Charges of Overdiagnsos, Overmedication of ADHD Are Exaggerated, Study Shows

Reports of the overdiagnosis of attention-deficit/hyperactivity disorder (ADHD) and overprescription of stimulants appear to be exaggerated, according to an article in the April 7 issue of the Journal of the American Medical Association (JAMA).

"Epidemiologic studies using standardized diagnostic criteria suggest that 3 percent to 6 percent of the school-aged population may have ADHD. The percentage of U.S. youth being treated for ADHD is at most at the lower end of this prevalence range," the authors state.

In some cases, however, a child's behavior in the physician's office or the child's own observations may lead to a missed diagnosis, while overreliance on parental reports of abnormal behavior alone may lead to overdiagnosis, add the authors.

The researchers reviewed studies published between 1975 and March 1997 about school-aged children with ADHD and the use of stimulants to treat ADHD, including the most commonly prescribed drug, methylphenidate.

Lead author and general psychiatrist Larry Goldman, M.D., told Psychiatric News, "The article repeatedly makes the point that ADHD is a real disorder and there is an amazing amount of good research that is comparable to or exceeds that of any other medical condition."

Goldman is the director of the Illinois Department of Mental Health in Chicago.

"There is little evidence to suggest that stimulant abuse or diversion is currently a major problem, particularly among those with ADHD. However, research trends suggest that this could increase with the expanding production and use of stimulants," the authors warn.

For example, between 1990 and 1993, the amount of methylphenidate produced per 1 million patients increased from 1.98 g to 2.53 g, which is a 27 percent increase.

"Clinicians need to be mindful of the risk of abuse and diversion. In addition to keeping careful records of medication prescribed, they should consider alternatives to stimulant use in high-risk patients who, for example, have a substance abuse disorder or a bipolar or conduct disorder," the authors recommend.

Goldman added, "It is clear that there are high rates of psychiatric comorbidity with ADHD that a little Ritalin is not going to solve. In more complicated cases, other specialists including child and adolescent psychiatrists should be consulted."

The AMA also adopted as policy last year the following recommendations by its Council on Scientific Affairs, whose members include the authors.

• The AMA encourages physicians to use standardized diagnostic criteria for ADHD, such as APA's DSM-IV, as part of a comprehensive evaluation of children and adolescents.



• The AMA encourages the creation and dissemination of practice guidelines for ADHD by appropriate specialty societies and their use by practicing physicians.



• The AMA encourages medical schools, residency programs, medical societies, and CME programs to increase physician knowledge about ADHD and its treatment.



• The AMA encourages individualized therapeutic approaches including pharm-aco--therapy, psychoeducation, behavioral therapy, school-based interventions, and psychotherapy to children diagnosed with ADHD.



• The AMA encourages physicians and medical groups to work with schools to improve teachers' abilities to recognize students with ADHD and appropriately recommend that parents seek medical evaluation for children who may have ADHD.



• The AMA reaffirms its policy to work with the FDA and DEA to ensure that appropriate amounts of methylphenidate and other Schedule II drugs are available for clinically warranted patient use.