Written by Lawrence Diller, M.D. Lawrence Diller, M.D.
Category: Reviews Reviews
Published: 09 November 2009 09 November 2009
"Diagnosis and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents," Larry S. Goldman, et al, Journal of the American Medical Association, vol. 279 (April 8, 1998), pp. 1100-1107.
This much ballyhooed article is in effect the American Medical Association's statement on the diagnosis of ADHD and its treatment today.
The authors, none of whom are connected with any particular ADHD/Ritalin camp, reviewed 22 years worth of citations in the literature about this subject. Given their methods, it is not surprising that the researchers concluded Although some children are being diagnosed as having ADHD with insufficient evaluation and in some cases stimulant medication is prescribed when treatment alternatives exist, there is little evidence of widespread overdiagnosis or misdiagnosis of ADHD or of widespread overprescription of methylphenidate by physicians. The findings were trumpeted both by CHADD and Novartis, the maker of Ritalin (who sent the article with a cover letter to most pediatricians), as organized medicineís support for their position that ADHD is a medical disorder and that Ritalin is the most effective treatment and is not overprescribed.
I have several criticisms of the report. Mark Wolraichís study of the practices of pediatricians from two mid-western towns is mentioned in the report (they incorrectly described it as a national study). They noted that only 3/4's of those children diagnosed by their doctor met criteria for diagnosis. Only half used teacher reports as part of their diagnostic evaluation. Michael Reiffís survey of 600 pediatricianís and child behavior specialists showed that while 90% of the physicians felt they used a regular set of diagnostic criteria for ADHD, researchers found that only 8% of the doctors surveyed used methods that could be replicated. Unfortunately in the real world of medical practice, ADHD remains a diagnosis very much in the eye of the beholder (see Chapter Three of Running on Ritalin for a much more detailed critique).
The AMA researchers acknowledge that published prevalence rates of ADHD vary widely (1.6% to 16%) . Relying primarily on Daniel Saferís data which follows trends in Baltimore County only, the researchers report that national rates of Ritalin use have not risen especially dramatically during the 1990s (despite a 700% increase in production) nor are they overly high given the prevalence of ADHD. They overlook the tremendous variation in Ritalin usage throughout the country and within individual states. Relying on ARCOS data from the DEA there is a six-fold difference between the highest (currently New Hampshire) and the lowest (perennially Hawaii) states in per capita use of Ritalin. There are twenty-fold variations within states with the most white, most affluent areas having the highest rates of Ritalin use and the most African American, poorest areas having the lowest rates. District-wide, 17 % of fifth grade boys in Virginia Beach, Virginia were found to be prescribed Ritalin in 1995-1996. Clearly there are areas of over prescription of Ritalin and areas, especially where there are minorities, where Ritalin is rarely prescribed.
The AMA report will be used to justify current diagnostic practices and treatment. Steady as she goes. No rocks ahead. Even in accepting Ritalinís short term effectiveness it still is not the moral equivalent to addressing the social, economic and political factors involved in the generation of childrenís behavior and performance problems.