6 ms·

The thing is, diagnosis rates in the U.S. are something like 3-4 times as high as in most countries in Europe, which are themselves 3-4 times as high as a count

The thing is, diagnosis rates in the U.S. are something like 3-4 times as high as in most countries in Europe, which are themselves 3-4 times as high as a country like France, which is averse to ADHD diagnoses. The main treatment for ADHD is lifelong maintenance of powerful amphetamines, when we have no idea what the long-term consequences of that would be, nor what proportion of children would normally develop out of the ADHD spectrum with time. Overdiagnosis at that rate means that millions of children are being given amphetamines, when they shouldn't be!

Broken_Hippo 10y ago
I looked, and it seems to be about double (though figures disagree). And I wonder if this isn't simply a difference in educational systems and expectations of children. I'm in Norway, and children play quite a bit, even in school. They take frequent breaks, have outdoor recess (in nearly all weather), and have no homework. The general attitude is that kids should be kids and not have to worry about stuff. Sure, there is more pressure as the child grows up, but it isn't comparable. School days are shorter as well. Far cry from what I remember as a kid in the US or what I see now. Little in the way of recess, homework starts early. I had a few hours every night at age 11. Sit still, be quiet for hours, do all the worksheets. I'm guessing there are kids with ADHD that might not need medication, merely time to learn and develop coping mechanisms. Perhaps some children wouldn't have such a problem in the one system whereas in the other would be quite a disruption. I have nothing to back this up, just a theory.
- Diederich 10y ago
  This is pretty important stuff, thank you for posting. Often times, 'a problem' exists largely because a person's behaviour and/or performance exists outside of the local norm. Given this, then by definition the amount and types of such problems are largely driven by the norm. As you said, I don't have anything at hand to back this up, but this seems like a very reasonable way to explain some of these big diagnosis deltas.
- vainguard 10y ago
  I think you are right. I would really prefer to change the world, than take medication. I say this without sarcasm and a little bit of sadness.
scottmf 10y ago
>we have no idea what the long-term consequences of that would be Perhaps you have no idea, but we actually have a pretty good idea from 80 years of stimulant medication usage. Do you have data suggesting negative consequences of decades of stimulant usage? No? Then it's surely the best decision to ignore this FUD and continue treating people of all ages with stimulants which have been shown to be safe in such low doses. Particularly when we have evidence suggesting not medicating is dangerous, as I mentioned in my other comments.
- panglott 10y ago
  The main question is whether medication-based treatment encourages ADHD to persist past adolescence. Non-medication-based treatment, of course, does not necessarily imply non-treatment or non-intervention.
falcolas 10y ago
> Overdiagnosis at that rate means that millions of children are being given amphetamines, when they shouldn't be! Only if you define overdiagnosis as "diagnosis relative to other countries" and not "diagnosis relative to the percentage of people with the ailment". If you use the first, we probably overdiagnose cancer, since countries like Mali have a much lower diagnosis rate... > children would normally develop out of the ADHD spectrum with time. And until they normally develop out, they would be behind in every measurable attribute as what we expect in their growth through school. Avoiding administrating a treatment which works because of our fear of the treatment is measurably bad for those affected. See, again, cancer and chemotherapy.
- panglott 10y ago
  When similar standards of diagnosis are used across countries, they find similar rates of ailment. The difference is that the criteria for diagnosis in the US catches a much larger percentage of the population. Moreover, the US is also much more likely to use pharmaceuticals as the front-line treatment to any ADHD diagnosis. Really, my concern isn't about children who would be diagnosed either way, or who unambiguously need pharmaceutical treatment (who exist in all areas). It's about the marginal cases where pharmaceuticals may not be warranted. It would be dreadful to administer chemotherapy drugs to patients who got a false-positive on a cancer screening (cancer is not a spectrum, but I'll run with your analogy). And as I said in another comment, skepticism of the long-term use of this medication in young children does not at all mean advocacy of non-treatment, non-intervention, or lack of support for children at the margins of the ADHD spectrum.
anexprogrammer 10y ago
