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ADHD-problem with society or our kids?

ADHD, which stands for Attention-Deficit/Hyperactivity Disorder, has been a household topic for discussion in recent years. Though descriptions of hyperactive behavior date back to Hippocrates, ADHD became an umbrella term for general disruptive behavior in children in the 90's; and its popularity has continued into the new millenium. Prescriptions in this country for Ritalin (Methylphenidate), the most used medication to manage this disorder, have increased nearly 10 fold since the late 1980's, though this drug was approved by the FDA way back in 1956. Dexedrine (dexamphetamine), another commonly prescribed medication in the treatment of ADHD, became available during FDR's second term. Both of these drugs are psychostimulant compounds and classified by the FDA as Schedule II drugs, which have a high potential for abuse and physical dependency. To give the reader some further perspective, Morphine and Cocaine also share this classification. While incidence rates (new cases/year) for ADHD in the U.S. have also increased significantly in recent years, they have remained relatively stable in Great Britain. Nonetheless, our "experts" in the mainstream psychiatric press will have us believe that ADHD is both underdiagnosed and undertreated.

Why the dramatic change? Have our kids changed that much in the past 10 years, or have we as a society?--probably a little of both. We live in a very unstable and frenetic culture, which has brought about changes in the nuclear family. Divorce and single pregnancy rates are at an unprecedented level. A high percentage of both parents in intact families are working full-time in order to maintain a decent standard of living. Classroom sizes are bigger than ever. All kids, particularly those with innately frisky temperaments, require structure, supervision, and stability (the "3 S's" as I like to refer to them) for normal maturation. However, such social changes have upset these essential environmental elements, resulting ultimately in profound effects on the psychological development of our children.

Apart from these factors, I've always had a beef with classifying syndromes, that are merely clusters of nonspecific symptoms, as diagnoses without careful consideration of other underlying causes. Imagine going to your family doctor for evaluation of your fever and cough, and being diagnosed with "FCD" or "Fever-Cough Disorder", prior to any investigation (beyond a cursory examination) of other underlying illnesses with well-defined diagnostic criteria and treatment protocols. This is precisely the scenario with the ADHD phenomenon. Every day, I see children who have been hastily diagnosed with ADHD based on subjective rating scales of their behavior by teachers and parents. More often than not, these children have not been assessed for learning disabilities, depression, anxiety, or family discord before being indelibly stamped with this label. Worse yet, many have already been medicated with a psychostimulant, in some cases for years, prior to a mental health referral.

Do I prescribe Ritalin and Dexedrine to frequently hyperactive, distractible, and impulsive children? Yes, but only after a reasonable evaluation process to rule-out other clinical syndromes or diagnoses, which cannot be easily remedied with an indiscriminate medication intervention. My evaluations often include a consultation request for psychological testing, which can be an invaluable tool for diagnostic clarification in perplexing cases. ADHD, by virtue of its ill-defined and all-encompassing nature, should be considered a diagnosis of exclusion for the aforementioned reasons. It's time to stop putting the cart before the horse!

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