Sunday, February 19, 2006

Won't some child psychiatrists come forward, to answer this post...and this one? I've posted on adult ADHD before, and my views haven't changed. (These are my personal views. I can't speak for my profession.)

I note Dr. McClellan's comments, in this online discussion at WAPO:
Alexandria, Va.: Not only has there been a rise in children diagnosed with Bipolar but also with ADHD. I'm not sure I understand why there has been an increase? Were these same behaviors not present 30 years ago and now are all of a sudden rearing its ugly head and if so, what type of environmental, social, emotional changes are causing such behavior? I believe the majority of the children are misdiagnosed and it is really just big pharmacutical businesses getting big bucks at the expense of our children.

Jon McClellan: This is a very good question, but complicated. In part I think our culture has changed about how we view mental illness, and in some ways the definition of what is normal has narrowed. Expectations for kids has increased. In a world dominated by technology and computers, being able to pay attention and focus is a much more necessary trait. Some of this shift is not necessarily bad. For example, it used to be more acceptable for kids to be physically aggressive, bullies were considered part of life, etc. What used to be "boys will be boys", in many ways is now recognized as a problem because of the impact such behaviors might have on others. However, that doesn't mean such behaviors are the same as having a mental illness.
I don't think this is an organized plot by the drug companies, yet they clearly benefit. Their marketing reflects what we want as a society; better moods, better sex, better social functioning, etc. The difference between treating an illness versus enhancing skills or quality of life has become blurry.
Here is Dr. Nancy Andreasen, no less, telling New Scientist:
In the US, at least, we have had some serious over-prescribing for conditions such as attention deficit disorders...
Dr. Gelwan, in his excellent blog, notes:
Stimulants, on the other hand, are superfluously prescribed for a condition that is vastly, epidemically, overdiagnosed in a loosey-goosey, unsystematic, irresponsible way. Unlike antidepressants, anyone almost anyone prescribed a stimulant like Ritalin or Adderall, ADHD or not, will feel better and the shoddy diagnosis becomes a self-fulfilling prophecy because a medication is seen to have caused improvement. Again, unlike antidepressants, the drugs have enormous potential for abuse, diversion to the street trade, and addictiveness, because they feel so good to use. Tolerance accelerates use and creates escalating need for higher and higher doses over time. And the cardiovascular consequences, including sudden death, are far from trivial risks.
I'm no ADHD expert. My attentionally-challenged patients tend to have diagnoses like depression, dementia or delirium. Do any child psychiatrists blog...or read blogs? They seem far too busy for such things. Their attention is focused on issues like this and this, as well as ADHD (and much more: see here).


Blogger Joel said...

This is interesting in light of some things which happened to me just yesterday.

First, someone (a fellow bipolar) approached me about something I had done two weeks ago. I listened and apologized. I said "I was in hypomania, but I want you to know that even so I take responsibility for my actions. Just because I am fogged in, doesn't mean that I can't hear foghorns."

Second, I had a run-in with a bipolar/ADHD. I don't know if the disease exists. What I do know is that this guy is a jerk. He mocks me and my feedback in group. He tried it yesterday and I put him in his place. He then went and whined about how he really liked me, how he wasn't aware of what he was doing.

I thought bullshit. Didn't call him on it (let him string out his own rope) and ignored him.

It's possible that he's jealous and that he is trying to undermine me. I've toyed with the notion that he suffers from adult borderline. And there's the possibility that he's just an asshole who uses his ADHD diagnosis to persist in being an asshole.

It's hard enough dealing with the suffering bipolars than to face a guy like this who does not want to improve his behavior. I can tell you plenty of stories about real bipolars (and I think what happened thirty years ago was that a lot of people just flew under the radar). This fellow never shares anything meaningful. He claims the drugs have managed his moods entirely. And he complains about fake bipolars a lot.

What could I be seeing here? Sometimes I think "a fraud".

11:44 AM  
Blogger Joel said...

I opened an open thread on these issues:

12:15 PM  
Anonymous DrumsNWhistles said...

