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"Put it into historical context. The use of sacramental vegetables has gone back, back, back in history to shamans and the Hindu religion and Buddhist religion. They were using soma. It's an ancient human ritual that has usually been practiced in the context of religion or of worship or of tribal coming together. I didn't pioneer anything. The use of psychedelics for spiritual purposes was started in the 50s by Allen Ginsberg and William Burroughs."—Tim Leary

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Evidence of Overdiagnosis and Overuse of Medication
Authors:
Gretchen B. LeFever and Andrea P. Arcona - Center for Pediatric Research, Eastern Virginia Medical School and Children's Hospital of the King's Daughters
David O. Antonuccio - University of Nevada School of Medicine, Veterans Affairs Sierra Nevada Health Care System.

Author Note:
Correspondence concerning this article should be addressed to Gretchen B. LeFever, Ph.D., Old Dominion University and Safety and Learning Solutions, 912 Queen Elizabeth Drive, Virginia Beach, VA 23452, gblefever@gmail.com.

Abstract:
The 700% increase in psychostimulant use that occurred in the 1990s justifies concern about potential overdiagnosis and inappropriate treatment of child behavior problems. A critical review of epidemiologic research suggests that attention-deficit/hyperactivity disorder (ADHD) is not universally overdiagnosed; however, for some U.S. communities there is evidence of substantial ADHD overdiagnosis, adverse educational outcomes among children treated for the disorder, and suboptimal management of childhood behavior problems. Evidence of ADHD overdiagnosis is obscured when findings are reported without respect to geographic location, race, gender, and age. More sophisticated epidemiologic tracking of ADHD treatment trends and examination of associated outcomes is needed to appreciate the scope of the problem on a national level. Meanwhile, a public health approach to ADHD that includes the development and implementation of data-driven, community-based interventions is warranted and is underway in some communities. Guidelines for promoting judicious use of psychotropic drugs are suggested.

Introduction
Until the latter half of the 20th century, treating childhood behavior problems with medication was an almost nonexistent practice. The current American proclivity toward psychiatric drug therapy for behavior-disordered children began in the 1960s, when the American medical profession deemed it acceptable to use psychostimulants (especially methylphenidate, commonly and hereafter referred to as Ritalin) to ameliorate symptoms associated with minimal brain dysfunction (MBD; Wender et al., 1971), or what is now described as attention-deficit/hyperactivity disorder (ADHD; American Psychiatric Association, 1994; Barkley, 1990). Over the last three decades the rate of drug treatment for behavior problems has increased exponentially, culminating in the prescription of ADHD drug treatment for at least 5 to 6 million American children annually (Diller, 1998; Sinha, 2001). The high rate of prescription for Ritalin and expensive brand-name drugs such as Adderall, Concerta, and Metadate reflect a more general reliance on psychotropic drugs in American healthcare practices. In 1998, doctors mentioned psychotropic drug treatment an estimated 85.8 million times during 36.7 million office visits (Health Care Financing Administration, 2001) averaging 2.3 documented references to psychotropic drug treatment per physician visit. The unprecedented levels of drug treatment for child behavior problems justify closer public and professional scrutiny. Available research has not supported the idea of a widespread overdiagnosis of ADHD across the country (Goldman, Genel, Bezman, & Slanetz, 199; however, there are clear indications of overdiagnosis and overtreatment in a growing number of communities. The fact that these problems are not universal should not serve to dismiss concerns for communities in which children are being diagnosed with and treated for ADHD at remarkably high rates. Careful investigation into the extent of overdiagnosis of ADHD and overuse of drug therapy is necessary to develop appropriate methods for improving ADHD care. This paper provides background information regarding ADHD treatment and a summary of historical trends in ADHD treatment, which set the stage for a critical review of epidemiological research on ADHD and its treatment.

Defining ADHD Overtreatment
Defining mental health disorders based on the concept of statistical rarity is arguably problematic for many mental health conditions (e.g., Wakefield, 1992), but not for all. In fact, definitions of some disorders-including ADHD-are reliant on the concept of statistical rarity, or what is sometimes referred to as developmental deviance. Consider the case of mental retardation vis-à-vis intelligence. Mental retardation (the condition) is defined by intelligence (the construct) that is measured to be at least two standard deviations below the population mean. While some individuals may have low intelligence, only those whose intelligence is significantly developmentally deviant (i.e., statistically rare) are considered disordered. The diagnosis of ADHD is conceptually akin to that of mental retardation in that the definition of both disorders relies on the concept of developmental deviance. As with intelligence, the hallmark symptoms of ADHD (impulsivity, hyperactivity, and inattention) exist in all children to some degree, but ADHD is said to exist only when the behaviors are expressed to an extreme or statistically rare degree.

