Between fall 2011 and spring 2012, record numbers of Americans went to their pharmacies to fill prescriptions for Adderall, Ritalin and other stimulants, primarily to treat attention-deficit/hyperactivity disorder (ADHD), only to find the medications were sold out. Several factors contributed to the shortage, but the main reason was that demand had outpaced supply.
The U.S. Drug Enforcement Agency reviewed and subsequently raised the quota for production of stimulants, but this shortage illustrates just how much ADHD diagnoses have ballooned over the past decade. In 2003, 7.8 percent of 4- to 17-year-olds had received a diagnosis of ADHD, according to data from the National Survey of Children's Health, sponsored by the Centers for Disease Control and Prevention.
By 2007, that number had jumped to 9.5 percent, an increase of 22 percent. In 2011, 11 percent of school-age children overall — including nearly one in five high-school-age boys in the United States — had received an ADHD diagnosis (Journal of the American Academy of Child & Adolescent Psychiatry, January).
The CDC also found that over two-thirds of children and teens who have been diagnosed with ADHD take medication for it.
What exactly is leading to the growing number of new ADHD diagnoses? Is there a true increase in the disorder — or are we simply expanding our definition of it, or are more aware of it? And why is the chance of receiving an ADHD diagnosis twice as high in Southern states as in Western states?
In their book "The ADHD Explosion: Myths, Medication, Money, and Today's Push for Performance," (2014, Oxford University Press), University of California, Berkeley, psychologist Stephen Hinshaw, PhD, and health economist Richard Scheffler, PhD, explore how education policies and the nation's increasing push for academic and job performance factor into the rise in diagnoses — and how psychologists can help distinguish ADHD from other mental health conditions.
Is this increase in ADHD diagnoses really warranted?
Hinshaw: The hard part is that ADHD is just like depression, just like autism, just like schizophrenia in that it's a symptom-based mental disorder. We don't have a blood test or a brain scan yet that's definitive. I believe that ADHD is a real condition, but it's on a spectrum, just the way that high blood pressure and autism are. It's always a bit arbitrary as to who is actually above the cut and who is below because we don't know exactly where the cut is.
Hinshaw: In analyzing the CDC data, it's hard to miss the alarming differences regionally and state by state. The South has much higher rates of diagnosis of ADHD than the West and other regions, and this was a puzzle for us.
Hinshaw: The hard part is that ADHD is just like depression, just like autism, just like schizophrenia in that it's a symptom-based mental disorder. We don't have a blood test or a brain scan yet that's definitive. I believe that ADHD is a real condition, but it's on a spectrum, just the way that high blood pressure and autism are. It's always a bit arbitrary as to who is actually above the cut and who is below because we don't know exactly where the cut is.
How did you evaluate the varying state and regional rates of ADHD diagnoses?
Hinshaw: In analyzing the CDC data, it's hard to miss the alarming differences regionally and state by state. The South has much higher rates of diagnosis of ADHD than the West and other regions, and this was a puzzle for us.
So we went on to look at several potential factors and used North Carolina and California as our comparison states. First, we looked at who lives in these states. We thought maybe there was more of a certain racial or ethnic group in one state or the other that might explain it. For example, there are more Hispanics in California than in North Carolina, and traditionally, Hispanics have had the lowest rates of ADHD diagnosis out of any ethnic group. So we equalized the states demographically, and when you do that, it reduces this discrepancy between North Carolina and California a little bit, but not much. There are still twice as many kids diagnosed with ADHD in North Carolina as in California.
Then we thought, well, maybe it's medical practice. We know from other studies that if you have more pediatricians or child psychiatrists in a given region, you might get more diagnoses there. We also thought younger clinicians might be more educated about ADHD and be more likely to diagnose it. So, we looked at all the possible configurations of medical practitioners, but it didn't explain any of the regional differences.
Now we're scratching our heads. We decided to look at the culture of the state. We thought maybe there's a culture of honor in the South or maybe there's rugged individualism out West, or perhaps different standards in the classroom for behavior. But once we started to look at this, we figured out that politics and culture might explain very local variations within a state, but they don't explain the state differences overall.
Scheffler: Finally, we decided to look outside of psychology and outside of the health-care system because inside it, we couldn't explain the discrepancies. [What we are surmising] is that policy had an indirect influence over these diagnoses. We found that during the late 1980s and throughout the 1990s, several states passed consequential accountability laws, which basically changed the philosophy of schools: Instead of funding schools based on the number of students in them, funding became based on their students' standardized math and reading test scores. Schools were rewarded for doing better. At the same time, standardized test scores in the South were the lowest in the nation — and as a result, these states didn't get as much funding.
That's when we knew we were onto something, because if you want to improve test scores, one way of doing that is to have children diagnosed so you can get extra money from the school district to help tutor them or put them in smaller classes. Basically, you diagnose these kids because improving their performance helps the school's performance.
Some states even allowed you to take students diagnosed with ADHD out of the pool that was used to judge your school, with the understanding that these kids probably perform lower, and if you have more of them, that shouldn't be held against you.
