Finding Guidance Amid Uncertainty of ADHD Diagnosis
Am Fam Physician. 2001 May 1;63(9):1694-1700.
The idea of collaborative care has been captured in the saying “It takes a whole village to raise a child.” This is also true with families who are raising children with attention-deficit/hyperactivity disorder (ADHD). This message echoes throughout the new ADHD clinical guidelines discussed by Herrerias and colleagues1 in this issue of American Family Physician.
The National Institutes of Health (NIH) issued a statement at the end of a Consensus Development conference in November 1998, stating that “ADHD has remained controversial in many public and private sectors.” The panel recognized that “we do not have an independent valid test for ADHD, and there is no data to indicate whether ADHD is due to a brain malfunction.” Recommendations by the panel were “further efforts to validate the disorder,” that “basic research is needed to better define ADHD,” and that “a more consistent set of diagnostic procedures and practice guidelines is of utmost importance.”2
In practice, it is not uncommon to see children in whom symptoms of ADHD are not clearly distinguishable from normal variations in temperament. Temperament research shows that there is wide variation in the activity level of normal children, and we do not have consistent pathologic changes or structural, functional or chemical markers to guide diagnosis. Diagnostic questionnaires tend to be highly subjective and impressionistic, adding to the complexity of acting as the family and child's advocate. However, an advantage of ADHD labeling is that it may remove the blame from parents and schools, and help such children get needed services and justification of medicine use.
Clinical practice guidelines summarized by Herrerias and colleagues1 are the first step toward using evidence-based criteria to diagnose ADHD. Recorded prevalence rates for ADHD vary substantially, partly because of changing diagnostic criteria over time,3 and partly because of variations in ascertainment in different settings and the frequent use of referred samples to estimate rates. Practitioners vary greatly in the degree to which they use criteria from the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV) to diagnose ADHD. Several recommendations were made to establish evidence-based criteria for ADHD. One important recommendation was that the DSM-IV work group incorporate a pediatrician, a family physician, or both, in their panel.
Public interest in ADHD has increased along with debate in the media concerning the diagnostic process and treatment strategies.4 Concern has been expressed about the overdiagnosis of ADHD by pointing to the several-fold increase in prescriptions for stimulant medication among children during the past decade.5 There is little objective evidence, however, of widespread overdiagnosis of ADHD or of widespread over-prescription of methylphenidate (Ritalin) by physicians.6
Screening for school performance at all office visits for school-aged children may improve early detection of ADHD. Screening can be done by asking questions regarding any concern of teachers or parents about a child's behavior or any learning issues noted by them. Yet even this step leaves the clinician at a loss when dealing with children who do not have a clear-cut diagnosis or when diagnostic criteria may actually be inappropriate for a particular child.
Finally, ADHD is a syndrome and does not always present in a classic manner. When ADHD is present, the impact on the life of the child and the family can be quite dramatic, demanding that practitioners intervene with the entire family. In one case, for example, parents reported that the ordeal has taught them how to be patient in raising their child. In the words of the great mystical poet Rumi7:
The core of every fruit is better than its rind.
Regard the body as the rind, and the human spirit the core.
Amer Shakil, M.D., is an assistant professor at the University of Texas Southwestern Medical Center at Dallas, Dallas, Texas.
Address correspondence to Amer Shakil, M.D., St. Paul Family Practice Residency Program, 5550 Harvest Hill Rd., Ste. 100, Dallas, TX 75230.
1. Herrerias CT, Perrin JM, Stein MT. The child with ADHD: the AAP clinical practice guideline. Am Fam Physician. 2001;63:1803–101811.
2. Carey WB. Problems in diagnosing attention and activity. Pediatrics. 1999;103:664–6.
3. American Psychiatric Association Diagnostic and statistical manual for mental disorders. 4th ed. Washington, D.C.: American Psychiatric Association, 1994.
4. Gibbs N. Latest on Ritalin. Time. 1998;152:86–96.
5. Safer DJ, Zito JM, Fine EM. Increased methylphenidate usage for attention deficit disorder in the 1990s. Pediatrics. 1996;98:1084–8.
6. Goldman LS, Genel M, Bezman RJ, Slanetz PJ. Diagnosis and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Council on Scientific Affairs, American Medical Association. JAMA. 1998;279:1100–7.
7. Mabey J, compiler. Rumi: a spiritual treasury. Boston: Oneworld Publications, 2000.
Copyright © 2001 by the American Academy of Family Physicians.
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