The author sees that there are many factors contributing to the over diagnosis of ADHD. In the United States, there are social, medical and parenting forces at play that contribute to more than 4.4 million children between the ages of 4 to 17 years old having an ADHD diagnosis and a dramatic increase of 250 percent since 1980 in stimulant medication prescriptions written for ADHD in the same age group (Meaux, Hester, Smith & Shoptaw, 2006).
The likely reason for over diagnosis is that children and their parents do not seek out mental health counselors or psychologists as a first course of action for problems but instead parents choose a medical path usually through a pediatrician or psychiatrist. The medical professionals choose brain drugs over other courses or action for treatment, such as parental skills building and education about normal child development and behavior. In addition, more and more pediatrician are prescribing stimulant drugs for young children (Gaviria, 2008) presumable with out the necessary testing to collaborate symptoms told to them by a parent.
Pediatricians and psychiatrists are medical doctors that are trained in a pathological view body and mind. These medical doctors treat with the tools that they have available to them, which are brain drugs such as stimulants, anti-depressants, anti-psychotics and other medications. Because of their view of disease, they rely heavily on information from parents and may be less likely to take a holistic view of a person such as parenting skills, socioeconomic status, classroom or teacher problems.
The next reason for high ADHD diagnosis is that the DSM criteria are designed to maximize sensitivity for capturing symptoms resulting in high false positives (Kirk, 2004). The DSM III used to have 8 criteria for diagnosing ADHD. The 4th edition of the DMS only have 6, making it easier to diagnosis symptoms. In addition, the 4th edition of the DSM, two of the criteria regarding behavior are very similar given more weight one behavior than if the 2 criteria were different (Kirk, 2004). Now with the latest release of the DSM, there are no changes to the criteria to make it more difficult to assess.
A medical doctor may not refer a child out for assessment testing to further corroborate the information given by parent. Instead, a doctor seeks out information from a distressed parent, who may have been told by school officials that their child has a problem and needs drugs (Gaviria, 2008). Unfortunately, the relationship between medical doctors and mental health counselors and psychologists are not strong but are rather antagonistic given the radically different training. The ability for the two professions to work collaborative tends not to happen and this may contribute to increased diagnosis and drug prescription.
Significant research has shown how complimentary and beneficial combining the medication of psychiatry along with psychotherapy has been in treating many AXIS I and II disorder (Winston, Been, & Serby, 2005). However, often the two professions do not work collaboratively together because of opposing views towards mental health and treatment (Winston, Been, & Serby, 2005). Normally, psychiatrists and pediatric doctors are the first line of treatment and diagnosis for children because parents familiar and comfortable with the medical model seek them out. Only occasionally do medical doctors refer ADHD patients to counselors or psychologists for complimentary help.
One way parents can overcome this is to see out help from their mental health provider. A mental health provider will spend significantly more time assessing the child’s development, environment and the parents knowledge and skills of cognitive development and normal behavior. The mental health provider can provide guidance and training to the parent on how to effectively change their behavior to get better results from their child that may see the supposed “ADD or ADHD” symptoms reduce or go away.
The author noticed that on many research websites such as the National Institute of Mental Health and the videos they have listed on ADHD, the presenters are medical doctors. The view is a very pathological one with a recommendation for drugs. Even on the documentary from Frontline called the “The Medicated Child”, all the information given came from medical doctors that stated drugs were the only course of action. There was never any discussion of operant condition or parenting skills to help the child or the family or screening the child for developmental trauma that can cause dsyregulated behavior. The only course of action was to prescribe drugs. In the documentary, there was never any integration or opinions given from the mental health community such as psychologists or mental health counselors on using treatment outside of medicine. The view is that ADHD can only be treated with drugs and appears not to focus on a holistic approach towards the child and family when seeking treatment.
In the documentary on Frontline entitled “The Medicated Child” many parents, who were seeing a psychiatrist and having drugs prescribed for their 3 year old and up children, expressed that they did not see any alternatives to medication (Gaviria, 2008). In fact, in one case on the program, a family specifically asked their psychiatrist if there was any other help or treatment that they could get such as behavior modification or counseling to help their 4 year old son who was diagnosis with ADHD and Bi-Polarism (Gaviria, 2008). The psychiatrists response was no, counseling would not help until the child’s symptoms were controlled by the drugs (Gaviria, 2008). This child 4 year old child was on 8 different brain medications.
Parents may want to consider an alternative. On the one hand it may be true that counselling for the child will not be effective, but parents need to look to their own behavior and knowledge. Child are behaving in their best known way to get their needs met and are responding to the behavior of their parents. Parents do not receive training in human development, child cognitive development or behavior. If parents can enhance their skills and knowledge they can become more effective in dealing with their child, resulting in their changing their behavior. Mental health professionals can assist parents with this.
Testing for ADHD is highly subjective and there are no blood tests that can confirm a diagnosis. Some research has shown that MRIs revealed that ADHD children have brain changes (Baughman, 2008; Gaviria, 2008). However, evaluation of that research shows patient controls were not in place and those results are questionable. MRIs are not conclusive and cannot be used for diagnosis. Nonetheless, more and more medical scanning centers are being established to measure children’s brains to see if they show signs of ADHD (Gaviria, 2008). Medical doctors run the clinics and make diagnosis off brain imagery and prescribe drugs (Gaviria, 2008). This contributes to an increase in the diagnosis.
