According to a recent report by the Centers for Disease Control and Prevention (CDC), one in every 10 American children over the age of three has been diagnosed with ADHD. Before turning 18, nearly 14 percent of children will have been diagnosed. Most will receive ADHD drugs. Fearing that the popular response to this report will be "shock," Psychiatrist John T. Walkup and two junior colleagues published a "reassuring" commentary. But, it appears to be an attempt to forestall public debate.
Dr. Walkup noted that CDC rate of parent-reported ADHD diagnosis has increased such that it is now close to the rate that researchers generate by applying established diagnostic criteria to large samples of children. These criteria are set out in the "bible" of psychiatric diagnosis — a book referred to as the Diagnostic and Statistical Manual of Mental Disorders (DSM). Walkup hailed the consistency between parent-reported and DSM-generated rates of diagnosis as evidence of improved care. He called it "a positive sign" while also lamenting that only 70 percent of those diagnosed get medicated.
Professionals who monitor the changes produced in association with various editions of the DSM know that each successive edition has led to increased rates of diagnosis. DSM architects and authors now openly admit that diagnostic inflation exists across a host of disorders, with 28 percent inflation in ADHD diagnosis that stemmed from changes specific to the edition that was in use during the CDC study. There is no biological marker or definitive test for ADHD. Imperfect as it is, we're stuck with the DSMS as the official psychiatric guide to help us distinguish the sick from the well. Nonetheless, the confluence of rates between parent-reported (actual) and DSM-generated (inflated) diagnosis has no bearing on the question of whether too many (or too few) children are being medicated for ADHD.
Answering that question remains a matter of opinion, which is best addressed through open dialogue about risks and benefits associated with rising rates of diagnosis and treatment. So, why would an informed psychiatrist like Dr. Walkup want to preempt debate about high rates of ADHD treatment?
It is impossible to know Dr. Walkup's motives; however, the good doctor is a paid consultant for companies that manufacture ADHD medications. He has received research funding from them and is a member of the speaker's bureau for a leading manufacturer of ADHD medication. Pharmaceutical companies pay "key opinion leaders" like Dr. Walkup to help advance the sale of prescription drugs. Such individuals may be patient advocates, but they run the risk of becoming marketing spokespersons for the industry — unwittingly or otherwise.
Perhaps the sheer volume of children that we perceive as needing drugs to succeed in school ought to shock us. More importantly, the more a drug is prescribed, the more it will be diverted for abuse.
As noted in a recent article, national poison control data for 1995-2005 documented a sharp rise in the number of children between 13 and 19 years of age who were reported due to ADHD medication abuse — an increase that was disproportionately higher than drug abuse generally or for teen substance abuse in particular. As early as 15 years ago in some communities, 16 percent of students in elementary through high school grades had been approached by classmates to share or sell their ADHD medications. By 2006, 34 percent of students attending a large southeastern college reported using ADHD drugs illegally. The widespread availability of ADHD drugs on high school and college campuses has led many young people to perceive these drugs as relatively safe and freely mix them with alcohol—a potentially lethal combination.
Doctors prescribe ADHD medications to help children perform better in school, but every single long-term study of ADHD drug treatment indicates that the drugs don't actually improve educational outcomes. Recently released analysis of the robust and 14-year long National Longitudinal Study of Canadian Youth indicated that educational and behavioral outcomes worsen with ADHD drug treatment.
ADHD drugs are prescribed with the goal of helping children be successful in school. If they don't actually lead to academic benefits over the long haul, isn't the risk of exposing children to these potentially addictive medications worthy of debate, especially if the cumulative impact contributes to substance abuse among American youth? With the New York Times expose of the tragic ADHD drug death of a young man from Virginia Beach, this is a particularly important topic for the Hampton Roads community.
Ten years ago, there was more public outcry when the rate of ADHD diagnosis was reported to be a fraction of what it is now. Rather than dismissing concern about potential ADHD overdiagnosis, it's time to re-open public debate about high and rising rates of ADHD diagnosis and treatment.
Watson is a clinical psychologist and President of Safety and Learning Solutions, a human performance consulting firm in Virginia. Send email to firstname.lastname@example.org.