Jump in ADHD diagnoses spurs concern |
On Board Online • May 13, 2013
By Gayle Simidian
Research Analyst
When reporters from The New York Times looked into attention deficit hyperactivity disorder (ADHD), they found something rather shocking: 11 percent of school children – including one in five high school boys – have been diagnosed with the disorder, which can interfere with learning.
The number of ADHD diagnoses has shot up 16 percent since 2007, according to an article that appeared on the front page of the March 31, 2013 issue of The New York Times. The newspaper used data from a government study of children’s health that included 76,000 phone interviews. The research was funded by a bureau of the U.S. Department of Health and Human Services and is available from the U.S. Centers for Disease Control’s website at http://www.cdc.gov/nchs/slaits/nsch.htm.
For perspective, On Board spoke with psychologist Steven Kurtz, senior director of the ADHD and Disruptive Behaviors/Disorders Center at the ChildMind Institute (www.childmind.org), an organization dedicated to transforming child mental health through clinical care, research and advocacy. According to the Institute, Kurtz is “one of the nation’s leading clinicians in the treatment of children’s behavioral problems and disorders, particularly attention-deficit hyperactivity disorder (ADHD) and the social anxiety disorder selective mutism (SM).”
Q: What, in your view, accounts for the soaring rates of ADHD?
Kurtz: We are doing a better job of identifying kids with ADHD, but with this comes the risk of some false positives. [This occurs] with whatever screenings you do. Anywhere you set a bar for cutoffs, just like with medical tests, you will have tradeoffs. If you have a liberal cutoff, you will identify all the kids with ADHD, but also some who don’t have it; if you set the bar too high, you will miss some of the kids who actually do have it and need intervention even though you will have fewer false positives, that is children who your screener says have it but really don’t. This is commonly seen and understood in PSA screening for prostate cancer and mammography screening for breast cancer.
Q: How can practitioners avoid false positives?
Kurtz: Follow the practiced guidelines at the American Academy of Pediatrics or the American Academy of Child and Adolescent Psychiatry. You need to get a comprehensive timeline history of the child consistent with what you know about the disorder – not just ratings on parent and teacher checklists. The narrative has to be consistent and make sense over time and be impairing in multiple settings – not just home, not just school.
There is no one symptom that’s pathognomonic, having an absolute 1:1 correspondence with ADHD and, conversely, a symptom like inattention can just as well be [indicative of] anxiety or depression. Further, other disorders often co-occur with ADHD. So carefully screening for the wider range of disorders is critical.
Q: Why are boys being diagnosed more than girls?
Kurtz: The jury is really out on this. The rates actually even out for diagnosis across the subtypes as children get older. Girls may be more prone to the inattentive subtype and thereby slip under a teacher’s radar as non-disruptive. It’s well known that adults tend to be less aware of kids’ internalizing problems, like anxiety or mood issues, than their externalizing, disruptive issues.
Q: How do environmental factors play a role in ADHD?
Kurtz: Biology accounts for most of ADHD onset but environmental factors play a secondary role. There is no consistent data about diet manipulations being helpful, but as always, a good diet is a good thing more generally. Likewise, exercise is always a positive thing. In studies where parents thought their kids were getting sugar but actually got a substitute, they rated their kids as more hyperactive but it was just an expectancy bias at work.
Statistically, once you have an accumulation of four to five psychosocial stressors (e.g., poverty, exposure to violence), this can be detrimental to a child, and where there is trauma involved, kids’ threshold for working around ADHD will be lower. Other known risk factors are pre-natal exposure to smoking, alcohol, or illicit drugs, as well as brain injury.
Q: Assuming the diagnosis is correct, what do you think of prescribing medication such as Ritalin or Adderall for ADHD?
Kurtz: Clearly there are more benefits than risks. Seventy-five to 80 percent respond very well to medication, [the] remaining 25 percent [are] in one of two categories – either non-responders or side-effects outweigh main effects [of the disorder] in which case there are still other medication options.
Ritalin and Adderall have a short half-life, meaning their effects going in and out of your system are short-lived. While this makes them safer, once they’re out of your system, you’re back to square one. The process is similar to seeing clearly with your glasses on, but once you take them off you can’t see.
What’s very important is that little kids’ brains change. So, if a medication doesn’t work well for a six-year-old, wait a couple of years and maybe two years later it will work well. Especially for kids with co-occurring conditions, like anxiety disorder, you need a treatment plan including medication, parent training and school consultation. It should be good news to educators and parents that there are no known long-term side effects to taking appropriate medications but there certainly are long term negative side effects to under-treating and not treating ADHD.
Q: How can schools best support children diagnosed with ADHD?
Kurtz: Teachers need child management skills and skill-building regarding ADHD rather than simply information and lectures. CMI has an ADHD workshop video series for educators available at http://www.childmind.org/en/hot-topics/adhd-parent-and-educator-workshop-videos.