Why does it always seem to come down to 'either/or'? Is it true that stimulants may be overprescribed? Probably by some doctors, and probably not by many others.

Here's what I'm getting out of the debate, as an adult with ADHD and the parent of a kid on ADHD (and I can show you many photos of both of us being genuinely happy like the Concerta photos....): It's time for the diagnostic standards to be overhauled and quantified. It's time for a requirement that the diagnosis be made by a mental health professional and not a family doctor.

The sooner that the shouting stops about how stimulant medications are evil/not evil and starts to become a dialogue about how best to identify those who do respond to stimulant medications and help others who do not, the better.

12:17 PM  
Blogger Joel said...

This comment has been removed by a blog administrator.

12:23 PM  
Blogger Joel said...

Just another thought: I looked over the diagnostic criteria for ADHD at this URL:

I saw many of my own "symptoms". But I thought: "The problem here is that it only focuses on schoolwork. I suffered from bipolar disorder and I suffered from abuse both at home and at school. Any of these would suffice to explain my erratic performance. Is ADHD putting too much of the focus on the student and not enough on issues such as domestic abuse and bullying in schools?"

12:25 PM  
Anonymous difficult patient said...

I'm just a parent, but these are my thoughts on the subject:

*sigh* I am so tired of people (in general) tossing around diagnostic terms and running this topic into the ground while some parents like me have to deal with severe symptoms displayed by a child they love.

Who cares what the diagnosis is? I know there is a problem with my son and am doing everything I can to help him with it. I hate the meds; he hates the meds, but right now they are absolutely necessary. We don't put up with excuses in our household for bad behavior--we have to deal with it. People are good at avoiding families like ours--blaming the parents, offering TONS of bad advice, etc. when they have absolutely no idea what it is like to walk in our shoes. Remember, there is still a small percentage of us out here with a real medical problem that we are dealing with, and judging us doesn't help the situation at all . . .

For those who really want to help someone who has a child diagnosed with ADHD, respect their wishes to exclude artificial colors/flavors from their diet (or other food items for that matter) and offer to babysit once and a while so they can have a break!

Okay, I'll get off my soap box now--I'm a little sensitive when it comes to this subject, and it seems to be the topic of choice on several blogs.

12:33 PM  
Blogger Flea said...

Could be the child psychiatrists are too busy seeing patients too blog.

What's our excuse?



2:37 PM  
Anonymous Anonymous said...

I know my son's pdoc is alway WAY busy. It takes at least two months to get into her.

7:35 PM  
Blogger jw said...

There's a lot of meat on this bone.

I'd bet there is heavy over prescription for ADD/ADHD/BP and other psych illnesses. To blame any one single part of the psych system would be wrong.

I see it as a system wide error. Also, one cannot begin to understand the whole thing without bringing in misandry; for in misandry we see at least two of the root causes of over prescription.

Like any complex thing within our extremely complex society there are direct, proximate and root causes for prescription drug use. We need to take the time to work out the root causes of the thing.

1:05 AM  
Anonymous Cheryl Fuller, Ph.D. said...

I often wonder is one force behind the narrowing of the range of normal isn't that parents tend to think they live in Lake Wobegon, where all the children are above average. What better than a disorder to account for one's more average than not child?

7:54 AM  
Anonymous John M. Grohol, Psy.D. said...

It's so easy to be nonchalant in throwing out terms like "overdiagnosis" just because there's been a large increase of diagnoses of these disorders. Frankly, if you look across the board of all psychological disorders, you'll find a similar increase in the amount of diagnoses. A simple MEDLINE search shows a variety of research on these issues, including fairly good studies that show both an overdiagnosis and an underdiagnosis of ADHD.

The key is not to harp on such things, since they are easily answered by empirical research, but instead ensure that as a clinician, you're doing the best job possible to ensure accurate and reliable diagnoses. The biggest issue with ADHD diagnoses, in my experience, has been that professionals aren't ensuring the behavior occurs in multiple settings. A child who is "under performing" in a school setting but not in any other setting doesn't qualify for this diagnosis.

