The start of a new school year, and with it the return to a regimented daily structure, can highlight problems such as attention deficit hyperactivity disorder, or ADHD. Many parents are concerned that their child may have the disorder, marked by persistent inattention, hyperactive or impulsive behavior, or both. Those whose kids are diagnosed with ADHD want to make sure they get the best treatment. But as the number of children on medication for ADHD climbs, some experts worry that the disorder is being overdiagnosed and overtreated. To help sort out the complex issue, Berkeley Wellness turned to Stephen Hinshaw, PhD, a professor of psychology at UC Berkeley and co-author (with Richard Scheffler) of The ADHD Explosion: Myths, Medications, Money, and Today’s Push for Performance (Oxford, 2014).
Are you concerned about the rising number of children prescribed medication for ADHD?
My first concern, really, is that many kids are being misdiagnosed with ADHD when they are in fact dealing with other issues. Many, if not most, children get diagnosed after about ten minutes in a pediatrician’s office. But you cannot make an accurate diagnosis that way. Since we don’t have a blood test or other simple way to diagnose ADHD, we depend on accurate detailed reports of symptoms and impairments in a child’s life. Both the American Academy of Pediatrics and the American Academy of Child & Adolescent Psychiatry have excellent evidence-based guidelines for diagnosing ADHD. Parents and teachers have to fill out detailed histories, with information about developmental milestones, early social relationships, language skills, and other items. It takes time to make a correct diagnosis. A cursory diagnosis means some kids are diagnosed with the condition when they don’t have it. And a cursory diagnosis also means some kids who do have ADHD are being missed. Some children can pull it together for ten minutes in a doctor’s office. You need to know what’s going on for them in the classroom, at home, with their friends, doing homework, in all parts of their lives.
Why are so many children being diagnosed with ADHD these days?
All the ads on television and all the publicity certainly cause parents to wonder if their kids have ADHD and need medication. Along with New Zealand, the U.S. is the only country that permits direct-to-consumer ads. And there are other forces at work. When the Individuals with Disabilities Education Act, or IDEA, was reauthorized in the early 1990s, ADHD was added as a diagnosis that could make a child eligible for special education services at school. After that happened, the diagnosed prevalence of ADHD soared by 30 to 40 percent. That doesn’t mean kids were suddenly getting ADHD. It means many more were being diagnosed.
What percentage of those kids are being prescribed medications?
The statistics are interesting. Over the past decade or so, for kids 4 to 17, the diagnosed prevalence has gone up by about 40 percent, giving the U.S. the highest rate of diagnosis of ADHD in the world. In all, more than one in 10 kids under the age of 17 is diagnosed with ADHD. The medication rate, it turns out, has held pretty steady—at about 70 percent of those who receive a diagnosis. So about 7 in 10 kids diagnosed with ADHD takes medication. Because more kids are being diagnosed, there are more kids on medication. But the market for ADHD medications for children has leveled off. That’s not surprising. Seventy percent is already pretty high. And we know that only about three out of four kids have a good response to medication.
Is medication recommended as the first line choice of treatment?
That depends on where you live. In European countries, practice guidelines say medication should be used only if behavioral therapies aren’t enough to help children control the symptoms of ADHD. In many countries, in fact, behavioral therapies are the first line of treatment. Medication is added if they aren’t working adequately. In the U.S., medication is the first line of recommended treatment for kids above preschool age. If that’s not enough, you add behavioral therapy for family support and education.
What’s the right approach? There’s still a lot of controversy. I think it helps to focus on the goal of treatment. If your goal is to reduce the annoying symptoms of fidgeting and impulsivity—calling out in class inappropriately, for example—medication works quickly and effectively for about 80 percent of kids if you use the right medication and the right dosage. But if your goal is to improve reading comprehension, improve math scores, and help kids get along better with their peers and at home, the evidence says a combination of medication and behavioral therapy is much more effective than either treatment alone.
Are there risks associated with ADHD medication?
The most commonly prescribed medications are stimulants. They tend to suppress appetite. And because they are stimulants, they can make it hard for kids to sleep at night. Some of those side effects can be managed by using the right dosage and timing. Unfortunately, too many doctors prescribe a standard dose and say, “Call me in six months.” Prescribing ADHD is a matter of establishing which drug in which dosage works best, often through trial and error. That process can take months. And you have to follow kids closely to monitor how they are doing.
Given so many uncertainties, what advice would you give worried parents?
Look for professionals who have experience treating children with ADHD. Find a psychologist or psychiatrist who has experience doing evidence-based assessments. Find a doctor who is going to closely monitor the medication, if one is prescribed. Find therapists who really know how to work with parents and teachers to create the right environment for kids with ADHD. Check with advocacy groups, if you need more information. The good news is that ADHD is eminently treatable. But it takes time and close attention.
Also see Is ADHD Overdiagnosed?