November 5, 2013

expert reaction to analysis paper on whether ADHD is being over-diagnosed

Scientists writing in the BMJ made the case that a broader definition of attention-deficit/hyperactivity disorder (ADHD) has contributed to a steep rise in diagnosis and prescriptions, particularly among children.

Prof Anita Thapar, Professor of Child & Adolescent Psychiatry Section, Institute of Psychological Medicine and Clinical Neurosciences and MRC Centre for Neuropsychiatric Genetics and Genomics, Cardiff University, said:

“It is important to highlight that properly diagnosed ADHD is a serious disorder with major consequences. Although this paper focuses on ADHD, a disorder that can provoke strong opinions, the issues discussed here are applicable across medicine; for example the same would apply to many other disorders such as Autism where there is not an immediately obvious clear cut boundary between ‘higher levels than most people’ and ‘clinical disorder’.

“The key messages people should take from this are:

• ‘Make diagnoses with care and caution’.
• ‘Start with simple, low risk treatments for mild problems and only move to more intensive, costly and higher risk treatments (e.g. medication, intensive school support) for those more severely affected’.

“The authors highlight that guidelines on ADHD treatment in the UK adopt this approach. The key risk of this press release is if everyone assumes that over-diagnosis and treatment are a problem in all contexts-that is in all countries and across all clinics. Most of this article is what sensible clinicians and hopefully the general public realises and need to be aware of. The statement that we are no closer to understanding causes and the neurobiological underpinnings of ADHD is, however, not correct. We certainly need to know more about ADHD – but to say we have learnt nothing about causes is factually incorrect.”

Prof Ilina Singh, Professor of Science, Ethics and Society, and Director of Research at the Department of Social Science, Health and Medicine at King’s College London, said:

“The authors raise important, but familiar, criticisms about the ADHD diagnosis. Given the harms of stigma and misunderstanding that the authors themselves raise, it is important to take care when making generalized claims about the drivers of ADHD diagnosis. In many regions, under-diagnosis and under-treatment of ADHD are also a significant concern. We need an approach to ADHD that addresses both the costs of under- and the costs of over-diagnosis and treatment of ADHD in a balanced way.

“The proposal for a stepped intervention doesn’t take us beyond what NICE already recommends for ADHD.  Parent training programmes are a difficult undertaking for many families. We need to develop a range of evidence-based treatment options that engage the broader social ecology in which children develop.”

Prof Eric Taylor, Emeritus Professor of Child and Adolescent Psychiatry, Institute of Psychiatry, King’s college London, said:

“It is incorrect to suggest that the situation in the UK is similar to that in The USA and Australia. There are very large international differences. The NHS applies strict criteria, and NICE already recommends careful specialist assessment and giving psychological treatments priority over medication in most cases. Probably too few children here get help. In the UK and Netherlands, the increase in stimulants being described was from a very low base rate:  4.8 per 1,000 schoolchildren in UK, 2.6 in Netherlands; by comparison with around 70 per 1,000 in parts of the USA. The increase in the UK follows an increased ability in the medical profession to recognize ADHD; but all too many children with severe problems still go untreated.”

Prof Barbara Sahakian, Professor of Clinical Neuropsychology, MRC/Wellcome Trust Behavioural and Clinical Neuroscience Institute (BCNI), University of Cambridge, said:

“I suspect that the reason for increased prescriptions of Ritalin and similar medications for ADHD has to do with better detection of the condition in children and the recognition that 50% or more of children with ADHD still have it as an adult. Therefore, whereas together with Dr Jonathan Dowson we set up the second ADHD clinic for adults here in Cambridge in about 2002, there are now many of them in the UK, most recently with the launch of the CPFT Adult ADHD clinic. In addition, I am sure there is also a grey line where some consultants would prescribe medication whereas others would deem the symptoms not sufficiently severe to warrant Ritalin.”

Prof Philip Asherson, Professor of Molecular Psychiatry at the MRC Social, Genetic and Developmental Psychiatry centre at the Institute of Psychiatry, King’s College London and consultant psychiatrist at the Maudsley Hospital, said:

“This paper makes a set of arguments relating to the inappropriate use of the diagnostic criteria for ADHD. I would see their arguments as largely correct, and does explain the potential dangers of over diagnosis of ADHD. However, it is important to clarify that they are not against the diagnosis and treatment of children with ADHD when this has been properly evaluated by specialists and a stepped care approach taken to mild or moderately impaired children where there is no immediate urgency to treat with medication because they are not severely impaired (needing more urgent treatment, with medication).

“I am not entirely convinced that the changing criteria represent the problem – because the criteria seem to more accurately represent what we know about the onset and course of the disorder from childhood through to adulthood. Furthermore the criteria for impairment are not weakened in DSM5 as suggested by these authors.

“However, there is a problem if the criteria are not properly applied by specialists, as advice in the UK NICE guidelines. Furthermore, the stepped care approach is a good once and is similar to that recommended by NICE – in other words it is common sense to take a cautious approach to the use of medication, particularly in young children, when there is no severe immediate need to treat urgently. Their suggested approach is sensible and aimed at accurate diagnosis and identification of children that require referral for diagnosis and treatment by specialists. Specific comments;

1. Prevalence rate increases may mean different things in different countries. Currently in the UK this most likely represents an increasing awareness of those that require treatment. In some parts of the US prescribing among primary care in some cases appears to be higher than indicated by the known prevalence and severity of the disorder.
2. I agree that the US approach of using primary care to diagnosis ADHD is not a good one and leads to over diagnosis. Note, that this is not a problem with the criteria but how they are applied. The same can be said for the over diagnosis of depression and use of antidepressants.
3. The problems listed under psychological harms all look like the consequences of ADHD rather than caused by the label.
4. The link of user groups to Pharma seems a little unfair. The user groups are struggling to do the best for their children and I see no evidence that their views are influenced by Pharma.
5. I agree with the assertion that clinicians will differ in their views in what level of symptoms and impairments is needed to establish the diagnosis – this is because ADHD is in reality a quantitative trait. When severe the diagnosis is easy to establish but it is less clear in its milder forms and simple interventions could still make an impact. Clinicians need to be aware of labelling normal developmental change, while at the same time being aware that ADHD can be a serious condition that requires treatment. The authors provide a sensible approach to deal with this problem in children.”

‘Attention-deficit/hyperactivity disorder: are we helping or harming?’ by Rae Thomas et al. published in BMJ on Tuesday 5th November.