Which is likely caused by general physicians and family docs and such doing the initial (and often, the final) diagnosis when ideally such cases should be referred to a mental health professional.

8:52 AM  
Blogger Joel said...

difficult patient: There's very good reason to care what the diagnosis is. If you prescribe the wrong drugs, you don't help the patient.

My problem with ADHD is that it appears to cover a lot of symptoms that only appear in school. They bother the teachers. There may be something about them, but I can also see that they can be neatly accounted for as bipolar disorder.

Judging from my informal sample, ADHD is the most common misdiagnosis for bipolar disorder. All of the symptoms accompany either depression or mania.

There may be another problem behind the symptoms -- a different disease. But I haven't heard of any studies isolating what is going on in brain with ADHD. If you know of any, please let me know.

9:39 AM  
Anonymous John M. Grohol, Psy.D. said...

Umm, yeah... Except that docs prescribe the "wrong" drugs regardless of the diagnosis, since we have no mechanisms in place to gauge whether the drug is working or not (except the patient's self-report).

I can assure you, in people with ADHD, it affects their progress and abilities in more arenas than school, and I believe the criteria accurately reflect that. What's not reflected is people's focus on school performance when more than one environment is needed to be observed in order to make an accurate diagnosis. People short-cut the criteria, make a sloppy diagnosis (for more numerous reasons than just the criteria themselves), and are surprised when people start talking about "over-diagnosis" of this issue.

This is indeed a complex problem and there's no easy or simple solution to the issue.

11:22 AM  
Blogger Dave_MSW said...

I think part of what makes this dilemna complicated is the assumption that medication must be considered from the very beginning of treatment. There is growing literature that says behavior therapy may be an effective treatment of ADHD. Given concerns about the long term effects of the medication and misdiagnosis, I think the standard of care may best be to treat with psychotherapy first, then if all else fails, consider medication. Then it is not so complicated right away. Of course such a standard would have to review all possible exceptions.

5:41 PM  
Anonymous difficult patient said...

Joel--Doctors don't agree on the diagnoses. One doctor sees Aspergers, another sees ADHD, and a third sees bipolar . . . Symptoms tend to overlap, and there are no blood tests. This is why my empasis is on the symptoms and not the diagnosis.

8:30 PM  
Blogger Bonita said...

It seems like once a generation of parents get paid SSI benefits to care for a 'disordered' child, they seem to have more of them, get a larger check, and continue to make sure their lifestyle perpetuates the disorder. I see a scam here - lets stop subsidizing parents with money and get them to employ better child-rearing methods and to have healthier lifestyles. It's a multi-faceted issue, and I believe the drug companies perpetuate it, schools demand drugged kids because teachers don't want the disruption, and parents aren't fully present with a workable child-raising routine that involves consistent boundaries and less self-indulgence. 60 years ago kids worked their tails off on the farm; they didn't have the energy left for an elitist diagnosis. Our times have spawned this phenomenum.

3:11 PM  
Blogger Joel said...

I never said that I denied symptoms or that most ADHD patients have real problems. Let's get that straight.

And I am still waiting for someone to explain the mechanism of ADHD in the brain. We can do that for depression, schizophrenia, and bipolar disorder. Is there research showing what it does?

And how is a stimulant supposed to curb hyperactivity?

3:57 PM  
Anonymous Anonymous said...

I'm staying anonymous here, as I blog under my real name and I'm talking about family members.

Bonita, you said, "It seems like once a generation of parents get paid SSI benefits to care for a 'disordered' child, they seem to have more of them, get a larger check, and continue to make sure their lifestyle perpetuates the disorder. I see a scam here -"

That's just downright offensive, Bonita. Six of my first- and second-degree relatives (three children, three adults) are now on medication for attentional and executive-function problems. The children are thriving. And Bonita, the adults are all taxpayers.

What makes you think that kids get SSI benefits for attentional difficulties? Prove your assetion.

9:34 PM  
Anonymous Perplexed said...

