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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 Are More Likely to Get ADHD Diagnosis and Consequently be Prescribed Psycho-stimulant Drugs : 2 conclusive studies show there can be a link and prove that there can be long term consequences through childhood and life for those 'labelled.' + Professional bodies still call for a national review of psychotropic drugs for children.

"You are one of the youngest in this class, just by a few months,  listen to me and take one of these tablets." says a 'trusted adult.'

"Youngest in school year more likely to be diagnosed with ADHD: research."

TELEGRAPH ARTICLE MAY 2012

Tens of thousands of children are being misdiagnosed with ADHD because they are the youngest in their class and their immaturity is being mistaken for hyperactivity, a study has suggested.

By Rebecca Smith, Medical Editor

 06 Mar 2012

Children who were born late in the school year and so are almost 12 months younger than their oldest classmates are more likely to be diagnosed and given medication like Ritalin for attention deficit hyperactivity disorder, it was found.

They are being 'inappropriately labelled and treated' the authors said.

Greater caution should be given to making the diagnosis in order to prevent children from being given potentially harmful medicines without justification, they said.

There are thought to be around 1.7m people with attention deficit problems in Britain with between three and seven per cent of school age children affected. 

There is no data collected on how many children in Britain are on drugs for the problem but in 2010 there were over 850,000 prescriptions dispensed for medicines to treat the condition in England and Wales at a cost of almost £44m.

The study was conducted on children in British Columbia in Canada where the school year coincides with the calender year.

It was found that children born in December, so the youngest in their school year, were 40 per cent more likely to be diagnosed and almost 50 per cent more likely to be treated for ADHD than children born in January, the start of the school year. 

In Britain this would correspond to children born in August compared with those born in mid to late September.
It is well known that the youngest children in the school year tend to struggle with academic performance, behaviour and sport, in what is known as the relative age effect.
The findings were published in the Canadian Medical Association Journal.

Lead author Richard Morrow, University of British Columbia, said: "The relative age of children is influencing whether they are diagnosed and treated for ADHD.
"Our study suggests younger, less mature children are inappropriately being labelled and treated. It is important not to expose children to potential harms from unnecessary diagnosis and use of medications." 

The side effects of ADHD drugs can include sleep disruption, increased risk of heart problems and slower growth rates. As well, younger children who have been labelled ADHD may be treated differently by teachers and parents, which could lead to negative self-perception and social issues, the authors said.
Coauthor and psychiatrist Jane Garland, University of British Columbia and BC Children's Hospital, said: "This study raises interesting questions for clinicians, teachers and parents. 

"We need to ask ourselves what needs to change. For example, attention to relative age of children for their grade and more emphasis on behaviour outside the school setting might be needed in the process of assessment."

The study investigated almost one million schoolchildren in British Columbia over ten years who were between the age of six and 12.

Although the prevalence of ADHD diagnosis and treatment is about three times higher in boys than girls, the effect of relative age applied to both.

Girls born in December were 70 per cent more likely to be diagnosed with ADHD than girls born in January.

The researchers wrote in the journal: "The potential harms of overdiagnosis and overprescribing and the lack of an objective test for ADHD strongly suggest caution be taken in assessing children for this disorder and providing treatment."

Experts in Britain said the findings could mean that ADHD was not not being picked up in the older children in the year group as well as or instead of too many diagnoses being made in the younger children. 

Dr Dave Coghill, Reader in Child and Adolescent Psychiatry, at University of Dundee, said: "In a culture where ADHD is over diagnosed it may be that relative age increases the likelihood that younger children in a year will be over diagnosed. 

"In cultures where there is under recognition of ADHD such as the UK and Canada the opposite may occur with there being a more appropriate recognition in younger children with under recognition of ADHD in the older children in a year.
"The researchers suggest that this relative age effect is likely to be driven by the teacher. In the UK parents are always intimately involved in the assessment for ADHD and in almost all cases it is them that provide the key information that drives the assessment process. As a consequence it is possible that the UK will be less prone to these relative age effects." 

