Friday, March 28, 2014

Increased Diagnosis of ADHD and Autism: Is This a Medical Issue or a Cultural One?

There are many issues regarding volitional use of cognition enhancing drugs but perhaps the most troubling is the epidemic of prescription drug abuse in ADHD. The treatment of ADHD has become a very controversial topic. Over the last few years there has been a rapid increase the number of ADHD diagnoses, particularly among young boys. Historically 3-7% of children have been diagnosed with ADHD, but recently over 20% of young males have received this diagnosis. It is hard to credit that there have been physiological changes in the population that would result in a trebling of the incidence of this disease. Rather it is likely that social and economic factors are impacting the situation. First, this is a very lucrative market and thus pharmaceutical firms have actively pushed their various drugs. Second, in a time of increasing economic stress it is natural for parents to want their children to do well in school, but at the same time parents may have less and less time to spend with their children. Thus a stimulant becomes a substitute for parental involvement in a child’s education. Third, the diagnosis of ADHD, which is diffuse and subjective to begin with, has been loosened in recent years, thus allowing physicians and parents more latitude in placing their children on medication. Finally, one wonders if the changing roles of males and females in our society may have something to do with the fact that boys receive the preponderance of ADHD diagnoses. What historically would be considered normal behavior for a young male, including a great deal of motor activity, restlessness, and some degree of aggressiveness, is now interpreted as pathological in a society increasingly influenced by female norms of behavior. This may be particularly relevant in the context of diagnosis of ADHD in elementary school children, where women continue to be the great majority of teachers. While some physicians have characterized ADHD drugs a ‘safer than aspirin’ there clearly are hazards in chronic use of powerful brain stimulants such as Ritalin®. Thus, as a society, we seem to be conducting an experiment of questionable value on our children.

Something similar may be happening with diagnosis of autism. A recent report (1) suggests a 30% increase in the frequency of autism in young males. While children with clear autistic characteristics obviously need to be identified and helped promptly, there seems to have been a loosening of diagnostic criteria so that more and more children are being caught in the net of  ‘autism spectrum disorder’. Once again it is unlikely that there is a physiological basis for the apparent increased frequency. More likely, behavioral characteristics that a generation ago would have been deemed just slightly unusual are now being defined as a disease. The driving forces for this are less clear since pharmaceutical companies are not making money from autism.

The long-term consequences of over-diagnosis (and in the case of ADHD over-medication) are very unclear. Some children may be helped by medication or treatment. However, what is the impact of being labeled abnormal to a child’s self-esteem? What are the consequences of chronic use of stimulants such as methylphenidate (Ritalin ®) or atomoxetine (Strattera ®). As a scientist I know that all drugs have side effects but in some cases those effects do not show up for many years. This is a difficult quandary for parents of affected children. 

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