Is ADHD on the rise? What the numbers really mean

by David Urion, MD, director of the Learning Disabilities/Behavioral Neurology Program at  Children’s Hospital Boston

A recent study showed that one out of every ten children in this country is currently diagnosed as having Attention Deficit Hyperactivity Disorder (ADHD).

That’s an astonishing number.

The study, done by the National Institutes of Health, also showed that the number of children diagnosed with ADHD has been on the rise steadily since the mid-1980s, and that the number of children being treated with stimulant medication (such as Ritalin or Adderall) has been increasing over this same period.

We could discuss whether this is a good thing or a bad thing, and you could pick your favorite social evil to explain this apparent rise in ADHD. We could point to how sound bites have replaced intelligent discussion on TV.  Or blame MTV, or ESPN’s plays of the week. Or all the technology that we grownups can’t use, but our offspring can. (In my case, that gives me a large number of choices). We can complain that the vast amount of information with which we are bombarded every day has made us all incapable of just sitting and listening. We can all be cranky about something, and say that is the cause of this increase in ADHD.

But in doing that, we might miss some very important pieces of information in this report.

David Urion, MD

Nearly sixty years of research shows that when you actually examine children, the percentage who have ADHD is fairly stable. Studies in the 1950s came up with numbers between 5 and 7 ½ percent and studies in the early 2000s came up with the same numbers. This current study didn’t examine children, but rather asked families if their children had been diagnosed with ADHD. That is the number that has been on the rise.

Maybe there really are more kids with ADHD. Maybe providers are getting better at diagnosing the condition, or their awareness of the condition has increased. But maybe, since the number diagnosed has overshot the number most of us think is actually out there, some children have been diagnosed incorrectly. Perhaps as much as a quarter of those who are said to have ADHD have something else.

The study suggests that less care is being taken in making the diagnosis, which isn’t surprising given the pressures on providers to see more patients in less time. It’s hard to be thoughtful, or much of anything else, in an encounter that is forced to be 12 minutes by productivity demands.

The study shows that there are variations in the number of diagnoses, and in the number of children prescribed stimulant medication, according to where children live (more in the East, less in the West), their gender (boys three times more often than girls), and, more worrisome, their ethnicity (Caucasians more likely than African-Americans or Latinos). Since all the evidence we have suggests that ADHD is a biological disorder that is equally present in all ethnic groups and both genders, we shouldn’t see these variations if children are being properly diagnosed.

To me, ADHD is a sort of sentinel. As a common disorder that is not that hard to diagnose but which does require some time and thought on the part of the provider, the variations in its diagnosis point to disparities in pediatric health care in this country.

Underdiagnosing or overdiagnosing based on where [a patient lives] or who they are, suggest that not everyone has equal access to good care. This is hardly a secret, and we should be ashamed of it.

Underdiagnosing or overdiagnosing based on where they live or who they are, suggest that not everyone has equal access to good care. This is hardly a secret, and we should be ashamed of it.

Misdiagnosed ADHD is not like a missed diagnosis of cancer or heart disease. It is not likely to kill a child. But it is either ignoring something else causing school problems, and sweeping it under the rug with a prescription, or it is a child who fails at school because he can’t pay attention. And school failure has dire consequences, especially in a bad economy.

I look at this study like urban planners looked at unplowed streets, or broken streetlights that don’t get fixed: not so bad in the small view, but speaking to a breakdown of the larger system. We need to have a system that gets small things right so it can get big things right. Especially when it comes to children, we need a system that is fair, uniform, and just.

Labor activist Joe Hill once said, “Don’t mourn. Organize.”

I think that this study is a call to arms.