What, specifically, did you find out about the effect of these education policies?
Hinshaw: Thirty states, including all of the Southern states, passed these accountability laws before the No Child Left Behind Act — which, like the state consequential accountability laws, sets standards and establishes measurable goals in an effort to improve education outcomes for students — went into effect in 2002, so we were able to compare those 30 states to the other 20 before and after it became federal law to have consequential accountability.
What we found was that standards-based education reform had likely played a large role in the nation's huge increase in ADHD diagnoses. Between 2003 and 2007, in those 20 states that didn't get consequential accountability until No Child Left Behind was implemented, we found a 59 percent increase in ADHD diagnoses among children who were within 200 percent of the federal poverty limit — so among the poorest kids in the state. Among middle- or upper-class kids in those states, there was only a 3 percent increase in ADHD diagnosis. That's a huge and statistically significant difference. But in states that had already passed the accountability laws before No Child Left Behind, rates of ADHD diagnosis only went up 20 percent, which is pretty much the national average, and there was no difference between poor and rich kids. Are we saying that consequential accountability is the cause? No. But there's a really strong association, and it's almost a smoking gun that when test scores really, really count in the public schools, for the poorest kids in a state, ADHD diagnoses go up dramatically shortly thereafter.
What's the sum total of this? School policies really seem to matter, in a way that factors such as ethnicity, medical professionals and culture don't. Can we say they're the absolute and only cause of these state and regional differences? No, but they sure seem to be implicated.
What are some of the dangers of this rise in ADHD diagnoses and the use of medication treatment?
Hinshaw: There's some evidence that if you get diagnosed with ADHD and treated with medication, medicine doesn't just make you sit stiller, it might actually boost test scores. This isn't a bad thing; I'm all for giving it to the kids who really do need it. However, the catch is, how carefully are we making these diagnoses? The average assessment for ADHD is a 10-minute office visit, especially for children on Medicaid.
In addition, while stimulants are usually safe and have relatively manageable side effects if monitored carefully by a knowledgeable professional, they can suppress appetite and interfere with sleep. Other potential side effects are cardiovascular — stimulants have a tendency to raise heart rate and blood pressure slightly. Some evidence also suggests that several years of consistent medication may reduce ultimate adult height by half an inch to an inch. There's also the whole issue of the use of medications for ADHD for people without ADHD. High rates of college students are taking stimulants, without any sign of having ADHD, and the short story is that stimulants are not as beneficial for cognitive performance for the general population as most people think. In those without ADHD, they may help you stay up later, but they don't really increase memory or learning. Importantly, if you don't have ADHD and you're taking these medicines as performance enhancers, there is also a much stronger chance you'll get addicted to the medication, and there are serious consequences of stimulant abuse. So it's another reason to take the diagnosis very seriously and not just dispense the pills if there's any small complaint of poor attention or poor concentration, because it can lead to serious trouble clinically.
Then we thought, well, maybe it's medical practice. We know from other studies that if you have more pediatricians or child psychiatrists in a given region, you might get more diagnoses there. We also thought younger clinicians might be more educated about ADHD and be more likely to diagnose it. So, we looked at all the possible configurations of medical practitioners, but it didn't explain any of the regional differences.
Now we're scratching our heads. We decided to look at the culture of the state. We thought maybe there's a culture of honor in the South or maybe there's rugged individualism out West, or perhaps different standards in the classroom for behavior. But once we started to look at this, we figured out that politics and culture might explain very local variations within a state, but they don't explain the state differences overall.
Scheffler: Finally, we decided to look outside of psychology and outside of the health-care system because inside it, we couldn't explain the discrepancies. [What we are surmising] is that policy had an indirect influence over these diagnoses. We found that during the late 1980s and throughout the 1990s, several states passed consequential accountability laws, which basically changed the philosophy of schools: Instead of funding schools based on the number of students in them, funding became based on their students' standardized math and reading test scores. Schools were rewarded for doing better. At the same time, standardized test scores in the South were the lowest in the nation — and as a result, these states didn't get as much funding.
That's when we knew we were onto something, because if you want to improve test scores, one way of doing that is to have children diagnosed so you can get extra money from the school district to help tutor them or put them in smaller classes. Basically, you diagnose these kids because improving their performance helps the school's performance.
Some states even allowed you to take students diagnosed with ADHD out of the pool that was used to judge your school, with the understanding that these kids probably perform lower, and if you have more of them, that shouldn't be held against you.
What, specifically, did you find out about the effect of these education policies?
Hinshaw: Thirty states, including all of the Southern states, passed these accountability laws before the No Child Left Behind Act — which, like the state consequential accountability laws, sets standards and establishes measurable goals in an effort to improve education outcomes for students — went into effect in 2002, so we were able to compare those 30 states to the other 20 before and after it became federal law to have consequential accountability.
