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SENATE CHALLENGES AMERICAN PSYCHIATRIC ASSOCIATION - DSM5 Task Group Faces Scrutiny Over Drug Industry Ties

Psychiatric Group Faces Scrutiny Over Drug Industry Ties

By BENEDICT CAREY and GARDINER HARRIS

Published: July 12, 2008

http://www.nytimes.com/2008/07/12/washington/12psych.html?_r=1&pagewanted=all 

CLICK ON LINK ABOVE FOR FULL ARTICLE

It seemed an ideal marriage, a scientific partnership that would attack mental illness from all sides. Psychiatrists would bring to the union their expertise and clinical experience, drug makers would provide their products and the money to run rigorous studies, and patients would get better medications, faster.

Senator Charles E. Grassley, right, Republican of Iowa, is demanding that the American Psychiatric Association give an accounting of its financing from the pharmaceutical industry.

Dr. Alan F. Schatzberg, president-elect of the American Psychiatric Association.

But now the profession itself is under attack in Congress, accused of allowing this relationship to become too cozy. After a series of stinging investigations of individual doctors’ arrangements with drug makers, Senator Charles E. Grassley, Republican of Iowa, is demanding that the American Psychiatric Association, the field’s premier professional organization, give an accounting of its financing.
The association is the voice of establishment psychiatry, publishing the field’s major journals and its standard diagnostic manual.
“I have come to understand that money from the pharmaceutical industry can shape the practices of nonprofit organizations that purport to be independent in their viewpoints and actions,” Mr. Grassley said Thursday in a letter to the association.
In 2006, the latest year for which numbers are available, the drug industry accounted for about 30 percent of the association’s $62.5 million in financing. About half of that money went to drug advertisements in psychiatric journals and exhibits at the annual meeting, and the other half to sponsor fellowships, conferences and industry symposiums at the annual meeting.
This weekend in Chicago, the psychiatry association’s board will meet behind closed doors, in part to discuss how to respond to the increasingly intense scrutiny and questions about conflicts of interest.
“With every new revelation, our credibility with patients has been damaged, and we have to protect that first and foremost,” said Dr. Steven S. Sharfstein, a former president of the association and now president of the Sheppard Pratt Health System in Baltimore. “I think we need to review all arrangements between doctors and industry and be very clear about what constitutes a conflict of interest and what does not.”
One of the doctors named by Mr. Grassley is the association’s president-elect, Dr. Alan F. Schatzberg of Stanford, whose $4.8 million stock holdings in a drug development company raised the senator’s concern. In a telephone interview, Dr. Schatzberg said he had fully complied with Stanford’s rigorous disclosure policies and federal guidelines that pertained to his research.
Blocking or constraining researchers from trying to bring medications to market “will mean less opportunities to help patients with severe illnesses,” Dr. Schatzberg said, adding, “Drugs that are helpful may not be developed by big pharmaceutical companies, for a variety of reasons, and we need some degree of communication between academia and industry” to expand options for patients.
Commercial arrangements are rampant throughout medicine. In the past two decades, drug and device makers have paid tens of thousands of doctors and researchers of all specialties. Worried that this money could taint doctors’ research plans or clinical judgment, government agencies, medical journals and universities have been forced to look more closely at deal details.
In psychiatry, Mr. Grassley has found an orchard of low-hanging fruit. As a group, psychiatrists earn less in base salary than any other specialists, according to a nationwide survey by the Medical Group Management Association. In 2007, median compensation for psychiatrists was $198,653, less than half of the $464,420 earned by diagnostic radiologists and barely more than the $190,547 earned by doctors practicing internal medicine.
But many psychiatrists supplement this income with consulting arrangements with drug makers, traveling the country to give dinner talks about drugs to other doctors for fees generally ranging from $750 to $3,500 per event, for instance.
While data on industry consulting arrangements are sparse, state officials in Vermont reported that in the 2007 fiscal year, drug makers gave more money to psychiatrists than to doctors in any other specialty. Eleven psychiatrists in the state received an average of $56,944 each. Data from Minnesota, among the few other states to collect such information, show a similar trend.
In both states, individual psychiatrists are not top earners, but consulting arrangements are so common that their total tops all others. The worry is that this money may subtly alter psychiatrists’ choices of which drugs to prescribe.
An analysis of Minnesota data by The New York Times last year found that on average, psychiatrists who received at least $5,000 from makers of newer-generation antipsychotic drugs appear to have written three times as many prescriptions to children for the drugs as psychiatrists who received less money or none. The drugs are not approved for most uses in children, who appear to be especially susceptible to the side effects, including rapid weight gain.
Senator Grassley’s investigations have not only detailed how lucrative those arrangements can be but have also shown that some top psychiatrists failed to report all their earnings as required.
After The Times reported on such an arrangement involving Dr. Melissa P. DelBello of the University of Cincinnati, Mr. Grassley asked the university to provide her income disclosure forms and asked AstraZeneca, the maker of the antipsychotic Seroquel, to reveal how much it paid her.
In scientific publications, Dr. DelBello has reported working for eight drug makers and told university officials that from 2005 to 2007 she earned about $100,000 in outside income, according to Mr. Grassley.
But AstraZeneca told Mr. Grassley it paid her more than $238,000 in that period. AstraZeneca sent some of its payments through MSZ Associates, an Ohio corporation Dr. DelBello established for “personal financial purposes.”
The University of Cincinnati agreed to monitor those payments more closely.
In early June, the senator reported to Congress that Dr. Joseph Biederman, a renowned child psychiatrist at Harvard Medical School, and a colleague, Dr. Timothy E. Wilens, had reported to university officials earning several hundred thousand dollars apiece in consulting fees from drug makers from 2000 to 2007 when in fact they had earned at least $1.6 million each.
Another member of the Harvard group, Dr. Thomas Spencer, reported earning at least $1 million after being pressed by Mr. Grassley’s investigators. The Harvard psychiatrists said they took conflict-of-interest policies seriously and had abided by disclosure rules.
In late June, after Mr. Grassley singled out Dr. Schatzberg, Stanford disputed some of the numbers in the report and has denied that Dr. Schatzberg violated any research rules devised to police such conflicts.
In an interview on Wednesday, Dr. Nada L. Stotland, president of the psychiatric association, said the group had studied Mr. Grassley’s letter and Stanford’s response and agreed with Stanford. Dr. Schatzberg will take over as president of the association as planned, she said.
“The larger issue here is that there’s a revolution going on” in how medicine handles industry money, said Dr. Stotland, a psychiatrist at Rush Medical College in Chicago. “That’s good, that’s what we need, and I believe we’ve been on the cutting edge of that revolution in many ways.”
Dr. Stotland said that the association began reviewing the income it received from pharmaceutical companies last March, to identify potential conflicts. Doctors and academic researchers generally worked at arm’s length from industry until the early 1980s, when Congress passed the Bayh-Dole Act. This legislation encouraged closer collaboration between researchers and industry to bring products to market more quickly. The act helped foster the growth of the biotech industry, and soon professors and universities were busy obtaining patents and building relationships with industry.
Some psychiatrists have long argued that consulting with a company — to help design a rigorous drug trial, for instance — benefits patients, as long as the researcher has no financial stake in the product and is not paid to speak about the drug to other doctors, like a traveling pitchman.
Others say industry and academic researchers are now so deeply intertwined that exposing doctors’ private arrangements only stokes suspicion without correcting the real problem: bias.
“Having everyone stand up like a Boy Scout and make a pledge isn’t going to quell suspicion,” said Dr. Donald Klein, an emeritus professor at Columbia, who has consulted with drug makers himself. “The only hope to rule out bias is to have open access to all data that’s produced in studies and know that there are people checking it” who are not on that company’s payroll.
Studies have shown that researchers who are paid by a company are more likely to report positive findings when evaluating that company’s drugs. The private deals can directly affect patient care, said Dr. William Niederhut, a psychiatrist in private practice in Denver who receives no industry money.
Dr. Niederhut said company-sponsored doctors had spread the word that new and expensive drugs were better in treating bipolar disorder than lithium, the cheaper old standby treatment.
“It’s a sales pitch, and now it’s looking like a whole lot of people would have done better if they’d started on lithium in the first place,” Dr. Niederhut said in a telephone interview. “The profession absolutely has to come clean on these industry deals, and soon.”
Tighter rules, stronger statements and more debate may not make much difference, if Mr. Grassley’s findings are any guide. Universities have rules requiring that faculty members disclose their outside income so that conflicts of interest in research or patient care can be managed. But some of the psychiatrists named in the investigations apparently ignored the rules.
“I think we may be coming to a point where hospitals and medical schools have to get serious about sanctioning,” said Dr. Paul S. Appelbaum, director of the division of psychiatry, medicine and the law at Columbia. “You can suspend doctors’ privileges, or suspend their right to treat patients; both have a huge impact on income and career. But if you’re serious about these disclosure policies, you have to be willing to back them up.”

