Shirah Vollmer MD

The Musings of Dr. Vollmer

No Need To Attend to the Changes: ADHD and DSM 5

Posted by Dr. Vollmer on June 24, 2013

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From WSJ June 16, 2013 “A Nation of Kids on Speed” by

By PIETER COHEN AND NICOLAS RASMUSSEN

 

“Last month, the American Psychiatric Association released the fifth edition of its Diagnostic and Statistical Manual of Mental Disorders—the bible of mental health—and this latest version, known as DSM-5, outlines a new diagnostic paradigm for attention-deficit hyperactivity disorder. Symptoms of ADHD remain the same in the new edition: “overlooks details,” “has difficulty remaining focused during lengthy reading,” “often fidgets with or taps hands” and so on. The difference is that in the previous version of the manual, the first symptoms of ADHD needed to be evident by age 7 for a diagnosis to be made. In DSM-5, if the symptoms turn up anytime before age 12, the ADHD diagnosis can be made.

It’s also easier to diagnose adult ADHD. Before, adults needed to exhibit six symptoms. Now, five will do. These changes will undoubtedly fuel increased prescriptions of the drugs that doctors use to treat ADHD: stimulants such as Ritalin and Adderall.”

 

ADHD stabilizes in DSM 5, but the debate about it does not. This quote above, from  the opinion section of the Wall Street Journal, expresses deep concern about the over-diagnosis and hence the over-treatment of kids and adults with stimulant medication. The arguments are tired and true, but also exaggerated. This is a clinical diagnosis. There are no objective findings. Physicians make a lot of money making this diagnosis and drug companies, in kind, profit from the illness. Kids are given stimulants with the potential message that they are not responsible for their own behavior. “Boys will be boys” and so why are we trying to push square pegs into round holes. In the comments, one writer expressed the notion that savvy parents help their kids get an ADHD diagnosis so the child can qualify for extended time on tests, as if extended time will necessarily help the child have a higher score. The issue of whether any child should have a timed test is yet another question in education, but that puts us on a tangent. The issue here is first, DSM 5 is not moving us forward in the ADHD world. Without an objective test, diagnosis abuse will continue. Financial incentives are there, and so abuse will happen. At the same time, for some kids, going on stimulants is like getting a pair of eye glasses. The world is simply clearer to them, so that they, and their families appreciate the monumental change in their interface with the world.  My solution is simple. The better the history taking, the more likely the physician will hit the mark and the less likely there is financial incentive to over-prescribe. Quickies, or short appointments, lead to “ADHD mills” where over-diagnosis and over treatment is rampant. Physicians who take considerable time exploring the possibility of ADHD are much less likely to be vulnerable to the pressure to prescribe. A prescription can be a quick tool to rapidly get someone to leave your office. These hasty interactions is what has got to change: not the diagnosis or the treatment.

4 Responses to “No Need To Attend to the Changes: ADHD and DSM 5”

  1. Jon said

    It does not surprise me that with better history taking and more thoughtful consultations that a better medical treatment can be offered. Sadly, it also does not surprise me that short appointments and overtreatment with perhaps unnecessary medication can lead to larger revenue for physicians and pharmaceuticals. If the overarching goal is to make money, the latter course will be followed. If the philosophy of Hippocrates is the overarching goal, the former course of action will be followed. However, this is a complicated world of multiple goals. Thus, we will muddle through with a combination of these and other courses of action. With luck, this post and others like it will help the pendulum swing in a better fashion.

    • Thanks, Jon. To add to the complication, insurance companies, and low-fee clinics also have a vested interested in “Quick” diagnoses and treatment, such that this is a larger issue than the possible greed in the physician. Thanks again.

  2. Shelly said

    What about the high school or college student who just wants to even the playing field with everyone else who is taking Ritalin and compete with them? Nearly everyone takes Ritalin to increase focus and “do better on tests,” etc…? What about the fakers who fake the symptoms so they can sell these drugs to their peers? Are you going to be able to weed these people out and not prescribe these stimulants to everybody to wants these drugs to make a quick buck?

    • Yes, indeed many college students avail themselves to these medications to enhance their retention of the material. This is another topic, which I will address in the future. For now, my main point is that when a physician spends a lot of time with college age students, and impresses upon him/her that this medication is only for the patient and not for his/her friends, then I believe there is a greater likelihood that the patient will not “help out” his friends during examination time. Thanks.

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