What we found was that standards-based education reform had likely played a large role in the nation's huge increase in ADHD diagnoses. Between 2003 and 2007, in those 20 states that didn't get consequential accountability until No Child Left Behind was implemented, we found a 59 percent increase in ADHD diagnoses among children who were within 200 percent of the federal poverty limit — so among the poorest kids in the state. Among middle- or upper-class kids in those states, there was only a 3 percent increase in ADHD diagnosis. That's a huge and statistically significant difference. But in states that had already passed the accountability laws before No Child Left Behind, rates of ADHD diagnosis only went up 20 percent, which is pretty much the national average, and there was no difference between poor and rich kids. Are we saying that consequential accountability is the cause? No. But there's a really strong association, and it's almost a smoking gun that when test scores really, really count in the public schools, for the poorest kids in a state, ADHD diagnoses go up dramatically shortly thereafter.
What's the sum total of this? School policies really seem to matter, in a way that factors such as ethnicity, medical professionals and culture don't. Can we say they're the absolute and only cause of these state and regional differences? No, but they sure seem to be implicated.
What are some of the dangers of this rise in ADHD diagnoses and the use of medication treatment?
Hinshaw: There's some evidence that if you get diagnosed with ADHD and treated with medication, medicine doesn't just make you sit stiller, it might actually boost test scores. This isn't a bad thing; I'm all for giving it to the kids who really do need it. However, the catch is, how carefully are we making these diagnoses? The average assessment for ADHD is a 10-minute office visit, especially for children on Medicaid.
In addition, while stimulants are usually safe and have relatively manageable side effects if monitored carefully by a knowledgeable professional, they can suppress appetite and interfere with sleep. Other potential side effects are cardiovascular — stimulants have a tendency to raise heart rate and blood pressure slightly. Some evidence also suggests that several years of consistent medication may reduce ultimate adult height by half an inch to an inch. There's also the whole issue of the use of medications for ADHD for people without ADHD. High rates of college students are taking stimulants, without any sign of having ADHD, and the short story is that stimulants are not as beneficial for cognitive performance for the general population as most people think. In those without ADHD, they may help you stay up later, but they don't really increase memory or learning. Importantly, if you don't have ADHD and you're taking these medicines as performance enhancers, there is also a much stronger chance you'll get addicted to the medication, and there are serious consequences of stimulant abuse. So it's another reason to take the diagnosis very seriously and not just dispense the pills if there's any small complaint of poor attention or poor concentration, because it can lead to serious trouble clinically.
What should the standard be, then, for a proper ADHD assessment?
Hinshaw: It has to be at least several hours. You have to get observations from the school or at least ratings from the teacher, normed ratings from parents and a really good developmental history of the child. These are things you can't do in a quick 10-minute office visit. But the national standard is for very quick diagnoses, which will certainly lead to over-diagnoses, because you can mistake all kinds of things for ADHD. But paradoxically, it also leads to under-diagnoses because some doctors will say, "He wasn't tearing up the waiting room," or "She sat very still in the office, so she can't have ADHD." Well, unless you see the child doing homework or when other people are giving directions, you'll miss it.
We also need reimbursement for these thorough assessments so we're not tempted to rule in or rule out ADHD on the basis of very flimsy evidence.
Scheffler: Psychologists also need to understand this academic pressure that happens in the schools, and make their diagnoses carefully because they may be getting kids sent to them due to these pressures.
Psychologists are the gatekeepers, and they have a lot of responsibility to look into this and make sure they take the time to look into the school, societal and parental pressures while doing a careful diagnosis.
In addition, treating the kid without getting the family and the school involved is not optimal. The problem with an ADHD diagnosis is that it's a catchall for lots of things. It's hyperactivity, it's focus, executive function and the like, but usually the best treatment is to also consider involving the family and teachers in behavioral strategies to help improve focus, and to have everyone lined up to deal with this.
Courtesy: APA
Hinshaw: It has to be at least several hours. You have to get observations from the school or at least ratings from the teacher, normed ratings from parents and a really good developmental history of the child. These are things you can't do in a quick 10-minute office visit. But the national standard is for very quick diagnoses, which will certainly lead to over-diagnoses, because you can mistake all kinds of things for ADHD. But paradoxically, it also leads to under-diagnoses because some doctors will say, "He wasn't tearing up the waiting room," or "She sat very still in the office, so she can't have ADHD." Well, unless you see the child doing homework or when other people are giving directions, you'll miss it.
We also need reimbursement for these thorough assessments so we're not tempted to rule in or rule out ADHD on the basis of very flimsy evidence.
Scheffler: Psychologists also need to understand this academic pressure that happens in the schools, and make their diagnoses carefully because they may be getting kids sent to them due to these pressures.
Psychologists are the gatekeepers, and they have a lot of responsibility to look into this and make sure they take the time to look into the school, societal and parental pressures while doing a careful diagnosis.
In addition, treating the kid without getting the family and the school involved is not optimal. The problem with an ADHD diagnosis is that it's a catchall for lots of things. It's hyperactivity, it's focus, executive function and the like, but usually the best treatment is to also consider involving the family and teachers in behavioral strategies to help improve focus, and to have everyone lined up to deal with this.
Courtesy: APA
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