Given that the definition of ADHD is based on statistical rarity, only a limited number of children can qualify as having the disorder. As in the case of mental retardation, the ADHD prevalence estimate was set at 3% to 5%, which restricts the disorder to those children whose ADHD-related behavioral characteristics are approximately two standard deviations away from the mean. The 3% to 5% estimate may constitute a liberal estimate because, as with mental retardation, statistical rarity is only one of several criteria for the diagnosis. The problematic behavior must also be persistent, pervasive, impairing, and not attributable to other conditions or factors. Consistent with this logic, some pediatric and behavioral experts argue that ADHD may affect as few as 1% to 3% of children (Carey, 1999, 2000). This notion received considerable attention by scientific experts on the NIH-sponsored ADHD Consensus Development panel (Diagnosis and Treatment of ADHD, 199, although the consensus was to maintain the decades-long prevalence estimate of 3% to 5%.

Some may argue that the current definition of ADHD is flawed and that the concept of developmental deviance or statistical rarity should be discarded. Because ADHD is presumed to be a biological disorder, there may be no natural limit to the number of children who could be affected by the disorder and the 3% to 5% prevalence would be not only arbitrary but also inappropriate. There is no pathognomonic biological marker for ADHD (Barkley, 1999; Todd, 2000) and no clearly defined and widely accepted ADHD assessment method (Kessler, 1980), making it impossible to know precisely how many children are actually affected by the disorder (Godow, 1997). Unless a biological marker is identified, an agreed-upon gold standard diagnostic procedure is established, or ADHD is redefined, a population-based ADHD rate exceeding 3% to 5% by definition represents a problem of ADHD overdiagnosis. Thus, the 3% to 5% prevalence estimate is presently the only benchmark that can be used to evaluate possible ADHD overdiagnosis and overtreatment. Throughout this paper, ADHD- related drug treatment trends and community-based assessments of ADHD diagnostic rates are evaluated against the 3% to 5% benchmark.

Review of National ADHD Drug Treatment Trends
Ritalin

For years, discussions about the overdiagnosis of ADHD and overprescription of Ritalin have been one in the same. Until the late 1990s the vast majority of children medicated for ADHD received a psychostimulant and in 90% of these cases Ritalin was prescribed (Hamilton, 2000; Wilens & Biederman, 1992). Most Ritalin prescriptions are associated with ADHD treatment among U.S. patients. Therefore, at least until the late 1990s, Ritalin consumption has been used to track general patterns of ADHD treatment in the United States (LeFever, Dawson, & Morrow, 1999). Prescribing trends prompted the United Nations International Narcotics Control Board to issue its second warning in recent years that American physicians may be overprescribing psychostimulants (United Nations Information Service, 1997). This may become an issue in other countries such as Australia (Carmichael, 1996) and Canada (Miller, Lalonde, McGrail, & Armstrong, 2001), where ADHD drug treatment is becoming increasingly popular.

The Early Years of Ritalin

Use As of 1960 negligible numbers of children were medicated for MBD/ADHD (Safer & Zito, 1999). A decade later, more than 150,000 school-age children were receiving psychostimulant treatment annually in the United States (Safer, 1971). Beginning with the conservative estimate that 50,000 American children were treated annually for ADHD in 1960, there was a six-fold increase in psychostimulant treatment between 1960 and 1975. The rising rate of stimulant treatment prompted one of the nation's foremost developmental psychologists to address the topic in the New England Journal of Medicine (Sroufe & Stewart, 1975). Psychologist Alan Sroufe and psychiatrist Mark Stewart cautioned against the dangers of continued escalation in psychostimulant treatment, including possible reduction in parent and teacher motivation to take other steps to help children, inadequate monitoring of drug treatment, and possible development of low self-esteem and drug abuse among individuals treated with stimulants. Although these issues have never been adequately resolved, stimulant treatment has continued to increase unabated. The trends Sroufe and Stewart observed during the 1970s pale in comparison with those of the last two decades.

