May 16, 2000

Why Guidelines for Attention Deficit Won't Work

The American Academy of Pediatrics (AAP) has just released in the current issue of the journal, Pediatrics, its long awaited guidelines for the diagnosis and evaluation of Attention Deficit-Hyperactivity Disorder (ADHD), a problem, primarily in children, of excessive impulsivity, inattention and activity. Use of Ritalin, the controversial stimulant drug for ADHD has soared over the past ten years and the AAP guidelines are meant to bring some sense to the ADHD diagnosis and reassure an uneasy public about the overprescription of Ritalin.

Of late Ritalin has been in the news virtually every week. In February a study in the Journal of the American Medical Association found increasing use of Ritalin in toddler age children. Two weeks later Hillary Rodham Clinton announced her concerns about kids taking Ritalin. As a result a White House conference on psychiatric drug use in children is planned for this fall. Next came news that one in five college students are snorting Ritalin for power studying or just getting high. Finally, a medical examiner in Pontiac, Michigan announced that he had found pathological heart changes linked to long term, doctor-prescribed Ritalin use in a fourteen year old boy who died suddenly in March. Its meaning for the nearly four million children taking Ritalin is unclear but worrisome.

Since ADHD is the overwhelming reason for using Ritalin, prescription rates for the drug are a marker for the diagnosis. The Drug Enforcement Administration (DEA) keeps close tabs on Ritalin and its amphetamine sisters, Dexedrine and Adderall. DEA data show that Ritalin prescription use varies widely within the U.S. New Hampshire and Vermont use four to five times per capita more Ritalin than Hawaii. Community rates within states vary even more, as much as twenty fold. Nationally, African and Asian American children are conspicuously underrepresented while one in five fifth grade white boys take Ritalin in certain Virginia school districts.

The subjective nature of the ADHD diagnosis is one of the reasons for the huge variability in Ritalin treatment. After hearing two days of expert testimony in front of the National Institutes of Health Consensus Conference on ADHD in 1998, the only pediatrician on the jury panel declared the diagnosis to be a mess. Another prominent pediatric researcher has publicly called it an embarrassment.

Neither denies the existence of ADHD. Simply, the current concept of ADHD, as determined by American psychiatry in the Diagnostic Statistical Manual (DSM-IV), and the practical realities of frontline primary care medicine create major confusion and contradictions on who should and shouldn't get Ritalin.

The AAP's efforts to bring order to this disorder simply won't work. First, the decision to use DSM criteria for ADHD diagnosis poses problems. According to the DSM a child either has or doesn't have ADHD. Black and white distinctions can be useful in research, but do not reflect the gray zone of ADHD in the real world where most of children being evaluated act only intermittently impulsive or are inattentive only in school. Many of these kids nevertheless get Ritalin. That DSM doesn't work for clinicians is reflected in a survey of nearly five hundred pediatricians, where less than one in ten used the DSM as their main criteria for diagnosis. Rather than arguing which children have or do not have ADHD it would be far more useful to decide what services or treatment each child needs. This kind of a needs based system is already in place for the treatment of mentally retarded children. Such a shift would be welcome for children's behavior and school problems also.

Furthermore guidelines, in general, do not influence doctors' practice very much. Doctors complain that the guidelines interfere with their clinical judgment. But the AAP guidelines, like many others guidelines prepared by professional organizations, do not acknowledge perhaps the greatest factor affecting doctor and patient decision making -- money. In primary care economics overhead typically runs about 70% of gross income. Many doctors believe they would go broke if they devoted the time necessary to perform the evaluation for ADHD recommended by the AAP -- interviews with the parents and child, communicating directly with the teacher, ruling out other behavior and learning problems - unless reimbursement for their time greatly increased. This is unlikely in the era of managed care medicine which has only exacerbated the economic pressures on doctors to act quickly. And parents, too, are reluctant to spend their own money for an adequate evaluation.

The common response of pediatricians and family doctors to reports of ADHD behavior at school or at home is, Let's try the medication and see if it works. Such practice while saving time and money belies Ritalin's specificity for treating ADHD. Everyone, child or adult, ADHD or not, will focus better on tasks they find boring or difficult when they take Ritalin. The drug works on the short term but is not a moral equivalent of or substitute for better parenting and schools for children. In our hurried, performance driven society, performance enhancers, like Ritalin, for the truly disabled child or for those struggling in the gray zone, will be attractive as a less costly faster alternative to smaller class size or teaching parents more effective approaches with their children. More tolerance for the likes of today's Tom Sawyers and Huck Finns would also help slow the ADHD/Ritalin epidemic. The AAP guidelines are well meant but are not going to change much in the real world of children and their doctors. Only major shifts in our social values or perhaps more reports of sudden death in children on Ritalin are likely to affect the way we address and treat our children's behavior, personality and performance problems.

(This article was submitted in part as testimony to the U.S. House of Representatives' Subcommittee on Early Childhood, Youth and Families at a hearing entitled, Ritalin Use Among Youth: Examining the Issues and Concerns, on May 16, 2000.)


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