Allen Frances, MD

Sharon Kirkey of Postmedia News has published 

 revealing that pediatricians can be just as reckless as  psychiatrists in their recommendations for Attention Deficit disorder (ADD).  Yesterday, the American Academy of Pediatrics (AAP) released 

  that recommend medication treatment for preschoolers as young as age 4-despite  the fact that such early use is not approved by the FDA. This radical  suggestion will further the already problematic overdiagnosis of ADD and expand  the inappropriate prescription of medication to young children.

It is absolutely clear that medication can be very helpful  for ADD in carefully diagnosed school-age kids who have moderate/severe problems  and who have not responded to patient watchful waiting, parent training, and  behavioral interventions. But in busy practice settings, ADD is often  inaccurately diagnosed and prematurely treated with medication-especially under  the pressure of heavy drug company marketing to physicians and direct  advertising to parents and teachers.

Medication for preschoolers should be undertaken only under  very special circumstances by people who are especially expert in ADD-like the  creators of the AAP guidelines. But it is a great mistake to encourage such  early use of medication in much less expert general practice-especially since  preschoolers are difficult to diagnose accurately and may be more prone to  harmful medication effects like loss of appetite, failure to gain weight  appropriately, abdominal pain, headaches, agitation, and disturbed sleep. And  there are rare but dangerous cardiac risks. Safety in young children has not  been studied nearly enough to inspire any confidence about short term problems  and long term risks. This should be a treatment of very last resort in  preschoolers, reserved for those with the most severe problems and delivered by  those with the greatest expertise.

Mark Wolraich, the lead author, is quoted as follows  justifying the guidelines "Because of greater awareness about ADHD and  better ways of diagnosing and treating this disorder, more children are being  helped. Treating children at a young age is important, because when we can  identify them earlier and provide appropriate treatment, we can increase their  chances of succeeding in school."

Clearly, he is touting the benefits (which certainly may be  appreciable for some), but ignoring the risks (which may be appreciable for  others), and the fact that very little research has been done to assess the  accuracy of diagnosis and the safety of medication in very young  children-especially in general practice settings.

The AAP guidelines do take the useful precaution of recommending a first line trial of behavioral interventions in preschool children with stimulants to be used later only for those with moderate to severe symptoms which have not improved after behavior therapy. But experience suggests that these cautions will be widely ignored in busy everyday practice, especially because behavioral approaches are usually unavailable and medication is so highly promoted and readily available.

Thus, despite its caveats and good intentions, the AAP guideline will surely invite an inappropriate glut of medication for preschoolers. And we will be largely flying blind about its impact. Much more study and cautious consideration of the risks and unintended consequences should have preceded the issuance of prestigious guidelines so likely to greatly influence practice habits. 

How could the AAP experts in ADD go so far wrong? It really should be no surprise-the ADD experts working on DSM 5 are making precisely the same kind of expansive, reckless mistakes. These poorly conceived AAP guidelines confirm the folly of placing responsibility for important public health decisions solely in the hands of highly specialized experts who have worked only in university settings. Experts are almost always hopelessly nave about how their guidelines will be misused in real life. We have already experienced a vast expansion in the diagnosis and medication treatment of ADD and these new AAP guidelines will encourage a further feeding frenzy of aggressive marketing by drug companies. The cautions included in the guidelines to protect against the first line use of medications will be routinely ignored, many young kids will be carelessly diagnosed, and they will receive unnecessary medication. The evidence that drugs are safe in preschoolers and will be judiciously prescribed in everyday practice is ridiculously incomplete. The ADD diagnosis will doubtless often be made prematurely in very young children who will then receive unnecessary and potentially harmful medication. If any diagnostic or treatment guideline can possibly be misused it will be-especially once drug company marketing distorts its intended use. 

The recklessness of the AAP in producing this treatment guideline for ADD and of the American Psychiatric Association in reducing the thresholds for the DSM 5 diagnosis for ADD together prove that important public health decisions cannot be entrusted to narrowly focused professional organizations. Experts on any topic have an inherent intellectual conflict of interest that prevents them from performing properly balanced and unbiased risk benefit analyses. They consistently tend to exaggerate the benefits and ignore the risks of their suggestions-especially as these will play out in general practice. Experts drawn from pediatrics and psychiatry are needed to inform, but should not exclusively control, the development of the diagnostic and treatment guidelines for ADD. 

In my view, the AAP treatment guidelines and the DSM 5 diagnostic guidelines both need to be tightened before they will fit for use by the average practitioner. In their current form, both are far too expansive and far too risky-they are best ignored.

Articles

Despite its caveats and good intentions, the AAP guideline will surely invite an inappropriate glut of medication for preschoolers . . .

Pediatricians Issue Dangerous New Treatment Guidelines For Attention Deficit Disorder

A recent front page story by Shari Roan in the 

 explores the heated controversy over the DSM-5 proposal to include a Disruptive Mood Dysregulation Disorder (DMDD) in DSM-5.  I very much oppose the inclusion of this new "disorder" -- fearing that DMDD would medicalize temper tantrums in children and run the risk of exacerbating the already shameful overuse of antipsychotics. 
 
When it comes to DMDD, everyone agrees on one thing only- that it is based on the thinnest possible research support; studies by one lone group for a mere 6 years. DMDD was largely dreamed up by the DSM-5 Work Group. They are trying to deal with a real problem -- the massive overdiagnosis of childhood bipolar disorder and its attendant stigma and overprescription of potentially dangerous medication. But the proposed  solution will create its own set of unintended consequences with the likely increase overprescription of medication for the new and inviting target of temper tantrums. And we are talking about lots of kids-- estimated at 3% now and likely to grow to many more once the diagnosis is official and drug companies get their hands on it. 

The right solution to the childhood bipolar fad is so much simpler and safer. DSM-5 should include a warning black box in its definition of Bipolar Disorder alerting clinicians to the dangers of overdiagnosis and overtreatment in children. My advice to child psychiatrists --  tame the fad you have already created and please don't create another fad of a new "disorder" that can so easily be misused. No one denies that irritable children are a problem, but let's not prematurely and blindly invent essentially meaningless, but potentially very dangerous labels for them.

The truly incredible thing about child psychiatrists is their inability to learn from their past experience of fad creation. These are the people who brought us the 3 main fads of the past 15 years -- childhood bipolar, attention deficit disorder, and autism. And now they recklessly suggest a potential fourth in DMDD. DSM-5 clearly needs some adult supervision with this thought in mind -- beware nosologists bearing new and untested child diagnoses.

This brings us to the most dispiriting chapter in this sad story. The DSM-5 "scientific review group" has proven not to be scientific and seems incapable of careful reviewing. Most remarkably, it has approved DMDD on tissue thin evidence and with no consideration of risk. A porous filter indeed. This highlights the obvious necessity for independent and evidence-based reviews (say by the Cochrane group) to ensure the scientific integrity and safety of DSM-5 suggestions. 
 

Allen Frances, MD

Articles

Pediatricians Issue Dangerous New Treatment Guidelines For Attention Deficit Disorder

Should Temper Tantrums Be Made Into A DSM-5 Diagnosis?