There are various assessments available to test older children to see if they meet the criteria for ADHD, however it takes several tests and a skilled diagnostician familiar with children to have a high confidence of the results (Smith & Corkum, 2007). It also requires a medical doctor make the referral to do the assessment. In the cases where parents get medication through their pediatricians, very little testing or follow up is made. With older children pediatricians do not check out how the child is doing on the medication, but simply write a prescription based on a parent’s request (Meaux, et al., 2006).
Assessment tests for ADHD, while useful are not as accurate on pre-school children (those 3 and under) (Smith & Corkum, 2007). Even though more and more children ages 2 and 3 are getting diagnosed with ADHD and even Bi-polarism, there are less test to validate a diagnosis. This subjectivity of diagnosis is probably increasing the rate of diagnosis
Another influence that compounds the over diagnoses and treatment of ADHD with brain drugs is the influence of pharmaceutical companies. It is well known that most drugs used on children have not been tested or approved by the FDA for treatment of children or pre-school children for ADHD (Gaviria, 2008). Pharmaceutical companies work closely with psychiatrists and medical doctors in providing them with more and more drugs to treat ADHD and Bi-Polarism in children. Most of these drugs are not tested or approved for use in children. Of the drugs tested, most show little to no effect on treating ADHD (Gaviria, 2008).
In 1997 Clinton mandated that brain drugs used on children must be studied and tested for use with children (Gaviria, 2008). However, many tests are sponsored and funded by the pharmaceutical companies themselves leading many to question the validity of the results (Gaviria, 2008). Other results have shown that the drugs used on children have little to no benefit on children, but continued to be prescribed.
From a societal standpoint, the United States is very much accepting of taking drugs to solve problems. Therefore parents tend to seek out medical doctors over counseling or psychology first for treatment. The author was shocked at the number of drugs advertised on TV with the recommendation to ask your medical doctor. Taking medication is a faster and easier way to deal with a problem child. Often parents feel a sense of relief when their child gets the ADHD diagnosis because its not related to the parent’s skill or lack there of it (Austin, Staat Reis, & Burghdorf, n.d.).
The United States society has also falsely bought into the belief that chemical imbalances exist and that only medication can treat these imbalances (France, Lysaker, & Robins, 2007). Plus with several million kids taking brain drugs for ADHD and now Bi-polar, the parents and society are more accepting of this diagnosis and treatment are less likely to question its legitimacy (Baughman, 2008). Other countries seem to be following in the path that the United States is cutting, unless parents take a more critical look at how they deal with what they are labeling misbehavior in their child(ren).
Even if a parent does challenge the diagnosis or the treatment, they are often pressured into accepting it from teachers, the school system and the medical doctors (Gaviria, 2008). Teachers are usually the first to identify a child as having problem behavior. There could be the Pygmalion phenomenon in which a teacher or other teachers, who label a kid with ADHD or troublesome behavior, create a self-fulfilling prophecy and put increased pressure on parents to get diagnosis, thus adding to the pressure of parents to comply.
Rather than focusing on the negative aspects of ADHD and its over diagnosis, perhaps more effort should be made to join psychotherapy and psychiatrists together in working with children who have questionable behavior. If these two professions could work more collaborative in using both medicine and therapeutic counseling to address behavior, cognitive and emotional issues of the child and his or her parent, we may see more accurate diagnosis or ADHD and better outcome with less use of questionable drugs on US children. The challenge to make this collaboration is large and probably will have to be lead by the mental health counseling community.
Tammy Fontana, MS NCC CTRT
All in the Family Counselling
Austin, M. Staats Reiss, N., & Burgdorf, L. (n.d.) ADHD assessment & Diagnosis. Retrieved on May 13, 2009from http://www.mentalhelp.net/poc/view_doc.php?type=doc&id=13857&cn=3
Baughman, F.A. Jr. (2008). Psychiatry’s “chemical imbalance” fraud: Who killed Rebecca Riley?Ethical Human Psychology and Psychiatry 10, (2), 96-109.
France, C. M., Lysaker, P.H., & Robinson, R.P. (2007). The “chemical imbalance” explanation for depression: Origins, lay endorsement and clinical implications. Professional Psychology: Research and Practice 38(4), 411-420
Gaviria, M. (2008). The medicated child. Frontline TV program. Retrieved on May 13, 2009 fromhttp://www.pbs.org/wgbh/pages/frontline/medicatedchild/
Kirk, S. A. (2004). Are children’s DSM diagnoses accurate? Brief Treatment and Crisis Intervention, 4(3), 255-271. Retrieved on May 12, 2009 from ProQuest Psychology Journals.
Meaux, J. B., Hester, C., Smith, B., & Shoptaw, A. (2006). Stimulant medication: A trade-off? The lived experience of adolescents with ADHD. Journal for Specialists in Pediatric Nursing, 11 (4), 214-227. Retrieved on May 13, 2009 from ProQuest Psychology Journals.
Smith, K. G. & Corkum, P. (2007). Systematic review of measures used to diagnose attention-deficit/hyperactivity disorder in research on preschool children. Topics in Early Childhood Special Education, 27(3), 164-175. Retrieved on May 12, 2009 from ProQuest Psychology Journals
Winston, A., Been, H., & Serby,M. (2005). Psychotherapy and psychopharmacology: Different universes or an integrated future? Journal of Psychotherapy Integration, 15(2), 213-223.
Ms. Fontana is a relationship counsellor specializing in helping people with their relationships whether it is dating, marriage, parenting or with their extended family. Her clients call her approach practical and found solutions to their problems. Ms. Fontana has obtained her Master Degree in Mental Health counselling from the United States and is a USA Nationally Certified Counsellor. She is also a Certified Choice Theory Reality Therapist and is USA trained Sex Therapist.