Doctors Urged to be More Thorough in ADD Diagnosis
Spurred by a surge in cases of attention deficit disorder, medical and advocacy groups say doctors should be more thorough in their diagnoses before they dash off prescriptions for drugs such as Ritalin.
To help, the groups are writing guidelines to help physicians identify who has the disorder — marked by inattentive, impulsive and sometimes uncontrollable behavior — and those who don’t.
“For many physicians, Ritalin is a diagnostic tool,” said Howard Morris, vice president of the National Attention Deficit Disorder Association. “They say, ‘If it works, then you’ve got it and if it doesn’t, then you don’t.’”
A flurry of news articles about the disorder has prompted a flood of patient inquiries at doctors’ offices.
And the production and use of the psycho-stimulant methylphenidate, widely known by the trade name Ritalin, has increased nearly sixfold since 1990, according to the Drug Enforcement Administration.
But while more people know about attention deficit disorder, there is little consistency in the way it is diagnosed and treated.
The National Attention Deficit Disorder Association, based in Ann Arbor, Michigan, has written diagnostic guidelines for doctors.
Medical groups such as the American Academy of Child and Adolescent Psychiatry, the American Psychiatric Association and the American Academy of Pediatrics also have written or are beginning to develop guidelines.
Ciba Pharmaceuticals of Summit, New Jersey, which makes Ritalin, plans to issue similar guidelines to doctors later this summer. And a managed behavioral health care company is doing the same.
The reported number of people with the disorder rose to more than 2 million last year, up from 900,000 in 1990, said Peter Jensen, chief of the child and adolescent disorders research branch at the National Institute of Mental Health.
The Education Department estimates that 3 percent to 5 percent, or up to 2.5 million school-age children, have attention deficit disorder.
There are thousands of cases where the disorder is missed, or mistaken for depression, laziness, lack of motivation, anxiety or a learning disability, said Dr. Tom Brown, associate director at the Yale Center for Attention and Related Disorders in Adults in New Haven, Connecticut.
He recently treated a teen-age girl who was studying five to six hours each night in order to earn A’s and B’s in high school.
“Initially they thought she was depressed, but it was very clearly attention deficit disorder,” Brown said. “She would be working … until 11 o’clock at night. She couldn’t get on the task. She was circling the airport.”
Diagnosing attention deficit disorder is complex, said Kevin Dwyer, assistant director of the National Association of School Psychologists.
“Yet in some situations, today’s primary care physician may be forced to make this diagnosis under a 15-minute guideline from a managed health care company,” he said.
To find out what treatments sufferers receive and why, the National Institute of Mental Health is surveying more than 13,000 children, ages 4 to 17. Among other things, the study will help determine how many children are being treated with medication when their needs might be best addressed through therapy or other means.
Value Behavioral Health Inc., a managed behavioral health company based in Falls Church, Virginia, sees significant variations in the way the disorder is treated, said Dr. Ian Shaffer, executive vice president.
“All attention deficit disorder patients don’t need Ritalin,” said Shaffer, whose firm is completing treatment guidelines. “All don’t need counseling. Some need both.”
According to the Attention Deficit Disorder Association’s guidelines, doctors should rule out other problems, such as depression. They also should use tests for memory and cognitive skills that are statistically valid and refer to other professionals when necessary.
When people think of attention deficit disorder, Yale’s Brown said, they often think of little boys squirming at their school desks. Few people, however, realize that it affects adults too, targets highly intelligent people and those with learning disabilities, tends to run in families and afflicts daydreamers as well as hyperactive children, he said.
Denise Conrad, a behavior specialist in the Toledo, Ohio, public schools, said students with the disorder can bring classroom learning to a screeching halt. But she said teachers are faced with a public that does not believe that the disorder is a legitimate condition.
“People often contend that a ‘firm hand’ will solve the problem,” Conrad testified at a House subcommittee hearing on the disorder last week.
“They do not see children who truly can’t control their extremely impulsive behavior and who whirl around the room like an out-of-control windup toy.”
Associated Press July 29, 1996