June 1st, 2013

ADHD diagnoses increase but is that rise because of awareness?

ADHD diagnosis rates continue to climb among school-aged children.

The Centers for Disease Control and Prevention conducted a 2011-2012 study of children’s health issues, interviewing more than 76,000 parents nation-wide, and will release its report this spring. The New York Times used the agency’s raw data to compile results and reported a 16 percent rise in ADHD diagnosis since 2007 and a 41 percent increase in the past decade, with 11 percent of children overall having received an ADHD medical diagnosis. Approximately two-thirds of those with a current diagnosis are receiving prescriptions for stimulants like Ritalin or Adderall.

The diagnosis increase may be partly because of increased awareness.

Robert M. Pressman, Ph.D., ABPP, director of research at New England Center for Pediatric Psychology in R.I., says that ADHD has become the “diagnosis du jour.” Pressman published a study in the American Journal of Family Psychology (2011) that found that 33 percent of Providence children had a physician or teacher at one time suggest that they may have ADHD.

“That doesn’t mean they had the diagnosis, but what it does mean is – it is something very much on people’s minds,” Pressman says. “That alone is going to increase the probability of an ADHD diagnosis.”

Kathryn H. Robbins, Ph.D., licensed psychologist, Child Clinical Psychology & Behavioral Health, Upper Valley Child & Family Psychology in Lebanon, N.H., says there’s also likely an increase in over-diagnosis or misdiagnosis. “I think ADHD symptoms are very similar to symptoms you see in other difficulties – learning disabilities, other mental illnesses, trauma,” Robbins says. “Often, children can present with these symptoms and they are more quickly diagnosed as ADHD than they more accurately might be, because of an increased public awareness of ADHD.”

Mark Reck, Psy.D., licensed psychologist-doctorate, University of Vermont Counseling & Psychiatry Services, has observed more students entering college disclosing an ADHD diagnosis over the past few years.

Based on his observations and anecdotal experiences, he believes the phenomenon may be more aligned with occasions of misdiagnosis. “I still see a number of young people who have never been diagnosed with ADHD and have been told that their problems stem from something else (e.g., depression, anxiety, bipolar disorder, just being ‘lazy’), yet have not responded to treatments focused on those things,” Reck says. “When further assessment is done, it seems clear that their problems stem from ADHD and, when treated for ADHD, experience significant improvement. Alternatively, I have seen a number of young people who have been diagnosed with ADHD, often by their pediatrician or family physician, but my further assessment does not match that diagnosis. When I consult with or request records from the diagnosing professional, it is unclear how they diagnosed the person in question.”

In terms of diagnostic criteria, several psychologists note that in the “Diagnostic and Statistical Manual of Mental Disorders” (DSM), all the symptom criteria start with the word “often.”

“That is a real problem with making an ADHD diagnosis,” Pressman says. The pivotal term, “often” as measure of frequency, is completely subjective, he says. “It is what I call an ‘in the eye of the beholder diagnosis.’ That makes it dangerous. It opens up the possibility of both false-positives and false-negatives,” Pressman says.

“The real driver in diagnosis from my perspective is what is happening in schools,” Pressman says. “From the clinical standpoint, what we see is that the start of the diagnostic process usually comes from concerns about performance in school.”

This situation is problematic in the face of school funding shortages, Pressman says. “In Rhode Island, we are seeing children in classrooms with 26-27 students. [In past years] when the CDC was putting out its figures, the size of an average classroom was about 22. What we have is an environment that is more difficult for the teacher and the child from an educational standpoint and for which there is much less tolerance for certain kinds of behavior. What results in many cases is a request for examination of the child, in regard to ADHD.”

Edward Jacobs, Ph.D., licensed psychologist, of Edward Jacobs & Associates in Londonderry, N.H., says two teachers may have different views on whether a child’s attention is “normal.”

“Attention, like any human trait, exists on a continuum,” Jacobs says. At what point does ‘normal’ end? That point is arbitrary. It’s a judgment call.”

Jacobs says the educational environment hasn’t adapted and is incompatible with children. “Children are growing up with more fast-paced stimulation – the Internet, video games, media – that delivers immediately response and reinforcement for your interaction,” Jacobs says. “And you have an educational system that is stuck in how it was 100 years ago.”

“The most common refrain I hear from kids is school is boring,” Jacobs says. “I think kids love to learn naturally and they need to be engaged. You’ve got to have an activated nervous system. The educational system has to do its job and activate the brain.”

Because the educational system has not kept pace, more children are not meeting the demands placed on them in that environment, Jacobs says. “If you have a different environment for some of these kids, they won’t show signs of ADHD.”

Additionally, many children are being diagnosed without a comprehensive examination. “I have a lot of people come to me to say my child was diagnosed with ADHD, but they had a 15-minute interview,” Jacobs adds. “We are seeing children present with mild symptoms that are not meeting the threshold of what would warrant the diagnosis.”

For treatment, Jacobs says that while medication is an acceptable path, it’s not a magic pill. “I think you should also take responsibility in learning ways to manage your attention,” Jacobs says. He’s had success with neurofeedback training.

Pressman says children can be helped by modifications to their daily routine. In his study, “Relationship of children’s daytime behavior problems with bedtime routines/practices: A family context and the consideration of faux-ADHD” he demonstrated a correlation between co-sleeping/irregular bedtimes and ADHD. He recommends that mental health professionals scrutinize a child’s routines at home, particularly those that involve bedtime, before making an ADHD diagnosis.

By Pamela Berard

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