Correspondence

I write to share with foreign child psychotherapy colleagues experiences with an American epidemic called Attention Deficit Hyperactivity Disorder (ADHD). I use the word ‘epidemic’ because a conservative estimate in 1993 would have placed 1.3 million 5- to 17-year-old American school children on stimulant medication for this so-called disorder, 2.9 per cent of all children in this age group (Sefer and Krager, 1994), while current estimates are of 2.0 million children receiving such medication, 4.4 per cent of the children in the age group (Merrow, 1995). I write in the hope that, if you are adequately aware of some of the factors that have facilitated this epidemic, you will be able to deal with it better than we have.

Attention Deficit Disorder (ADD) first appeared in 1980 in the third edition of the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-III). Some feel that the diagnosis was conceived at that time so that there could be an entity for which amphetamines could be prescribed for ‘hyperactive’ children (McGuinness, 1989), replacing the then recently discredited diagnosis of minimal brain damage and minimal brain dysfunction. The medications most used for ADHD are amphetamine derivatives — Ritalin, the proprietary drug, and methylphenidate, the generic and less expensive version.

In the spring of 1994 I obtained estimates from eight European countries on the use of psychostimulants with children (England, Italy, France, Germany, Norway, Sweden, Denmark and Finland) (Furman, 1996). In the eight countries, whose combined populations exceed that of the USA (273,800 million to 246,100 million), there were less than 6,000 children on psychostimulants, the drugs being used less than four-tenths of 1 per cent as often as in the States. Exploration of this discrepancy brought a number of factors to light, the first of which concerns diagnosis.

In line with DSM-III and its subsequent editions, diagnosis of