The Centers for Disease Control and Prevention (CDC) reported last year that one in nine kids had received a diagnosis of attention-deficit hyperactivity disorder (ADHD)—a significant increase from the previous decade. The rise also represents a greatly expanded market for the powerful stimulant medications prescribed for ADHD. In a just-published book that is receiving widespread attention, two UC Berkeley professors link the phenomenon to the growing popularity of school-based performance measures in the 1990s and 2000s—an approach that emerged in a number of states across the country and was implemented at the federal level by President George W. Bush in his signature No Child Left Behind legislation.
Publishers Weekly wrote that the book, The ADHD Explosion: Myths, Medication, Money, and Today's Push for Performance (Oxford University Press, 2014), was a “powerful, fact-packed survey [that] is complex, thought-provoking, and urgent." The Wall Street Journal wrote that the authors—Richard Scheffler, Ph.D., professor of health economics and public policy, and Stephen Hinshaw, Ph.D., professor of psychology—“present some striking evidence that the answer lies, at least partly, in changes in educational policy.” We spoke recently with Scheffler to discuss the authors' concerns that the current push for early childhood education could lead to a dramatic spike in ADHD diagnoses in very young kids, an issue they discussed recently in an opinion piece in the New York Times.
What did your research on ADHD uncover?
What we found in general was a relationship between the rates of ADHD diagnoses and the move in the 1990s by many states to change how they budgeted schools—by providing money based on the number of students moving toward performance measures like graduation rates and test scores. And then, in the early 2000s, President Bush made federal dollars subject to the same kind of budgeting for performance. We were able to show that these moves were highly correlated with spikes in various states in the diagnosis of ADHD.
Why did the spikes in ADHD diagnoses occur in school-aged children?
There are two different kinds of mechanisms. The first is the notion that schools are going to be paid based on graduation rates and some kind of achievement tests. This makes a school look for kids who possibly have ADHD, and make sure their parents are aware of it and get them into treatment—with the notion that they would do better in school and that they might do better on test scores. The second mechanism is that certain states and certain school districts allow you to take the ADHD child out of the performance metric, to not count them.
How might changes in early childhood education affect ADHD diagnosis rates?
The push now is to get children into schools as young as four, and rather than being just playgroups, there would actually be a curriculum for the kids, and their performance would be looked at. ADHD is generally diagnosed when kids hit school, because that’s when they have to sit in a seat, do homework and be in a group. If you kick this back from age six to four, the same thing would happen. So we’re concerned about the possibility of a spike in ADHD diagnoses at those earliest ages.
How is ADHD diagnosed?
The diagnosis has to be very carefully done. There’s no blood test, there are no brain scans. It’s a symptom list—do they have trouble focusing, do they squirm and so on. Even if a child potentially has ADHD, the symptoms have to be occurring in different environments—at least two or three, such as at school and at home, and sometimes in a play situation. You can get a bored child acting out in class simply by having a lousy teacher. We see a lot of quick and dirty diagnoses, and that can lead to the labeling and stigmatizing of children who don’t have ADHD, and to them being put on powerful medications.
Is ADHD being overdiagnosed?
ADHD is real—it’s not made up. But it exists on a continuum. There’s no marker or white line that says you’re in the "definite" or "highly likely" group. There’s almost unanimous agreement that five or six percent clearly have enough of these symptoms for an ADHD diagnosis. Then there’s the next group, where the diagnosis is more of a judgment call, and for these kids, behavioral therapy might work. And then there’s a third group, on the borderline. These are the ones we’re worried about being pushed into an inaccurate diagnosis.
We think it’s a good thing that millions of four- and five-year-old kids will be put into preschool education. But we're worried about a spike in ADHD diagnoses. It could be a good development if we accurately diagnose four- and five-year-olds with ADHD and get them into treatment, but this is a group we don’t have a lot of experience diagnosing. So we really need to be cautious as we move forward.