According to a recent report by the Centers for Disease Control and Prevention (CDC), one in every 10 American children over the age of three has been diagnosed with ADHD. Before turning 18, nearly 14 percent of children will have been diagnosed. Most will receive ADHD drugs. Fearing that the popular response to this report will be “shock,” Psychiatrist John T. Walkup and two junior colleagues published a “reassuring” commentary that accompanied the CDC report (Journal of the American Academy of Child and Adolescent Psychiatry, November 2013). Of concern, the commentary appears to be an attempt to forestall important public debate that has critical safety implications for college and university campuses.
Walkup noted that CDC rate of parent-reported ADHD diagnosis has increased such that it is now close to the rate that researchers generate by applying established diagnostic criteria to community samples. These criteria are set out in the codebook for psychiatric diagnosis—a book referred to as the Diagnostic and Statistical Manual of Mental Disorders (DSM). Walkup hailed the consistency between parent-reported and DSM-generated rates of diagnosis as evidence of improved care. He called it “a positive sign” while also lamenting that only 70 percent of those diagnosed get medicated. His position appears to be clouded by conflicts of interest.
Professionals who monitor the changes produced in association with various editions of the DSM know that each successive edition has led to increased rates of diagnosis. DSM architects and authors now openly admit that diagnostic inflation exists across a host of disorders, with 28 percent inflation in ADHD diagnosis stemming from changes specific to the edition that was in use during the CDC study (Saving Normal by Alan Frances, Harper Collins Publishers, 2013). There is no biological marker or definitive test for ADHD. So, imperfect as it is, we’re stuck with the DSM as the official psychiatric guide to help us distinguish the sick from the well. Nonetheless, the confluence of rates between parent-reported (actual) and DSM-generated (inflated) diagnosis has no bearing on the question of whether too many (or too few) children and youth are being medicated for ADHD.
Answering that question remains a matter of opinion, which is best addressed through open dialogue about risks and benefits associated with ADHD trends. Why, then, would an informed psychiatrist like Walkup want to preempt debate about high rates of ADHD treatment? It is impossible to know Walkup’s motives; however, he is a paid consultant for companies that manufacture ADHD medications. He has received research funding from them and is a member of the speaker’s bureau for a leading manufacturer of ADHD medication. It is likely that financial incentives and/or reputation management clouded Walkup’s expressed views. Pharmaceutical companies pay “key opinion leaders” like Walkup to help advance the sale of prescription drugs. Such individuals may be patient advocates, but they run the risk of becoming marketing spokespersons for the industry—unwittingly or otherwise.
Potential for abuse
Conflicts of interest aside, perhaps the sheer volume of students that we perceive as needing drugs to succeed in school ought to shock us—even if industry-paid spokespersons say otherwise. Moreover, the more a drug gets prescribed, the more it will be diverted for abuse. And, that’s exactly what’s happening on college campuses.
As noted in a recent journal article, national poison control data for 1995-2005 documented a sharp rise in the number of children between 13 and 19 years of age who were reported due to ADHD medication abuse—an increase that was disproportionately higher than drug abuse generally or for teen substance abuse in particular. As early as 15 years ago in some communities, 16 percent of students in elementary through high school grades had been approached by classmates to share or sell their ADHD medications. By 2006, 34 percent of students attending a large southeastern college reported using ADHD drugs illegally. The widespread availability of ADHD drugs on high school and college campuses has led many young people to perceive these drugs as relatively safe and freely mix them with alcohol—a potentially lethal combination. Growing numbers of students are now sharing, swapping, stealing, and abusing ADHD medications (Journal of Contemporary Psychotherapy, August 2013).
Doctors prescribe ADHD medications to help children perform better in school, but every single long-term study of ADHD drug treatment indicates that the drugs don’t actually improve educational outcomes. Recently released analysis of a robust and 14-year long national study indicated that educational and behavioral outcomes worsen with ADHD drug treatment. The authors concluded, “Our results suggest that observers of the large increases in the use of medication for ADHD in the U.S. are right to be concerned” (National Bureau of Economic Research Working Paper No. 19105, June, 2013). Unlike Walkup, these authors are not industry-paid opinion leaders.
ADHD drugs are prescribed with the goal of helping students be successful in school. If they don’t actually lead to academic benefits over the long haul, isn’t the risk of exposure to these potentially addictive medications worthy of debate, especially if the cumulative impact contributes to substance abuse among American youth? After the case of Richard Fee, an aspiring medical student, who died from Adderall addiction that all began by borrowing a college friend’s ADHD medication to boost his studying skills, was exposed nationally (New York Times, February 2, 2013), college administrators ought to take note of ADHD trends.
Ten years ago, there was more public outcry when the rate of ADHD diagnosis was reported to be a fraction of what it is now. Rather than dismissing concern about potential ADHD overdiagnosis, it’s time to re-open public debate about high and rising rates of ADHD diagnosis and treatment.
—Gretchen LeFever Watson is a clinical psychologist and president of Safety and Learning Solutions, a human performance consulting firm in Virginia. Email her at firstname.lastname@example.org.