Friday, April 25, 2014

What It Will Take to Decrease ADHD Rates, Part 1

I have nothing but respect for Dr. Allen Frances, who has done as much as anyone to raise awareness about the dangers of over-diagnosis and medicalizing normality. He had written extensively about the causes behind the rising rates of Attention-Deficit/Hyperactivity Disorder (ADHD). His recent blog post, My Prediction: The ADHD Fad Is About to Fade, surprised me with its optimistic tone.

First, Dr. Frances points out some of the forces that have led to the excessive diagnosis of ADHD and its treatment with stimulants, including big pharma with their lobbyists and deep pockets, perfectionistic parents, recreational users, chaotic schools, and ADHD experts who see only the benefits but not the risks of treatment. He then goes on to list his reasons for "making the long-shot bet that [the ADHD fad] will now begin to fade":
  • The percentage of kids being diagnosed (11 percent overall, and 20 percent of teenage boys) is so absurdly high that reasonable people can no longer accept that the label is being applied with anything approaching sufficient care and caution.
  • The astounding rate of stimulant use (6 percent overall, and 10 percent in teenage boys) shocks us into the realization that we are creating a generation of drugged kids.
  • Studies show that stimulants are much less effective than we originally thought in improving long-term school performance.
  • Some of the leading experts who developed the concept of ADHD and did the best research are speaking out about their surprise and dismay at the way it is now being misused.
  • The press is now on the case, with frequent expos├ęs of careless ADHD diagnosis and stimulant misuse. Alan Schwarz of The New York Times deserves special mention (and a Pulitzer prize) for his vivid, in-depth reporting, but this story is now receiving extensive international coverage and has long legs.
I hope that Dr. Frances is right. However, I am not nearly as hopeful as he is "that parents will now play an active role in curtailing the ADHD fad, protecting their kids from unwarranted diagnosis and potentially harmful medication treatment."

I certainly agree with Dr. Frances's first two points about the "absurdly high" rates of diagnosis and "astounding rate" of stimulant use. However, I am not convinced that statistics like this will lead to people clamoring for change. As the saying (apocryphally attributed to Stalin) goes, "A single death is a tragedy; a million deaths is a statistic." For example, the U.S. locks up far more of its adults than any other developed nation. Yet I do not detect much outrage, except among the minority populations that are disproportionately incarcerated. Even liberal Americans who are upset by the high rates of incarceration would probably not mind if someone who burglarized their house got the maximal sentence. Similarly, the average person reading about the skyrocketing rates of ADHD might be taken aback, but that feeling is unlikely to translate into action, especially if this person's child is falling behind in school or not behaving, and the doctor offers a pill as the standard treatment.

In my own experience, the rising rates of ADHD treatment have just made it a more acceptable topic of everyday conversation, so I sometimes have parents come to me saying that the child of an acquaintance of theirs was transformed by a medication, and now they want the same pill for their child as well. The parents I meet who would prefer not to have their child on a medication by and large know nothing about the rates of ADHD diagnosis and treatment; they just think it's wrong to give their child a brain-altering pharmaceutical.

As for the third and fourth points, I think the experts who are dismayed by the high rates of ADHD are still in the minority, while most ADHD experts tend to have views similar to those expressed in a recent JAACAP editorial:
Importantly, although rates of medication use have increased in the past decade, approximately 70% of children and teens with current ADHD are receiving medication treatment (6.1% divided by 8.8%). Although not every child or adolescent with ADHD requires medication treatment, the study documents a pattern of undertreatment. Because stimulant medication is the core evidence-based treatment for ADHD, undertreatment is an important take-home message from this study.
When academics such as these discuss the studies showing lack of long term benefit from stimulants, they tend to emphasize that that the children and adolescents studied were on too low of a dose (usually blamed on pediatricians and PCPs), or did not take the medication for long enough.

As for Dr. Frances's last point, I hope the media keeps up their coverage. However, I think back to circa 2008, when Senator's Grassley investigations put many big-name psychiatrists on the hot seat, and I wonder how much lasting change resulted from those news reports. It seems that the news cycle moved on, and unethical behavior and conflicts of interest continue to be pervasive amongst the top echelons of medicine and psychiatry.

While I may come across as quite pessimistic here, in a future post I will outline some things that I do think can eventually help decrease the over-diagnosis and treatment of ADHD.