Is there an overdiagnosis of ADHD?

A recent study in Pediatrics found that African American and Hispanic children are less likely to be diagnosed and treated for Attention Deficit Hyperactivity Disorder than white children. It was a very well designed, carefully measured study based on a representative sample of over 15,000 children being followed in a longitudinal study. The problem is these now 20-year-olds, were all born in 1993 and the measurement was of how many were diagnosed between their kindergarten year of 1998 and eighth grade in 2003.  It is a great snapshot, but an old snapshot.

We've now seen diagnostic rates for ADHD rise dramatically in the past 10 years (a 53 percent increase), and the Centers for Disease Control and Prevention estimates that over 11 percent of children are now diagnosed with ADHD. This includes nearly one in five high school age boys who have been diagnosed over the course of their lives by a professional.

It also appears that race or ethnicity no longer predicts how likely a child will be diagnosed with ADHD. Children from low income families who have Medicaid insurance are more likely to be diagnosed, as are children of single mothers. Poverty is now the strongest predictor. The CDC says that the differences between racial and ethnic groups are diminishing. The leadings states for ADHD diagnosis? Alabama, North Carolina, Mississippi.  The lowest numbers are in Wyoming and Utah.

So what is causing the surge of diagnoses?  I would suggest two factors happening at the same time. The first is that many children diagnosed with ADHD have not received an appropriate evaluation. Many are diagnosed by their primary care physician, and research shows that the majority of those physicians do not systematically gather data from home and school, nor do they have the time to fully review the history to rule out other causes.

The most frequent referral recommendation comes from teachers who suggest to parents that they see the doctor.  The doctor then has to evaluate and diagnose in an impossibly short amount of time.  These quick diagnoses and subsequent trials of medicine have increasingly become the norm.  And since all children will respond to a stimulant, response to the drug does not make it a correct diagnosis. This pattern and the ever loosening of the diagnostic criteria for ADHD are leading to increasing numbers of being diagnosed, labeled, and treated.

The second cause is an increasing number of children exposed to environmental risk conditions for ADHD. ADHD is a disorder of poorly developed impulse control, self-control, and focus and attention – areas of function that psychologists call executive functioning. Think of executive functioning as the air traffic control in a child's mind, deciding when to stop, when to start, holding back one impulse while doing something else to completion. Without it, the planes crash. We know how children develop good air traffic control.  It is through having adults, parents in particular, who can help their child manage their emotions, guide them through life's difficulty in the first few years and offer a safe, predictable environment.

Indeed, there are some children who will develop ADHD no matter what is done for them. They are genetically programmed in that direction. This is probably 3 percent of the population. There are others who can develop the needed coping skills.  Early help for parents and families can prevent the development of full fledged ADHD. These kids make up 8 percent of the current 11 percent being diagnosed.  But with the ever increasing numbers of children in poverty and living with stressed single parents, coping with jobs, basic needs and often low quality child care, I am not surprised to see the numbers go up.

With regards to the diagnosis, differences between ethnic and racial groups in diagnosis are on the decline.  What is increasing? Children in poverty receiving an ADHD diagnosis and medication instead of the help that they really need.

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