by Gregory K. Fritz, MD, Bradley Hospital medical director and Hasbro Children's Hospital child and family psychiatry director. Fritz is also editor of the Brown University Child and Adolescent Behavior Letter, where this article first appeared.
Attention deficit/hyperactivity disorder (ADHD) is neither a new nor rare condition confronting children and those who teach, treat or love them. However, the disorder has recently attracted considerable attention as its prevalence and persistence have been recognized. Two major studies and the conclusions of a blue-ribbon consensus conference on ADHD sponsored by the National Institutes of Health have been published in the past year. This level of scientific agreement allows several myths about ADHD to be confronted directly.
Myth: ADHD does not exist as a real psychiatric disorder; rather, it is an unfortunate labeling of normal childhood behavior promulgated by ineffectual parents, incompetent teachers and the pharmaceutical industry.
ADHD has received more scientific scrutiny than any other childhood psychiatric disorder since Charles Bradley's initial 1937 report of effective treatment with stimulants of children at the Emma Pendleton Bradley Hospital in East Providence. ADHD has met the same standards as other major psychiatric disorders included in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, 4th Edition. Studies have shown that experts can reliably agree on the diagnosis of individual patients with ADHD and can do so consistently. Better genetic evidence exists for ADHD than most other psychiatric disorders.
What remains at issue is whether ADHD is a categorical or "continuous" condition in children. Is ADHD a discrete disease, like diabetes, or the extreme end of a continuum of symptoms, like essential hypertension? Further research is needed to answer this important question, but that it remains unanswered in no way invalidates serious psychiatric concern about other aspects of ADHD.
Myth: ADHD is a minor problem with little impact if adults can just let children be children.
Abundant evidence documents the academic, social and behavioral difficulties of children with ADHD. Far from "growing out" of them, the problems of children with ADHD are often compounded as they reach adolescence. Conduct disorders, drug abuse, antisocial behavior and injuries of all sorts build on earlier developmental deficits. Parents of children with ADHD experience the same frustrations, marital discord and increased levels of depression common to other chronic diseases of childhood. Individuals with ADHD consume a disproportionate share of resources from the health care, juvenile justice and educational systems.
For example, the nation's public schools were estimated to have spent more than $3 billion in 1995 on additional services for children with ADHD. Evidence is mounting as to the ongoing difficulties associated with ADHD as it persists into adulthood.
Myth: There is no really effective treatment for ADHD; medications are oversold as a marketing ploy by the pharmaceutical industry.
A substantial body of evidence now exists concerning the efficacy of behavior treatment, medications and combined therapies. Several large scale, rigorous studies have concluded that: a) both stimulant medication and behavioral treatment are effective; b) stimulant medication is consistently more effective than behavioral treatment when the two are compared singly, head-to-head; and, c) a combination of the two treatments is most effective and lets lower doses of stimulant medication be maintained over time.
Myth: Treatment with stimulant medications is a risky undertaking, fraught with side effects and the likelihood of drug abuse later in life.
Adverse reactions to stimulant medications do occur, but they are usually dose-related, i.e., they are more likely to occur at high doses. The NIH consensus panel of experts concluded that there is no evidence that careful therapeutic use of stimulants is harmful The potential for abuse exists with stimulant medications, as reflected in their popularity on college campuses, but such effects are not evident within the therapeutic dosage
While there is clearly an increased risk of cigarette smoking and drug abuse associated with ADHD, it is hard to untangle possible causes: the use of stimulant medications, the characteristics of ADHD, and the effect of co-modid conditions. In fact, two reports in the past year attested that effective treatment of ADHD with stimulant medication my actually decrease the risks for later drug use.
The ambiguities, concerns about over-treatment, and public skepticism associated with ADHD stem from the highly variable approaches to the problem that are applied in practice. Too often, the diagnostic process is cursory and inadequate, treatment is unsystematic, and long-term care is superficial and/or fragmented. Further research is essential regarding many aspects of ADHD, and clinical practice needs to adhere closely to the evidence that already exists if affected children are to receive appropriate care for this disorder.