So says a report just out in Clinical Pediatrics, using data from the major US National Ambulatory Medical Care Survey (NAMCS). The rate of office based visits (i.e. visits when a doctor saw or treated a patient, outside of a hospital) was the main outcome measure. The authors looked at the number of visits reporting a diagnosis of ADHD, and also the number of ADHD visits also involving psychostimulant medication, for kids aged 5 to 18.
See above - that's a big increase, and a lot of visits (remember the Y axis is visits per 1000 children per year.) One thing to remember is that the increase might not mean that there are more patients with ADHD - it could reflect more visits per patient, but that seems unlikely to account for all of it.
A few thoughts -
The rise of ADHD parallels the recent increase in autism diagnoses. Yet people don't seem to be talking about it to the same extent. We're always hearing about "the autism epidemic", the "Age of Autism". Why aren't we equally concerned about the ADHD 'epidemic'? Why don't we have minor celebs railing about vaccine-damaged ADHD children?
Next - like autism - it seems likely that much or all of the increase is due to changes in awareness and willingness to diagnose the disorder. If so, logically, ADHD must either be being seriously overdiagnosed now, or was being seriously underdiagnosed previously. Or both.
This is especially true of boys. Rates in girls rose pretty much steadily for 15 years but in boys, there have been swings up and down, although the overall trend is still upward. It's always possible that this is a quirk of the NAMCS dataset, but if not, it suggests that ADHD diagnosis in boys is especially prone to changes in diagnostic fashion.
It's tempting, actually, to see the recent fall in boys with ADHD as a consequence of the rise of autism diagnoses over the same period. Autism is predominantly diagnosed in boys and the two disorders are often comorbid.
Maybe, boys are now getting autism diagnoses which are then felt to explain their behaviour, meaning that they don't "need" an ADHD diagnosis, which previously they would have got. But that's just my speculation, and it's probably reading too much into the data, because there was also a peak in 1994 which I can't see any explanation for.
Sclar DA, Robison LM, Bowen KA, Schmidt JM, Castillo LV, and Oganov AM (2012). Attention-Deficit/Hyperactivity Disorder Among Children and Adolescents in the United States: Trend in Diagnosis and Use of Pharmacotherapy by Gender. Clinical pediatrics PMID: 22399571
21 comments:
I'm reluctant to look like I'm jumping on any antimedication/antiADHD bandwagon. The problem does exist, and many do seem to be helped by meds. But fashions in diagnosis like these do not happen by themselves. It would be intriguing to see the annual budget for ADHD drug "detailing" mapped onto the graph on the post to see if it matches - or predicts - the increases and decreases in diagnosis and treatment.
I have a daughter who is now thirty,we called her a "bottle bum" she couldn't sit still and couldn't concentrate for more than a few minutes at a time,she now has an adult diagnosis of ADHD.....our medicine was keeping her life busy and well structured,she didn't have time for the often destructive behaviours these young people often show.
"It's tempting, actually, to see the recent fall in boys with ADHD as a consequence of the rise of autism diagnoses over the same period. Autism is predominantly diagnosed in boys and the two disorders are often comorbid."
Actually, comorbidity means they have both, so an increase in autism diagnoses with comorbidity would mean more ADHD diagnoses.
I have to say has definitely been a time where we have talked about the rise in ADHD. I remember a few years ago, you couldn't view some popular news outlet without hearing about 'the overmedicated kid'.
Anyway, huge factor of treatment of behavioral disorders has to do with societal beliefs. We discriminate against those with mental illness or other 'invisble' disorders in ways we don't for such overt issues like paralysis or cancer. I would bet that part of the huge rise in medical treatment has to do with a lessening of the stigma associated with ADHD. People are (seemingly) starting to recognize more readily that these are real issues, not some made-up problem. That the child is not just a trouble-maker, but has a true biochemical difference that can be treated, even if that difference isn't fully understood.
If you, like I have, have ever worked with a child with ADHD and see them both on and off their meds, it's easy to understand the huge increase in their use.
"[T]he child... has a true biochemical difference that can be treated, even if that difference isn't fully understood."
