Attention Deficit Hyperactivity Disorder (ADHD): A study examining geographical variations in the diagnosis and treatment of ADHD across England over a period of one year.
Background and statement of the problem
Case for over-diagnosis All children exhibit the hallmark symptoms of impulsivity, hyperactivity and inattention to some degree; however, ADHD can only be positively diagnosed when these behaviours1,2 are expressed to an extreme or statistically rare extent together with clinical impairment in social, academic or occupational functioning.3 Treatment includes medical, social, psychological and behavioural interventions.
Despite these clear criteria, ADHD remains one of the most controversial psychiatric disorders due to its complicated diagnosis by differences in how rigorously the set of elements in the ICD-10 are applied.4 Other factors which affect the diagnosis of ADHD are the varying sources of information (parents, teachers or the patient) used to assess symptoms and whether the diagnosis is based on behaviour checklists, direct interviews or both.5,6
One study in 2004 revealed that eleven per cent of children were diagnosed with ADHD, albeit with no associated clinical impairments,7 which means that a high proportion of children were diagnosed incorrectly. With the lack of a biological marker,8 it may be argued that data exhibiting a prevalence exceeding four–eight per cent2 succinctly points to an issue of ADHD overdiagnosis.9 Variation in treatment across PCTs
In addition to the above, prescribing data in England and Wales10 over Quarter 4 of 2010 and Quarter 1 of 2011 reveals a variation of approximately 8,100 per cent in the total number of dispensed prescriptions for ADHD and 3,640 per cent in the net ingredient cost. Data for Quarter 4 of 2010 followed the same trend. his regional variation is likely to be influenced by several factors, such as demographic differences, including the number of secondary care assessment centres and the number of general practitioners (GPs) trained as ADHD specialists.
Methylamphetamine has abuse potential similar to that of cocaine and d-amphetamine, and it is used to improve concentration and alertness, to get a “high” or for experimentation.11
Studies have shown that some patients are likely to “make up” the symptoms of ADHD to access stimulant drugs for abuse,12,13 either for personal use or for diversion to the illicit market.
Given the magnitude of the regional variation in the drugs prescribed and benefits and concerns about medication use, including side effects (disturbed appetite and sleep patterns, the high possibility of cardiovascular problems15 and inhibited growtstrong6), no study has been conducted that is methodologically rigorous to dismiss concerns about the overdiagnosis or overtreatment of ADHD or even abuse potential. better understanding of the issue will be obtained by considering ADHD prevalence on a primary care trust (PCT) basis.
This study aims to evaluate geographical variations in the diagnosis and treatment of ADHD among a nationally representative population of children under 18 years of age.
Variables such as sex, age, race, deprivation index, unemployment, population and others will also be taken into account.
Study population and sampling
Children under 18 years of age diagnosed as having ADHD across GP practices across England and Wales as per the ICD-10.
Data analysis methods
Data from the Quality and Outcomes Framework and prescribing databases held by NHS IC will be abstracted, tabulated systematically, and subjected to statistical analysis.
A multiple logistic regression model with random effects could be used to analyse simultaneously for the effect of age, gender, diagnostic tool and setting. This model accommodates the fact that each study estimated ADHD rates differently under slightly varying conditions.
How the data may be used
It is hoped that the data from this epidemiological study will help to inform public health policy for a specific segment of the population that cannot articulate its own needs.