DSM5 - The American Psychiatric Association’s proposal for ADHD – Making lifelong patients of even more healthy people - COURTESY OF SPEEDUPSITSTILL.COM - WEBSITE

The American Psychiatric Association’s DSM5 proposal for ADHD – Making lifelong patients of even more healthy people

July 25, 2011 by martin whitely

http://speedupsitstill.com/dsm-5-proposal-adhd-%E2%80%93-making-lifelong-patients-healthy-people#comments 

The American Psychiatric Association (APA) has published its draft changes for the fifth edition of its internationally influential Diagnostic and Statistical Manual of Mental Disorders (DSM5), due for final release in May 2013.  Along with other worrying changes the APA seems determined to further loosen its already absurdly broad diagnostic criteria for ADHD.

Four more ways to display ADHD

The most obvious of the changes is the inclusion of four extra ways of exhibiting ADHD. For a diagnosis of the primarily hyperactive subtype instead of children having to display 6 of 9 (67%) impulsive/hyperactive diagnostic criteria, 6 of 13 (47%) would be sufficient. The four additional criteria are;

1- Tends to act without thinking, such as starting tasks without adequate preparation or avoiding reading or listening to instructions. May speak out without considering consequences or make important decisions on the spur of the moment, such as impulsively buying items, suddenly quitting a job, or breaking up with a friend.

