Attention deficit hyperactivity disorder may be the most extensively studied childhood mental disorder as well as the most controversial. In recent years, the use of methylphenidate (Ritalin) for the treatment of ADHD has been under scrutiny. The use of Ritalin increased by 150% during the 1990's (Diller, 1996). In addition, there is evidence to suggest that this stimulant is used inappropriately; administered to children who are not truly "disabled" and not administered where needed especially with children from low-income families. If true, this situation is likely due in part to the lack of definitive diagnostic criteria and the nonspecific nature of treatment. Dysfunction of the control of attention may be induced by the disruption of a number of different processes both psychological and medical/physiological. These different subtypes are typically lumped in appropriately under the ADHD diagnostic label and treated as a unified disorder; a situation that can and should be remedied.

Attention to this public health problem has increased in recent years. In 1998, the National Institutes of Health held a consensus development conference on the diagnosis and treatment of ADHD. The conclusions of the eminent members of this panel were briefly:

1) ADHD poses a costly and major public health threat.
2) Although there is evidence that this disorder is valid, no reliable method of diagnosis exists.
3) ADHD is a disorder of multiple dimensions and complex co-morbidity (coexisting conditions) that need study.
4) Long-term randomized clinical trials of stimulant medication treatment in ADHD are needed.
5) The use of medication in ADHD varies widely across regions and physicians.
6) The diagnosis, treatment, and follow-up of patients with ADHD need improvement.
7) These factors need to be integrated with educational services.
8) The causes of ADHD need to be understood in order to develop strategies for preventions.

Following the NIH venue in September of 1999, The Developmental Disabilities Branch of the Center of Disease Control and Prevention sponsored a conference that focused also on defining the public health concerns surrounding ADHD and recommendations for research to remedy these problems (Lesesne, et al., 2000). Later during May of 2000, the American Academy of Pediatrics released a 13-page set of guidelines for Pediatricians to use when evaluating children suspected of having ADHD (Wolraich, 2000). These guidelines seek to distinguish children whose condition warrants treatment from those exhibiting behavior that is developmentally normal.

Action of a different nature in response to the ADHD controversial emerged in the legal arena. In May of 2000, a class-action lawsuit signed by several hundred parents was filed in Texas against the American Psychiatric Association, an advocacy group call Children and Adults with Attention Deficit Disorder (CHADD), and the manufacturer of Ritalin (Novartis), alleging that these organizations fraudulently over-promoted the diagnosis of ADHD and failed to warn the public of the negative influence of the drug on the cardiovascular and nervous systems of children. Not long after, similar lawsuits were filed in both California and New Jersey.

To address the issue of behavioral drug use in our nation's school's, the Education Committee of the U.S. House of Representatives held a hearing in September of 2000. U.S. Congressman Bob Schaffer of Colorado presided over this hearing as a means in part of investigating the possibility that federal incentives (e.g., the Supplementary Social Income for welfare families with diagnosed children and additional special education funds allocated to schools for children who are diagnosed with ADHS) may be encouraging the wide-spread use of psychotropic medication by our children. Speakers at this hearing included representatives of the American Academy of Neurology, Department of Education, American Psychiatric Association, American Academy of Child and Adolescent Psychiatry, and National Alliance for the Mentally Ill. Schaffer ended the hearing with a statement regarding the importance of continued discussion on this issue among lawmakers, with particular scrutiny directed at the "correlation between financial public incentives and the frequency of psychotropic drug use among schoolchildren". Indeed, the issue has more recently been the focus of state legislative bodies including Michigan. Michigan ranked third in the country in the use of Ritalin at the end of this decade.

The State of Michigan has been engaged in a legislative and administrative debate over this situation since September of 2001. Both legislative bodies have voted repeatedly during this process to form an advisory council of a multidisciplinary nature to investigate and make policy recommendations pertaining to the use of psychotropic drugs among children. The last vote on the House Bill 5083 was late in April, 2002 when the Senate approved its most recent version. The bill, however, was vetoed by the Governor. The political situation is uncertain, and the fate of this bill is also uncertain. Nonetheless, there is clearly a need for research that is designed to gain a better understanding of ADHD diagnostic and treatment practices within our region and options for improved practice. In addition to gaining a better understanding of regional practices, the investigator hopes to create a network of communication on these issues of great importance to the welfare of our children.

Methods

This study surveyed the strategies used by physicians in the diagnosis and treatment of Attention Deficit Hyperactivity Disorder (ADHD). The survey instrument used was developed by Health Canada, and was slightly modified and used with the permission of this organization. The initial survey was restricted to physicians practicing the following specialties in the Saginaw, Bay City, and Midland regions of the state: Family Practice, Neurology, Pediatrics, and Psychiatry. The survey may be expanded to physicians practicing in the state of Michigan beyond this local region

Contact information was obtained from the public records maintained by medical institutions of their affiliated physicians. The original database of 229 physicians was obtained from the public records of the Saginaw County Medical Society, the Saginaw Cooperative Hospitals (St. Mary’s Hospital and Covenant Medical Center), Bay Medical Center, and Mid-Michigan Health (Midland/Auburn/Freeland).

A survey package containing the following materials was sent directly to each physician’s professional address: a cover letter that described the nature and purpose of the survey, a copy of the survey (containing no request for identity), a pre-addressed business-class envelope for the return of the survey, and a pre-addressed postcard that the physicians could choose to use upon completion of the survey. Several months following the initial mailing of the survey, a postcard served as a reminder.

In addition to receiving the hard-copy survey, the physicians were given the option to go to an Internet site to take the survey. The Internet version automatically entered each subject’s data into a database for analysis. Each case (survey taken) was identified only by a number, which was assigned in sequence. No other identification of the cases was recorded. All surveys that were returned in written form were scanned into the study’s database.

The survey results are reported in aggregate form. No attempt was made to link the individual characteristics reported by subjects in the study with subject identity.

Preliminary Key Findings

This pilot study was a prelude to research on the causes and diagnosis of Attention Deficit Hyperactivity Disorder (ADHD). It involved a survey of physicians to determine (a) how they treat ADHD, and (b) their beliefs about the diagnosis of ADHD. A survey (Health Canada) was mailed to 200 physicians in Saginaw, Midland, and Bay City. The results provided insights into the methods used locally by 18 physicians (Family Practice, Pediatrics, and Psychiatry). All but one (94%) have seen patients with ADHD. Teacher (72%) and parental (67%) concern are the primary sources of patient referral and frequently used in the diagnostic process. Most believe that ADHD diagnosis needs improvement, with 61% believing there are too few properly qualified diagnosticians. DSM-IV criteria are most frequently used, although 44% believe that these criteria are too vague. Preferred outside referral for assessment is to Psychologists (61% always or often), most commonly for motor skills and speech and language testing (72%). Most (94%) have prescribed methylphenidate routinely as the first treatment of choice. Sixty-one percent reported pressure from a variety of sources to medicate. Forty-four percent use two or more interventions; the most commonly used being parent training (44%) and behavior training (39%).