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Promoting ADHD Diagnoses and Stimulant Prescriptions

January 6, 2014

Promoting ADHD Diagnoses and Stimulant Prescriptions

  1. Martin T. Stein, MD

A pediatrician's response to “The Selling of Attention Deficit Disorder,” published in the New York Times.

  1. Martin T. Stein, MD

In a recently published front-page article in the New York Times entitled, “The Selling of Attention Deficit Disorder,” an investigative journalist observed: “Although proper ADHD diagnoses and medication have helped millions of children lead more productive lives, concerns remain that questionable diagnoses carry unappreciated costs.” The article examined reasons for the increasing number of children (and now adults) diagnosed with ADHD and the surging sales of stimulant medications during the past decade — from nearly $US2 billion in 2002 to more than $US8 billion in 2012 (based on data from a private pharmaceutical marketing company). The author concluded that the proliferation of ADHD diagnoses and stimulant prescriptions stem from similar sources, including:

  • Promotion of ADHD medication by pharmaceutical companies to doctors, educators, and parents through sponsored lectures at professional meetings, direct marketing in doctors' offices, and advertising in medical journals and parents' magazines. (For example, advertisements for ADHD medications increased from none in 1990 to 1993 to 100 pages per year a decade later in one major child psychiatry journal).

  • Promotion of medical treatment of ADHD by high-profile physicians paid by drug companies.

  • Online questionnaires about ADHD symptoms that are often misleading and suggest a diagnosis in children and adults. (A recent national telephone survey conducted by the Times asked adults about six symptoms found in a Web-based test: 33% scored in the “ADHD possible” category; 16% scored in the “ADHD likely” category.)

  • Diagnosis of ADHD by primary care physicians. The majority of physicians who diagnose ADHD are primary care physicians with less training in mental health than child psychiatrists.

Comment

As a pediatrician, my response to this extensively covered critique is as follows:

  • Get the diagnosis right. Precise use of ADHD diagnostic criteria ensures an accurate clinical diagnosis. A useful resource is the American Academy of Pediatrics (AAP) evidence-based guideline for the diagnosis and treatment of ADHD.

  • Evaluation must include parent/teacher reports of the child's behavior and screening for coexisting mental health disorders (e.g., anxiety and oppositional behaviors) and learning disabilities, which can coexist or be the cause of ADHD-like behaviors.

  • Consider a time-management strategy for ADHD evaluations in primary care. Schedule three 20-minute office visits for each patient to obtain teacher reports, interview the parents and child, perform a complete physical exam, and provide education about ADHD and a monitoring plan for evidence-based treatment (behavior modification and medication).

  • For clinical guides to diagnosis and treatment, use the AAP toolkit, Caring for Children With ADHD: A Resource Toolkit for Clinicians, and, for parents of children with ADHD, ADHD: What Every Parent Needs to Know.

  • Remember that pharmacy representatives who visit offices and clinics are typically biased sources of information.

  • Disclosures for Martin T. Stein, MD at time of publication Consultant / advisory board BioBehavioral Diagnostics; OptumRx Speaker’s bureau Indiana University; Michigan State University; University of Wisconsin Grant / research support Eli-Lilly Editorial boards Journal of Developmental and Behavioral Pediatrics

Citation(s):

Reader Comments (2)

J ROSS HESTER Other Healthcare Professional, Psychiatry, Edcom Associates Holistic Health

We are fortunate that ADHD, unlike Major Depression and Dysthymia, lends itself to assessment with tests of concentration, focus, and sleep latency at varying dosages [start low, go slow] of psycho-stimulants, and other substances with similar effects. Thus a "WYSIWYG" approach, similar to adjusting glasses prescriptions, in the hands of a clinician with sufficient time and concern can allow customization independent of Big Pharma's influences. If we don't take time to do this, patients self-medicate with nicotine, caffeine, etc.

Furman, Lydia MD Physician, Pediatrics/Adolescent Medicine

There is not an underlying etiology for ADHD. The diagnosis is completely symptom-driven, so many children with many different difficulties are unhelpfully lumped into one diagnostic category. This is terrific for pharmaceutical companies but does not lead to thoughtful care of the child.

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