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Ped Med: Diagnosing attention deficits

By LIDIA WASOWICZ, UPI Senior Science Writer

SAN FRANCISCO, Feb. 10 (UPI) -- Diagnosing attention-deficit/hyperactivity disorder can be fraught with frustrations.

For one thing, there are too few specialists trained and experienced in the intricately complex art of separating sure signs of mental illness from the widely ranging behaviors that fall within the healthy range of children's development.

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The physician making the call must rely primarily on subjective observations. There is no reliably accurate medical test that detects the confounding condition, which can mimic other disorders, such as depression and anxiety, as well as resemble normal childish comportment.

The potential for error is rising as insurers' belt-tightening in benefits shrinks the accessibility to specialists and the time availability of pediatricians, who now see the bulk of the cases.

"The reliability of diagnosis is pretty high among experts, but pediatricians and internists and primary-care physicians need more training -- and more time -- to identify these problems," said pediatric psychopharmacologist Ronald Brown. He is dean of the College of Health Professions and professor of public health, psychology and pediatrics at Temple University Health Sciences Center in Philadelphia as well as author of "Medications for Children: A Guide for the Practitioner" (Guilford Press).

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"They're squeezed to see a certain number of patients in an hour to be viable, and you can't do a diagnostic workup in the time they're allowed to see a patient," he noted.

Robert Resnick, professor of psychology at Randolph-Macon College in Ashland, Va., agreed.

"Over-diagnosis results from a knee-jerk (reaction) to put a child on medication after a 5-to-7-minute evaluation by a primary-care doctor," he said.

Acknowledging a system in disarray, the American Academy of Pediatrics, the nation's main overseer of child-centered medicine, issued new ADHD diagnostic guidelines in May 2000. The official representative of 60,000 physicians serving America's infants, children, adolescents and young adults, the AAP made note of the public's concern about over-diagnosis and the professional disparity in identifying and treating the disorder.

"(T)here are significant regional variations in the amount of stimulants (the most popular ADHD treatment) prescribed by physicians," the agency said. "Practice surveys among primary-care pediatricians and family physicians reveal wide variations in practice patterns about diagnostic criteria and methods."

The stakes involved in getting it right were highlighted Thursday when a Food and Drug Administration advisory panel urged regulators to place strong new warnings on ADHD drugs because of a risk of heart attacks, strokes or sudden death associated with the medications.

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A similarly discordant note sounded in the results of a Harris Interactive poll, sponsored by Shire Richwood, a subsidiary of the international pharmaceutical giant Shire Pharmaceuticals Group that makes the anti-ADHD drug Adderall.

The surveyed child and adult psychiatrists, on average, estimated only half of those with the disorder are being diagnosed. Pediatricians put the rate higher, at six in 10 children, or 63 percent.

On the other hand, parents and grandparents of youngsters identified with the condition thought it is overstated in school-age children. Physicians judged one in four youngsters diagnosed with ADHD either is misdiagnosed or does not actually have the disorder. More than half, 57 percent, of teachers, often the first front-line observers of questionable behavior, said children are "sometimes" misdiagnosed and treated for ADHD when, in fact, they have some other irregularity.

One-third of child psychiatrists, 41 percent of psychiatrists and 24 percent of pediatricians reported a lack of consensus among doctors on ADHD symptoms and diagnosis.

Unlike childhood maladies such as meningitis or mononucleosis -- though, psychiatrists point out, in keeping with medical conditions like migraine headaches or lower back strain -- ADHD is not revealed through a blood test or other biological exam.

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Screens for abnormal levels of thyroid hormone or lead in the blood, brain imaging studies and electroencephalography, the measurement of the brain's electrical activity, all fail to "show reliable differences between children with ADHD" and those without, the pediatricians found. Thus, they concluded, these cannot serve to identify the disorder.

"There are no data to offer precise estimates of when diagnostic behaviors become inappropriate," they acknowledged.

The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, the gold standard for defining mental illness, also notes: "There are no laboratory tests, neurological assessments, or attentional assessments that have been established as diagnostic in the clinical assessment of attention-deficit/hyperactivity disorder" and "no specific physical features associated with (ADHD)."

Rather, the DSM stipulates a child must exhibit at least six of nine hyperactive or inattentive behaviors -- such as squirming, fidgeting, losing or forgetting things and interrupting -- that begin before age 7, last more than six months, interfere with life at school and home and are not the result of some other emotional or physical condition.

Clearly, the standardization performs a service in providing a roadmap that gives more solid footing to methods for identifying children with severe behavioral disturbances that tread on their ability to function. What drives critics to distraction are calls made on shakier ground where the many more youngsters with milder symptoms and less impairment straddle the wobbly fence between sickness and health.

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"All children have difficulty paying attention and controlling their behavior at times," the advocacy group Consumers Union points out in a report assessing the effectiveness, safety and price of drug treatments for ADHD. "Indeed, almost all children (and many adults) have bouts or periods of hyperactivity, lack of focus and poor attention. This does not mean they ... have a mental or behavioral disorder."

Next: Drawing the ADHD line

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(Editors' Note: This series on ADHD is based on a review of hundreds of reports and a survey of more than 200 specialists.)

UPI Health News welcomes comments on this column. E-mail: [email protected]

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