What is causing the global surge in ADHD diagnoses?

What is causing the global surge in ADHD diagnoses? This article believes it has to do more with marketing than medicine.

You can't catch attention deficit hyperactivity disorder (ADHD). Yet the diagnosis and treatment of this behavioral condition is spreading like a contagion -- surging as much as tenfold in some countries.

Call it an economic and cultural plague, but not necessarily a medical one, says Brandeis professor Peter Conrad. In a recent paper in the journal Social Science and Medicine, Conrad and coauthor Meredith Bergey examined the growth of ADHD in the United Kingdom, Germany, France, Italy and Brazil.

Until recently, North America tallied by far the most ADHD diagnoses, and the United States consumed 90 percent of all Ritalin, one of the most common ADHD drugs. ADHD diagnoses continue to grow in the U.S., but Americans account for only 75 percent of Ritalin users today.

Conrad and Bergey attribute ADHD's growth to five trends. Drug companies are effective lobbyists, and have spurred some countries to relax marketing restrictions on stimulants. Psychoanalytic treatment with talk therapy is giving way to biological psychiatry -- treating psychological problems with drugs. More European and South American psychologists and psychiatrists are adopting the American-based Diagnostic and Statistical Manual (DSM) standards, which are broader and have a lower threshold for diagnosing ADHD. Vocal ADHD advocacy groups work closely with drug companies to promote pharmaceutical treatment. Lastly, the easy availability of ADHD information and self-diagnosis via the Internet empowers consumers to ask for prescription treatment.

Many websites promoting ADHD drugs offer checklists with questions like these:

• Do you fidget a lot?
• Is it hard for you to concentrate?
• Are you disorganized at work and home?
• Do you start projects and then abandon them?

"These checklists turn all kinds of different behaviors into medical problems," Conrad says. "The checklists don't distinguish what is part of the human condition and what is a disease."

According to the study, in the U.K., diagnosis of the disorder in school-age children grew from less than one percent in the 1990s to about five percent today. In Germany, prescription ADHD drugs rose from 10 million daily doses in 1998 to 53 million in 2008.

Growth in Italy and France has been slower, in part due to those countries' more restrictive pharmaceutical drug laws. However, even those nations are becoming more lax, says Conrad. In Brazil, a rising number of ADHD advocacy groups, many with close ties to the pharmaceutical industry, are raising awareness of the disorder.

"There is no pharmacological magic bullet," says Conrad. No drug can account for nonmedical factors that may contribute to behavior. A fidgety student may be responding to the one-size-fits-all compulsory education system, Conrad says, not a flaw in his brain chemistry.

ADHD continues a long history of medicalizing behaviors, especially in the U.S., Conrad says. A century ago, masturbation was considered a disease. Men and women diagnosed with masturbatory insanity were institutionalized or subjected to surgical treatment.

"I think we may look back on this time in 50 years and ask, what did we do to these kids?" Conrad says.

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ADHD diagnosis by involuntary eye movements

A study shows that ADHD can accurately be diagnosed by a person's involuntary eye movements.

Attention Deficit Hyperactivity Disorder (ADHD) is the most commonly diagnosed -- and misdiagnosed -- behavioral disorder in children in America, according to the Centers for Disease Control and Prevention. Unfortunately, there are currently no reliable physiological markers to diagnose ADHD. Doctors generally diagnose the disorder by recording a medical and social history of the patient and the family, discussing possible symptoms and observing the patient's behavior. But an incorrect evaluation can lead to overmedication with Ritalin (methylphenidate), which has parents everywhere concerned.

Now a new study from Tel Aviv University researchers may provide the objective tool medical professionals need to accurately diagnose ADHD. According to the research, published in Vision Research, involuntary eye movements accurately reflect the presence of ADHD, as well as the benefits of medical stimulants that are used to treat the disorder.

Keeping an eye on the eyes

Dr. Moshe Fried, Dr. Anna Sterkin, and Prof. Uri Polat of TAU's Sackler Faculty of Medicine, Dr. Tamara Wygnanski-Jaffe, Dr. Eteri Tsitsiashvili, Dr. Tamir Epstein of the Goldschleger Eye Research Institute at Sheba Medical Center, Tel Hashomer, and Dr. Yoram S. Bonneh of the University of Haifa used an eye-tracking system to monitor the involuntary eye movements of two groups of 22 adults taking an ADHD diagnostic computer test called the Test of Variables of Attention (TOVA). The exercise, which lasted 22 minutes, was repeated twice by each participant. The first group of participants, diagnosed with ADHD, initially took the test un-medicated and then took it again under the influence of methylphenidate. A second group, not diagnosed with ADHD, constituted the control group.