2- Is often impatient, as shown by feeling restless when waiting for others and wanting to move faster than others, wanting people to get to the point, speeding while driving, and cutting into traffic to go faster than others.

3- Is uncomfortable doing things slowly and systematically and often rushes through activities or tasks.

4- Finds it difficult to resist temptations or opportunities, even if it means taking risks (A child may grab toys off a store shelf or play with dangerous objects; adults may commit to a relationship after only a brief acquaintance or take a job or enter into a business arrangement without doing due diligence).¹

(The full list of the proposed DSM5 behavioural criteria are listed at the end of this blog or from http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=383)

All of the new DSM5 criteria are normal human behaviours. I for one never read instructions, am often impatient, frequently give into temptation, sometimes speed (and occasionally get angry with those who don’t and sit in the passing lane). I do these things because like the other 7 billion odd people on the planet I am far from perfect.

To anyone with a modicum of common sense or empathy the absurdity of these extra diagnostic criteria is self-evident. Although in fairness they are no more ridiculous than the current DSMIV criteria which include disliking homework and chores, losing toys, not listening, fidgeting, butting in, talking excessively or being easily distracted or forgetful.

In my experience the two most common reactions when people read the current DSMIV criteria for the first time is to say either “that’s me” or “that’s everybody”. (More detail about DSMIV is available at http://speedupsitstill.com/dodgy-diagnosis ) Arguably the changes proposed for DSM5 will make it harder not to meet the diagnostic criteria than to meet them.

Setting the bar even lower for Adult ADHD

For anyone 17 or older the ADHD bar will be lowered even further. It will be sufficient to meet as little as 4 (down from 6) of either the 9 inattentive or 4 of the expanded 13 impulsive/hyperactive criteria.² These changes continue the long term trend of lowering the bar for a diagnosis of ADHD.  DSMIII required six of nine inattentive behaviours and six of nine impulsive/hyperactive behaviours.  The bar was lowered significantly in DSM-IV when reduced to six of nine inattentive or six of nine hyperactive/impulsive behaviours.³ DSM5 lowers it even further.  Effectively an adult was required to display at least 12 of 18 (67%) behaviours in DSMIII, however for DSM-5 it proposed that as few as 4 of 22 (17%) will qualify for a diagnosis.

Other subtle but nonetheless significant changes include:

1- The relaxation of the DSMIV expectation that teachers independently provide evidence.⁴

2- Replacing hyperactive actions in the wording of criteria to feelings or perceptions of ‘restlessness’.⁵

3- The medicalisation, of the normal phenomena that ADHD behaviours are ‘typically more marked during times when the person is studying or working’ than ‘during vacation’. ⁶

4- The inclusion of adult relevant examples in most of the diagnostic criteria which had previously been primarily orientated to children in a school setting. ⁷

5- The change in the requirement that signs of the behaviour should be displayed before age seven to age twelve.⁸

$ The Bottom Line $

All the DSM5 proposed changes if implemented are likely to increase ADHD patient numbers and pharmaceutical company profits. Too often regulators like the FDA and TGA treat big pharmaceutical companies as if them as if they are benevolent enterprises. In reality they are morally neutral profit maximisers, superb marketers and completely indifferent as to whether their products help or harm humanity. They know how to promote ’experts’ who, however well intentioned, advocate their products and they thrive in the current largely self-regulated environment.⁹ It is time for policy makers to understand how much it is economics rather than science that is behind the explosion in ADHD prescribing.

The history of ADHD is a classic example of how to create and then expand a previously non-existent market. It was initially sold as a boy’s disorder requiring both hyperactivity and inattention. Then passive ADD (without the H for Hyperactivity) was marketed as a gender equity issue with the argument that ‘quiet girls’ were believed to be missing out as their ‘disability’ was ‘under-recognised’.¹⁰ The changes proposed for DSM5 will protect and enhance the child market and create continuity of the pharmaceutical company’s customer base into adulthood and likely replicate the massive explosion in psychotropic drug prescribing rates that occurred when DSMIV replaced DSMIII in 1994.¹¹

With the benefit of hindsight, Dr Allen Frances, who was the chief of psychiatry at the Duke University Medical Centre and led the effort to update DSM-IV, regretted broadening the diagnostic criteria and warned of problems with the drafting of the next edition, DSM-V, due for final release in 2012. Frances believes: ‘We learned some very, very, painful lessons in doing DSM IV…we thought we were being really careful about everything we did and we wanted to discourage changes. But inadvertently, I think we helped to trigger three false epidemics. One for Autistic Disorder…another for the childhood diagnosis of Bi-Polar Disorder and the third for the wild over-diagnosis of Attention Deficit Disorder.’ ¹²