We don't yet know how many of those are being overdiagnosed - we don't yet know the limits of the spectrum. There's a lot of opinion on both sides, which is never helpful. I can say that I wish I had had 30 more years on amphetamines, the difference has been marked. For the first time in my life the engine wasn't misfiring. If it were certain to take a decade or more of my remaining life, I'd continue fully aware. I still drift, but I think that's more because I have the habits. For me it'll still be a lifelong process to try and correct the bad habits and thought patterns reinforced throughout the first half of my life. Others will be less clear beneficiaries of treatment or better served in other ways. I think diagnosing and treating toddlers and 7 year olds is appalling - better to try and manage it, or look into causative factors like poor home environment and such. A more Scandinavian approach to school may help more (The UK would benefit from this too). A good proportion will grow out of it. That comes back to wider real awareness though especially with first contact - teachers and GPs etc.
jrapdx3 10y ago
Some of these questions have been studied. When the same criteria are used, prevalence is comparable in Germany, Brazil and other locations. The recognition of the condition is affected by cultural factors but that's true for many conditions. ADHD by definition is a condition that originates in childhood and persists into adulthood in about 1/2 or more of cases. In adults ADHD is indeed a chronic condition that often responds to amphetamine or methylphenidate treatment. At therapeutic doses, long-term treatment with such agents is generally well-tolerated, but careful monitoring is necessary to assure medication use remains effective and tolerable. Interestingly, amphetamine has been used for this purpose for nearly 80 years, and methylphenidate for >50 years. Despite the several decades these agents have been employed, nothing more effective has yet been developed. As I pointed out in my other comment, among adults anyway, the issue is that ADHD is vastly undertreated to the severe detriment of individuals, their families, communities and nation as a whole.
- panglott 10y ago
  > ADHD by definition is a condition that originates in childhood and persists into adulthood in about 1/2 or more of cases. Right, and all of this is a question about under what conditions it persists or fails to persist. Does ADHD medication, relative to say behavioral therapy or nontreatment/nonintervention, make it more or less likely that ADHD will persist in adulthood? This is a very important question of those who fear ADHD medication is overused, and may be encouraging ADHD to persist past adolescence.
  - jrapdx3 10y ago
    Very important questions indeed, while there's no complete answer some data is encouraging. Imaging studies, for example, have shown children treated continuously to early adulthood show more robust brain development (white fiber tracts) vs. untreated subjects. Medication treatment is certainly not harmful in that respect and probably helpful. The role of behavioral therapies is unclear, though practitioners point to instances where that makes a big difference in the outcome. Admittedly it is a hard subject to study systematically given the individualized nature of behavioral treatments. However research is hardly saying that medication is the only factor. Lately, there is a great deal of attention in the field directed to findings that childhood adversity, e.g., abuse, malnutrition, environmental impoverishment contributes greatly to conditions that resemble ADHD. The implication is clear that reducing the negative impacts of inner-city poverty, etc., would have salutary effects on reducing incidence of psychiatric disorders including ADHD. In adults, ADHD sufferers with long-term medication treatment show better functioning than untreated peers (matched for age, sex, education, etc.) if less well than unaffected individuals. Most such studies have used medication therapy as the marker of treatment. So far the contribution of behavioral therapies has been hard to pin down. However, clinical experience is that medication alone is inadequate for adults to improve. The saying is "pills don't build skills". Indeed, guided behavioral practicing is an essential element of ADHD treatment, though optimized medication treatment can be very useful to enhance neurophysiological infrastructure necessary for normalizing functioning. An individually optimized combination of treatment approaches is most likely to be successful, but hard to determine a priori, thus hard to study experimentally. I don't believe my response truly satisfies your excellent question, but I'm very glad to know there are people like you who are thinking intelligently about these problems that affect all of us directly or indirectly.
PhasmaFelis 10y ago
> The thing is, diagnosis rates in the U.S. are something like 3-4 times as high as in most countries in Europe, which are themselves 3-4 times as high as a country like France, which is averse to ADHD diagnoses. I've heard people from France say that many French doctors absolutely will not diagnose ADHD in anyone, no matter what their symptoms, preferring to tell sufferers that they're lazy. It may be possible that the US overprescribes and Europe in general is a happy medium. France is systemically failing to treat people with a genuine medical need, and it ruins lives. If it has to be one or the other, I'd prefer to err on the side of helping people in need. Please see my other post on the effects of ADD: https://news.ycombinator.com/item?id=12345969 https://news.ycombinator.com/item?id=12345969

