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September 14, 2012, 3:09 p.m. ET
The Journal Report: Big Issues in Health Care
In recent years, the number of children in the U.S. being treated with prescription medication for attention deficit hyperactivity disorder has grown dramatically.
That trend has led to concern among some doctors, parents and child advocates that many children are taking ADHD medication unnecessarily.
These critics suggest that in many cases ADHD is a mistaken diagnosis for children who are simply immature or undisciplined. And even when the diagnosis is correct, they say, many children who are taking medication for ADHD could do as well or better with alternative treatments, including dietary and behavioral therapies, that have fewer side effects.
Others say the critics greatly exaggerate the number of incorrect diagnoses. Heightened awareness of the disorder has fueled the rapid growth of ADHD cases, they say, not a failure to recognize simpler developmental or parental influences on behavior.
ADHD medications, these proponents say, are safe and more effective than any alternatives.
Sanford Newmark, head of the pediatric integrative neurodevelopmental program at the University of California, San Francisco, makes the case that ADHD drugs are overprescribed. Harold S. Koplewicz, president of the Child Mind Institute in New York, argues that the notions of overdiagnosis and overuse of ADHD drugs aren't based in fact.
Yes: We Diagnose Too Fast By Sanford Newmark
There is no question that ADHD is a real disease that can have serious consequences. It is also true that medications can be of great benefit for certain patients with ADHD.
University of California, San Francisco
SANFORD NEWMARK: 'There are no rigorous studies that prove ADHD medications work over the long term.'
But I also believe that ADHD is significantly overdiagnosed. And for those who do have the condition, medications aren't always the best or only option.
First, let's look at overdiagnosis. In a 2010 study in the Journal of Health Economics, researchers found that the youngest children among U.S. kindergartners (those born in August) were 40% more likely to be diagnosed with ADHD and twice as likely to take ADHD medications as the oldest kindergartners studied (those born in September). Similar results were found in a study of children ages 6 to 12 published this year in the Canadian Medical Association Journal.
Simply put, this means that the people making the diagnoses aren't distinguishing, in many cases, between normal developmental immaturity and ADHD. The author of the U.S. study estimates that this mistake could account for 20% of the current ADHD diagnoses in the U.S., or about 900,000 children, by his count.
Too Quick a Fix
One reason for the overdiagnosis of ADHD is that it is often diagnosed without the type of thorough history and examination needed for an accurate assessment. This would involve talking to parents, the child and teachers, as well as reviewing school records and other testing. Instead, many children are diagnosed after a visit of 15 to 20 minutes with a pediatrician or other professional.
Many other problems, such as learning disabilities, anxiety, sleep apnea and child abuse, or a child being gifted, can cause symptoms that may be misdiagnosed as ADHD. Too often practitioners don't take the time needed to make that distinction.
Finally, I believe ADHD is overdiagnosed because of the constantly increasing demands on children and families that didn't exist a generation ago. Imagine a family with two working parents picking up their exhausted child from after-school care around 5:30, rushing home to get some food on the table and then starting homework. Is it any wonder kids in that situation can't concentrate or that consistent discipline and support are lacking? Add that to the proliferation of videogames and other electronic distractions that have been linked to behavior typical of children with ADHD, and it is easy to see how a diagnosis of ADHD and a simple pill to fix it can become an easy choice.
But overdiagnosis isn't the only reason too many kids are taking ADHD medication. Even among children in whom ADHD is correctly diagnosed, medication is overprescribed.
Most studies show that ADHD medications decrease symptoms in about 70% of children. However, they can have side effects—mostly mild but in rare cases severe—including decreased appetite, irritability, nausea and insomnia, among others. One mother, who after 1½ years took her child off ADHD medication because a teacher noted the girl looked depressed, told me it was "as if the medication was a dam holding back her happiness."
More important, there are no rigorous scientific studies that prove ADHD medications work—or are safe—over the long term. No studies have adequately looked at the effect of five, 10 or 15 years of stimulant use on the developing brain.
Alternative Treatments
What's more, there are other ways to help these children.
Working with families on behavioral-management programs and optimizing the classroom environment can lead to major improvements in ADHD symptoms.
Diet can play a big part. A study published recently in Lancet, a leading medical journal, found that 64% of children with ADHD had substantial improvement in their symptoms when certain foods were eliminated from their diets. Omega-3 fatty-acid supplements and the elimination of iron and zinc deficiencies also have been shown to significantly improve ADHD symptoms in many children.
