ADHD: Overdiagnosis or Something Worse?

The increasing incidence of attention-deficit/hyperactivity disorder (ADHD) diagnoses in children, particularly among boys, is a cause of great concern for parents and medical professionals. In a recent discussion inspired by a thoughtful post by pediatrician Gregory Lawton in his A Musing Pediatrician blog on Medscape, physicians and nurses discussed this pressing issue.

Dr. Lawton began the discussion by sharing his deepest fears concerning ADHD:

What if we are not overdiagnosing it? What if there really is something to how our society thinks and acts and entertains itself and rewards itself and measures itself? What if an iPad in every child's hand feeds into the problem?... The current system almost encourages the diagnosis and treatment of ADHD. There are few financial or health-based reasons to not diagnose and treat. All the incentives are strongly in favor of diagnosing and treating ADHD.

Overdiagnosis or a True Rising Trend?

A school nurse from Ohio took a strong stand that ADHD is being overdiagnosed and that many children simply suffer from "brat syndrome." They have "parents who are ineffective in their jobs and have been for years [and who] wait until the behavior becomes annoying or the physical assaults begin to hurt before trying to stop it."

Another nurse agreed and added, "Instead of medicating alone, perhaps evaluation of the entire family structure needs to occur to include educating parents on how to handle their children."

A pediatrician offered an analogy:

The ability to pay attention (or activity level) is like height -- there is a bell-shaped curve with really tall people (kids who can sit still and pay attention for long periods) and short people (kids who have difficulty sitting still or paying attention), and most people are in between. Who says how short is abnormal? Maybe endocrinologists will define it as being less than the third percentile. But with ADHD, that number has crept up over the years. So, do 20% of school-aged boys have a disease called ADHD? Definitely not. But do 20% of kids end up in the lower 20% of their class? Of course.

Another pediatrician saw parenting as the primary engine of the prevalence of ADHD and even broke it down along cultural lines:

I have yet to diagnose ADHD in a Japanese or Indian child. They sit still in my office on the chair they are placed in and do not speak before they are asked to, whereas American kids dismantle my office and act like maniacs on drugs... I can walk into a classroom in Europe and see order compared with the complete chaos in my kids' school here... What is needed is discipline from birth and not medications.

Yet another pediatrician also questioned such widespread labeling of children and saw sinister intent behind it:

Most of the elementary school-aged boys [that I see] are very high-energy, and not every kid is academically inclined... does that mean that there is actually something wrong with their brains? I have seen too many bright young boys started on stimulants and then suffer severe side effects such as anxiety and then are started on selective serotonin reuptake inhibitors. I know we live in a capitalist society, but how far are we willing to go to make a quick buck?

An internist also saw the venality of patients as a factor, writing, "There is a strong component to many mothers [wanting] to get their child diagnosed as severe enough that he or she will be classified as 'disabled' and get a Social Security income check."

A nurse practitioner cited regrettable practicalities rather than overt corruption:

It is easier to medicate kids than to have small classes, lots of playground time, and lots of classroom structure. Unfortunately, I think we are doing a disservice to kids when we medicate them instead of keeping them active enough to take the edge off their behavior and then teaching them how to behave in school and at home.

Are We Medicating Healthy Kids?

A pediatrician drew from valuable, nonprofessional experience:

As the mother of a young man with ADD (and Asperger's), [I agree that] it is our society that in many ways has created this epidemic. Where were these boys 50 or 100 or 1000 years ago? They were outside, they were busy doing things, they lived in societies and cultures that had a place where they could develop their talents; and their behavior, for the most part, was tolerated. In our modern society, a premium is placed on being mostly sedentary and quiet.

A nurse agreed with this and suggested appreciating the variation between the different forms the condition can take:

We need to make a distinction between ADHD in brain-damaged kids and ADHD in children who are intellectually gifted. In the former group, providing medication to suppress ADHD symptoms is helpful because it allows them to function at a higher level. However, I question the indiscriminate use of medications in gifted children... People with untreated ADHD are easily distracted, but this also means that they are more observant and more creative. Do we really want to force everyone to be equally boring through medications?

The final word goes to another pediatrician who suggested that we may be sacrificing some of our greatest minds: "If Einstein and Steve Jobs were born in this decade, I am sure they would have been classified as something and maybe started on meds, and then the world would not have seen their genius."

Full discussion of this topic is available here.

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