Few topics have generated as much public concern as the diagnosis of attention-deficit/hyperactivity disorder (ADHD). According to data from the Centers for Disease Control and Prevention, outpatient visits for ADHD jumped from 1.6 million to 4.2 million per year from 1990 to 1993. More than 70% of those patients walked away with a prescription for Ritalin (methylphenidate).
During the past decade, a growing body of research has reported that stimulant medications such as dextroamphetamine (Dexedrine, Adderall) and methylphenidate (Concerta, Methylin, Metadate) are safe and effective for treating ADHD. And the number of patients with ADHD continued to grow in the waiting rooms of pediatricians and family practitioners. Still, negative perceptions about ADHD diagnosis and treatment have been slow to change. This may be partially due to media outlets that raised alarms throughout the 1990s and 2000s about overdiagnosis and the dangers of treating children and adolescents with stimulants, which are schedule II drugs.
"I think there's a lot of public discomfort about kids being on medication," said Craig L. Donnelly, M.D., director of pediatric psychopharmacology at Dartmouth-Hitchcock Medical Center.
Psychiatrists have not done the best job of getting the message out that ADHD is a medical disorder that leads to significant dysfunctions that can be effectively treated, Donnelly told Psychiatric Times.
In Connecticut, fear of teachers pushing medications on children was strong enough to influence legislation. Since July 2001, school personnel are prohibited from recommending the use of psychotropic drugs for any child. The law applies to all written and oral communications and affects nurses, guidance counselors, mental health care professionals and social workers.
"I think that's clearly overkill," Donnelly said. He added that, by and large, teachers have experience with children and are able to correctly identify problem behaviors. But there's a perception among some parents that teachers want children medicated simply so they will behave in the classroom.
While the public concerns itself with overprescription, about half of children with ADHD go without treatment in a given year. "Most of our research indicates that it's probably both over- and underdiagnosed," David Fassler, M.D., told PT. Fassler is past chair of the American Psychiatric Association's Council on Children, Adolescents and their Families.
The key is an accurate diagnosis, said Fassler, who practices child and adolescent psychiatry in Burlington, Vt. The only way to achieve an accurate diagnosis is through a comprehensive assessment by a mental health care professional with expertise in ADHD.
There are cases when problematic behaviors have resulted in parents being encouraged or pushed into getting their child evaluated and treated, Donnelly said. Often the cause of the misbehavior or academic problems is not ADHD, but a learning disability, anxiety disorder or depression. This underscores the need for a thorough, comprehensive psychiatric evaluation.
While there is no blood test or brain scan for identifying ADHD, researchers have found that a thorough assessment using the DSM-IV criteria can accurately diagnose the disorder, said Christopher Kratochvil, M.D., assistant director of the Psychopharmacology Research Center at University of Nebraska Medical Center.
"With a thorough assessment, the reliability of the diagnosis is very high," Kratochvil told PT. "If you ask two independent clinicians to examine the same child, they will quite reliably reach the same diagnostic conclusion."
But in places like Nebraska, finding a clinician with that kind of training can be hard to come by. The state only has 18 child and adolescent psychiatrists. Historically, adult psychiatrists have not been trained in diagnosing and treating ADHD, Kratochvil said, and, for the most part, primary care physicians have not had significant training in this area either.