"We had two objectives going into this research," said Dr. Fried, who as an adult was himself diagnosed with ADHD. "The first was to provide a new diagnostic tool for ADHD, and the second was to test whether ADHD medication really works -- and we found that it does. There was a significant difference between the two groups, and between the two sets of tests taken by ADHD participants un-medicated and later medicated."

Foolproof, affordable, and accessible diagnosis

The researchers found a direct correlation between ADHD and the inability to suppress eye movement in the anticipation of visual stimuli. The research also reflected improved performance by participants taking methylphenidate, which normalized the suppression of involuntary eye movements to the average level of the control group.

"This test is affordable and accessible, rendering it a practical and foolproof tool for medical professionals," said Dr. Fried. "With other tests, you can slip up, make 'mistakes' -- intentionally or not. But our test cannot be fooled. Eye movements tracked in this test are involuntary, so they constitute a sound physiological marker of ADHD.

"Our study also reflected that methylphenidate does work. It is certainly not a placebo, as some have suggested."

The researchers are currently conducting more extensive trials on larger control groups to further explore applications of the test.

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MRI may help prevent ADHD misdiagnosis

MRI scans may help prevent potential misdiagnosis of ADHD.

Brain iron levels offer a potential biomarker in the diagnosis of attention deficit hyperactivity disorder (ADHD) and may help physicians and parents make better informed treatment decisions, according to new research published online in the journalRadiology.

ADHD is a common disorder in children and adolescents that can continue into adulthood. Symptoms include hyperactivity and difficulty staying focused, paying attention and controlling behavior. The American Psychiatric Association reports that ADHD affects 3 to 7 percent of school-age children.

Psychostimulant medications such as Ritalin are among the drugs commonly used to reduce ADHD symptoms. Psychostimulants affect levels of dopamine, a neurotransmitter in the brain associated with addiction.

"Much debate and concern has emerged regarding the continual rise of ADHD diagnosis in the U.S. given that two-thirds of those diagnosed receive psychostimulant medications," said Vitria Adisetiyo, Ph.D., postdoctoral research fellow at the Medical University of South Carolina in Charleston, S.C. "We wanted to see if we could identify brain iron as a potential noninvasive biomarker for medication-naïve ADHD to prevent misdiagnosis."

For the study, the research team measured brain iron levels in 22 children and adolescents with ADHD, 12 of whom had never been on medication for their condition (medication naïve), and 27 healthy control children and adolescents using a magnetic resonance imaging (MRI) technique called magnetic field correlation imaging. The technique was introduced in 2006 by study co-authors and faculty members Joseph A. Helpernadhd di, Ph.D., and Jens H. Jensen, Ph.D. No contrast agents were used, and blood iron levels in the body were measured using a blood draw.

The results showed that the 12 ADHD medication-naïve patients had significantly lower brain iron levels than the 10 ADHD patients who had been on psychostimulant medication and the 27 children and adolescents in the control group. In contrast, ADHD patients with a history of psychostimulant medication treatment had brain iron levels comparable to controls, suggesting that brain iron may increase to normal levels with psychostimulant treatment.

"Our research suggests that iron absorption into the brain may be abnormal in ADHD given that atypical brain iron levels are found even when blood iron levels in the body are normal," Dr. Adisetiyo said. "We found no differences in blood iron measures between controls, medication-naïve ADHD patients or pscyhostimulant-medicated ADHD patients."

Magnetic field correlation imaging's ability to noninvasively detect the low iron levels may help improve ADHD diagnosis and guide optimal treatment. Currently, ADHD diagnosis is based only on subjective clinical interviews and questionnaires. Having a biological biomarker may help inform clinical diagnosis, particularly in borderline cases, Dr. Adisetiyo noted.

If the results can be replicated in larger studies, magnetic field correlation might have a future role in determining which patients would benefit from psychostimulants -- an important consideration because the drugs can become addictive if taken inappropriately and lead to abuse of other drugs like cocaine.

"We want the public to know that progress is being made in identifying potential noninvasive biological biomarkers of ADHD which may help to prevent misdiagnosis," Dr. Adisetiyo said. "We are currently testing our findings in a larger cohort to confirm that measuring brain iron levels in ADHD is indeed a reliable and clinically feasible biomarker."

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More boys are diagnosed with ADD and ADHD

This article discusses an apparent gender bias which causes more boys than girls to be diagnosed with ADD and ADHD.