Whilst it is heartening that Dr Frances has learned the lessons of DSMIV it is clear from the draft of DSM5 the American Psychiatric Association (APA) have not. Given the APA’s long history of close ties to Big Pharma¹³ and recent revelations about undisclosed drug company payments to the world’s most frequently cited ‘ADHD expert’ Harvard Professor Joseph Biederman, it is easy to assume the ‘experts’ guiding the DSM5 changes are motivated by money. (see http://speedupsitstill.com/world-leading-adhd-%e2%80%98expert%e2%80%99-harvard-professor-joseph-biederman-sanctioned-hidden-drug-company-money-allegations )

However, the APA have made some effort recently to restrict their reliance on pharmaceutical company funding and I believe most ADHD enthusiasts are not corrupt. Rather they are fervent believers in the ‘disorder’ and it’s hypothesised ‘biological roots’. It is likely money is not the primary motivation of those developing the DSM5 criteria for ADHD. Instead they are probably suffering from the one ‘disorder’ that is both very common and destructive but yet to be officially recognised, CSDD (Common Sense Deficit Disorder).

Either way being disorganised impatient, inattentive, impulsive, or failing to resist temptation isn’t disease, its humanity. And giving children amphetamines for basically being immature, annoying, inconvenient or embarrassing isn’t a medical treatment, its child abuse. Too many young Australians have suffered from our country’s blind acceptance of the American Psychiatric Association’s approach to mental health. This doesn’t just apply to ADHD. As I will outline in coming blogs the APA’s DSM5 proposals for other disorders are just as troubling.

The Australian response to DSM5 must be unequivocal. It is time to go it alone and abandon our slavish devotion to the American Psychiatric Association’s model because although DSMIV contained more than its fair share of crap, DSM5 smells far worse.

Appendix – The American Psychiatric Associations proposed new DSM5 diagnostic criteria fo ADHD are listed below.

A.   Either (1) and/or (2).

1.  Inattention: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that impact directly on social and academic/occupational activities. Note: for older adolescents and adults (ages 17 and older), only 4 symptoms are required. The symptoms are not due to oppositional behavior, defiance, hostility, or a failure to understand tasks or instructions.

(a)  Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities (for example, overlooks or misses details, work is inaccurate). 

(b)  Often has difficulty sustaining attention in tasks or play activities (for example, has difficulty remaining focused during lectures, conversations, or reading lengthy writings).

(c)  Often does not seem to listen when spoken to directly (mind seems elsewhere, even in the absence of any obvious distraction).

(d)  Frequently does not follow through on instructions (starts tasks but quickly loses focus and is easily sidetracked, fails to finish schoolwork, household chores, or tasks in the workplace).

(e)  Often has difficulty organizing tasks and activities. (Has difficulty managing sequential tasks and keeping materials and belongings in order. Work is messy and disorganized. Has poor time management and tends to fail to meet deadlines.)

(f)   Characteristically avoids, seems to dislike, and is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework or, for older adolescents and adults, preparing reports, completing forms, or reviewing lengthy papers).

(g)  Frequently loses objects necessary for tasks or activities (e.g., school assignments, pencils, books, tools, wallets, keys, paperwork, eyeglasses, or mobile telephones).

(h)  Is often easily distracted by extraneous stimuli. (for older adolescents and adults may include  unrelated thoughts.).

(i)   Is often forgetful in daily activities, chores, and running errands (for older adolescents and adults, returning calls, paying bills, and keeping appointments).

2.  Hyperactivity and Impulsivity: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that impact directly on social and academic/occupational activities. Note: for older adolescents and adults (ages 17 and older), only 4 symptoms are required. The symptoms are not due to oppositional behavior, defiance, hostility, or a failure to understand tasks or instructions.

(a)  Often fidgets or taps hands or feet or squirms in seat.

(b)  Is often restless during activities when others are seated (may leave his or her place in the classroom, office or other workplace, or in other situations that require remaining seated).

(c)  Often runs about or climbs on furniture and moves excessively in inappropriate situations. In adolescents or adults, may be limited to feeling restless or confined.

(d)  Is often excessively loud or noisy during play, leisure, or social activities.

(e)  Is often “on the go,” acting as if “driven by a motor.” Is uncomfortable being still for an extended time, as in restaurants, meetings, etc. Seen by others as being restless and difficult to keep up with.

(f)   Often talks excessively.

(g)  Often blurts out an answer before a question has been completed. Older adolescents or adults may complete people’s sentences and “jump the gun” in conversations.

(h)  Has difficulty waiting his or her turn or waiting in line.

(i)   Often interrupts or intrudes on others (frequently butts into conversations, games, or activities; may start using other people’s things without asking or receiving permission, adolescents or adults may intrude into or take over what others are doing).

(j)   Tends to act without thinking, such as starting tasks without adequate preparation or avoiding reading or listening to instructions. May speak out without considering consequences or make important decisions on the spur of the moment, such as impulsively buying items, suddenly quitting a job, or breaking up with a friend.

(k)   Is often impatient, as shown by feeling restless when waiting for others and wanting to move faster than others, wanting people to get to the point, speeding while driving, and cutting into traffic to go faster than others.

(l)   Is uncomfortable doing things slowly and systematically and often rushes through activities or tasks.