Hmm, I can not comment about the US but it is possible to qualify for Disability Living Allowance and various other benefits in the UK for attentional difficulties if they have a diagnosis of ADD, ADHD etc. A recent article entitled 'Naughty Child Syndrome' costs taxpayers 170 million (good to see a complete lack of bias and a use of neutral rather than weasel words) claimed the following:

"[Parents] can pick up a disability living allowance of up to £5,350 a year, a carer's allowance of up to £2,376 a year and a disabled child tax credit of £2,300 a year."

I should point out that the above is per child. There have been several notorious cases in the UK where families were in receipt of somewhere between 20,000 to 50,000 pounds per year in various allowances, depending upon the number of children diagnosed within the family, and the level of allowance for which they qualified.

I don't know how these allowances are calculated. I've no idea if they offset any additional costs involved in having a family member with these diagnoses.

10:21 AM  
Blogger BiPolar Guy said...

"our definition of normal has narrowed"

I don't entirely agree with this. In many ways our definition of normality has expanded, become more accomodating and inclusive.

11:01 PM  
Blogger a psychiatrist who learned from veterans said...

I practice psychiatry. I rather wish I would hear, 'There is an overdiagnosis of obsessive compulsive disorder' because when I hear about someone's proper global imperative frequency, for ADHD, I feel I'm in for a beating. One could discuss the proper way to study this issue and I wish Dr. Andreasen would address her efforts to that; no study seems to come up in these discussions. Rather like SUVs or Mexicans etc..

I was asked once to do an evaluation on a fortyish year old man to get money back from a truck driving school. Allegation: 'He was not qualified to drive a truck and the school should have know it.' History: He had been passed from grade to grade through high school in a country school with little learning. Went to the Army. No 'mental problems,' got through 12 years. You're sargeant material then, have to supervise others. Apparently could do simple task assigned but no more. Discharged from Army then. Articulate in an ordinary conversational way. Particular criteria for ADHD. He had gone to the driving school sometime after the Army, taken their course. It took him 3 attempts with their cramming and coaching with him to finally get him over the CDL paper test. He went to get a job. Test ride with a boss. Short ride. As the potential boss is getting out of the cab, he says, "You should never be in a truck." There was some consternation when my diagnosis was that he had ADHD, the perception of which and rejection from training for, should not be at the feet of the driving school. The overdiagnosis of ADHD at least hasn't been a clear, generation long epidemic then in my experience.

5:25 PM  
Blogger Kim said...

My now 22-year-old nephew always had trouble concentrating. He managed to make it through grade school but his GPA in high school was very low. He felt stupid and was becoming depressed and frustrated.

And this was a model kid growing up. Polite, well-behaved, his mom said, in retrospect, all she could see was some impulsive behavior. This was NOT "naughty child syndrome".

His ADD medication helped him focus so well that his GPA went from a D to a B+ average within a semester.

I've seen it happen in my own family.
It is a real diagnosis and I saw the medication have a profound effect on his life.

This year he graduates from college with a BA and will be married.

It may be over-diagnosed, but in some cases, the diagnosis is correct.

12:41 AM  
Anonymous Donna said...

It maybe diagnosed propery, but what other options were tried first other than prescription medications? Things like diet or seeing if there is a possible allergy, or even just letting the children out to play.Our brains are made to pick up backgound stuff like noises and such, mainly for our own protection, like we used to live as hunter gatherers. Our brains haven't evolved much since then, but our technology has.

And what of those with seizure and heart and circulatory systems and those who are pregnant? do they and those who are unborn suffer from the side effects of the ADHD treatments? Alot of those who iether make the products,(Ie drug companies) or the Goverment programs,(ie FDA), say the benefits are worth it than the cost of the side effects. Tell that to those families who lost their sons, daughters and sons and daughters thatwere on the treatments and those who have yet to be born.You will have a strikingly different point of view.
Someteachers medicate because of nochild left behind and larger class sizes stresses them out. Parents drug their children because the yare themselves too "frazzled" to dea lwith normal misbehavior. the children lose out in both arenas. and it is sad.

10:22 AM  

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