No such biochemical difference has been detected. For mental illness generally, the chemical imbalance hypothesis has never been validated.
So perhaps it is more proper to say that the difference isn't understood period, without the qualifier 'fully'
Rob, you're right, of course. I was thinking faster than I was typing! I really meant 'neurological or biochemical' in that there is definitely a difference in something, just where and in what is not yet known. (though I really believe that neural networks will become more important in our understanding, and that focus will eventually fade on specific areas of the brain correlating with these 'behavioral disorders', as there currently seems to be)
EJC: Right. What I mean though is that suppose there are boys who could get a diagnosis of both autism and ADHD; if they get a diagnosis of autism first, their parents / doctors might then be less likely to consider ADHD.
In adult services there is definitely a massive increase in the numbers of both those 'graduating' from child and adolescent services with a diagnosis of ADHD at 18yrs and adults with new diagnoses of ADHD (often from private psychiatrists).
This is partly due to DSM insistence that you can't Dx ADHD with Autism (I don't have time or energy at the moment to get into the myriad problems of DSM for neurodevelopmental disorders and associated co-morbidities; those interested can look at my and Len Koziol's book "Subcortical Structures and Cognition")
Nevertheless, many clinicians continue to treat ADHD symptoms with or without the formal Dx.
1. ASD and ADHD are both 'diagnosed' on the basis of behaviour.
2. Behaviour has multiple interacting causes; genetic, epigenetic, environmental and previous behaviour.
3. The combination of awareness of ASD and ADHD as 'diagnoses' and a whole host of possible contributory causes such as viral infections, diet, environmental pollution, societal expecations of normal behaviour etc etc could have led to these 'epidemics'.
4. It is highly likely that ASD and ADHD each have a range of possible causes across individuals.
5. If some people's ADHD characteristics are caused by low dopamine levels, then it's hardly surprising that those characteristics might be ameliorated by a dopamine agonist. It doesn't follow that everyone's ADHD characteristics will be caused by dopamine issues, nor that medication, per se, is a good or bad thing.
@Neuroskeptic:
"This is especially true of boys. Rates in girls rose pretty much steadily for 15 years but in boys, there have been swings up and down, although the overall trend is still upward. It's always possible that this is a quirk of the NAMCS dataset, but if not, it suggests that ADHD diagnosis in boys is especially prone to changes in diagnostic fashion."
Not that I necessarily disagree with you, but it is possible that the reverse of this could be true. That is, the diagnosis of boys is consistent with ADHD itself showing a fluctuating trend, and the rates in girls only appear to be consistent because they are less likely to be diagnosed with ADHD. We know that there is an underdiagnosis problem with girls in this area, and it's mainly because in classrooms teachers are more focused on the boys - regardless of actual disruption caused by either gender.
So in the boys we could see the fluctuations because they are natural patterns of borderline cases being accepted or rejected, whereas with girls these borderline cases aren't even noticed, and only the most serious, and consistent, cases of ADHD in girls are diagnosed.
Mike: You're right, that's possible. But I find it pretty implausible that rates of ADHD (or any non-infectious disease) would go up-down-up-down so much over so short a period.
@Neuroskeptic: True, I didn't quite word what I meant very well there. I meant more that the edges of what is and is not ADHD can be a bit fuzzy, so when you have a larger sample of possible cases, you'll include more of these borderline cases. The fluctuation then could be a case of a number of variables entirely unrelated to changes in diagnostic criteria (like changes in educational policies, characters in popular media, etc), and these fluctuations might not be present in girls just because less of them are getting caught in the net.
Just a thought.
Oh OK, I see what you mean. Yes, good point.
I'm wondering too, how many of these children were rigorously assessed for psychiatric disorders and/or cognitive issues versus a 15-minute doctor visit and the litmus test of stimulant medications.
Note that to the extent that there are trendlines, they aren't necessarily due to differences in diagnostic criteria used by psychologists or M.D.'s.
You don't pay a professional to assess a child unless you conceptualize what is going on with a child as a professionally treatable condition. If public awareness (which ebbs and flows) rises, more people take kids in to see if that diagnosis is appropriate, if public awareness wanes, few kids end up in a professional's office. This part of the process towards an ADHD diagnosis is almost completely divorced from what happens once the kid ends up in the office.