Dr Liz Didcock, mental health lead at the Royal College of Paediatrics and Child Health, said:‬ "This paper adds an interesting perspective on the diagnosis and treatment of ADHD in children.

"It reminds us of the importance of understanding behaviour in its context, particularly in relation to the influence of parental and teacher expectations. 

"The potential 'over-medicalisation' of what can be considered 'normal' childhood behaviour is an obvious concern. It is vital that all clinicians from Paediatric and Child and Adolescent Mental Health Services teams are skilled in the assessment of children's development, including their social and emotional health.

"Assessments must take into account biological, social and psychological factors before a diagnosis is made and appropriate treatment is prescribed."

 

 

CONRAVERSIAL FINDINGS.

Youngest Kids in Class More Likely to Get ADHD Diagnosis: Study with very important conclusions.

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 and are give drugs as a result -CRAZY!

Monday, March 5, 2012 

• 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)

Influence of relative age on diagnosis and treatment of attention-deficit/hyperactivity disorder in children

1. Richard L. Morrow, MA,et al.

1. From the Department of Anesthesiology, Pharmacology and Therapeutics (Morrow, Maclure, Dormuth), University of British Columbia, Victoria, BC.

1. Correspondence to:
   Richard Morrow, richard.morrow@ti.ubc.ca.

Abstract

Background: 

The annual cut-off date of birth for entry to school in British Columbia, Canada, is Dec. 31. Thus, children born in December are typically the youngest in their grade. We sought to determine the influence of relative age within a grade on the diagnosis and pharmacologic treatment of attention-deficit/hyperactivity disorder (ADHD) in children.

Methods: 

We conducted a cohort study involving 937 943 children in British Columbia who were 6–12 years of age at any time between Dec. 1, 1997, and Nov. 30, 2008. We calculated the absolute and relative risk of receiving a diagnosis of ADHD and of receiving a prescription for a medication used to treat ADHD (i.e., methylphenidate, dextroamphetamine, mixed amphetamine salts or atomoxetine) for children born in December compared with children born in January.

Results: 

Boys who were born in December were 30% more likely (relative risk [RR] 1.30, 95% confidence interval [CI] 1.23–1.37) to receive a diagnosis of ADHD than boys born in January. Girls born in December were 70% more likely (RR 1.70, 95% CI 1.53–1.88) to receive a diagnosis of ADHD than girls born in January. 

Similarly, boys were 41% more likely (RR 1.41, 95% CI 1.33–1.50) and girls 77% more likely (RR 1.77, 95% CI 1.57–2.00) to be given a prescription for a medication to treat ADHD if they were born in December than if they were born in January 

SO NEARLY DOUBLE THE RATE OF DIAGNOSIS!

Interpretation: 
The results of our analyses show a relative-age effect in the diagnosis and treatment of ADHD in children aged 6–12 years in British Columbia. These findings raise concerns about the potential harms of overdiagnosis and overprescribing. These harms include adverse effects on sleep, appetite and growth, in addition to increased risk of cardiovascular events.

FEEDBACK IS VERY POSITIVE TO THIS STUDY:

 "Thank you! Thank you! Thank you!"

 Finally a proper study that shows that this pseudo disorder has nothing to do with the child but everything to do with the environment in which the child has to live.
I have practiced paediatrics in BC for more than 25 years and fought this ADHD nonsense for as long. The diagnosis criteria are wrong: the Conner's rating scale (and all its clones) was never intended as a diagnostic tool but as a follow-up tool and is a purely subjective questionnaire with no gold standard (e.g.: how long a child of a specific age, and specific socio- cultural and economical background, in a standardized situation should stay at a standardized task?). The labeling is wrong: there is NO disorder, at the most there is a behavioural issue that is perceived as a problem. The approach is wrong: medicating these young brains in the middle of their development with amphetamine will be looked down on by future generations the way we look today at lobotomies, to cite only one of numerous erroneous dogmas medicine has produced.
A child who is too young to be put in a cohort of other children and learn material he/she can't, will misbehave. Similarly, the familial environment is more than too often "in-adapted" to the child's needs and the child, of course misbehaves. I have seen so many children put on one of these poisonous drugs because they lived in an environment no adult could survive intact!
A child who misbehaves always has a good reason to do so. Sometimes it is a trivial reason that is easy to remedy, a reason the child perceived as traumatic but is not an abnormal situation; other times it is a genuine and really traumatic problem that must be addressed. Medicating these children and telling them they have a "brain disorder", is wrong in both cases. Neuro-stimulant medication should be the exception instead of the rule.