There's a gender bias when it comes to diagnosing Attention Deficit Disorder and Attention Deficit Hyperactivity Disorder.

That's according to the woman who runs the largest ADHD coaching program in North America.

Shanna Pearson, the founder and president of One Focus Total Success Inc., told CFRA it's because the symptoms present more clearly in men.

"It's more noticeable in men, so a lot more of them are actually going to seek a diagnosis or it's just being pointed out to them," she said. "With women a lot of them, it's just going under the wire. They're not being noticed. They're not picking up on it."

Research shows two out of every three women with ADD or ADHD are misdiagnosed by doctors as having depression.

"And it's almost understandable how they would, because a lot of ADHD symptoms, especially for women because it's more on the emotional spectrum, a lot of ADHD symptoms can look like depression," she said.

She said women need to be aware about what is going on for them.

"It's not necessarily that they're just overly emotional or very scattered or absent-minded or some of the other labels that people put on women who are like that," Pearson said.

"It could be that they have ADHD, so I would say that if you're a woman who has more drama in your life than most people you know, if you're somebody who gets overwhelmed very, very easily or you experience a lot of anxiety on a regular basis or you tend to get frozen in your thoughts or overwhelmed and you can't move forward - those types of symptoms, I would say you might want to get a diagnosis," she added.

Pearson said once a person is properly diagnosed by a specialist, they can learn how to better manage the symptoms that come with the disorder.

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CDC claims 1 in 10 children has ADHD

A new poll by the CDC shows that 1 in every 10 children has ADHD. This is higher than the last poll done in 2007 showing ADHD cases are rising.

One in every 10 U.S. children has been diagnosed with attention-deficit/hyperactivity disorder (ADHD), but the steady rise in cases has started to slow, a new government survey shows.

The 2011 poll of more than 95,000 parents showed that about 11 percent -- or about 6.4 million -- of children aged 4 to 17 had been diagnosed with ADHD. That's up from a 2007 survey that found that 9.5 percent of youngsters in that age group had an ADHD diagnoses.

Nearly one in every five high-school age boys, and about one in every 11 high school age girls, was reported by their parents as being diagnosed with having ADHD, the U.S. Centers for Disease Control and Prevention report found.

Numbers also varied widely between states, as well, with 15 percent of children in Arkansas and Kentucky reporting a history of ADHD treatment, compared to just 4 percent of those in Nevada.

The number of children placed on ADHD medications -- which include stimulants such as Ritalin or Concerta -- also rose by about 1 million between 2003-04 and 2011-12, the CDC said. That means that more than 3.5 million youngsters between the ages of 4 and 17 are now taking an ADHD drug.

The survey was published Nov. 22 in the Journal of the American Academy of Child and Adolescent Psychiatry.

According to the survey, half of children with ADHD are diagnosed with the disorder by the age of 6.

"This finding suggests that there are a large number of young children who could benefit from the early initiation of behavioral therapy, which is recommended as the first-line treatment for preschool children with ADHD," study author and CDC researcher Susanna Visser said in a journal news release.

Not every child with ADHD is getting proper treatment, the study found. According to the survey, 18 percent of kids with ADHD had not received either psychiatric counseling or drug therapy during 2011-2012.

"This finding raises concerns about whether these children and their families are receiving needed services," Dr. Michael Lu, senior administrator at the U.S. Health Resources and Service Administration (HRSA), said in the journal news release.

There was some good news from the survey, however. The CDC noted that ADHD diagnoses among American children were rising at a rate of about 6 percent a year in the mid-2000s, but that rate slowed to 4 percent a year from 2007 to 2011.

Visser told the Associated Press that this slower rate of diagnoses might reflect that doctors are closer to identifying most of the youngsters with the disorder.

ADHD makes it difficult for kids to pay attention and control impulsive behaviors. Treatments can include drugs, behavioral therapy or both.

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Sunny climates may reduce ADHD prevalence

A study shows that the prevalence of ADHD may be influenced by sunny climates and amount of sunlight.

Attention-deficit/hyperactivity disorder, or ADHD, is the most common childhood psychiatric disorder. Scientists do not know what causes it, but genetics play a clear role. Other risk factors have also been identified, including premature birth, low birth weight, a mother’s use of alcohol or tobacco during pregnancy, and environmental exposures to toxins like lead.

