Doctor's orders: a new prescription for ADHD medication abuse.

AuthorRigney, Erinn L.
PositionAttention deficit hyperactivity disorder

"Th[is] stuff [Adderall] is like an ... anabolic steroid." --Mitch (1)

In a society that never stops, discovering a quick fix grants one an immeasurable competitive edge whether it be in the academic or professional arena. The world of athletics has grappled with the use of anabolic steroids for years, finally implementing anti-doping laws (2) and strict guidelines for athletes. However, in the academic setting, a similar problem has arisen that cannot be solved by random drug testing or other anti-doping mechanisms. Since the genesis of ADD/ADHD in the early 1980s, affected individuals have been able to procure medications that enhance cognitive capabilities: the ability to focus, concentrate, and retain information. Those truly suffering from ADHD reap the benefits of these medications while many non-affected people now acquire the drug for themselves to get ahead, primarily within academic settings. The prevalence of Adderall and the ease with which individuals, particularly students, can obtain it, through a diagnosis or illegal procurement, is alarming and presents ethical issues. Various solutions, including random drug testing, heightened disciplinary procedures, and education programs, have been proposed but do not attack the crux of the issue. Instead, this Note posits that to stem the abuse of ADHD medications in academic settings, the Individuals with Disabilities in Education Act (IDEA) should be amended to include ADHD as a specific learning disability and to develop a mandatory standardized diagnostic test that must be performed prior to the diagnosis of ADHD and the prescribing of Adderall that focuses on the adverse educational effect the disorder has on individuals. Currently, individuals can obtain an ADHD diagnosis and an Adderall prescription without much effort by meeting highly subjective criteria. By addressing the high rate of ADHD diagnoses and the ease with which this Schedule II Controlled Substance is obtained, only those requiring the drug will be able to obtain it and those seeking a competitive edge will be out of luck. This Note will proceed in five parts. Part I will identify background information on ADHD including diagnosis and treatment. Part II will address the current problem surrounding ADHD medications, specifically Adderall, focusing on the misuse/abuse on college and university campuses. Part III will discuss the Individuals with Disabilities in Education Act (IDEA) as well as [section] 504 of the Rehabilitation Act and the services provided to students with disabilities and/or ADHD. Part IV will propose a two-pronged solution to the overabundance of Adderall and the subsequent misuse by students. By amending IDEA and implementing a standard diagnostic test for ADHD, access to Adderall will decrease and the potential for abuse will be greatly lowered. Finally, Part V will address the implications of this alteration as well as aspects that cannot be addressed by a legislative mandate. The inclusion of ADHD as an enumerated learning disability under IDEA combined with a standardized identification and diagnosis procedure will allow individuals suffering from ADHD to receive appropriate treatment while preventing the illegal use of Adderall by those seeking an academic boost.

  1. THE ADHD EPIDEMIC: DIAGNOSIS & TREATMENT

    "The drugging of children for A.D.H.D. has become an epidemic." (3)

    Attention Deficit Hyperactivity Disorder (ADHD) is one of the most common neurobehavioral disorders diagnosed in children that can persist into adulthood. (4) Since its induction into the American Psychiatric Association's (APA) Diagnostic and Statistical Manual-IIIR (DSM-IIIR) in 1987 and its replacement of Attention Deficit Disorder (ADD) in the DSM-IV in 1994, ADHD diagnoses have risen an average 5.5% per year from 2003-2007. (5) ADHD manifests in various types dependent upon the primary behavior exhibited. (6) Currently, about 3-7% of school-age children suffer from ADHD; however, since 2007, about 9.5% of children aged four to seventeen have been diagnosed with the disorder. (7) In addition, though the disorder primarily appears in childhood, many older students and adults have been diagnosed with ADHD. (8) Adderall sales increased 3135.6% over a four year period from 2002-2006. (9) In a study conducted at the University of New Hampshire, researchers discovered that 50% of the students were first diagnosed with an attention disorder while in high school or college. (10)

