Clearer, but less dramatic, evidence for overdiagnosis comes from a 2012 study in which psychologist Katrin Bruchmüller of the University of Basel and her colleagues found that when given hypothetical vignettes of children who fell short of the DSM-IV diagnosis, about 17 percent of the 1,000 mental health professionals surveyed mistakenly diagnosed the kids with ADHD. These errors were especially frequent for boys, perhaps because boys more often fit clinicians' stereotypes of ADHD children. (In contrast, some researchers conjecture that ADHD is underdiagnosed in girls, who often have subtler symptoms, such as daydreaming and spaciness.)
Published reports of using stimulants for ADHD date to 1938. But in 1944 chemist Leandro Panizzon, working for Ciba, the predecessor of Novartis, synthesized a stimulant drug that he named in honor of his wife, Marguerite, whose nickname was Rita. Ritalin (methylphenidate) and other stimulants, such as Adderall, Concerta and Vyvanse, are now standard treatments; Strattera, a nonstimulant, is also widely used. About 80 percent of children diagnosed with ADHD display improvements in attention and impulse control while on the drugs but not after their effects wear off. Still, stimulants sometimes have side effects, such as insomnia, mild weight loss and a slight stunting of height. Behavioral treatments, which reward children for remaining seated, maintaining attention or engaging in other appropriate activities, are also effective in many cases.
Many media sources report that stimulants have been widely prescribed for children without ADHD. As Dutch pharmacologist Willemijn Meijer of PHARMO Institute in Utrecht and his colleagues observed in a 2009 review, stimulant prescriptions for children in the U.S. rose from 2.8 to 4.4 percent between 2000 and 2005. Yet most data suggest that ADHD is undertreated, at least if one assumes that children with this diagnosis should receive stimulants. Psychiatrist Peter Jensen, then at Columbia University, noted in a 2000 article that data from the mid-1990s demonstrated that although about three million children in the U.S. met criteria for ADHD, only two million received a stimulant prescription from a doctor.
The perception that stimulants are overprescribed and overused probably has a kernel of truth, however. Data collected in 1999 by psychologist Gretchen LeFever, then at Eastern Virginia Medical School, point to geographical pockets of overprescription. In southern Virginia, 8 to 10 percent of children in the second through fifth grades received stimulant treatment compared with the 5 percent of children in that region who would be expected to meet criteria for ADHD. Moreover, increasing numbers of individuals with few or no attentional problems—such as college students trying to stay awake and alert to study—are using stimulants, according to ongoing studies. Although the long-term harms of such stimulants among students are unclear, they carry a risk of addiction.
A Peek at the Future
The new edition of the diagnostic manual, DSM-5 (due out in May), is expected to specify a lower proportion of total symptoms for an ADHD diagnosis than its predecessor and to increase the age of onset to 12 years. In a commentary in 2012 psychologist Laura Batstra of the University of Groningen in the Netherlands and psychiatrist Allen Frances of Duke University expressed concerns that these modifications will result in erroneous increases in ADHD diagnoses. Whether or not their forecast is correct, this next chapter of ADHD diagnosis will almost surely usher in a new flurry of controversy regarding the classification and treatment of the disorder.