By themselves, none of these interventions may be as powerful as medication. But when carefully combined for each child, they often solve the problem without the need for pharmaceuticals. I have seen the efficacy of this type of treatment countless times in my own practice over many years.
Certain children are going to need ADHD medications. However, we must take the time to diagnose this condition carefully and, rather than reaching reflexively for a prescription pad every time a child is diagnosed with ADHD, implement safe and reasonable interventions whenever possible before using powerful pharmaceuticals whose long-term effects are largely unknown.
Dr. Newmark is head of the pediatric integrative neurodevelopmental program at the University of California, San Francisco. He can be reached at reports@wsj.com.
No: Drugs Work—and Safely By Harold S. Koplewicz
Increased awareness and treatment of ADHD in recent years have prompted a very vocal backlash. Some people charge that there's an epidemic of medicating ordinary kids just because their parents and teachers are having trouble controlling them, and that we're exposing children to harmful or dangerous drugs.
HAROLD S. KOPLEWICZ: 'What we don't need is hysteria that we are handing out dangerous drugs to kids like candy.'
Neither charge is based on fact. ADHD is real, it is widespread, and the stimulants commonly prescribed for it are the most effective treatment, have few side effects and are nonaddictive. Overuse of these medications isn't rampant.
Awareness, Not Delusion
The past 15 years have seen a great increase in public awareness of childhood psychiatric disorders, leading many more children to get early attention and treatment. For ADHD, the rate of diagnosis has gone up 3% to 5% a year, depending on the study. This isn't some grand delusion. It is the result of more parents and teachers recognizing the signs that certain children have serious problems concentrating, settling down and controlling their impulses.
Children with ADHD aren't just immature. To be diagnosed with the disorder they must be clearly outside the range of other children their age (not their year in school) in inattentiveness, impulsivity and hyperactivity. And they must be seriously impaired—these are kids who are in serious distress, not because of bad parenting or poor teaching, but because their brains work differently than those of most children.
Since ADHD affects only about 5% of children in the U.S., most people have no acquaintance with kids who have it. What they do know is that any child can get unruly without the right guidance, so their mental model of ADHD is largely of children who haven't been properly loved or reared. Because of this, the notion has gained traction that we routinely medicate ordinary rambunctiousness.
Granted, some of the children receiving medication don't meet the diagnostic criteria for ADHD. When prescriptions are written after a 10-minute visit with a harried pediatrician, best practices are not always followed.
But that happens in every corner of medicine, and nowhere else has it produced the outcry against medication that we hear in discussions of ADHD. What we do hear in other fields are questions about the expertise of the professionals who are doing the prescribing.
To cut down on mistakes, we need better training of the pediatricians who write most of the prescriptions for ADHD. We need better monitoring to make sure the medication is effective as kids grow and change. And we need more cooperation among all those who can offer insight into an individual child's behavior.
What we don't need is hysteria that we are handing out dangerous drugs to kids like candy.
Safe and Effective
It has been shown over and over again, in controlled scientific trials, that stimulant medication is the best and safest means of counteracting the symptoms of ADHD. As many as 80% of children respond well to one of these medications.
Of course, there are side effects associated with all medications. The ones that are common with stimulants are appetite suppression and trouble falling asleep. These can be unpleasant, but they cause no lasting harm to a patient's health. And in the largest and longest investigation into stimulant medication for ADHD, 85% of respondents reported only mild or no side effects.
When we hear that children are being sedated or turned into zombies by ADHD medications, we know that they aren't being managed competently. That is a reason to focus on improving the training of health-care professionals, not a reason to take kids off medication entirely.
It's true that no studies have examined the effect of long-term use of these medications on the developing brain. But ADHD medications have been in use for 70 years, and there is no evidence that suggests any adverse effects. On the other hand, the long-term effects of not treating ADHD are well documented: school failure, difficulty with relationships, employment problems, dangerous behavior and conflicts with authority.
Alternative behavioral or dietary treatments have regularly failed when evaluated objectively in scientific trials. Studies that, on the surface, suggest otherwise often fail on closer inspection. For instance, in a recent study of restrictive diets, parents knew their children were on the diets, so their reports of improved behavior aren't objective measures.
The fact is the unfounded mistrust of ADHD medications is more dangerous than the drugs. Fear, stigma and misinformation still stand in the way of many children receiving effective, sometimes life-changing treatment. Those are the kids we need to worry about.
Dr. Koplewicz is president of the Child Mind Institute in New York. He can be reached at reports@wsj.com.
A version of this article appeared September 18, 2012, on page B9 in the U.S. edition of The Wall Street Journal, with the headline: Are ADHD Medications Overprescribed?.
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