Is ADHD On The Rise – Or Just Overdiagnosed?

Monday, April 1st, 2013

The latest numbers on the rate of ADHD are extraordinary. The New York Times has reported data collected from the Centers for Disease Control and Prevention which suggest that 11% of youth (between 4 and 17 years of age) have been diagnosed with ADHD at some point in their lifetime. 

This is troubling – primarily because the data come from phone surveys of parents. This means that parents are receiving this diagnosis at unprecedented rates – not that kids are being properly diagnosed with ADHD at higher rates than before. It is too easy for kids to get labeled ADHD and not go through the comprehensive screening that should take place as administered by a multidisciplinary team of professionals.

It’s becoming clear that ADHD is being used as a label to try to provide a quick handle on behavior that may – or even may not – be somewhat troublesome. ADHD involves much more than not sitting still and not paying attention. All kids exhibit “ADHD” like behaviors now and then. It’s a difficult condition to diagnose because it is based on increased frequencies of a number of behaviors across a number of contexts (home and school) for a sustained period of time which cause impairment for the child. Without a detailed diagnostic process, it can be too easy to misread normative behaviors as symptoms of ADHD.

Part of the increase comes from diagnoses of older kids including those in high school. Diagnostic criteria are beginning to reflect the thinking that symptoms can develop later in childhood and even in the teen years (and not just the early years). That said, it can also become another convenient label for a kid who is not doing well in school. At the other end of the spectrum, diagnosing preschoolers can raise related issues in terms of figuring out which kids are really showing early signs and which kids are just being kids.

There are a number of problems with overdiagnosis. Kids typically get treated with drugs that are not appropriate for them. They get labeled rather than receive the kind of attention that they deserve (for example, to improve their engagement in the classroom). And some kids get diagnosed simply because they are in very large classrooms which promote inattention and not sitting still.

The less obvious issue is that the cursory diagnosing that may be going on is also a disservice to kids who do suffer from ADHD. They should be getting full assessments and comprehensive treatment plans that find optimal combinations of psychosocial intervention and, when necessary, well monitored use of drug therapy. Tossing around labels and drugs as a diagnostic and treatment strategy is not going to give them the help they need, especially since we know that ADHD can persist into adulthood and cause much in the way of academic and social impairment.

The bottom line? If you are a parent, and you (or someone else) suspects that your child might have ADHD, try to seek out an assessment from a multidisciplinary team that has the requisite experience to know how to sort out normative behaviors and issues from clinically meaningful ADHD. You might need to network with other parents, your pediatrician, and educators to locate a provider. But it will be worth your time and effort to make sure your child isn’t misdiagnosed as having ADHD – or not given the proper assessment and treatment plan if they do show the clinically meaningful symptoms of ADHD.

ADHD image via Shutterstock.com

As Rates Of Autism Spectrum Disorder Rise, Will Access To Intervention Decline?

Saturday, March 31st, 2012

This week you all heard about the recent CDC report on the rising rate of autism spectrum disorders (ASD) (click here if you didn’t read the synopsis on Parents News Now). And you have had a chance to hear experts answer a number of important questions via To The Max (click here if you didn’t read it yet). What I’d like to offer is a consideration of the CDC report in light of the current debate going on about DSM-5, the new version of the diagnostic manual to be used by the American Psychiatric Association. 

If you recall, not so long ago there were troubling suggestions that the proposed revisions to diagnostic criteria could result in a substantial number of youth no longer meeting the definition of ASD. This issue is far from settled, and the new CDC report acknowledges that the estimated rate of ASD could change (meaning it may decline) once new diagnostic criteria are in place. But there is a more troubling concern. As it was explained to me by Dr. Gil Tippy, the real issue comes down to this: the DSM-5 approach will “lump” all the ASD subtypes into one clinical diagnosis of ASD, but then apply severity criteria to each individual. This is the slippery slope, because while the rate of ASD may not be affected, a substantial number of  youth may be rated clinically as having only “mild” impairment and thus potentially lose insurance coverage for services that their kids desperately need. Keep in mind this is, in a sense, simply a consequence of the language of the proposed DSM-5. If the various subtypes of ASD were “split” into separate diagnoses rather than “lumped” these severity criteria would not be necessary.

There is no perfect formula here. Diagnostic criteria are always revised in light of current understanding of both the causes of a disorder and how it is expressed clinically. I’ve personally witnessed drastic changes in the estimates of ASD from the early 1980s until now: when I was in college, the rate was 4 in 10,000 – now it’s 1 in 88. Much of this recognition has come from refining the diagnostic criteria and developing standardized methods for diagnosis that can be applied reliably by clinicians. But we all have to wary of the paradox that may emerge: just when we acknowledge the extent of the ASD epidemic, we may also be putting into place a diagnostic system that will decrease access to the interventions that are crucial for improving many kids’ lives. And it’s well established that these interventions need to start as early as possible and persist as long as possible to give kids with ASD the best possible developmental outcomes. Perhaps it’s time that science and practice be given equal consideration in diagnostic systems, and we all mobilize to find ways to be sure that we can, as a society, make services available and accessible for all youth who need it.

Image of question mark via Shutterstock.com

Is ADHD On The Rise? Part One: Some Scientific Questions and Answers

Tuesday, August 30th, 2011

Many parents have seen reference to new data released by the Centers for Disease Control and Prevention (CDC) that suggests that rates of ADHD have risen over the past decade. Whenever data like these are publicized, it raises questions for parents that range from the scientific to the practical. Here is a little scientific Q & A — with myself — that focuses on some typical scientific questions that parents might ask:

Is ADHD really increasing?

These data don’t speak to this issue. The data were drawn from Census reports and are, in essence, descriptive. All we know is that as compared to prior data gathering efforts that used the same approach, more parents reported that their kids had ADHD.

So the parents reported on their kids ADHD?

Yes, parents were asked the following question (quoted from the CDC website):

“Has a doctor or health professional ever told you that your child had Attention Deficit Hyperactivity Disorder (ADHD) or Attention Deficit Disorder (ADD)?”

Is this a good way to determine the rates of ADHD?

Well, it’s not the best way. The gold standard would be to conduct diagnostic interviews with large numbers of parents and children who are representative of the population. This survey assumes that a given child has already been referred for assessment. So in fact it may be that some kids in the study showed signs of ADHD but if they were not referred for screening, or did not seek it out on their own, then they may in fact meet diagnostic criteria as well.

Does that mean the data could actually underestimate ADHD?

Yes, that’s possible. That said, the estimates from this study are in line with other diagnostic studies of kids.

Why should be concerned with the idea that the rate of ADHD may be going up?

There are two concerns here. First, it may be that, in the past, we have underestimated the rate, and now we are getting better estimates of the number of kids who might require assessment and proper treatment. Second, if the rate is really going up, then it suggests that there might be changes in either the frequency of risk factors, or the emergence of new risk factors, which could be targeted in prevention or earlier intervention.

In Part Two, we’ll continue with this idea that there may be changes in risk factors that are increasing the rates of ADHD.