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| ----------------------------------------------------------------------- Journal
of the American Medical Association Week of April 8, 1998 ------------------------------------------------------------------------ LITTLE EVIDENCE FOUND OF INCORRECT DIAGNOSIS OR OVERPRESCRIPTION FOR ADHD CHICAGO—Misdiagnosis, overdiagnosis and overprescription of stimulants for attention-deficit hyperactivity disorder (ADHD) are not widespread, according to an article in the April 8 issue of The Journal of the American Medical Association (JAMA). Larry S. Goldman, M.D., and colleagues from the Council on Scientific Affairs of the American Medical Association searched the National Library of Medicine database to review studies reported from 1975 through March 1997. They analyzed studies about school-aged children with ADHD and the use of stimulants to treat ADHD, including the most commonly prescribed drug, methylphenidate. The authors found little evidence of widespread overdiagnosis or misdiagnosis of ADHD, or of widespread overprescription of methylphenidate: "Epidemiologic studies using standardized diagnostic criteria suggest that 3 percent to 6 percent of the school-aged population may have ADHD. ... The percentage of U.S. youth being treated for ADHD is at most at the lower end of this prevalence range." But they also point out that in some cases, children may be diagnosed incorrectly because of insufficient evaluation: "Too much focus on a child's behavior in the physician's office or the child's own observations may lead to a missed diagnosis, while overreliance on parental reports of abnormal behavior alone may lead to overdiagnosis." Other psychiatric conditions often occur with ADHD, including mood disorders, conduct disorders, oppositional defiant disorder and learning disorders. Bipolar disorder is being increasingly recognized. And longer-term follow-up studies now show that the symptoms of ADHD persist into adulthood in many cases. Studies show stimulants are effective in reducing ADHD symptoms of hyperactivity, impulsivity and inattentiveness. The authors write: "They improve classroom behavior and academic performance; diminish oppositional and aggressive behaviors; promote increased interaction with teachers, family, and others; and increase participation in leisure time activities. Finally, stimulants have demonstrated improvement in irritability, anxiety and nail biting." Production and use of methylphenidate has been increasing significantly in the United States, tripling between 1990 and 1995 alone. The increase has heightened concern that the drug could be abused by those with ADHD, or that children and teenagers with access to methylphenidate could divert their medication to others, who would abuse it. The authors found little evidence that stimulant abuse or diversion is a major problem at this time. But they warn: "Clinicians need to be mindful of the risk of abuse and diversion; in addition to keeping careful records of medication prescribed, they may consider alternatives to stimulant use in patients at high risk (e.g., patient or family members with substance use disorders or bipolar or conduct disorder co-occurrent in the patient)." Recommendations for Treating ADHD These recommendations from the Council on Scientific Affairs were adopted as AMA policy in 1997: •The AMA encourages physicians to use standardized diagnostic criteria in making the diagnosis of ADHD, such as the American Psychiatric Association's DSM-IV, as part of a comprehensive evaluation of children and adolescents presenting with attentional or hyperactivity complaints. •The AMA encourages the creation and dissemination of practice guidelines for ADHD by appropriate specialty societies and their use by practicing physicians and will assist in making physicians aware of their availability. •The AMA encourages efforts by medical schools, residency programs, medical societies, and continuing medical education programs to increase physician knowledge about ADHD and its treatment. •The AMA encourages the use of individualized therapeutic approaches for children diagnosed as having ADHD, which may include pharmacotherapy, psychoeducation, behavioral therapy, school-based and other environmental interventions, and psychotherapy as indicated by clinical circumstances and family preferences. •The AMA encourages physicians and medical groups to work with schools to improve teachers' abilities to recognize ADHD and appropriately recommend that parents seek medical evaluation of potentially affected children. •The AMA reaffirms Policy 100.975, to work with the FDA and the DEA to help ensure that appropriate amounts of methylphenidate and other Schedule II drugs are available for clinically warranted patient use. ------------------------------------------------------------------------ © 1995-1998 American Medical Association. All rights reserved. |