The Post-1990 Era of Ritalin Use

During the 1990s there was a 700% increase in the use of psychostimulants, with the United States consuming nearly 90% of the world's supply of the drugs (Mackey & Kipras, 2001; Marshall, 2000). As of 1999, school nurses across the country delivered more medications for mental health conditions than for any other chronic health problem, and more than half of these were specifically for ADHD (McCarthy, Kelly, & Reed, 2000). As of today, up to an estimated 5 to 6 million American children receive ADHD-related drug treatment annually (Sinha, 2001). These figures indicate that from 1960 to the turn of the century there was a more than 100-fold increase in the annual rate of ADHD drug treatment among U.S. children. Moreover, the use of psychostimulants and other psychotropic drugs continues to rise.

Accumulating evidence indicates that Ritalin use is highly variable across the country, with widening variation in state-level and community-level ADHD drug treatment over time. Drug Enforcement Agency (DEA) data for the years 1990 to 1995 indicated that the rate of Ritalin use was 6 times higher in some states compared with others (Morrow, Morrow, & Haislip, 199 and was 20 times higher in some communities compared with others (Eaton & Marchak, 2001; LeFever, Arcona, & Stewart, 2001). In the years 1997 to 1999, some states used 30 times more Ritalin than other states, and some communities used 100 times more than others. Although the validity of DEA data for capturing treatment patterns in not entirely clear, the data represent one of the few sources of information currently available for tracking treatment patterns nationwide. Monitoring such data is also important because if treatment varies substantially across geographic regions, then the "average" practice may not be a very helpful index of the legitimacy of concern (Angold, Erkanli, Egger, & Costell, 2000).

Other Psychotropic Drugs

National statistics on the use of psychotropic drugs suggest that the current ADHD debate is no longer just about such psychostimulants as Ritalin (Zito & Safer, 2001). Between 1995 and 1998, antidepressant use increased 74% among children under 18, 151% among children between 7 and 12, and 580% among children younger than 6 years of age. Mood stabilizers increased 400% among children under 18, while the use of new antipsychotic medications increased 300% among the same age group (Diller, 2000). Recent analyses of the Kansas Medicaid database indicate that antidepressants were prescribed to children twice as often as any other type of psychotropic drug from 1995 to 1996 (Fox, Foster, & Zito, 2000).

These changes are also relevant to ADHD treatment practices because general practitioners and psychiatrists increasingly prescribe a variety of psychotropic drugs and drug combinations to ADHD children (Boles, Lynch, & DeBar, 2001; Popper, 2000; Zarin, Suarez, Pincus, Kupersanin, & Zito, 199. Perhaps the most common of these regimens is the combined use of psychostimulants and antidepressants (Findling & Dogin, 1998; Zito et al., 2002). This pattern was observed in over one quarter of the children treated for ADHD in southeastern Virginia (LeFever, 2000). These increases have occurred despite the lack of convincing efficacy data for antidepressants in children (Antonuccio, Danton, DeNelsky, Greenberg, & Gordon, 1999). Still fewer data are available regarding the use of other psychotropics and psychotropic drug combinations in children. In one study, almost one fifth of children receiving prescriptions for ADHD from psychiatrists received drugs other than psychostimulants (Zarin et al., 199. Although ADHD drug treatment estimates are often based on psychostimulant data, failure to consider a broader set of drugs substantially underestimates the magnitude of ADHD drug treatment in the United States.

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All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Dec 2012. | This topic last updated: Aug 30, 2012.
INTRODUCTION — Attention deficit hyperactivity disorder (ADHD) is a disorder that manifests in childhood with symptoms of hyperactivity, impulsivity, and/or inattention. The symptoms affect cognitive, academic, behavioral, emotional, and social functioning (table 1) [1].

This topic review focuses on the clinical features and evaluation of ADHD. The epidemiology, pathogenesis, management, and prognosis of ADHD in children and adolescents and ADHD in adults are discussed separately.

