ADHD, which stands for Attention-Deficit/Hyperactivity Disorder, has become a household topic for discussion in recent years. Though hyperactive behavior was first described in the medical literature over 100 years ago, ADHD became an umbrella term for general disruptive behavior in the 1990s; 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 1980s. Interestingly, this drug was approved by the FDA way back in 1955. Dexedrine (dexamphetamine), another commonly prescribed medication in the treatment of ADHD, became available even earlier in 1952. 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. While incidence rates 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 mutated that much in the past 10 years, or have we as parents?--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. These social changes have diminished structure and increased anxiety on the homefront, 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 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 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!


Scott Zentner