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![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
Too Many ADHD Referrals?--Or Too Few?
Interesting Study, Raises More Questions
Adult ADD
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Oren Mason, Grand Raipds, MI USA Family Physician, Advantage Health
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Dr. Sax has begun an interesting inquiry into the ADHD referral process. This particular study is noteworthy for its simple and undoubtedly efficient design, but that simple design limits the usefulness of the conclusions. The data collected queried physicians regarding their estimation of the referral process. It did not directly measure the process. There was not an attempt to correlate physicians’ estimates with any referral path data in the charts. The authors were not quite wary enough with their conclusion: "Who First Suggests the Diagnosis of ADHD? Teachers were the most likely to be the first to suggest the diagnosis of ADHD, followed by parents, primary care physicians…" We do not, in fact, know this to be true from the data collected. We do know that physicians believe it is likely to be true. Next we need Dr. Sax or others to actually study the process and tell us whether our beliefs were right or wrong. It is perhaps obvious that school teachers would be at least an important element in the referral process of children. Children are given cognitive workloads that stress executive function in uniform group settings. What better place to uncover ADHD? Many important questions await the follow up studies Dr. Sax proposed. These studies need to directly measure the process of identification and referral. How does it dawn on a parent that his or her child may have ADHD? How long is that thought resisted? How many prior suggestions of ADHD are needed before a teacher’s recommendation prompts a clinical encounter? What prior beliefs lead a parent either to rush toward or unreasonably resist an explanation for this or other behavioral deviance? It would be most helpful to include attention to the referral paths of ADHD adults in any future studies. Children have teachers to help screen for ADHD; adults have no such setting with uniform structure and expectation. Some adults with undiagnosed ADHD develop several compensatory mechanisms and live quietly but below their capabilities. Others learn how to recover from repeated failures. Some develop savant- like abilities in one dimension of their lives with chaos in every other dimension. How have the few who have been diagnosed come to it? Who will bring the vast undiagnosed majority of adult ADHD patients to clinical attention? Can primary care physicians screen for ADHD as reliably as we do for diabetes, hypertension, hyperlipidemia and depression? Finally, Dr. Sax questions whether ADHD is overdiagnosed: "One study of students in North Carolina found that only 43% of students taking medication for ADHD met the Diagnostic and Statistical Manual of Psychiatric Disorders (DSM-III-R) criteria for ADHD . An investigator commenting on this paper conjectured that 'parents and teachers may be lobbying doctors to write stimulant prescriptions in the hope that they will help children do better in school.'(1)" Studies of this concern in children have documented inaccuracies of diagnosis, but the larger problem is still under-diagnosis(2). Use of DSM -IV criteria results in a higher rate of diagnosis of ADHD due to inclusion of the inattentive sub-type(3). The authors have cited a study which used now-dated DSM-III-R criteria in a longitudinal study from 1992- 1997; that study would be expected to find “overuse” as most practitioners came to use the more inclusive DSM-IV criteria during the course of the study. Primary care physicians should strive for “proper use” in a world that is troubled by both “overuse” and the still more common “under-use”. (1) Angold A, Erkanli A, Egger HL, Costello EJ. Stimulant treatment for children: a community perspective. J Am Acad Child Adolesc Psychiatry 2000;39:975–984. (2) Rowland AS, et. al. Studying the Epidemiology of Attention- Deficit Hyperactivity Disorder: Screening Method and Pilot Results. Can J Psychiatry 2001;46:931–940 (3) Wolraich ML, Hannah JN, Pinnock TY, Baumgaertal A, Brown J. Comparison of diagnostic criteria for attention-deficit/hyperactivity disorder in a county-wide sample. J Am Acad Child Adolesc Psychiatry 1996; 35:319-324 Competing interests: None declared |
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Terry Matlen, ACSW, Birmingham, Michigan USA Clinical Social Worker, private practice- www.addconsults.com; Attention Deficit Disorder Ass.
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This interesting study raises more questions than it answers, which may be a good thing. The author ponders the results, wondering if the reason for teachers being front line AD/HD screeners are because of the increase in academic pressures seen in kindergarden. The study does not indicate what grades these teachers are identifying their possible AD/HD students in, and that is information I would have liked to have seen. Obviously, parents and teachers are the folk who see children most consistantly, so it makes sense that they would be red flagging these kids. But I also wonder if these same parents are discussing their concerns with the MDs treating their children and seeing them for their annual physicals. Is it that the parents are wary of bringing up behavioral/academic concerns with the pediatrician or family physician? What does this say about the psychological/emotional care all children need? Are our MDs lacking in screening for all possible problems in these arenas? Another area that begs consideration is the stats here that show that 75% of children being treated medically for AD/HD are boys. Is it that parents, teachers *and* parents are not aware of how AD/HD impacts girls? Most do not present with overt behavioral problems, so perhaps their need for diagnosis and treatment are not being met. All in all, an interesting study that hopefully will be followed up with more, to address the concerns I mention here. Competing interests: None declared |
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MaryLiz Roth, M.D. FACPE, Allentown Pa Sacred Heart Hospital
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In children the teacher who spends the majority of prime daylight hours with the child suggests ADHD. But who might suggest that adults have ADD? Funny that very few people suggest it for people over 30. Especially if that adult with behavioral problems has not been diagnosed earlier as a child. Often the thought arises as the adult's child is diagnosed after a teacher's intervention! So who might suggest adult ADD? Employers experience the behaviors of adults with ADD… the lateness, failures to meet deadlines, workmen's compensation claims and dysfunction in the work place. Ex-wives and ex- husbands can describe the chaotic lifestyle and inappropriate parenting while married to someone with ADD. "Having a third adolescent " in the household are descriptors of the fabric of life living with Adult ADD. The caffeine addict chases an OTC stimulant? When does the family physician suggest adult ADD? Hopefully when the problem list has many of the warning symptoms: accident prone, teen pregnancy, multiple marriages/relationships, single parent, frequent job changes, drug abuse especially stimulants and cocaine, bipolar (like) behaviors, deep debt, disruptive impatience in the doctor's office, parenting problems, etc. These are patients who use excess medical resources through accidents, mood problems and chaotic medical care. Women with ADD have nine times the teen pregnancy rate. Young adults from "good" families who have problems with the law often have ADD. Doctors with ADD compensate for their lack of internal organization by forcing themselves to meet deadlines. The energy spent to get the office charts done and show up on time is excessive. Adult ADD occurs in about 5% of American adults. One a day in the office. Yet rarely is it suggested by the family physician who sees these troubled adults? Let's raise our awareness that ADD is not a problem of intelligence nor of academic achievement but is a disorder of executive functioning. It robs adults of greater and comfortable success in work and relationships. Perhaps family physicians should be first line in suggesting Adult ADD in their adult patients not at ease in the world and failing to make life's deadlines. The World Health Organization's screening test makes it so easy and relevant to screen for Adult ADD in the office. (www.WebMD.com/adultADHD) Suggest patients take the test in the office or online. The impact on quality of life may be astounding to us all. Competing interests: None declared |
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