Broken_Hippo 10y ago

I looked, and it seems to be about double (though figures disagree). And I wonder if this isn't simply a difference in educational systems and expectations of children. I'm in Norway, and children play quite a bit, even in school. They take frequent breaks, have outdoor recess (in nearly all weather), and have no homework. The general attitude is that kids should be kids and not have to worry about stuff. Sure, there is more pressure as the child grows up, but it isn't comparable. School days are shorter as well. Far cry from what I remember as a kid in the US or what I see now. Little in the way of recess, homework starts early. I had a few hours every night at age 11. Sit still, be quiet for hours, do all the worksheets. I'm guessing there are kids with ADHD that might not need medication, merely time to learn and develop coping mechanisms. Perhaps some children wouldn't have such a problem in the one system whereas in the other would be quite a disruption. I have nothing to back this up, just a theory.

Diederich 10y ago
This is pretty important stuff, thank you for posting. Often times, 'a problem' exists largely because a person's behaviour and/or performance exists outside of the local norm. Given this, then by definition the amount and types of such problems are largely driven by the norm. As you said, I don't have anything at hand to back this up, but this seems like a very reasonable way to explain some of these big diagnosis deltas.
vainguard 10y ago
I think you are right. I would really prefer to change the world, than take medication. I say this without sarcasm and a little bit of sadness.

scottmf 10y ago

>we have no idea what the long-term consequences of that would be Perhaps you have no idea, but we actually have a pretty good idea from 80 years of stimulant medication usage. Do you have data suggesting negative consequences of decades of stimulant usage? No? Then it's surely the best decision to ignore this FUD and continue treating people of all ages with stimulants which have been shown to be safe in such low doses. Particularly when we have evidence suggesting not medicating is dangerous, as I mentioned in my other comments.

panglott 10y ago
The main question is whether medication-based treatment encourages ADHD to persist past adolescence. Non-medication-based treatment, of course, does not necessarily imply non-treatment or non-intervention.

falcolas 10y ago

> Overdiagnosis at that rate means that millions of children are being given amphetamines, when they shouldn't be! Only if you define overdiagnosis as "diagnosis relative to other countries" and not "diagnosis relative to the percentage of people with the ailment". If you use the first, we probably overdiagnose cancer, since countries like Mali have a much lower diagnosis rate... > children would normally develop out of the ADHD spectrum with time. And until they normally develop out, they would be behind in every measurable attribute as what we expect in their growth through school. Avoiding administrating a treatment which works because of our fear of the treatment is measurably bad for those affected. See, again, cancer and chemotherapy.

panglott 10y ago
When similar standards of diagnosis are used across countries, they find similar rates of ailment. The difference is that the criteria for diagnosis in the US catches a much larger percentage of the population. Moreover, the US is also much more likely to use pharmaceuticals as the front-line treatment to any ADHD diagnosis. Really, my concern isn't about children who would be diagnosed either way, or who unambiguously need pharmaceutical treatment (who exist in all areas). It's about the marginal cases where pharmaceuticals may not be warranted. It would be dreadful to administer chemotherapy drugs to patients who got a false-positive on a cancer screening (cancer is not a spectrum, but I'll run with your analogy). And as I said in another comment, skepticism of the long-term use of this medication in young children does not at all mean advocacy of non-treatment, non-intervention, or lack of support for children at the margins of the ADHD spectrum.

