ADHD: Good News or Bad?

When a major study finds that the rate of attention deficit/hyperactivity disorder has skyrocketed, with more and more children and teens being given medication to ease its symptoms, debate is sure to follow.

That has pretty much been the response to a survey by the Centers for Disease Control (CDC), which found a 42% increase in the number of reported cases of ADHD since 2003. The study is published in the current Journal of The American Academy of Child & Adolescent Psychiatry.

One in five high school boys received an ADHD diagnosis in 2011.

Not every child diagnosed with ADHD is given medication, but many are, so this rise in reported cases also indicates that a lot of medication is being prescribed to treat this condition.

So is this a problem or a positive development? Are too many children receiving a psychiatric diagnosis just for being kids, or are children who need help and support to succeed finally getting the medical and educational attention they need?

Attention deficit disorder (ADD) and attention deficit hyperactivity disorder (ADHD) are neurodevelopmental disorders that typically start in childhood and often continue into adulthood.

The primary symptoms are inattention and impulsivity, and in the case of ADHD, hyperactivity. Children with ADHD find it difficult to focus on any one thing for long, even play. They find it impossible to sit still and listen for any length of time. They may talk incessantly, blurt out in class, and be unable to wait their turn.

An ADHD diagnosis is most accurately reached after a thorough clinical evaluation that includes information from many sources including teachers, parents, and doctors, as well as the children themselves.

Because of this impulsiveness and volatility, children with ADHD have trouble functioning at home, school, and in social settings with their peers. They tend to have more injuries than non-affected peers, more emergency room visits, and higher rates of academic failure. Adults often have trouble keeping a job and difficulty with social relationships.

The precise causes of ADHD are not known, but multiple factors are suspected, including genetic predisposition, environmental exposures, brain injuries, some abnormalities or exposures (such as smoking and drugs) during pregnancy and delivery, diet, among others.

The American Psychiatric Association in its Diagnostic and Statistical Manual of Mental Disorders (DSM-5) estimated that 5% of children have ADHD. The increase found in the CDC study put the prevalence at closer to 11%.

The increase is not quite so extreme as it may seem, however. Community samples taken in the U.S. have found rates closer to those found by the CDC.

There is currently no single test, imaging study, or laboratory test to diagnose ADHD. The diagnosis is most accurately reached after a thorough clinical evaluation that includes information from many sources including teachers, parents, and doctors, as well as the children themselves. The child's behavior and ability to function is examined in several settings including home, school, and childcare before a diagnosis is reached.

Attention deficit hyperactivity disorder can be effectively treated with medications, most often stimulant medications such as methylphenidate and amphetamine (for example, Adderall, Concerta, Strattera, and Ritalin).

Behavioral interventions can also teach children and adults the skills they need to function better, but because of cost, lack of availability, and the concern that these therapies are not proven to be effective, they are used less commonly than medication.

Researchers at the CDC compared the data on the Incidence and Prevalence of ADHD and medication treatment of patients from 2011 to data from 2003 and 2007. They used information from phone interviews of parents regarding the health status of their children made for the National Survey of Children’s Health.

They asked the parents whether they had ever been told by a health care provider that their child had ADHD, whether the child currently had ADHD, and if so, whether the symptoms were mild, moderate or severe, and were they currently being treated with medications.

In 2011, a million more children were taking ADHD medication compared to 2003.

Their results confirmed that the number of children and teens diagnosed with ADHD has been increasing steadily, by about 5% a year since 2003. In 2003, 7.8 % of US children carried the diagnosis, in 2007 it had increased to 9.5%; and in 2011 the total was 11.0%.

The percentage of children with ADHD between ages four and 17 increased by 42% from 2003 to 2011 — an increase of 2 million children.

Put another way, 6.4 million of U.S. school-aged children had received an ADHD diagnosis by a health care provider by 2011.

The number of children being treated with medication for ADHD also increased steadily, by about 7% a year since 2003. In 2011, a million more children were taking ADHD medication compared to 2003.

As alarming as this increase may seem, however, large numbers of children diagnosed with ADHD (17.5%) are not receiving medication or counseling for their condition. This represents a major treatment gap for a significant number of affected children and teens.