(m) Finds it difficult to resist temptations or opportunities, even if it means taking risks (A child may grab toys off a store shelf or play with dangerous objects; adults may commit to a relationship after only a brief acquaintance or take a job or enter into a business arrangement without doing due diligence).

ADHD RATES WITH YOUNG FOR AGE GROUP CHILDREN - Does ADHD Have a Season? - COURTESY OF THE GOOD THERAPY WEBSITE

Does ADHD Have a Season?

May 23, 2012.
 http://www.cmaj.ca/content/early/2012/03/05/cmaj.111619.full.pdf+html
 

In North America, children begin their formal academic education in kindergarten. Different regions throughout the United States and Canada have different entry dates for school admittance. The birth month of a child determines what year they will enter school. Children whose birthdays fall closest to the cutoff date are the youngest members of their grade, while those whose birthdays fall immediately after the cutoff date are the oldest. This results in classrooms teaching to children that can be a full year apart in age. Although this does not usually present an issue for most children, some children who develop behavioral maturity later than others may have difficulty keeping up with their classmates. The birth season of a child can significantly impact how their social, academic, and behavioral skills are in relation to their peers. This is one reason that experts believe the rates of attention-deficit hyperactivity disorder (ADHD) diagnoses are disproportionately high among the youngest students in American classrooms.

The topic of birth season has been explored with relation to other mental issues, including autism and schizophrenia. However, little research has focused on how relative age influences ADHD diagnoses in various countries. To determine if the social and medical differences between Canada and America would impact the rates of diagnoses in each country, Richard L. Morrow of the Department of Anesthesiology, Pharmacology and Therapeutics at the University of British Columbia led an 11-year study that looked at the rates of ADHD among nearly one million children ranging in age from 6 to 12 years. He categorized them based on birth season and reviewed which children were prescribed medication for ADHD.

In Canada, the cutoff date for birthdate to enter school is December 31. When he analyzed the results, Morrow found that the boys with December birthdays had more than a 30% higher risk for ADHD diagnosis than those who were born only 1 month later. For girls, the likelihood of being diagnosed was 70% higher if they were born in December. Morrow also discovered that the children with December birthdays were more likely to be on medication than those with January birthdates. These findings support the relative-age theory and suggest that the youngest children in a class may be at a much higher risk for overdiagnosis of ADHD than those who, by entry date guidelines, are only days younger but are a full grade behind. This underscores the importance of considering age and maturity when evaluating teacher and parent ratings of children. Morrow added, “It is possible that closer consideration of a child’s behavior in multiple contexts, including those outside of school, may lessen the risk of unnecessary diagnosis when assessing children for ADHD.”

Reference:
Morrow, R. L., Garland, E. J., Wright, J. M., Maclure, M., Taylor, S. (2012). Influence of relative age on diagnosis and treatment of attention-deficit/hyperactivity disorder in children: CMAJ. Canadian Medical Association Journal, 184.7, 755.

CONTRAVERSIAL FINDINGS : Youngest Kids in Class More Likely to Get ADHD Diagnosis: 2 STUDIES SHOW THERE CAN BE A LINK AND PROVE THERE CAN BE LONG TERM CONSEQUENCES THROUGH CHILDHOOD

 

 

 

Youngest Kids in Class More 

Likely to Get ADHD Diagnosis: Study

http://www.nlm.nih.gov/medlineplus/news/fullstory_122586.html 

CLICK ON LINK TO GET FULL ARTICLE

Researchers suggest some may just be immature for their grade

Monday, March 5, 2012

Related MedlinePlus Page

• Attention Deficit Hyperactivity Disorder

MONDAY, March 5 (HealthDay News) -- A new Canadian study provides more evidence that too many young kids may be diagnosed with attention-deficit/hyperactivity disorder, or ADHD, simply because they're younger than their peers in the same classrooms.
Researchers found that nearly 7 percent of boys aged 6 to 12 were diagnosed with ADHD overall, but the percentage ranged from 5.7 percent for those who were the oldest in their grade levels to 7.4 percent for the youngest. There was a similar gap for girls, although they're much less likely to be diagnosed.
The findings, which are similar to those from U.S. studies, don't prove definitively that any kids are being wrongly diagnosed with ADHD or being diagnosed purely because they're younger than their peers.
Still, "it's good for parents to know about this," said study author Richard Morrow, a health research analyst at the University of British Columbia. "In general, the younger you are within your grade, the more likely you are to receive this diagnosis and get treatment."
ADHD is a controversial developmental disorder, and there's been debate about whether it is overdiagnosed. The researchers launched the study to determine whether a student's age in relation to his or her peers may have something to do with the likelihood of diagnosis.
The study authors examined the records of over 930,000 kids in British Columbia who were between the ages of 6 and 12, during the time period from 1997 to 2008. They focused on differences between kids born in January (who'd typically be the oldest in their classes) and December (who'd typically be the youngest due to cut-off dates for school enrollment).
The level of ADHD diagnosis was lowest for kids born early in the year -- the oldest ones in their classes -- and highest for those born later in the year. Kids born in January and December had the lowest and highest rates, respectively: 5.7 percent of boys and 1.6 percent of girls for those born in January, and 7.4 percent of boys and 2.7 percent of girls among those born in December.
Boys born in December were 30 percent more likely to be diagnosed and 41 percent more likely to be treated with ADHD medications than boys born in January were, while the youngest girls were 70 percent more likely to be diagnosed and 77 percent more likely to be treated with medications than the oldest girls were, the study found.
"There is no reason for them to have this kind of difference in their diagnosis," Morrow said. "The way we would interpret that is that there are differences in maturity that are coming into play."
In other words, physicians and teachers may think kids have ADHD when they're actually just younger and less mature than their peers.
Richard Milich, a professor of psychology at the University of Kentucky who studies ADHD, said the findings make sense considering that the disorder is difficult to diagnose, especially at younger ages.
When ADHD becomes an issue, Milich said, parents should be aware of this kind of research and bring it up with their pediatrician or whomever else is appropriate. However, "I hope it doesn't get to the point that people say it's not a valid disorder," he said.
Kids with ADHD "do poorer in school, they're more likely to be left behind and more likely to drop out of school early. Across the board, they are impaired," Milich said. "Whether you want to call it a disorder or not, we know that's what they're at risk for."
The study appears in the March 5 issue of the CMAJ (Canadian Medical Association Journal).