anexprogrammer 10y ago

We don't yet know how many of those are being overdiagnosed - we don't yet know the limits of the spectrum. There's a lot of opinion on both sides, which is never helpful. I can say that I wish I had had 30 more years on amphetamines, the difference has been marked. For the first time in my life the engine wasn't misfiring. If it were certain to take a decade or more of my remaining life, I'd continue fully aware. I still drift, but I think that's more because I have the habits. For me it'll still be a lifelong process to try and correct the bad habits and thought patterns reinforced throughout the first half of my life. Others will be less clear beneficiaries of treatment or better served in other ways. I think diagnosing and treating toddlers and 7 year olds is appalling - better to try and manage it, or look into causative factors like poor home environment and such. A more Scandinavian approach to school may help more (The UK would benefit from this too). A good proportion will grow out of it. That comes back to wider real awareness though especially with first contact - teachers and GPs etc.

jrapdx3 10y ago

Some of these questions have been studied. When the same criteria are used, prevalence is comparable in Germany, Brazil and other locations. The recognition of the condition is affected by cultural factors but that's true for many conditions. ADHD by definition is a condition that originates in childhood and persists into adulthood in about 1/2 or more of cases. In adults ADHD is indeed a chronic condition that often responds to amphetamine or methylphenidate treatment. At therapeutic doses, long-term treatment with such agents is generally well-tolerated, but careful monitoring is necessary to assure medication use remains effective and tolerable. Interestingly, amphetamine has been used for this purpose for nearly 80 years, and methylphenidate for >50 years. Despite the several decades these agents have been employed, nothing more effective has yet been developed. As I pointed out in my other comment, among adults anyway, the issue is that ADHD is vastly undertreated to the severe detriment of individuals, their families, communities and nation as a whole.

panglott 10y ago
> ADHD by definition is a condition that originates in childhood and persists into adulthood in about 1/2 or more of cases. Right, and all of this is a question about under what conditions it persists or fails to persist. Does ADHD medication, relative to say behavioral therapy or nontreatment/nonintervention, make it more or less likely that ADHD will persist in adulthood? This is a very important question of those who fear ADHD medication is overused, and may be encouraging ADHD to persist past adolescence.
- jrapdx3 10y ago
  Very important questions indeed, while there's no complete answer some data is encouraging. Imaging studies, for example, have shown children treated continuously to early adulthood show more robust brain development (white fiber tracts) vs. untreated subjects. Medication treatment is certainly not harmful in that respect and probably helpful. The role of behavioral therapies is unclear, though practitioners point to instances where that makes a big difference in the outcome. Admittedly it is a hard subject to study systematically given the individualized nature of behavioral treatments. However research is hardly saying that medication is the only factor. Lately, there is a great deal of attention in the field directed to findings that childhood adversity, e.g., abuse, malnutrition, environmental impoverishment contributes greatly to conditions that resemble ADHD. The implication is clear that reducing the negative impacts of inner-city poverty, etc., would have salutary effects on reducing incidence of psychiatric disorders including ADHD. In adults, ADHD sufferers with long-term medication treatment show better functioning than untreated peers (matched for age, sex, education, etc.) if less well than unaffected individuals. Most such studies have used medication therapy as the marker of treatment. So far the contribution of behavioral therapies has been hard to pin down. However, clinical experience is that medication alone is inadequate for adults to improve. The saying is "pills don't build skills". Indeed, guided behavioral practicing is an essential element of ADHD treatment, though optimized medication treatment can be very useful to enhance neurophysiological infrastructure necessary for normalizing functioning. An individually optimized combination of treatment approaches is most likely to be successful, but hard to determine a priori, thus hard to study experimentally. I don't believe my response truly satisfies your excellent question, but I'm very glad to know there are people like you who are thinking intelligently about these problems that affect all of us directly or indirectly.

PhasmaFelis 10y ago

> The thing is, diagnosis rates in the U.S. are something like 3-4 times as high as in most countries in Europe, which are themselves 3-4 times as high as a country like France, which is averse to ADHD diagnoses. I've heard people from France say that many French doctors absolutely will not diagnose ADHD in anyone, no matter what their symptoms, preferring to tell sufferers that they're lazy. It may be possible that the US overprescribes and Europe in general is a happy medium. France is systemically failing to treat people with a genuine medical need, and it ruins lives. If it has to be one or the other, I'd prefer to err on the side of helping people in need. Please see my other post on the effects of ADD: https://news.ycombinator.com/item?id=12345969 https://news.ycombinator.com/item?id=12345969