Again thank you RL Morrow, EJ Garland, JM Wright, M Maclure, S Taylor and CR Dormuth for this superb article. Thank you also to the CMAJ for publishing it. 

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.

Pediatrics Vol. 117 No. 4 April 1, 2006
pp. e601 -e609
(doi: 10.1542/peds.2005-1308)

Abstract
 
OBJECTIVE. 
To investigate factors that are associated with the probability of attention-deficit/hyperactivity disorder (ADHD) diagnosis among U.S. elementary school children, including child, family, school, and policy factors.
 
METHODS. 
Logistic regression was used to estimate relative risks associated with independent variables using a nationally representative sample of 9278 children in the 2002 follow-up of the Early Childhood Longitudinal Survey–Kindergarten Cohort. Most children in the sample were in third grade at this point. Previous ADHD diagnoses by professionals were reported by parent respondents.
 
RESULTS.  
A total of 5.44% of children were reported to have received an ADHD diagnosis. Girls, black children, and Hispanic children were less likely to have the diagnosis even after controlling for other characteristics. Living with one's biological father was negatively associated with ADHD diagnosis. We also found regional variation in diagnosis with the western region of the United States having significantly lower instances of ADHD cases. Higher diagnosis rates were associated with having an older teacher, and lower rates were associated with having a white teacher, relative to a nonwhite teacher. In schools that were subject to stricter state-level performance accountability laws, we found higher odds of ADHD diagnoses, but we found no differences associated with larger class sizes or the presence of state laws that restrict school personnel from discussing ADHD treatment options with parents.
Who Receives a Diagnosis of Attention-Deficit/ Hyperactivity Disorder in the United States Elementary School Population?
Helen Schneider, PhDa,
Daniel Eisenberg, PhDb


CONCLUSIONS. 
ADHD diagnosis is likely to be influenced by a child's social and school environment as well as exogenous child characteristics. Concerns that increased pressures for school performance are associated with increased ADHD diagnoses may be justified.

Behaviour drugs given to four-year-olds prompt calls for inquiry

ADHD medication given in breach of NHS guidelines as professor says parents putting pressure on GPS.

• Rowenna Davis
• guardian.co.uk, Friday 18 March 2011 21.08 GMT

Children as young as four have been prescribed Ritalin-style drugs in breach of NHS guidelines. Photograph: Murdo MacLeod