Also, the way that teachers run their classrooms, for example, is not independent of the diagnostic criteria. An ADHD diagnosis requires a finding that there is "impairment" and borderline ADHD might be an impairment in some kinds of classrooms with certain expectations, and not in another.
This said, Sue Gerrad's statement about diagnosis of ASD and ADHD being purely based on behavior which can have lots of causes, which technically true, can be overstated. One of the clinical skills that diagnostic professionals bring to the table is a shared understanding of what the DSM is trying to get at for which the official criteria are really just reminders and cues to something deeper than can be observed in a clinical setting e.g. official criteria are utterly opaque when it comes to how intense a behavior must be to count under a criterion) and part of the shared understanding is that the condition is not some transitory thing but fits the gestalt profile of individuals who have long term stable conditions that fit the type. Causes like viral infection, diet, classroom expectations, etc. are generally alternatives that diagnostic professionals seek to rule out.
Also, drug treatment for psychiatric conditions generally is very much a hit and miss, trial and error affair. There are a few guidelines on where to start, but most of what psychiatrists in office practices do is regularly tinker with the meds of regular patients, only now and then making a new diagnosis. This willingness of psychiatrists to do this kind of tinkering over a wide range of conditions reflects an implicit acknowledgement that the mechanisms of the conditions they diagnosis people with may vary. And, of course, the industry standard treatment, for example, for ADHD, is a "drugs plus" set of treatment prescriptions, not a "drugs only" prescription.
New autism diagnostic criteria may encourage symptomatic approach to drug use said a Financial Journal
and I think many people will understand the link with the subject of that NS post
http://www.ft.com/cms/s/2/909caabe-6ed1-11e1-a
-those finance people are bright and they may have understood before some British academics that lack of morals in treating autism is a good thing for Big pharma but up to a point and not under an obama administration...
The gremlins in my computer have been messing up with the link I entended to give you:
http://www.ft.com/intl/cms/s/2/909caabe-6ed1-11e1-afb8-00144feab49a.html#axzz1pYltNNYI
Other new services are beginning to report on this-
http://www.medicalnewstoday.com/releases/243118.php
I feel like many doctors are misdiagnosing ADHD symptoms and "cures". By 14 or so, a child with ADHD has most likely developed coping mechanisms for their ADHD and would not need medicine to help them focus. Children younger than 14 would benefit from medicine though because they have not found ways to cope.
I find it interesting that more boys are diagnosed with ADHD than girls. Since ADHD is diagnosed only by observed behavior, I would assume there is a great margin of error for misdiagnosis. The diagnosis for boys has also fluctuated throughout the years which adds to the margin of error theory.
Also, ADHD is often diagnosed with autism. This seems illogical to me because both are diagnosed with only observed behavior. Also autusim deals with an overload of sensory perceptions while ADHD deals with the need of sensory perceptions in order to function normally.
I couldn't get access to the full text version so I might be wondering about things the authors already addressed.
I wonder about the contribution of combination of the radical change in US schooling since 2001 (the No Child Left Behind Act) which has shifted the educational focus to performing well on standardized tests & demanding that kindergarten* through third grade children perform at developmentally-inappropriate levels with direct-to-consumer marketing of medications specifically for ADHD***.
I also wonder about the influence of what Morrow** et al found:
Boys and girls born in the month before the age cutoff for entry into kindergarten were 30% more likely to be diagnosed with ADHD and 41% more likely to receive a prescription for an ADHD medication than those born in the month after the cutoff, according to Richard Morrow, MA, of the University of British Columbia in Victoria, and colleagues.
*http://earlychildhoodcolorado.org/inc/uploads/Crisis_in_Kindergarten.pdf
**Morrow R, et al "Influence of relative age on diagnosis and treatment of attention-deficit/hyperactivity disorder in children" CMAJ 2012; DOI: 10.1503 /cmaj.111619
***http://jeffreylacasse.squarespace.com/storage/articles/leo%20lacassse%20adhd%20ads.pdf
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