Laura Batstra

Attention-deficit/hyperactivity disorder: are we helping or harming?

#### Summary box Prevalence and prescribing rates for attention-deficit/hyperactivity disorder (ADHD) have risen steeply over the past decade, partly in response to concerns about underdiagnosis and undertreatment.1 2 But although clinicians have become better …

Quantifying psychiatric comorbidity - Lessions from chronic disease epidemiology

Background Comorbidity research in psychiatric epidemiology mostly uses measures of association like odds or risk ratios to express how strongly disorders are linked. In contrast, chronic disease epidemiologists increasingly use measures of clustering, like multimorbidity (cluster) coefficients, to study comorbidity. This article compares measures of association and clustering. Methods Narrative review, algebraical examples, a secondary analysis of an existing dataset and a pooled analysis of published data. Results Odds and risk ratios, but the former more than the latter, confound clustering with coincidental comorbidity. Multimorbidity coefficients provide a pure estimate of clustering which is the proportion of the association between disorders that is of etiological interest. Odds and risk ratios can express comorbidity between no more than two disorders, whilst clustering coefficients, although computationally laboursome, can capture multimorbidity of any number of disorders. Cluster coefficients depend less on the prevalence of illness in study groups than measures of association. Conclusion Odds and risk ratios are well suited for comorbidity research which focuses on which sets of disorders or syndromes tend to occur in combination and the implications of this for, for instance, nosological classification, a traditional interest of psychiatric epidemiology. However, the cluster coefficient is to be preferred if the interest is more aetiological, addressing for example why certain individuals are prone to multiple health problems.

Diagnostic Inflation Causes and a Suggested Cure

Abstract There have been a striking diagnostic inflation and a corresponding increase in the use of psychotropic drugs during the past 30 years. DSM-5, scheduled to appear in May 2013, proposes another grand expansion of mental illness. In this article, we will review the causes of diagnostic exuberance and associated medical treatment. We will then suggest a method of stepped care combined with stepped diagnosis, which may reduce overdiagnosis without risking undertreatment of those who really need help. The goal is to control diagnostic inflation, to reduce the harms and costs of unnecessary treatment, and to save psychiatry from overdiagnosis and ridicule.

DSM-5 Further Inflates Attention Deficit Hyperactivity Disorder

Abstract Since the publication of DSM-IV in 1994, attention deficit hyperactivity disorder (ADHD) prevalence and medication use unexpectedly increased significantly. In this article, we explore the DSM-5 proposals for ADHD that are likely to further increase its prevalence. We also address the possible harmful consequences of further expansion of this already broad, defined, and inflated DSM category.

Can breast feeding modify the adverse effects of smoking during pregnancy on the child’s cognitive development?

Harmful effects of maternal smoking during pregnancy on cognitive development of the child have been shown,1 as have beneficial effects of breast feeding.2 We examined whether adverse effects of maternal smoking can be modified by breast feeding. The Perinatal Project Groningen (PPG) is a cohort of 3162 singleton infants born in the University Hospital Groningen in 1975–1978. Perinatally, detailed sociodemographic, obstetric, and neonatal data were collected, including the average number of cigarettes smoked daily by the mother during pregnancy. For this study we focused on those children (n=570) whose reading, spelling, and arithmetic performance was tested around their 9th birthday using short standardised Dutch tests. For sample and test characteristics see Hadders-Algra et al 1988.3 The mothers of the 570 children examined at 9 years breast fed their children less often than the mothers whose children were not followed up (28.7% v 33%; χ2 (2) =10.56, p=0.005) and they smoked more (4.9 v 4.4 cigarettes a day; t =−1.73, p=0.094). However, our comparisons are valid within the …

The neurology of learning and behavioural problems in pre-adolescent children

Objective: The aim of the study was to evaluate whether in pre‐adolescent children specific types of minor neurological dysfunction (MND) are related to specific types of learning and behavioural problems, and whether it is the type or the severity of neurological dysfunction that matters most.

