carey2

   The problems
Our concern here today is not primarily with that small group but with the rest of the up to 20% of our children getting the ADHD diagnosis inappropriately and being treated with cerebral stimulants like Ritalin (methylphenidate). As we all know, the controversy over the management of these other children has reached a critical state. The three main points I would like to make are that: I) The diagnosis itself is seriously flawed; II) This highly flexible diagnosis is being widely misapplied; most children given the diagnosis today do not have the designated symptoms but have instead a wide variety of other problems that are not being adequately diagnosed or managed; and III) A favorable response to the drugs like Ritalin is not proof of the correctness of the diagnosis because almost all children (and adults) function better with drugs that stimulate the brain. The effects are similar to those of another familiar brain stimulant, caffeine, which makes most of us temporarily more alert but does not really solve any of our other problems.
I) The flawed ADHD diagnosis
The ADHD diagnosis was developed by a committee of the American Psychiatric Association in 1980 and has been revised twice since then. The current criteria are that the child must exhibit 6/9 inattention or 6/9 hyperactivity/impulsivity symptoms for 6 or more months, from before the age of 7 years, with impairment in two or more settings (school, home, etc.), and not due to other conditions. Additional assumptions include that: it is clearly distinguishable from normal; it constitutes a neurodevelopmental disability; it is uninfluenced by the environment; and it can be adequately diagnosed by brief questionnaires. We should recognize some of the flaws in the diagnosis:
1) The supposedly abnormal behaviors said to define ADHD are not clearly distinguishable from normal temperament variations. In other words, the criteria for ADHD are also normal but potentially annoying temperament variations, and many children who have them are free from dysfunction in behavior or school performance. By definition half of any population are more active and half are less attentive than average. Where normal leaves off and abnormal begins has never been defined and it is therefore up to the individual observer to decide. The decision that 6 out of 9 of these annoying behaviors constitute brain malfunction has not been validated by any objective tests. There is no objective test of any kind available to establish the diagnosis. Thus, this inadequate differentiation of normal and abnormal has created much of the current chaos by allowing the observer to decide what is abnormal.
2) There is no clear evidence that the ADHD symptoms are related to abnormal brain function. That prevailing assumption is unfounded. Some preliminary brain imaging studies have shown inconsistent differences in children with the ADHD diagnosis but there is no proof that they are abnormalities.
3) The present ADHD diagnostic criteria completely ignore the role of the environment and interactions with it as causes of the symptoms. The problem is seen as being entirely in the child. Not only is this assumption generally unsupportable but also it means that the true complexity of the problematic behavior in the child is likely to be ignored and the management oversimplified.
4) The diagnostic questionnaires for ADHD now in general use are highly subjective and impressionistic. How is one to rate such items as "often talks excessively" or "often has difficulty awaiting turn?" They probably measure parent or teacher discomfort or perplexity as much or more than the actual behavior of the child.
5) There are several other problems with the current ADHD diagnosis: the fact that the most important factors in the children getting the ADHD label today are probably low adaptability and learning problems; its lack of cultural and historical perspective; and the small practical usefulness and possible harm from the label.
II.) The widespread misapplication of the present ADHD label
Quite apart from the inadequacies of the ADHD label itself is the issue of how inaccurately it is being applied today. Recent studies have documented the fact that many professional persons have not even bothered to apply the existing criteria in arriving at the diagnosis. A recent report in the leading pediatric journal described a survey of 401 primary care pediatricians and family practice physicians with a study population of 22,000 children throughout the country. Only about half of the physicians obtained school reports and only 38% used the official criteria in arriving at the diagnosis of ADHD. Another study just published in the principal journal of child and adolescent psychiatry revealed that the administration of methylphenidate to members of a sample of 4500 children in western North Carolina was for most of them not supported by fulfilling the accepted criteria for the diagnosis of ADHD.
III.) The nonspecific effects of Ritalin and other stimulants
The widespread overuse and misuse of Ritalin and other stimulants is well documented and deeply concerning. It has become an easy "quick fix," a substitute for a more adequate evaluation and appropriately individualized management of the child in question. Many professional persons and members of the general public assume that, if stimulant administration leads to an improvement in a child's behavior, this is solid proof of the ADHD diagnosis and good reason to continue giving it. What they evidently do not understand is that, as with other cerebral stimulants such as caffeine, the effect of improved attention is experienced by almost all who take it, including completely normal persons and not just those who have a major difficulty with attention. The popular practice of a trial on Ritalin as a diagnostic measure is, therefore, an irrational procedure.