(See "Attention deficit hyperactivity disorder in children and adolescents: Epidemiology and pathogenesis".)
(See "Attention deficit hyperactivity disorder in children and adolescents: Overview of treatment and prognosis".)
(See "Pharmacology of drugs used to treat attention deficit hyperactivity disorder in children and adolescents".)
(See "Attention deficit hyperactivity disorder in children and adolescents: Treatment with medications".)
(See "Cardiac evaluation of patients receiving pharmacotherapy for attention deficit hyperactivity disorder".)
(See "Adult attention deficit hyperactivity disorder".)
CLINICAL FEATURES

Core symptoms — ADHD is a syndrome with three categories of symptoms: hyperactivity, impulsivity, and inattention (table 1). Each of the core symptoms of ADHD has its own pattern and course of development. The complaint regarding symptoms of ADHD may originate from the parents, teachers, or other caregivers [2].

Hyperactivity — Hyperactive behavior is identified through excessive fidgetiness or talking, difficulty remaining seated when required to do so, difficulty playing quietly, and frequent restlessness or seeming to be always "on the go" (table 1).

The hyperactive symptoms typically are observed by the time the child reaches four years of age and increase during the next three to four years [3,4]. They peak in severity when the child is seven to eight years of age, after which they begin to decline steadily. By the adolescent years, the hyperactive symptoms can be barely discernible to observers, but adolescents often report internal restlessness or inability to settle down.

Impulsivity — Impulsive behavior almost always occurs in conjunction with hyperactivity in young children. Impulsive behavior is manifested by difficulty waiting turns, blurting out answers too quickly, disruptive classroom behavior, intruding or interrupting other's activities, peer rejection, and unintentional injury (table 1).

Similar to the hyperactive symptoms, the impulsive symptoms typically are observed by the time the child reaches four years of age and increase during the next three to four years to peak in severity when the child is seven to eight years of age [3,4]. In contrast to hyperactive symptoms, impulsive symptoms usually remain a problem throughout the life of the individual. (See "Attention deficit hyperactivity disorder in children and adolescents: Overview of treatment and prognosis", section on 'Prognosis'.)

The focus of impulsivity is related to the environment. As an example, adolescents with ADHD who are untreated and in an environment where alcohol and other commonly abused substances are readily available are at greater risk of engaging in drug use or experimentation than are adolescents without ADHD [5].

Inattention — Inattention may take many forms, including forgetfulness, being easily distracted, losing or misplacing things, disorganization, academic underachievement, poor follow-through with assignments or tasks, poor concentration, and poor attention to detail (table 1).

The symptoms of inattention typically are not apparent until the child is eight to nine years of age [3,4]. This delay may relate to reduced sensitivity of assessment of attention problems or increased variability in the normal development of the cognitive skills. Similar to the pattern of impulsivity, symptoms of inattention usually are a lifelong problem. (See "Attention deficit hyperactivity disorder in children and adolescents: Overview of treatment and prognosis", section on 'Prognosis'.)

Subtypes of ADHD — Depending upon the predominant symptoms, ADHD can be categorized into one of three subtypes: predominantly inattentive; predominantly hyperactive-impulsive; and combined. The subtype of ADHD in a given patient can change from one to another over time [1,6-8].

The predominantly inattentive subtype of ADHD is characterized by reduced ability to focus attention and reduced speed of cognitive processing and responding [9,10]. Children with the inattentive subtype often are described as having a sluggish cognitive tempo and frequently appear to be daydreaming or "off task" [11]. The typical presenting complaints center on cognitive and/or academic problems. Symptoms may include [1]:

Failing to pay close attention to details or making careless mistakes in schoolwork or other activities
Difficulty sustaining attention in tasks or play activities
Not seeming to listen when spoken to directly
Not following through on instructions and failing to finish schoolwork, chores, or duties (not because of oppositional behavior or failure to understand instructions)
Difficulty organizing tasks and activities
Avoidance or reluctance to engage in tasks that require sustained mental effort (such as schoolwork or homework)
Losing things necessary for tasks or activities (eg, toys, school assignments, pencils, books, or tools)
Being easily distracted by extraneous stimuli
Forgetfulness in daily activities
The predominantly hyperactive-impulsive subtype of ADHD is characterized by the inability to sit still or inhibit behavior. Symptoms may include [1]:

Fidgeting with hands or feet or squirming in seat
Leaving seat in classroom or in other situations where he or she is expected to remain seated
Running about or climbing excessively in situations in which it is inappropriate
Difficulty playing or engaging in leisure activities quietly
Often being "on the go" or acting as if "driven by a motor"
Excessive talking
Blurting out answers before questions have been completed
Difficulty awaiting his or her turn
Interrupting or intruding on others (eg, butting into conversations or games)
Children with the hyperactive-impulsive subtype of ADHD have relatively good attention skills. Cognitive performance may be unaffected [12]. Children with the hyperactive-impulsive subtype of ADHD usually are diagnosed at six to seven years of age, when symptoms of hyperactivity and impulsivity peak.