    Because there is no known cause for the disorder,11 there is not an objective and standardized mechanism for diagnosing individuals with ADHD. (12) As specified by the American Academy of Pediatrics (AAP) in its diagnostic guideline, other diagnostic tests "contribute little to establish[] the diagnosis of ADHD." (13) Since the discovery of the disorder, the diagnostic criteria have evolved with guidelines issued by both the APA and the AAP. The APA's DSM-IV-TR established criteria to be utilized by medical professionals when diagnosing ADHD. (14) The APA's Diagnostic Guideline outlines the following factors: the persistence of symptoms of either inactivity or hyperactivity/impulsivity for a period of at least six months--symptoms which must be evaluated by parents or educators as many symptoms do not present in a clinical environment; the manifestation of symptoms prior to age seven; the presence of symptoms in two or more settings and "clear evidence of interference with developmentally appropriate social, academic, or occupational functioning." (15) The most important provision of the DSM-IV-TR states that children who meet the diagnostic criteria for the behavioral symptoms of ADHD but who demonstrate no functional impairment do not meet the diagnostic criteria for ADHD. (16)

    The AAP's clinical practice evidence-based guideline (17) outlines the diagnostic and evaluative techniques that should be utilized in the process of diagnosing a child with ADHD. This guideline encompasses six recommendations including the satisfaction of the DSM-IV criteria. (18) The recommendations are as follows:

    Recommendation 1: In a child six to twelve years old who presents with inattention, hyperactivity, impulsivity, academic underachievement, or behavior problems, primary care clinicians should initiate an evaluation for ADHD.

    Recommendation 2: The diagnosis of ADHD requires that a child meet DSM-IV criteria.

    Recommendation 3: The assessment of ADHD requires evidence directly obtained from parents or caregivers regarding the core symptoms of ADHD in various settings, the age of onset, duration of symptoms, and degree of functional impairment.

    Recommendation 4: The assessment of ADHD requires evidence directly obtained from the classroom teacher (or other school professional) regarding the core symptoms of ADHD, the duration of symptoms, the degree of functional impairment, and coexisting conditions. A physician should review any reports from a school-based multidisciplinary evaluation where they exist, which will include assessments from the teacher or other school-based professional.

    Recommendation 5: Evaluation of the child with ADHD should include assessment for coexisting conditions.

    Recommendation 6: Other diagnostic tests are not routinely indicated to establish the diagnosis of ADHD. (19)

    The first recommendation specifically mentions "academic underachievement" as a factor while the following recommendations rely on data obtained from the home and school environments and provide for the identification of other disorders. (20) By identifying other disorders--primarily "conduct and oppositional defiant disorder, mood disorders, anxiety disorders, and learning disabilities"--health care professionals can recommend special education services that are tailored to the coexisting disability rather than only to ADHD. (21)

    The AAP addresses the limited scope of the DSM-IV-TR criteria in effectively diagnosing ADHD, (22) again reinforcing the subjective nature of the process. As highlighted in Recommendation 2, "[f]urthermore, the behavioral characteristics specified in the DSMIV[-TR], despite efforts to standardize them, remain subjective and may be interpreted differently by different observers." (23) The subjective nature of the diagnosis and the failure to have a mandatory procedure for diagnosis are major factors in the rise of ADHD medication access by non-sufferers. A key component that is required by the DSM-IV-TR, yet is only part of the guideline, is that there must be some adverse impact upon the individual in a social, academic, or occupational environment.

    Though these two prominent guidelines exist (in addition to numerous rating scales), (24) studies have shown that medical providers do not routinely follow either the AAP or APA's standards for diagnosing ADHD. (25) A 2002 study of Michigan primary care physicians, found that only 25.8% utilized all "4 diagnostic components in the survey." (26) Though a majority of physicians were familiar with the guidelines, few utilized the DSM-IV-TR criteria routinely in practice. (27) Many selected a few of the recommendations promulgated by the AAP but adherence to the Clinical Algorithm for diagnosing ADHD was quite low. (28) Though the guidelines were not followed as specified by the AAP, "[n]early every (97.8%) respondent had prescribed a medication for ADHD in the past year." (29) Physicians, especially primary care doctors, are faced with overcrowded waiting rooms, short appointments, and a variety of other factors that prevent a thorough evaluation prior to diagnosis. In addition, the multi-step process for diagnosis places a strain on physicians and because the procedures are simply guidelines, many doctors circumvent them. Furthermore, the need for concert between educators, parents, and health care professionals in order to ascertain an individual's diagnosis consumes more time than a one visit consultation. The lack of a standardized and mandatory...

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