The researchers offer a number of explanations for the increase in diagnoses. One is that increased health education and awareness efforts mean there is better detection of ADHD.

Non-psychiatric clinicians such as primary care providers have become more confident about diagnosing and treating mental health conditions such as ADHD and the diagnosis is being made more often by family medicine, pediatric, and general practice offices where more people have access to care.

Another factor may be increased exposure of developing fetuses and babies to toxins, many of which have been associated with ADHD. These include illicit drugs, cigarette smoke, and environmental pollutants.

Medication helps a person be receptive to learning new skills and behaviors, those skills and behaviors don’t magically appear. They have to be taught.

Stimulant medication has been considered to be the cornerstone of ADHD treatment and the researchers contend that patients and families are often eager to try it and willing to continue using stimulants because they work so well. Although the medications are generally considered safe for most patients, their long-term effects have not been well studied.

The rise in diagnosis and treatment among high school students raises another issue. The CDC study found that, “Nearly 1 in 5 high school boys and 1 in 11 high school girls had been diagnosed with ADHD...and 69% of these children and adolescents (6.1% nationwide) were taking medication for ADHD.”

Students — and their parents — may be using the diagnosis to obtain drugs believed to improve academic performance. As the study notes, “Attention to the transitional needs of the large population of high school students taking medication for ADHD (6.4%) may be warranted, particularly given increasing concerns about abuse, misuse, and diversion of medication to others.”

An editorial in the same issue of the Journal of the American Academy of Child & Adolescent Psychiatry, however, sees it somewhat differently. “The CDC's report of a 42% increase in diagnosis in less than a decade and a 28% increase in treatment in 4 years sounds shocking. However, when considering the similarity between the current diagnostic and treatment rates and community-based prevalence rates, the issue is much more clear — the CDC data suggest that we are getting to a point when children with ADHD in the United States may actually be getting an opportunity for a diagnostic assessment and appropriate evidence-based treatment.”

In their view, the increase in diagnoses is evidence that the public health campaign to improve the recognition and treatment of ADHD in the U.S. is paying off.

Shortly after the CDC study was published, the New York Times looked back at a landmark 1999 study that determined that medication alone, compared to medication plus behavioral therapy, was the optimum treatment for ADHD and likely contributed to rise in diagnosis and medical treatment seen today.

The authors of that study have reassessed their conclusions. They believe they may have undervalued the contribution home- and school-based behavioral therapy can make in the overall treatment of ADHD. Their study was designed to test the impact of treatments on impulsivity and inattention. It did not investigate the longer-term academic and social skills that are typically targeted by behavioral therapies.

Papers published since then, as well as further research on the subjects in the original 1999 study, have cast doubt on the conclusion that drugs alone are best. Based on this new information and long-term follow up, several of the investigators have expressed regret that their study may have steered parents and educators away from behavioral therapy and encouraged them to embrace drugs as the best treatment for ADHD.

“There was lost opportunity to give kids the advantage of both and develop more resources in schools to support the child — that value was dismissed, ” Dr. Gene Arnold, one of the principal researchers on the study and a child psychiatrist and professor at Ohio State University and told the Times.

“Medication helps a person be receptive to learning new skills and behaviors,” said Ruth Hughes, a psychologist and the chief executive of the advocacy group Children and Adults With Attention-Deficit/Hyperactivity Disorder said in the same article. “But those skills and behaviors don’t magically appear. They have to be taught.”

ADHD is a real disorder. It is a very common, often highly impairing condition which starts in childhood and may persist into adulthood. The increase in its diagnosis is likely both a hopeful sign that children who cannot pay attention, who cannot sit still for even short periods of time, and who suffer socially from these difficulties are finally getting some help; and at the same time it may be a signal that the diagnosis is sometimes misused.

Parents and educators may be tempted to give unruly children a pill rather than structure classroom time with enough recess and time off task to help young children who simply have trouble focusing for extended periods. Similarly, parents of high school students who are having trouble getting their work done may be turning to an ADHD diagnosis to obtain stimulant drugs in hopes of improving test scores and grades.

Children with ADHD are likely to benefit most from treatment that takes a holistic approach that includes addressing a child’s behaviors and strategies at home and school rather than simply focusing on medicating the core symptoms of inattention and impulsive behavior.