ADHD is characterized by an inability to focus, poor attention, hyperactivity, and impulsive behavior, and the normal process of brain maturation is delayed in children with ADHD. Many individuals with ADHD also report sleep-related difficulties and disorders. In fact, sleep disorder treatments and chronobiological interventions intended to restore normal circadian rhythms, including light exposure therapy, have been shown to improve ADHD symptoms.

Estimates suggest that the average worldwide prevalence of ADHD ranges from about 5 to 7%, but it also varies greatly by region. A simple visual comparison of data maps released by the U.S. Centers for Disease Control and Prevention and the U.S. Department of Energy that display ADHD prevalence rates by state and solar intensities (sunlight) across the country, respectively, reveals an interesting pattern indicative of an association. So does this mean that there could be an identifiable relationship between ADHD prevalence rates and the sunlight intensity levels of particular regions?

The accumulation of these points led Dr. Martijn Arns and his colleagues to systematically and scientifically investigate this question. They collected and analyzed multiple data-sets from the United States and 9 other countries. Reporting their findings in the current issue of Biological Psychiatry, they did find a relationship between solar intensity and ADHD prevalence.

Even after controlling for factors that are known to be associated with ADHD, both U.S. and non-U.S. regions with high sunlight intensity have a lower prevalence of ADHD, suggesting that high sunlight intensity may exert a ‘protective’ effect for ADHD.

To further validate their work, they also looked at this same relationship with autism and major depressive disorder diagnoses. They found that the findings were specific to ADHD, with no associations observed between the other two disorders.

“The reported association is intriguing, but it raises many questions that have no answers,” commented Dr. John Krystal, Editor of Biological Psychiatry. “Do sunny climates reduce the severity or prevalence of ADHD and if so, how? Do people prone to develop ADHD tend to move away from sunny climates and if so, why?”

As with all scientific research, further work is necessary, including a prospective replication of these findings. It is also important to realize that this data reflects only an association – not a causation – between ADHD and solar intensity levels so worried parents should not start planning cross-country moves.

However, these findings do have significant implications, explains Dr. Arns. “From the public health perspective, manufacturers of tablets, smartphones and PCs could investigate the possibility of time-modulated color-adjustment of screens, to prevent unwanted exposure to blue light in the evening.”

“These results could also point the way to prevention of a sub-group of ADHD, by increasing the exposure to natural light during the day in countries and states with low solar intensity. For example, skylight systems in classrooms and scheduling playtime in line with the biological clock could be explored further.”

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US children more likely to be diagnosed with ADHD than children in the UK

A study shows that 6.3% of children in the US are diagnosed with ADHD while only 1.5% of children in the UK are diagnosed with ADHD.

New research suggests that children are far less likely to be diagnosed with Attention deficit hyperactivity disorder (ADHD) in the UK than they are in the US.

However, the same study, led by the University of Exeter Medical School, suggests that autism diagnosis is still rising.

The study is published online in theJournal of Autism Developmental Disorders, published by Springer, and was supported by the NIHR Collaboration for Leadership in Applied Health Research and Care in the South West Peninsula (NIHR PenCLAHRC).

ADHD is thought to be the most common disorder of childhood. A 2009 study in the USA found that 6.3 per cent of children aged 5-9 were diagnosed with ADHD. In contrast, just 1.5 per cent of parents in the UK reported a diagnosis of ADHD in children aged between 6-8. The team looked at figures from the UK Millennium Cohort Study, which is a sample of more than 19,000 children, representative of the UK population.

Dr Ginny Russell of the University of Exeter Medical School, lead author of the study, said: "Our findings reveal that doctors in the UK are far less likely to deploy the ADHD label than their US counterparts. This difference may be a result of cultural factors. For example, more stringent criteria for diagnosing ADHD are used in the UK, or it may be that parental concerns over using drugs such as Ritalin to treat younger patients mean that they resist diagnosis for their children.

"It is important to identify diagnostic trends and the reasons behind them, as various criteria in different cultural contexts may mean that children are missing out on health services -- the diagnostic label may determine the support families receive," Dr Russell added. "Equally, it is important that children are not over-diagnosed."

The same study shows that autism diagnosis is on the rise. Some I.7 per cent of parents reported that children aged 6-8 had been identified as having an Autism Spectrum Disorder (ASD). " Increasing awareness of autism, the de-stigmatisation of ASD, and diagnosis of children at a younger age may all be contributing towards the label of ASD being used increasingly in the UK," Dr Russell said.