The combined subtype of ADHD is characterized by symptoms of hyperactivity, impulsivity, and inattention. The combined subtype is the classic subtype of ADHD and the subtype that is most easily identified. Presenting complaints may include disruptive or aggressive behavior, overactivity, disinhibition, and reduced attention span.

Children with the combined subtype of ADHD usually are diagnosed at six to seven years of age, when symptoms of hyperactivity and impulsivity peak.

Impaired functioning — In order to meet criteria for ADHD, core symptoms must impair function in academic, social, or occupational activities [1]. Social skills in children with ADHD often are significantly impaired. Problems with inattention may limit opportunities to acquire social skills or to attend to social cues necessary for effective social interaction, making it difficult to form friendships. Hyperactive and impulsive behaviors may result in peer rejection [13]. The negative consequences of impaired social function (eg, poor self-esteem, increased risk for depression and anxiety) may be long-standing.

DIFFERENTIAL DIAGNOSIS — The symptoms of ADHD overlap with a number of other conditions, including developmental variations, neurologic or developmental conditions, emotional and behavioral disorders, psychosocial or environmental factors, and certain medical problems (table 2) [1,2,14,15]. Some of these conditions can coexist with ADHD and may or may not be responsible for some of the symptoms (eg, children who have learning disabilities may develop inattention as a result of inability to understand new information) [16]. These conditions usually can be differentiated from ADHD with a thorough history and/or the use of a broadband behavior rating scale. If the diagnosis remains uncertain, psychometric testing or a mental health evaluation may be necessary. (See 'Coexisting disorders' below.)

Developmental variations – Developmental variations include intellectual disability; giftedness; and behaviors that are within the normal range for the child’s level of development and do not impair function (eg, a short-attention span or increased motor activity in a preschool child; occasional impulsivity in a school-age child) [14,15,17]. (See "Intellectual disability (mental retardation) in children: Definition; causes; and diagnosis" and "Intellectual disability (mental retardation) in children: Evaluation".)

Children with developmental variations do not meet the criteria for ADHD (table 1).
Neurologic or developmental conditions – Neurodevelopmental conditions that can mimic or co-occur with ADHD include learning disabilities, language or communication disorders, autism spectrum disorders, neurodevelopmental syndromes (eg, fragile X, fetal alcohol syndrome), seizure disorder, sequelae of central nervous system infection or trauma, and motor coordination disorders [14]. (See "Specific learning disabilities in children: Clinical features" and "Clinical features of autism spectrum disorders" and "Clinical features and diagnosis of fragile X syndrome in children and adolescents" and "Overview of the classification, etiology, and clinical features of pediatric seizures and epilepsy" and "Etiology of speech and language disorders in children", section on 'Language disorders'.)

These disorders usually can be distinguished from ADHD through history and examination. Specialized testing may be necessary in some circumstances (eg, psychometric testing for learning disabilities; genetic testing for fragile X syndrome; electroencephalography for seizure disorder; occupational therapy evaluation for motor coordination disorder, etc).
Emotional and behavioral disorders – Emotional and behavioral disorders that can mimic or co-occur with ADHD include anxiety disorder, mood disorders, oppositional defiant disorder, conduct disorder, obsessive compulsive disorder, post-traumatic stress disorder, and adjustment disorder. The use of a broadband behavior scale may be helpful in the assessment of these disorders. However, evaluation by a mental health professional generally is necessary for diagnosis. (See 'Coexisting disorders' below and 'Behavior rating scales' below and 'Indications for referral' below.)
Psychosocial and environmental factors – Environmental factors that can contribute to inattention, impulsivity, or hyperactivity include a stressful home environment or an inappropriate educational setting. In contrast to ADHD, psychosocial and environmental factors generally affect behavior only in one setting (eg, at home but not at school, or at school, but not at home). Parent-child temperament or “personality” mismatch and parental mental health conditions (particularly maternal depression) can contribute to parent report of ADHD-type symptoms in the home setting. However, mothers of ADHD children with limited resources or support may also develop stress-related mental health conditions; in such circumstances, multiple respondent (eg, teacher, coach) reports help to confirm the diagnosis of ADHD.
Medical conditions – Medical conditions that may have clinical features that mimic ADHD include hearing or visual impairment, lead poisoning, thyroid abnormalities, sleep disorders (eg, obstructive sleep apnea, restless-leg/periodic limb movement disorder), medication effects (eg, albuterol), and substance abuse disorders [18,19]. (See appropriate topic reviews.) These conditions usually can be differentiated from ADHD because their symptoms fluctuate with the disease course or exposure to medication. In contrast, the symptoms in ADHD are persistent and pervasive