Children as young as four are being given Ritalin-style medication for behavioural problems in breach of NHS guidelines, the Guardian has discovered, prompting the leading psychological society to call for a national review.
Family-based therapy is recommended for treating children with ADHD (attention deficit hyperactivity disorder), with prescription drugs used only for children over six years old and as a last resort.
The figures, based on data from 479 GPs, show prescription rates were highest for children aged six to 12, doubling to just over eight per 1,000 in the five years up to 2008. Children aged 13 to 17 had the second highest rate at six per 1,000, while those aged 25 and over had less than one per 1,000.
Concern is greatest over children under six who should not be receiving drugs at all, says the National Institute for Health and Clinical Excellence (Nice).
There are no reliable figures for how many children under six have been given Ritalin. But Professor Tim Kendall, joint director of the National Collaborating Centre for Mental Health, who chaired the Nice guideline committee, confirmed that he had heard reliable reports of children in nursery and pre-school being prescribed medication unnecessarily, and that it was often parents who were putting pressure on GPs.
He said: "There are two reasons why parents go shopping for a diagnosis. The first is to improve their child's performance at school, and the second is to get access to benefits. There are always GPs that will do it, but it's wrong to give a child a diagnosis without also consulting schools and teachers."
In one case seen by the Guardian, a five-year-old from the West Midlands was found to be receiving a double dose of methylphenidate, commonly known by the brand name Ritalin, the drug used to treat ADHD, despite his school insisting that he is "among the best-behaved children in his class".
In notes seen by the leading educational psychologist in the case, the boy's headteacher reports that the school does not believe he has ADHD, but that the medication is being prescribed "to help mum at home".
In another case in the West Midlands a five-year-old was put on the drugs for three years at the request of his parents without any consultation with teachers or psychologists.
Kendall said prescriptions could continue to rise due to impending health cuts. "It's a false economy … all the evidence says that parent training courses combined with partnership working with schools is what works, but these programmes are being cut by local councils."
Speaking on behalf of the British Psychological Society, Peter Kinderman, chair of the division of clinical psychology, said he supported calls for a review, saying he would be concerned if children were being prescribed medication as a quick fix.
He added that mental health services were already "grossly under-resourced" and that cuts were likely to put services to children at risk.
Kinderman expressed particular worries about the cases uncovered by the Guardian. "Many psychologists are very concerned at the use of psychiatric and medical diagnoses in cases such as mild social anxiety or shyness, not only because of doubts about the validity of many of the diagnostic approaches, but because of the possible adverse effects."
But Dinah Jayson, consultant child and adolescent psychiatrist at Trafford general hospital and a spokesperson for the Royal College of Psychiatrists, insisted that in some cases it could be "cruel" not to treat children of any age if all other options had been exhausted.
She said: "With every child there is a risk of doing something but there is also a risk of doing nothing. We know early [medical] intervention can help children who would otherwise be losing out."
Professor Ian Wong, director at the Centre for Paediatric and Pharmacy Research, who led the prescriptions research, pointed out that prescription rates were still below the expected number of diagnoses for hyper-kinetic disorders.
"GPs and psychiatrists are much more aware of mental illness, and the drugs are so effective and have such a big effect that it's tipped the balance. They [drugs] can make a real difference not just to the child but to households and classrooms where children may be causing real disruption."
According to Nice guidelines, between 1% and 9% of young people in the UK now have some form of ADHD, depending on the criteria used. NHS figures show a rise in all methylphenidate prescriptions across all age groups by almost 60% in five years, rising from 389,200 in 2005 to 610,200 in 2009.
Side-effects include sleeplessness, appetite loss and reduced growth rates. Wong, who says the long-term effects are inconclusive, recently received a €3m (£2.6m) grant from the European commission to investigate side-effects further.
Professor Paul Cooper, a psychologist and professor of education based at Leicester University, who has completed qualitative research with adolescents on psychostimulant medication, expressed concerns about the possible effects of the drugs on personality development.
"Some young people say that it affects their personality but accept it because it gets mum and dad off their case or stops them getting into trouble," he said. "They don't like it, but take it for the benefit of other people."
Medical experts in the West Midlands say over-prescription continues to be a problem. "This whole area needs public scrutiny – there has to be some kind of review," said the educational psychologist who oversaw the cases but did not want to be named. "Handing out strong psychotropic drugs to children should be a last resort, but they're being handed out like sweets."

Other Related Telegraph Articles:

• Overdue babies more likely to have ADHD: research
  03 May 2012
• Give Ritalin to four-year-olds with ADHD, say experts
  17 Nov 2011
• Doping difficult kids is wrong
  17 Sep 2011
• 'Shy' children could be diagnosed with mental disorder
  14 Sep 2011
• ADHD stops children being able to switch off daydreaming brain
  05 Jan 2011
• Summer babies 'more likely to be diagnosed with ADHD'
  18 Aug 2010

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

 

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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

 

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Attention Deficit Hyperactivity Disorder (ADHD)

• 
  

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.