J. Indian Assoc. Child Adolesc. Ment. Health 2014; 10(3): Editorial

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1 145 J. Indian Assoc. Child Adolesc. Ment. Health 2014; 10(3): Editorial Is ADHD being over diagnosed? An Indian perspective Vivek Agarwal MD, Sujit Kar MD Address for correspondence: Dr. Vivek Agarwal, Editor JIACAM & Professor, Department of Psychiatry, King George s Medical University, Lucknow. drvivekagarwal06@gmail.com Attention Deficit Hyperactivity Disorder (ADHD) is a common neuro-developmental disorder of childhood with the prevalence of 3-7% in school age children [1]. Concerns have been raised in the Western literature as well as in media about over diagnosis of ADHD and over use of medications in children. The evidence given is that in US diagnosis of ADHD has increasing trend (approximately 7% in 1997 to 9.5% in 2007) [2]. Similarly in recent years there has been increase in prescription of ADHD medication in many developed countries, which is summarized in the table below. Country Time span Increase in the prescription rates of ADHD medications Australia [2, 3] % Netherlands [2, 4] times

2 United Kingdom [2, 5] United States [6, 7] times (children) 4 times (adult) 4 times The probable reasons for over diagnosis has been cited as changing diagnostic criterions in DSM itself as well as compared to ICD. It is well known that as compared to DSM IIIR, DSM IV diagnoses more ADHD. Similarly as compared to ICD 10 hyperkinetic disorder, DSM IV diagnosis of ADHD is more because ICD 10 criteria are more stringent [2]. DSM 5 is being criticized for similar reasons that it has further liberalized the diagnostic criteria which will lead to over diagnosis of ADHD [2, 8, 9]. Other reasons given were commercial interests of pharmaceutical companies and errors in the diagnosis [2]. However, one should carefully examine the evidence in this regard. Are we diagnosing more children with ADHD as per the prevalence given in the community studies? Rather much less children are brought for consultation with psychiatric disorders especially in low and middle income countries. There were variety of barriers have been identified which limit the use of mental health care services like lack of resources, stigma, lack of awareness about disorders etc. In Western countries increasing diagnosis may be due to increasing awareness in the public as well as in the physicians about ADHD in children 146

3 147 as well as adults [2]. However this does not rule out misdiagnosis of ADHD in some cases which often lead to the focus of media and distorts the perception of public. Therefore the focus should be on decreasing the misdiagnosis or errors of diagnosis. The reasons for misdiagnosis could be due to presence of comorbidities like mental retardation, oppositional defiant disorder, conduct disorder, learning disorders etc. Then there are overlapping symptoms with anxiety and depression. A proper diagnosis of ADHD requires detailed evaluation preferably with diagnostic instruments. The evidence shows that physicians may not do comprehensive assessment or follow proper diagnostic criteria for diagnosis of ADHD. This may lead to wrong diagnosis and treatment [1]. There is need to study the prevalence of ADHD in children and adults in our country. Studies should also look in to the issue of errors in diagnosis and how to decrease it. ADHD has a serious effect on the development of the child and can lead to adverse outcome as adult. Any such misconception in public that ADHD is being over diagnosed will be counterproductive in our country. Efforts should be done to increase awareness about the ADHD in general population as well as pediatricians should be trained to diagnose and treat ADHD in primary care. References 1. Sciutto MJ, Eisenberg M. Evaluating the evidence for and against the overdiagnosis of ADHD. J Atten Disord Sep;11(2): Thomas R, Mitchell GK, Batstra L. Attention-deficit/hyperactivity disorder: are we helping or harming? BMJ Nov 5;347:f6172.

4 Stephenson CP, Karanges E, McGregor IS. Trends in the utilization of psychotropic medications in Australia from 2000 to Aust NZ J Psychiatry 2013;47: Hodgkins P, Sasané R, Meijer W. Pharmacologic treatment of attentiondeficit/hyperactivity disorder in children: incidence, prevalence, and treatment patterns in the Netherlands. Clin Ther 2011;33: McCarthy S, Wilton L, Murray ML, Hodgkins P, Asherson P, Wong CK. The epidemiology of pharmacologically treated attention deficit hyperactivity disorder (ADHD) in children, adolescents and adults in UK primary care. BMC Pediatrics 2012;12: Safer DJ, Zito JM, Fine EM. Increased methylphenidate usage for attention deficit disorder in the 1990s. Pediatrics. 1996;98(6, pt 1): Visser SN, Lesesne CA, Perou R. National estimates and factors associated with medication treatment for childhood attention-deficit/hyperactivity disorder. Pediatrics. 2007;119 (suppl 1):S99-S Diagnostic and statistical manual of mental disorders (DSM-5), 5th edn. Arlington, VA: American Psychiatric Association; Zinkstok J, Buitelaar J. DSM-5: neurodevelopmental disorders. Tijdschr Psychiatr. 2014;56(3):162-6.

5 149 Vivek Agarwal, Editor JIACAM & Professor, Sujit Kar, Lecturer, Department of Psychiatry, King George s Medical University, Lucknow.