Dr. Sussman is editor of Primary Psychiatry as well as Associate Dean for Post-Graduate Programs and professor of psychiatry at the New York University School of Medicine in New York City.
Dr. Sussman reports no affiliation with or financial interest in any organization that may pose a conflict of interest.
Attention deficit/hyperactivity disorder (ADHD) may be one of the most controversial diagnoses in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.1 The controversy does not so much involve the specific diagnostic criteria delineated in the manual as it does the question as to whether this disorder is over diagnosed and whether too many children and adolescents are being prescribed medication for this condition. ADHD is a highly controversial psychological disorder. Some of the debate focuses on whether ADHD represents an actual mental disorder or is merely a collection of symptoms or developmental delays. It is also often argued that the prevalence of ADHD is exaggerated, which leads to overuse of medications to treat children. More extreme critics decry the use of any medications to treat children with ADHD. This issue of Primary Psychiatry contains an educational review—“The Black Book of ADHD”—as well as two related articles about the disorder. These articles should help clinicians form their own opinions on the diagnostic validity of ADHD and on the appropriate use of various interventions, including medication.
In the “Black Book of ADHD,” David W. Goodman, MD, makes numerous points that should reassure clinicians that ADHD is a true disorder. He cites a 1998 American Medical Association Scientific Council report that ADHD “is one of the best researched disorders in medicine.” Goodman also notes that neuro-imaging has shown clear differences in the brains of patients with ADHD from normal controls. In addition, he addresses the high degree of heritability that has been demonstrated among patients with ADHD. Important as well is the finding that the majority of children with ADHD “will continue to have persistent and impairing symptoms” as adults. Of course, the latter point can be altered with appropriate and timely intervention. The benefits of pharmacologic and behavioral therapies are well established. The tables and figures in this educational review are concise yet comprehensive.
William W. Dodson, MD, and colleagues, address the issues of ADHD symptom overlap and possible comorbidity with depressive illness. In a report on their research about the sociolinguistic analysis of in-office dialogue between psychiatrists and adult patients with depression and possible comorbid ADHD, they point out that accurate diagnosis and treatment of both conditions depends on adequate communication between physicians and their patients. Their study analyzes the interaction between psychiatrists and patients with depression that subsequently screened positive for possible ADHD. They report that psychiatrists often fail to consider the possibility of comorbidity. They draw a number of important conclusions from the study. One of these is that treatment failure or partial remission of depression or ADHD may be due to failure to consider coexisting diagnoses. Another is that the data have implications for the training of mental health professionals. They conclude that a better nosological system in adults is necessary to distinguish between depression and ADHD.
Lenard A. Adler, MD, and colleagues report on a study that evaluated participants 2 years after they screened positive for ADHD at a screening day event to assess their clinical course in terms of diagnosis and treatment. They found that only ~50% of the participants with no prior ADHD diagnosis followed up to seek a formal diagnosis. A major inference from this finding is that screening alone is not sufficient to ensure subsequent evaluation and treatment.
There is considerable noise that surrounds the topic of ADHD diagnosis and treatment. Recent headlines about leading researchers in the field who had failed to report conflicts of interest involving companies that market ADHD treatments has given ammunition to those who vocally denigrate the body of evidence that validates the serious nature of ADHD and its consequences and the effectiveness of psychiatric interventions. Having practiced psychiatry for 35 years, I have observed that some of the most dramatic improvements in functioning and quality of life have involved patients who were found to have had ADHD and who were treated accordingly. While I know that the information contained in this issue will not convert those who have philosophical antipathy to the work we do in psychiatry, I do hope that receptive clinicians will take away a better understanding of how to help those who suffer from ADHD. PP
1. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 2000.