Holding the Line against Diagnostic Inflation in Psychiatry

pet diagnoses and from consumer advocacy groups who worry a great deal about false negatives but tend toward indifference about false positives. The only pushback against all of these pressures causing diagnostic inflation comes from those practice guidelines that suggest a cautious, stepped care approach to treatment [5, 6] . However, these efforts have not been sufficient to hold the diagnostic line in psychiatry and in primary care practice. Rates of diagnosis and use of psychotropic medication continue to escalate [2, 7] . Our purpose here is to suggest an explicitly stepped approach to diagnosis that will increase the acceptance and practicality of stepped care for mental disorders. The goal is to reduce the high rate of false positives without risking undertreatment for those who need it.

Childhood emotional and behavioral problems: reducing overdiagnosis without risking undertreatment

LAURA BATSTRA| MIJNA HADDERS-ALGRA| EDO NIEWEG| DONALD VAN TOL| SIP JAN PIJL| ALLEN FRANCES 1 Department of Special Needs Education and Child Care, University of Groningen, Groningen, the Netherlands. 2 Department of Pediatrics – Developmental Neurology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands. 3 Jonx Department of Child and Adolescent Mental Health, Lentis Psychiatric Institute, Groningen, the Netherlands. 4 Metamedica, Department of Health Sciences, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands. 5 Pedagogical Department NTNU, University of Technology and Science, Trondheim, Norway. 6 Department of Psychiatry, Duke University Medical Center, Durham, NC, USA.

Why So Many Epidemics of Childhood Mental Disorder

Allen Frances, MD,* Laura Batstra, PhD† Since the publication of DSM-IV in 1994, the rates of 3 mental disorders have skyrocketed: attention deficit disorder (ADD) tripled, autism increased by 20-fold, and childhood bipolar disorder by 40-fold. It is no accident that diagnostic inflation has focused on the mental disorders of children and teenagers. These are inherently difficult to diagnose accurately because youngsters have a short track record; are in developmental flux that makes presentations transient and unstable; are sensitive to family, peer, and school stresses; and may be using drugs. If ever diagnosis should be conservative, it should be in kids. Instead, we have experienced an unprecedented diagnostic exuberance encouraged in part by DSM-IV, but mostly stimulated by the powerful external forces of drug company marketing and the close coupling of school services to a diagnosis of mental disorder. ADD is a prime example. The DSM-IV field trial had predicted that the rates of ADD would increase by just 15% in response to a criterion change that made it a bit easier to make the diagnosis in girls (who more often present only with inattentiveness).1 The unexpected tripling of ADD rates to 10% of all kids has resulted in a jump of medication use to 4%. Some of this explosive growth may have resulted from increased awareness and better case finding, but most certainly, there was also a dramatic overshoot. Four large studies showed that relative age is a significant determinant of attention-deficit hyperactivity disorder (ADHD) diagnosis and treatment.2–5 The youngest children in class are up to 70% more likely than their classmates to receive a diagnosis of ADHD and medication. Being young should not be medicalized inappropriately into mental disorder. Three years after DSM-IV was published, drug companies introduced new and expensive on-patent drugs that provided the incentive and resources for an aggressive marketing campaign to psychiatrists, pediatricians, and family doctors. Simultaneously, successful drug company lobbying gave them unrestricted freedom to advertise directly to consumers. Parents and teachers were inundated with the message that ADD was terribly underdiagnosed and easily treated with a pill. Sales of ADD drugs ballooned to an astounding

Birth months as predictor of ADHD medication use in Dutch school classes

7 billion. Childhood bipolar disorder is an even more chilling case. DSM-IV had wisely rejected a proposal that there be a separate and much looser definition of bipolar disorder in children. The argument for inclusion rested on the unreplicated findings of just 1 (albeit very influential) research group suggesting that kids present a developmentally different prodromal form of bipolar disorder characterized by ambient irritability, impulsivity, and temper outbursts, rather than the typical cyclical mood swings of adults. Rejection by DSM-IV did not stop charismatic thought leaders (who were heavily financed by drug companies) from spreading the gospel of childhood bipolar disorder. The 40-fold increase in rates was accompanied by an increase in antipsychotic spending up to