Quoted Text

ADHD is best understood as a cultural construct
SAMI TIMIMI
ERIC TAYLOR
+ Author Affiliations

Ash Villa Child & Adolescent Unit, Willoughby Road, South Rauceby, Sleaford, Lincolnshire NG34 8QA, UK. E-mail: stimimi@talk21.com
Institute of Psychiatry, De Crespigny Park, Denmark HIll, London SE5 8AF, UK.
Edited and introduced by Mary Cannon, Kwame McKenzie and Andrew Sims.

Declaration of interest

None.

Declaration of interest

E.T. has received menaces from an anti-psychiatry organisation, which may have biased him against their views. He and his department have received fees for lecturing at educational meetings and scientific conferences that had sponsorship from pharmaceutical companies – including Eli Lilly and Janssen-Cilag, who manufacture drugs used in ADHD. He is a lead clinician in a National Health Service trust, so could have an interest in keeping costs of treatment down.


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INTRODUCTION

Attention-deficit hyperactivity disorder (ADHD) has received significant research attention and is a problem that is rarely out of the news – whether it is concerns about treating children with amphetamines, its over- or underdiagnosis, or the long-term outcomes.

Despite all the research it has been difficult to gain and maintain professional agreement on what ADHD is or what should be done about it. In 2002 an eminent group of psychiatrists and psychologists published the first consensus statement on the science, diagnosis and treatment of ADHD ( Barkley et al, 2002). However, the statement could probably best be described as a position statement because the diverse views of what ADHD is and what should be done about it were not reflected or represented. Fundamental to the discussion are questions about whether the diagnosis of ADHD actually holds water and what it is that psychiatrists are trying to treat. Are differences in the rate of ADHD a reflection of changes in its incidence or in society’s tolerance for behaviour that does not conform? We asked Dr Sami Timimi, a child and adolescent psychiatrist and author of Pathological Child Psychiatry and the Medicalization of Childhood, and Professor Eric Taylor, a child psychiatrist from the Institute of Psychiatry and researcher into the aetiology, outcome and treatment of ADHD, to discuss the proposition that ADHD is best understood as a cultural construct.

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FOR

There are no specific cognitive, metabolic or neurological markers and no medical tests for ADHD. Because of uncertainty about definition, epidemiological studies produce hugely differing prevalence rates: from 0.5% to 26% of children. Despite attempts at standardising criteria, in cross-cultural studies major and significant differences between raters from different countries in the way they rate symptoms of ADHD, as well as major differences in the way children from different cultures are rated for symptoms of ADHD, are apparent. More than 30 neuroimaging studies have been published; however, researchers have yet to compare unmedicated children diagnosed with ADHD with an age-matched control group. Sample sizes in these studies have been small and have produced a variety of inconsistent results. In no study were the brains considered clinically abnormal, nor is it possible to work out whether any differences seen are caused by (rather than being the causes of) different styles of thinking, or are the result of the medication the children had taken. What we end up with is a modern version of the long-discredited ‘ science’ of phrenology. Genetic studies show that ADHD is linked with being male (boys are four to ten times more likely to get this diagnosis in practice) and is associated with the normal genetic variation found with traits such as height. Comorbidity is extremely high, throwing doubt on the specificity of the diagnosis. There are no specific treatments for ADHD, with the most widely debated treatment (methylphenidate) being known to have similar effects on otherwise normal children. There is no established prognosis, and association and cause frequently are confused in the literature. ADHD has generated huge profits for the pharmaceutical industry against a background of poor-quality research, publication bias and payments to some of the top academics in this field. Thus, the mainstream dogma on ADHD is contaminated and misleading ( Timimi, 2002).

