Don’t throw out the baby with the bath water

To the Editor

I agree with most of my good friend Martin Whitely’s (2015) critique and congratulate his efforts, here and everywhere, to tame the attention deficit hyperactivity disorder (ADHD) epidemic. It is scandalous that the ADHD diagnosis is made so loosely and that treatment is prescribed so recklessly. We are bathing our kids’ brains in stimulant medication—often without clear indication, without the slightest idea of its long-term impact and without informed consent. The drug companies have successfully disease mongered ADHD to doctors, parents and teachers—great for shareholders, but terrible for kids. Doctors need to be re-educated, parents need to protect their children and schools need smaller classes and more gym periods to let kids blow off steam.

But I think Martin goes too far. Because most kids are misdiagnosed doesn’t mean that all are. Reliability for any diagnosis is not an absolute—it always depends on the circumstances. Reliability is much higher for severe, clear-cut cases than for shades-of-gray, fuzzy-boundary cases.

Lesson 1: make the diagnosis only in the classic clear-cut and clearly impaired cases. Reliability is much higher when diagnosis is done carefully by knowledgeable clinicians, not in a rush and not pressured by drug salesman or parent. Lesson 2: watchful waiting and counseling first, with diagnosis and treatment a last resort.

The National Institute of Mental Health (NIMH) Research Domain Criteria (RDoC) project is a necessary new research approach, but has no clinical application now and won’t deliver useful results for a very long time, if ever. However flawed, we have to use the available diagnostic tools—we just have to apply them with a great deal more restraint.

There is no ‘true’ rate for ADHD, or any other diagnosis in psychiatry, and thresholds are necessarily arbitrary. The same is true for most diseases in general medicine, and over-diagnosis is just as problematic in all other specialties. Diagnostic thresholds must be based on clinical utility, not ‘gold standards’. My guess is that an ADHD diagnostic rate of around 2% in the general population would best balance harms and benefits. I am shocked, alarmed and ashamed by ADHD rates of over 10%. But a 0% rate would be equally distressing. We need to tame the epidemic of ADHD, not eliminate the ADHD diagnosis.