Tuesday, September 13, 2016

"ADHD Nation" Perpetuates ADHD Myths & Half-Truths

The recent book, "ADHD Nation", by Alan.Schwarz, MD and the WSJ story, "The Ritalin Generation", by Sally Satel, MD, perpetuate the existing myths and half-truths about ADHD.

Here's a list of some of those myths/half-truths along with the REALITY as I know it from 40+ years as an ADHD specialist.

1. There's an epidemic of over-diagnosis and the blame lies with:
Overzealous Physicians  -  FALSE.
     REALITY:  The vast majority of ADHD diagnoses are done by primary MD's who are poorly trained and poorly informed about ADHD.  Furthermore, most of them tend NOT to follow AMA guidelines for diagnosing or treating ADHD.  A study by AAP in 2014 confirmed this at a level of 92%!  By a very wide margin, MD's have more influence than any other single entity over how and whether ADHD is diagnosed and how treatment is done.
Nervous Parents  -  SLIGHTLY TRUE.
     REALITY:  The vast majority of parents tend to follow the family physicians' advice.  Thus, most parents are as badly misinformed as the their physicians.
Schools Looking to Rein in Troublemakers  -  SLIGHTLY TRUE.
     REALITY:  Most school staff (public or private) tend to be as misinformed about ADHD as most physicians.  The Federal Gov't. sets the rules by which ADHD students are assessed and taught. Many of those rules are inconsistent with evidence-based research about ADHD. Also, a substantial portion of ADHD students are not "troublemakers."  However, they are either struggling or failing academically and often go unidentified.
Pushy Drug Companies  -  PARTLY TRUE.
     REALITY:  Many pharmaceutical firms that market ADHD medications are clear examples of "bad capitalism", i.e., their profit motive has overtaken their ethical obligations to patients with ADHD.  However, again, physicians have much more influence over who is diagnosed with ADHD, how, and what treatment approaches are used.
     REALITY:  The REAL epidemic is one of mis-diagnosis and mis-treatment by primary MD's with insufficient knowledge about ADHD diagnosis and treatment; and failure to make appropriate referrals to ADHD specialists.
2. Many experts agree that the prevalence of ADHD is about 5%  -  SOMEWHAT TRUE.
     REALITY:  Most experts agree that we have no idea of the actual prevalence of ADHD.  Many "experts" believe that the prevalence is significantly higher than 5%.  ADHD is a "spectrum" disorder just as Autism and most other mental disorders.  This means that there are some people who definitely meet the full clinical criteria and that there are others who's symptoms are somewhat below full-clinical-criteria, but who none-the-less have significant difficulty functioning in life.  It is important to note that in recent years epidemiologists have conceded that the prevalence of OCD and Bipolar Disorders have been vastly under-estimated for decades.
3. Diagnosis of ADHD is commonly determined by a checklist  -  PARTLY TRUE.
     REALITY:  A large percentage of primary physicians reportedly do use checklists as their main or only means of diagnosis.  Overwhelmingly, those clinicians who specialize in ADHD adhere to AAP or AACAP guidelines for ADHD diagnosis.  Those guidelines are rigorous and exhaustive.  Few primary MD's refer potential ADHD patients to ADHD specialists.
4. Medication is the default treatment option  -  PARTLY TRUE.
     REALITY:  More primary MD's are recognizing the importance of behavioral/family therapy as a FIRST treatment choice.  However, many do continue to "default" to medication.  There have been several recent studies confirming the value and effectiveness of therapy first.
5. It's easy to fake ADHD symptoms in order to get medication.  -  FALSE.
     REALITY:  For the "trained observer" (i.e., ADHD Specialist) this is generally untrue.  For the common primary MD, with minimal knowledge about ADHD and a very busy schedule this a distinct possibility  - but it needn't be!
6. Horrible reactions and side-effects to ADHD meds. are common.  FALSE.
Case examples given in the above publications are of the "horror story" type, e.g., patient is diagnosed with ADHD, put on medication and later develops addictions to various licit and/or illicit substances
     REALITY:  Those cases are in the minority and largely develop as a direct result of improper physician diagnosis and/or treatment, e.g., primary MD's rarely have the time or inclination to perform the necessary follow-up needed with ADHD patients.  Without proper F/U bad things are bound to happen.
7.  C. Keith Conners, "Father of ADHD", has decried the "over-diagnosis" of ADHD in "epidemic" proportions.  -  FALSE.
     REALITY:  Dr, Conners' persona as the "Father of ADHD" and his recent comments are being misused to dramatize certain statistics about ADHD diagnosis and medication prescription  -  data whose meaning and true causes are still under debate.  This is being done by those who want to force the beliefs of "over-diagnosis" and "Bad Big Pharma" onto the public.  Dr. Conners actually expressed more concern about mis-diagnosis and consequent mistreatment.  The misuse of Dr. Conners in this manner only serves to side-track clinicians from a focus on patient-centered-care and evidence-based practice.  

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