SOURCES: Richard Morrow, M.A., health research analyst, University of British Columbia, Vancouver, Canada; Richard Milich, Ph.D., professor, psychology, University of Kentucky, Louisville; March 5, 2012, CMAJ (Canadian Medical Association Journal)

The importance of relative standards in ADHD diagnoses: evidence based on exact birth dates.

Elder TE.

Source

Economics Department, Michigan State University, East Lansing, MI 48824-1038, USA. telder@msu.edu

Abstract

This paper presents evidence that diagnoses of attention-deficit/hyperactivity disorder (ADHD) are driven largely by subjective comparisons across children in the same grade in school. Roughly 8.4 percent of children born in the month prior to their state's cutoff date for kindergarten eligibility - who typically become the youngest and most developmentally immature children within a grade - are diagnosed with ADHD, compared to 5.1 percent of children born in the month immediately afterward. A child's birth date relative to the eligibility cutoff also strongly influences teachers' assessments of whether the child exhibits ADHD symptoms but is only weakly associated with similarly measured parental assessments, suggesting that many diagnoses may be driven by teachers' perceptions of poor behavior among the youngest children in a classroom. These perceptions have long-lasting consequences: the youngest children in fifth and eighth grades are nearly twice as likely as their older classmates to regularly use stimulants prescribed to treat ADHD.

BEHAVIOURAL GUIDELINES - Attention Deficit Hyperactivity Disorder (ADHD) In-Depth From A.D.A.M. Treatment - COURTESY OF THE NEW YORK TIMES

 

 http://health.nytimes.com/health/guides/disease/attention-deficit-hyperactivity-disorder-adhd/treatment.html

CLICK ON LINK ABOVE

Attention Deficit Hyperactivity Disorder (ADHD)

In-Depth From A.D.A.M. Treatment

A combination of a psychostimulant, most commonly methylphenidate (Ritalin), and cognitive-behavioral therapy is proving to be the best option for treatment of children with ADHD. Although medication can be helpful during the initial years of treatment, some research indicates that the benefits of medication eventually wear off. It appears that ADHD symptoms may improve naturally over time, regardless of the treatment approach.
Signs that ADHD may be easing include not having to adjust medication dosages during growth spurts, no deterioration when a drug dose is missed, or new abilities to concentrate during “drug holidays.” (School vacation times are a good period to test the effectiveness of temporarily stopping medication.) The American Academy of Child and Adolescent Psychiatry suggests that parents evaluate whether medication can safely be withdrawn when children with ADHD have been free of symptoms for at least 1 year. If a child’s condition worsens after medication withdrawal, the drug should be resumed.
Developing a Treatment Approach. The following guidelines may be useful in determining a treatment approach for children with ADHD:

• Behavioral techniques should be tried first.
• If the symptoms are severe or do not respond, a trial using medication (usually psychostimulants), in combination with behavior modification therapy, is recommended.

Determining a Medication Regimen . Doctors still have a difficult time predicting which medications will produce beneficial results, so treatment is individualized and performed on a trial and error basis, which requires close observation and cooperation between all participants. In developing an effective medication plan, the following steps may be helpful:

• Before any drug is administered, a child should be given a thorough examination for any medical problems to be sure there are no medical conditions that interfere with the medication. It is especially important that children be checked for heart problems prior to initiating stimulant medication. (See “Risks of Stimulants” in the Medications section of this report.)
• Both the doctor and the parents should be very clear about the specific behaviors they hope the medication will target.
• The goal is to use the lowest possible dosage that produces improved behavior.
• If an initial regimen doesn't work, changing the dosage, or changing to a different medication often brings improvement.
• Frequent follow-up visits should be scheduled to assess the response and to detect possible side effects.