To explain the recent rise, to epidemic proportions, of rates of diagnosis of ADHD, a cultural perspective is necessary. The immaturity of children is a biological fact, but the ways in which this immaturity is understood and made meaningful is a fact of culture. In modern Western culture many factors adversely affect the mental health of children and their families. These include loss of extended family support, mother blame (mothers are usually the ones who shoulder responsibility for their children), pressure on schools, a breakdown in the moral authority of adults, parents being put in a double bind on the question of discipline, family life being busy and ‘ hyperactive’, and a market economy value system that emphasises individuality, competitiveness and independence ( Prout & James, 1997). Throw in the profit-dependent pharmaceutical industry and a high-status profession looking for new roles and we have the ideal cultural preconditions for the birth and propagation of the ADHD construct.

Is a medical model of ADHD therapeutically helpful? Quite the opposite; it offers a decontextualised and simplistic idea that leads to all of us – parents, teachers and doctors – disengaging from our social responsibility to raise well-behaved children. We thus become a symptom of the cultural disease we purport to cure. It supports the profit motive of the pharmaceutical industry, which has been accused of helping to create and propagate the notion of ADHD in order to expand its own markets. By acting as agents of social control and stifling diversity in children, we are victimising millions of children and their families by putting children on highly addictive drugs that have no proven long-term benefit ( Timimi, 2002) and have been shown in animal studies to have brain-disabling effects ( Moll et al, 2001; Sproson et al, 2001; Breggin, 2002). By conceptualising problems as medically caused we end up offering interventions (drug and behavioural) that teach ADHD-type behaviour to the child. ADHD causes ‘tunnel vision’ in the system, making it more difficult to think about context, leading to interpersonal issues being marginalised. ADHD scripts a potentially life-long story of disability and deficit, resulting in an attitude of a ‘pill for life’s problems’. We create unnecessary dependence on doctors, discouraging children and their families from engaging their own abilities to solve problems. ADHD is de-skilling for us as a profession as there is minimal skill involved in ticking off a checklist of symptoms and reaching for the prescription pad.

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AGAINST

Hyperactivity is neither a social construct nor a genetic disease. The professional task is to understand how genetic and social influences interact, not to simplify into a polemic.

Individual differences in hyperactivity have known physical counterparts: in brain structure and function and DNA composition ( Schachar & Tannock, 2002). Genetic influences are strong and some molecular genetic variations (especially of genes affecting dopamine systems) have been robustly replicated. They work in interaction with the environment, and the psychological environment helps to set the course into adjustment or disorder. Consistent associations with changes in brain structure have been found, even in unmedicated children, with neuroimaging.

Severe hyperactivity is a strong predictor of poor psychosocial adjustment ( Taylor et al, 1996). The developmental risk is not trivial. Even those who are not diagnosed or medicated are more prone to accidents, conduct disorder, psychiatric problems in adolescence, educational and occupational failure, and a lack of constructive occupations or satisfactory relationships. This is why mental health services get involved.

Some authorities suggest that the institutions of society can actually cause the problem. For example, the decay of the family, or the school, or social cohesion, or leisure activity can be blamed for children going ‘ out of control’. (Different countries vary in the choice of scapegoat according to their perceived social problems.) Evidence for this is lacking. Indeed, twin studies indicate that individual differences are very little influenced by the shared environment. If there were a social determinant of hyperactivity, it would need to be seen as making the whole population more hyperactive; that is, the prevalence of a diagnostic category such as ADHD would have to be increasing over time and be related to social structures. In the UK, this is probably not so. Two epidemiological studies 20 years apart have produced very similar prevalence rates for ‘ hyperkinetic disorder’ ( Taylor et al, 1991; Meltzer et al, 2000). Powerless groups such as immigrants do not have markedly increased rates, and ‘ADHD’ affects all classes.

Social factors can probably influence the degree of hyperactivity that is seen as a problem. Children do not usually refer themselves for help (although they often try); they are dependent upon others to determine their caseness. Families, schools and cultures vary somewhat in their tolerance. For example, epidemiological research in Hong Kong used the same measures as had been used in London, England, and found a higher rate of hyperactivity in Hong Kong when ratings were used, but a lower rate when more objective measures were employed. The likely interpretation is that hyperactive behaviour had a greater impact in the Hong Kong environment, which attaches particular importance to academic success.

