Facts, values, and Attention-Deficit Hyperactivity Disorder (ADHD): an update on the controversies

Child and Adolescent Psychiatry and Mental Health BioMed Central Commentary Open Access Facts, values, and Attention-Deficit Hyperactivity Disorder (ADHD): an update on the controversies Erik Parens* and Josephine Johnston Address: The Hastings Center, 21 Malcolm Gordon Road, Garrison, New York 10524, USA Email: Erik Parens* - ; Josephine Johnston - * Corresponding author Published: 19 January 2009 Child and Adolescent Psychiatry and Mental Health 2009, 3:1 doi:10.1186/1753-2000-3-1 Received: 22 September 2008 Accepted: 19 January 2009 This article is available from: http://www.capmh.com/content/3/1/1 © 2009 Parens and Johnston; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract The Hastings Center, a bioethics research institute, is holding a series of 5 workshops to examine the controversies surrounding the use of medication to treat emotional and behavioral disturbances in children. These workshops bring together clinicians, researchers, scholars, and advocates with diverse perspectives and from diverse fields. Our first commentary in CAPMH, which grew out of our first workshop, explained our method and explored the controversies in general. This commentary, which grows out of our second workshop, explains why informed people can disagree about ADHD diagnosis and treatment. Based on what workshop participants said and our understanding of the literature, we make 8 points. (1) The ADHD label is based on the interpretation of a heterogeneous set of symptoms that cause impairment. (2) Because symptoms and impairments are dimensional, there is an inevitable "zone of ambiguity," which reasonable people will interpret differently. (3) Many other variables, from different systems and tools of diagnosis to different parenting styles and expectations, also help explain why behaviors associated with ADHD can be interpreted differently. (4) Because people hold competing views about the proper goals of psychiatry and parenting, some people will be more, and others less, concerned about treating children in the zone of ambiguity. (5) To recognize that nature has written no bright line between impaired and unimpaired children, and that it is the responsibility of humans to choose who should receive a diagnosis, does not diminish the significance of ADHD. (6) Once ADHD is diagnosed, the facts surrounding the most effective treatment are complicated and incomplete; contrary to some popular wisdom, behavioral treatments, alone or in combination with low doses of medication, can be effective in the long-term reduction of core ADHD symptoms and at improving many aspects of overall functioning. (7) Especially when a child occupies the zone of ambiguity, different people will emphasize different values embedded in the pharmacological and behavioral approaches. (8) Truly informed decision-making requires that parents (and to the extent they are able, children) have some sense of the complicated and incomplete facts regarding the diagnosis and treatment of ADHD. Background The US Centers for Disease Control estimates that approximately 4.6 million (8.4%) American children aged 6–17 years have at some point in their lives received a diagnosis of Attention-Deficit/Hyperactivity Disorder (ADHD). Of these children, nearly 59% are reported to be taking a pre- Page 1 of 17 (page number not for citation purposes) Child and Adolescent Psychiatry and Mental Health 2009, 3:1 http://www.capmh.com/content/3/1/1 scription medication [1]. Rates of stimulant use have been growing fast in both the US and Europe [2-4]. Indeed, in the last 10 years, Germany has seen a 47-fold increase [5]. But per capita stimulant consumption remains greater in the US than in all of Europe. According to the International Narcotics Control board [6], "The per capita consumption of methylphenidate in the US between 2003 and 2005 was approximately six times greater than that of Australia, eight times greater than that of Spain, and 18 times greater than that of Chile" [7]. last 100 years – and, arguably, for much longer. Generally, children are brought to their physicians because parents or teachers are concerned that the child's behavior is preventing him or her from functioning normally at home, in school, or in other settings. In the majority of cases, teachers are the first to suggest that a child might have ADHD [14]. Initial assessments are often carried out by school psychologists or clinical psychologists before a referral is made to a physician. Workshop participant and educational psychologist Roy Martin noted: "In the vast majority of cases, that physician is a pediatrician. In my experience only 5 to 10% of cases result in a specialized referral to a psychiatrist." Because physicians do not observe the child's behavior in school or at home, they must rely heavily on parents' and teachers' reports. According to Martin, "Physicians are under pressure to try to help, and therefore tend to respond to the felt needs of parents and teachers." That response often takes the form of a diagnosis, which physicians base on their training, clinical judgment, and experience, as well as on diagnostic tools and guidelines, such as those in the American Psychiatric Association's Diagnostic and Statistical Manual (DSM). Not just school-age children are being treated with stimulants. Stimulant use among preschool children is also greater in the US than elsewhere: 0.44% of preschoolers in the US are prescribed stimulants, compared with 0.05% of preschoolers in the Netherlands, 0.02% of preschoolers in Germany, and 0% of preschoolers in the UK [8]. The duration of treatment and complexity of the treatment regimen is also growing. Before 2000, most children treated for ADHD received short-acting drugs, during school, for 1 or 2 years. Today many receive long-acting drugs while in – and out – of school and the prevailing recommendation from ADHD experts is to start medication early and to continue as long as medication is needed. This suggests that, if they adhere to their regimens, many American children diagnosed with ADHD will receive far higher lifetime doses than similar children in the past [9]. Even outside the US, a study of Dutch youths showed that between 1995 and 1999, duration of exposure to stimulants increased [10]. In addition, children are more likely than in the past to have more than one diagnosis and therefore to be taking multiple medications simultaneously [11]. Even without any further increase in the rate of stimulant use (data from a federal survey suggest it may be leveling off [12], whereas Health Management Organization population-based data show a slight but continuing increase [4]) current usage rates raise a range of questions conce (...truncated)