Arguments For and Against Psychostimulants. Many parents are very disturbed by the idea of putting their children on intensive stimulant drug regimens, possibly for years. Although the decision to use these drugs should not be made lightly, the negative social and emotional effects of the disorder itself for many children with ADHD are far more severe and long-lasting than the use of these drugs. For some parents and children, medication seems like a miracle and can provide desperate families with a quality of life for which they had almost given up hope. Whether or not psychostimulants are used, children and families should understand that ongoing efforts around behavior control will be necessary.
Of great concern is the dramatic increase in prescriptions for psychostimulants among preschool children. Although low doses of methylphenidate (Ritalin) may help preschoolers (ages 3 - 5 years) with ADHD, the drug can cause considerable side effects in many children. Doctors must carefully consider the risks versus benefits when prescribing ADHD drugs to preschoolers. Children who do receive these drugs need to be carefully monitored by their doctors.
Treatment for Adult ADHD . As with children, adults with ADHD are treated with a combination of medication and psychotherapy. For medication, stimulant drugs or the non-stimulant drug atomoxetine (Strattera) are usually first-line treatments, with antidepressants a secondary option. Most stimulant drugs, as well as atomoxetine, are approved for adults with ADHD. Adults who have heart problems or heart condition risk factors should be aware of the cardiovascular risks associated with ADHD medication. There have been ADHD medication-associated incidents of sudden death in patients with underlying serious heart problems, and reports of stroke and heart attack in adults with cardiac risk factors.

Help for Families and Teachers

Interventions for the child with ADHD should also include the parents if they are to be successful. Teachers and school officials should also be educated and involved in the process.
Parents who feel they have the most control over their child's situation experience less psychological stress and depression. Parents who are responsive in a positive way can help reduce the chances for their child developing oppositional behaviors.
In addition to behavioral therapy for the child, family therapy may help children with ADHD and their parents and siblings cope with the emotional conflicts that can arise in the process of managing the condition. Separate psychological therapies for specific family members may also be helpful.

More Information on This Topic

Review Date: 2/27/2012
Reviewed By: Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.

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NEW YORK TIMES - Attention Deficit Hyperactivity Disorder (ADHD) : In-Depth From A.D.A.M. Behavioral Management

 

 http://health.nytimes.com/health/guides/disease/attention-deficit-hyperactivity-disorder-adhd/behavioral-management.html

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Attention Deficit Hyperactivity Disorder (ADHD)

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In-Depth From A.D.A.M. Behavioral Management

Behavioral techniques for managing the child with ADHD are not intuitive for most parents and teachers. To learn them, caregivers may need help from qualified mental health care professionals or from ADHD support groups. At first, the idea of changing the behavior of a highly energetic, obstinate child is daunting. It is futile and damaging to try to force a child with ADHD to be like most children. It is possible, however, to limit destructive behavior and to instill in the child a sense of self-worth that will help overcome negativity.

Behavioral Techniques at Home

Bringing up a child with ADHD, like bringing up any child, is a process. No single point is ever reached where the parent can sit back and say, "That's it. My child is now OK, and I don't have to do anything more." The child's self esteem will evolve with an increasing ability to step back and consider the consequences of an action and then to control that action before taking it. But this does not happen overnight. A growing child with ADHD is different from other children in very specific ways, presenting challenges at every age.
Setting Priorities for the Parent. Parents must first establish their own levels of tolerance. Some parents are easygoing and can accept a wide range of behaviors, while others cannot. To help a child achieve self-discipline requires empathy, patience, affection, energy, and toughness. Some tips to help parents include:

• Parents should prepare a list giving priority to those behaviors they think are the most negative, such as fighting with other children or refusing to get up in the morning. The least negative behaviors on the bottom of the list should be ignored temporarily or even permanently (refusing to wear anything but red T-shirts).
• Certain odd behaviors that are not hurtful to the child or to others may be an indication of creative or humorous attempts to adapt (making up silly songs or drawing violent pictures). These should be accepted as part of the child's unique and positive development, even if they seem peculiar to the parent.
• It is important to keep in mind that no one is a saint. Loving parents who occasionally lose their tempers will not damage their children forever. In fact, non-abusive open disapproval or dismay is far less destructive to both parent and child than harboring resentment beneath a false calm.

Establishing Consistent Rules for the Child. Parents must be as consistent as possible in their approach to the child, which should reward good behavior and discourage destructive behavior. Rules should be well-defined but flexible enough to incorporate harmless idiosyncrasies. It is very important to understand that children with ADHD have much more difficulty adapting to change than do children without the condition. (For example, the child should do homework every day but might choose to start it after a TV show or computer game.) Parents should establish a predictable routine, and provide a neat, stable home environment (particularly in the child’s room).
Managing Aggression. Some useful tips for managing aggression include:

• Parents should try to give little attention to mildly disruptive behaviors that allow this energetic child to let off some harmless steam. The parent will also be wasting energy that will be needed when the negative behavior becomes destructive, abusive, or intentional.
• The use of "time-out," isolating the child immediately for a short period of time, is an effective measure for allowing both the caregiver and the child to cool down. The child should immediately (and without emotion) be removed from a situation in which they are endangered or endangering others. The child should view time out as a way of cooling off and getting a distance on their behavior, not as isolation from others.
• To channel physical aggression and impulsivity in a toddler with ADHD, the parents must teach them to use verbal responses. (A parent may need to allow verbal responses that would be unacceptable in another child.)
• When the child becomes older and if the verbal responses become intentionally abusive and socially undesirable, the parent must redirect this form of aggression into more acceptable activities, such as competitive one-on-one sports, energetic music, video games, or big colorful paintings. Competitive video games, such as sports games, may also be an option.
• Sometimes a parent can anticipate situations when a child with ADHD is likely to misbehave, but all too often the child explodes for no apparent reason. If the blow-up occurs in public, the parents should complete their activities and leave as quickly as possible.

