NEW YORK – A diagnosis of attention-deficit/hyperactivity disorder might not be forever.
In fact, it can be pretty fleeting. Analysis of serial assessments of more than 8,000 U.S. children and adolescents for attention-deficit/hyperactivity disorder (ADHD) showed that the diagnosis often did not persist after follow-up of 1 year or longer, J. Blake Turner, Ph.D., said at the meeting
ADHD diagnoses “are extremely transient over a 1-year period. Generally, loss of the diagnosis is more likely than persistence,” said Dr. Turner, a researcher in the division of child and adolescent psychiatry at Columbia University in New York.
The findings suggest that problems exist with current nosology for ADHD, and that current prevalence estimates from community studies may be inflated. “We need to examine the predictors of ADHD persistence over time,” he said. “We need to look at what's going on here and what predicts the persistence of disruptive disorders.
“If patients are diagnosed with ADHD and it is transient – if it is reactive distress that is likely to go away – do we want to identify them?” he asked in an interview. “If a diagnosis is made of ADHD, do you let it go because it will likely resolve on its own, or will treatment help it resolve more quickly?” We think of ADHD as something that lasts, not something that comes and goes. Perhaps we need [a diagnosis] that's more stable,” possibly by basing it on a larger number of symptoms. “That would mean changing the ADHD diagnosis,” he said.
Preliminary analysis of serial assessments for oppositional defiance disorder and conduct disorder in the same data set of 8,714 children and adolescents showed similar, transient patterns after an initial diagnosis, Dr. Turner added.
“It troubles me that the [ADHD] phenotype looks so unstable,” commented Dr. Daniel S. Pine, chief of the Section on Development and Affective Neuroscience at the National Institute of Mental Health. “A lot of people are struggling with the threshold for [diagnosing] ADHD. This is a very different conceptualization of ADHD; we don't usually think of it as something that's gone in 2 years. If this is [children having] a transient reaction to stress, I don't want to talk about it [in] the same way as clinical ADHD.
Dr. Pine suggested that Dr. Turner's new finding might help explain the high reported prevalence rates of ADHD, and that the results also raised issues about using stimulants to treat newly diagnosed ADHD.
“I look at some of the prevalences [reported], and it's absurd. I find it very hard to believe that 20% of American boys have ADHD,” but that is what some recent reports documented, Dr. Pine said. Other reports said that about 6% of all American children and about 12% of boys receive stimulant treatment for ADHD. “When I look at these data [in Dr. Turner's report], the question of stimulant use is right behind there.”
Dr. Turner used data collected by 4 of the 16 studies done by researchers in the DISC (Diagnostic Interview Schedule for Children) Nosology Group. All of the studies used the DISC to assess a group of children, adolescents, or both. The four studies used by Dr. Turner included serial assessments using the DISC for ADHD a year or more apart. Depending on the study and whether the diagnostic criteria included the age of onset, the range of ADHD prevalence at the initial examination was 5%–40%, with roughly 1,200 total cases identified.
At a follow-up visit at least 1 year after the initial examination, loss of the ADHD diagnosis occurred in roughly 55%–75% of the patients who had been diagnosed with inattention ADHD the first time. In patients who were initially diagnosed with hyperactive ADHD, the loss rate at follow-up ran 55%–65%. Those who were first diagnosed with combined ADHD had a more stable course, with about 18%–35% not maintaining the diagnosis at follow-up.
Additional analysis showed that lost ADHD diagnoses usually did not occur as a small change in an initially marginal diagnosis. Patients who changed from having ADHD to not having it lost five ADHD symptoms, on average. And the remitters and nonremitters all had a similar pattern of disease severity at their initial diagnosis. Patients' age had no association with whether or not an ADHD diagnosis disappeared. And patients who received treatment had a higher likelihood of retaining their ADHD diagnosis at follow-up than did those who did not receive treatment, possibly because the patients who were treated generally had more chronic ADHD.
Dr. Turner had no disclosures.