Rates of ADD in kids have tripled in just 15 years. This astounding jump has three possible explanations: 1) ADD was previously way underdiagnosed so that increased awareness accounts for the bulk of new cases; 2) ADD is now being way overdiagnosed, a fad greatly promoted by drug companies; or 3) some combination of both 1 and 2. The question is hugely important for the more than 9 percent of kids who now qualify for the diagnosis (almost half of whom are on medication) and for their parents, family members and teachers.
ADD has clearly become a public health problem. It is much less clear the degree to which the increased rates are real vs. being a manufactured fad. We have no definitive way to give precise weights to the three options or to determine what is the true rate of ADD. Certainly, some of the increase is due to better recognition of real cases. But the circumstantial evidence strongly favors the hypothesis that we are also in the midst a fad largely engineered by drug company salesmanship.
It is no coincidence that rates began skyrocketing immediately after two unrelated events that occurred almost simultaneously in the late 1990s. First, new drugs for ADD were brought to market that were no better than the old drugs, but they were lots more expensive and provided a rich profit incentive for aggressive marketing. Second, FDA deregulation freed drug companies to pursue unrestrained direct-to-consumer multimedia advertising. The companies quickly determined that peddling the ADD ill was the royal road to expanding the market for their new expensive pills.
Attention deficit disorder consists of nonspecific symptoms and behaviors that are widely distributed in the general population: poor concentration, distractability, impulsivity, and hyperactivity. At the poles, the diagnosis is easily made. At one end, the kid who presents with classic early onset, severe ADD is unmistakable. At the other, most kids clearly do not have ADD. But in between (at an arbitrary, flexible, fuzzy and heavily-populated boundary), it is tough to distinguish clinical ADD from normal kids who are no more than extremely frisky and difficult to manage.
The epidemic started precisely when aggressive drug company marketing succeeded in "educating" and sensitizing doctors, parents, and teachers to spot ADD in kids previously considered to be on the normal side of the spectrum's boundary. Extreme diagnostic exuberance surely picks up previously missed true cases who need medical attention, but it also captures many false positives who have been loosely diagnosed and unnecessarily treated.
The drug company cause has been furthered by heavily subsidized thought leaders (usually psychiatrists), by physicians (especially in primary care) who are too free in diagnosis and treatment, and by harried parents and teachers trying to figure out how best to help and manage their difficult children. The trouble is that the medication is often prescribed carelessly and without clear indication -- causing troubling side effects for the individual and troubling societal costs. The overdiagnosis and loose prescription habits have fostered a thriving secondary market for pills that were originally intended for ADD but are instead illegally diverted for recreational use and/or performance enhancement. Remarkably, one-third of college students now use stimulants. Things have gotten so out of hand that two federal agencies are now tussling over control of stimulant distribution: The Drug Enforcement Agency has clamped down on the production of stimulants, causing the Federal Drug Administration to express concern that not enough pills are available for legitimate use.
What started as a childhood epidemic is now also spreading rapidly to adults. ADD promises to become a very popular diagnosis in this new market because virtually everyone would like to concentrate better and be less distractable. And the differential diagnosis in adults is particularly difficult because nonspecific ADD-like symptoms accompany virtually every one of the psychiatric disorders. Far too often, ADD is becoming a common tag along diagnosis -- especially used by clinicians prone to prescribing polypharmacy drug cocktails. Adult ADD should be diagnosed only when symptoms are clear cut, definitely impairing, and had their onset in childhood. There is no such thing as late onset ADD.
So, how can we sort things out -- i.e., succeed in reducing the overdiagnosis of ADD without risking under-recognition and undertreatment? Dutch psychologist Laura Batstra has developed an effective, common sense approach aimed at simultaneously accomplishing both goals. She recommends the stepped diagnosis of ADD, accompanied by stepped treatment. The management of the milder presentations of hyperactive and inattentive behaviors starts with watchful waiting, normalizing, parent and teacher training on managing difficult kids, and simple behavior modification and environmental manipulation -- all done before making the confirmed diagnosis of ADD. Only in cases where this approach proves insufficient is definitive ADD diagnosed and medication treatment offered.
Dr. Batstra states:
"A medical approach to ADD type behaviors is warranted only for the minority of kids who have really severe and persistent concentration problems and disruptive behaviors. Most kids respond to simpler methods and don't need an ADD diagnosis. Medical treatment should be offered as the last, not the first step -- clearly necessary for those who really need it; but unnecessary and even harmful for those who don't."
The stepped approach makes great sense. People get just the amount of treatment they really need -- not more, not less. It also includes the family in decision making about the types and intensity of approach most likely to be helpful. What is my advice if your child is already taking ADD medication? If he or she is a classic case and/or is doing well, don't rock the boat. But suppose your child has only mild or atypical problems, or is not doing well, or has disturbing side effects -- then get second or even third opinions. Do nothing unilaterally to change the treatment regimen.
The ADD proposals being considered for DSM 5 are perversely wrong-headed. Rather than attempting to contain a runaway ADD epidemic, DSM 5 would further fan its flames. Diagnostic thresholds would be dropped precipitously. Dr. Batstra worries that: "DSM 5 will further inflate the already too broadly defined category of ADD, especially for adults. This will lead to even more misdiagnosis -- with consequent misuse and illegal use of stimulant drugs, stigma, needless expense, and resource misallocation."
DSM 5 is not official yet, and there will soon be an opportunity for the public to register its concerns and objections. The DSM 5 leadership has to date soldiered on stubbornly defending indefensible positions. But I hope that the reckless ADD proposals receive enough searching scrutiny to bring DSM 5 to its senses. Otherwise, the diagnosis of ADD will seem even more ubiquitous and the misuse of stimulant medication even more routine.
Allen Frances is a professor emeritus at Duke University and was the chairman of the DSM-IV task force.
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