This interaction between the child and the expectations of the adult world is important clinically. It is a reason to take more pains in making a diagnosis than just accepting a rating from a parent or teacher. Impairment and risk are as important as symptomatology. An assessment should be thorough enough to clarify the interaction in the individual case (as well, of course, as to be able to detect the emotional problems and the relationship difficulties that can both mimic hyperactivity and result from it).

Could these social influences lead to the condition being overdiagnosed? This carries particular weight because of the frequent use of stimulant medication. If there is overdiagnosis, then children treated will often be found to fall short of rigorous diagnostic criteria. In the USA, this may sometimes happen. There is some evidence there for a patchy mixture of undertreatment and overtreatment, and a high rate of medication in preschool children suggests that some practitioners are going beyond guidelines.

In the UK, however, the chief evidence is for undertreatment. Most children with markedly hyperactive behaviour are still not identified, referred or treated; yet they remain at risk. The obstacle probably lies largely in medical attitudes rather than public ones ( Sayal et al, 2002). This is a pity, because there are several good ways of supporting children with severe hyperactivity.

In short, broad social influences probably contribute to the recognition of disorder rather than its presence. But these do not amount to a social construction of disorder – rather, in the UK at least, they work against recognition of a treatable risk.

Quoted Text

A.D.H.D. Study Suggests Links Between Medication and Fewer Crimes
By PAM BELLUCK
Published: November 21, 2012
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A large study suggests that people with serious attention deficit hyperactivity disorder are less likely to commit crimes when taking medication.
Related

Well: Younger Students More Likely to Get A.D.H.D. Drugs (November 20, 2012)
Health Guide: ADHD
The study, published in The New England Journal of Medicine, examined records of 25,000 people in Sweden to see if those with A.D.H.D. had fewer criminal convictions when taking medication than when they were not.

Of 8,000 people whose medication use fluctuated over a three-year period, men were 32 percent less likely and women were 41 percent less likely to have criminal convictions while on medication. Patients were primarily young adults, many with a history of hospitalization. Crimes included assault, drug offenses and homicide as well as less serious crimes. Medication varied, but many took stimulants like Ritalin.

“The study adds a lot,” said Dr. Gabrielle Carlson, director of child and adolescent psychiatry at Stony Brook University medical school, who was not involved in the study. “Cutting the crime rate, that’s not trivial. Maybe it will get some help for people in jail. It gives people who were on the fence maybe a little more confidence in this treatment.”

Studies suggest that people with A.D.H.D. are more likely to commit crimes. And while people, especially boys, are often prescribed medication as children, they often resist taking it as teenagers. Studies have not shown that medication has long-term effects on symptoms.

Dr. Paul Lichtenstein, a study author and a professor at Karolinska Institute, cautioned against concluding that everyone with A.D.H.D. should be continuously medicated.

“There are pros and cons to medication,” he said. But “in young adults, the age where criminality is most common, you should consider medication because it is more harmful for these people to be involved in criminal activities. Also for prisoners and people who have left prison.”

Researchers said that correlations between medication and decreased crime held regardless of the type of medication or crime and the presence of other disorders. They tried to determine if patients stopped treatment because of criminal convictions, but found that treatment itself appeared linked to fewer crimes.

Among psychiatric experts, when, and sometimes whether, to prescribe A.D.H.D. medication is still debated. Drugs do not work for everyone, and side effects can include jittery feelings and suppressed appetite and growth.

William Pelham, director of the Center for Children and Families at Florida International University, said nondrug therapies like behavioral modification worked as well as medication in the short run. He said that the study did not prove that medication caused less criminality, and because most subjects were seriously ill adults, the results were irrelevant for most American children.

Jason Fletcher, an associate professor at the Yale School of Public Health, said that despite some weaknesses, the study provided a “very suggestive piece of evidence” supporting medication. “Because crime is so expensive, if you can reduce it, even by half of what they’re saying, you might still say this is really effective medication.”

He did wonder if medication is reducing crime or “making better criminals,” who avoid arrest. Dr. Lichtenstein deemed that unlikely. “I don’t think you would commit the crime,” he said, “and then just not get caught.”