the United States between the ages of 8 and 15 years, or approximately 2.4 million children, meet validated ADHD diagnostic criteria. However, more than half have not been diagnosed and about two-thirds are not receiving consistent treatment with ADHD medications8.

One study shows that psychiatrists are less confident about making the diagnosis of ADHD in patients with learning disability, especially adults. Hence the diagnosis may go undetected with a resultant lack of appropriate treatment which may furthercompound existing impairments9.

CONCLUSION

The important thing is making sure these kids get really good treatment, not just medication.


SOURCES & RÉFÉRENCES

1 ZITO, J.M. et al. (2003). Psychotropic practice patterns for youth: a 10-year perspective. Archives of Pediatrics & Adolescent Medicine, 157(1), pp.17-25.2CASTLE, L. et al., 2007. Trends in medication treatment for ADHD. Journal of Attention Disorders, 10(4), pp.335-342.3MÉNARD, SÉBASTIEN. (2010). “32 millions de pilules : Le Québec, champion du Ritalin”, le Journal de Montréal, 29 décembre 2010, http://lejournaldemontreal.canoe.ca/journaldemontreal/actualites/sante/archives/2010/12/20101228-035500.html, , [Accessed December 30, 2010].

4 “Niveaux records : Le Québec, champion du Ritalin”, 28 décembre 2010, Canoe.ca, http://tvanouvelles.ca/lcn/infos/national/archives/2010/12/20101228-072836.html, [Accessed December 30, 2010].

5 MÉNARD, SÉBASTIEN., (2010). “Quebecers pop Ritalin in record amounts”, Toronto Sun, QMI Agency, http://www.torontosun.com/news/canada/2010/12/28/16689801.html, [Accessed December 30, 2010].

6 “Nearly 1 million children potentially misdiagnosed with ADHD”, Michigan State University, Aug. 17, 2010, http://news.msu.edu/story/8160, [Accessed December 30, 2010].

7 HARMON, Katherine., (2010). “Are some ADHD-labeled kids just young for their grade?”, Scientific American, Aug 17, 2010, http://www.scientificamerican.com/blog/post.cfm?id=many-adhd-diagnoses-might-be-blamed-2010-08-17, [Accessed December 30, 2010].

8 “Study Shows ADHD Underdiagnosed and Undertreated”, Cincinnati Children’s Hospital Medical Center, January 2008, http://www.cincinnatichildrens.org/health/subscribe/ped-insights/01-08/adhd-study.htm, [Accessed December 30, 2010].

9 S. Buckley, P. Dodd, A. Burke, S. Guerin, J. McEvoy, and J. Hillery, “Diagnosis and management of attention-deficit hyperactivity disorder in children and adults with and without learning disability,” Psychiatric Bulletin, vol. 30, no. 7, pp. 251-253, Jul. 2006.

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