Establishing a Reward System. Children with ADHD respond particularly well to reward systems. One study reported that they performed equally well when encouraged either by a direct reward for a correct response or with the use of a system called response-cost. With this system, the child is given the reward first and allowed to keep it if their behavior remains appropriate.
Some suggested tips for rewarding the ADHD child are:

• Create charts with points or stars for good behavior or for completed tasks. It is important to give points for even simple positive behaviors, which may be taken for granted in other children (responding happily to a change in plans, changing an obscenity to a more acceptable expletive).
• Rewards for any child can include playing a favorite game, extending bedtime by an hour, or allowing an extra half-hour of TV.
• Rewards of food or gifts should be used infrequently, if at all. They can create other problems, such as being overweight, having a bad diet, or making continuous demands for objects.
• A reward system should rotate different types of rewards, because such children are easily bored.
• Children with ADHD respond better with small rewards promised in the short-term than large rewards offered in the future. One approach that uses both short- and long-term rewards is a system that gives the child points for specific positive behaviors. As the children accumulate points, they can use them for larger tangible rewards, such as a favorite video game or CD.
• Rewards should be promised only when caregivers are fairly certain they can follow through. Children with ADHD respond with much greater frustration than children without ADHD to disappointment, and are likely to have a strong (and noisy) negative reaction. A parent must remember that this response is part of the child's make-up and not necessarily in their control.

Improving Concentration and Attention. Children with ADHD perform significantly better when their interest is engaged. Parents should be on the lookout for activities that hold the child's concentration. Options include swimming, tennis, and other sports that focus attention and limit peripheral stimuli. (Children with ADHD may have difficulty with team sports require constant alertness, such as football or basketball.)
Martial arts, such as Tae Kwon Do, can also offer an appropriate and controlled emotional outlet, and help to focus attention, and teach self-restraint, self-discipline, and tolerance. Learning an instrument can help a child to develop a more rhythmic and balanced sense of self.

Management at School

Even if a parent is successful in managing the child at home, difficulties often arise at school. The ultimate goal for any educational process should be the happy and healthy social integration of children with ADHD with their peers.
Preparing the Teacher. Although teachers can expect at least one student in every classroom to have ADHD, there is generally little training that prepares them for managing these children. The teacher should be prepared for certain behaviors in the child with ADHD:

• Students with ADHD are often demanding, talkative, and highly visible.
• Inattention is a major factor in low academic performance and can cause children to frequently forget homework or miss assignments. Children with ADHD often require frequent reminders or visual cues (such as posters) for rules and regulations. Having the child sit in the front of the classroom may be helpful for both increasing attention and reducing noisy activity.
• Lack of fine motor control makes taking notes very difficult, and handwriting is often poor. Using a computer can compensate for this.
• Rote memorization and math computation, which require following a set of ordered steps, are often difficult. (Children with ADHD may do better with math concepts .)
• Many children with ADHD respond well to school tasks that are rapid, intense, novel, or of short duration (such as spelling bees or competitive educational games), but they almost always have problems with long-term projects where there is no direct supervision.

The Role of the Parent in the School Setting. The parent can help the child by talking to the teacher before the school year starts about their child's situation. The first priority for the parent is to develop a positive, not adversarial, relationship with the child's teacher. Finding a tutor to help after school may also be helpful
Special Education Programs . The Individuals with Disabilities Education Act (IDEA) requires the school to identify and evaluate children who may need help and to provide special services. However, parents sometimes report pressure by the school to put their children on medication or force them into special classrooms without clear educational justification. The schools, in these cases, may be acting illegally.
High-quality special education can be extremely helpful in improving learning and developing a child's sense of self worth. However, programs vary widely in their ability to provide quality education. Parents must be aware of certain limitations and problems with special education:

• Special education programs within the normal school setting often increase the child's feelings of social alienation.
• If the educational strategy focuses only on abnormal behavior, it will fail to take advantage of the creative, competitive, and dynamic energy that often accompanies ADHD behavior.
• There is no federally funded special education category specifically targeted to ADHD.

The best approach may be to treat the syndrome as a variant of the norm and train teachers to manage these children within the context of a normal classroom.
Special programs are also required under the Rehabilitation Act and by the Americans with Disabilities Act (ADA) for students at institutions of higher learning. It is the student's responsibility, however, to inform the administration at their college or university that they need such services.