Questions remain over whether the rises in ASD diagnoses reflect 'real' rises in the frequency of the disorders or whether they are due entirely to changing diagnostic criteria and increased awareness. Dr Russell is currently examining data from two UK birth cohort studies to try to help establish whether there has been an increase in symptoms, or simply a rise in reporting and diagnosis. "It is important to establish if there is a real increase in children with symptoms because we can then try to discover the environmental or social factors behind the rise in order to take preventive measures," Dr Russell said.

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Brain wave test to diagnose ADHD approved by FDA

The FDA approved a brain wave test to diagnose ADHD, one of the only objective tests for this purpose.

The first brain wave test that could help diagnose children and teens with attention-deficit/hyperactivity disorder (ADHD) has been approved by the U.S. Food and Drug Administration.

The device can be used in patients between the ages of 6 and 17 as part of a complete psychological examination to either help confirm an ADHD diagnosis or bolster a doctor's decision that more testing for ADHD or other disorders is needed, the FDA said in a news release Monday.

Called the NEBA system, the 20-minute noninvasive test uses an electroencephalogram (EEG) to calculate the ratio of two brain wave frequencies, called theta and beta, which studies have shown is higher in children and teens with ADHD.

One expert offered a word of caution about the device.

"For clinicians and researchers interested in ADHD, an objective diagnostic test that is accurate, sensitive and specific has been one of the 'holy grails' which has long been sought," said Dr. Andrew Adesman, chief of developmental & behavioral pediatrics at Steven & Alexandra Cohen Children's Medical Center of New York, in New Hyde Park, N.Y.

However, he added, "it is doubtful that this EEG test newly approved by the FDA will be as accurate and reliable as clinicians and families would ideally want.

"Given concerns among the public and some professionals about the steady increase in the number of children and adolescents being diagnosed with ADHD, it would be wonderful if clinicians had an objective test to assist in the diagnostic process," Adesman said. "Although this new EEG test may prove helpful to clinicians, neither parents nor professionals will be able to rely upon it as a standalone 'litmus test' for whether a child has ADHD."

Adesman also noted that the FDA has approved other "objective" diagnostic tests for ADHD that have not become a common part of diagnosing the disorder, and the fate of the NEBA system remains to be seen.

The device, made by NEBA Health of Augusta, Ga., is already used to assess sleep issues, measure unconsciousness, diagnose side effects from head injuries and monitor the brain during surgery, according to CBS News.

The FDA's approval of the device was based on a company-funded study of 275 children and teens with attention or behavioral problems. The study showed that the test, when used with standard diagnostic criteria, helped doctors more accurately diagnose the disorder when compared to a doctor's exam alone, the agency said in its statement.

"Diagnosing ADHD is a multistep process based on a complete medical and psychiatric exam," Christy Foreman, director of the Office of Device Evaluation at the FDA's Center for Devices and Radiological Health, said in the news release. "The NEBA System along with other clinical information may help health care providers more accurately determine if ADHD is the cause of a behavioral problem."

ADHD is a common childhood disorder. Nine percent of American teens have ADHD and the average age of diagnosis is 7, according to the American Psychiatric Association. Symptoms of ADHD include inattention, hyperactivity, impulsivity and behavioral problems. Treatments for ADHD include medication, behavioral modifications and therapy.

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Implications of rising number of ADHD diagnoses

Interesting opinion article on the implications of the rising number of diagnoses and medicating of those with ADHD.

Let’s say that rates of ADHD diagnoses among kids in America are continually rising. Let’s say that stimulant medication use — both prescribed by doctors, and as the result of illegal trade with friends —  is on the rise, too. What do we make of that information? What do we do with it? In particular, how do we use it to improve children’s and teenagers’ lives?

The answers speak volumes about where we are as a society and where we ought to be headed.

The default response, every time we get news about any sort of uptick in the diagnosis and treatment of children’s mental disorders, is to issue condemnations of bad parents, bad doctors, bad teachers, and bad schools. (Not to mention big bad pharma, of course, which, it seems, will never rise from the bed of nails it has built for itself  over the years.)

A more thoughtful response would be to ask what the rise means. Are more children with the disorder who previously went unnoticed — girls, African Americans, Latinos, notably — now being identified and counted? We know that’s true, and it accounts for some of the rise. Does the increased social acceptability of the ADHD diagnosis mean that it’s the “label” doctors are most likely to stick on kids who, in addition to distractibility, have a whole host of more scary-sounding problems, in the hope of getting reluctant parents to sign on for some sort of treatment? Does the decreased stigma surrounding ADHD (the commonly-heard, “everyone has it, so it’s no big deal” view) mean that parents who’ve been told their kids have “attention issues” in addition to, say, a learning disability or a mood disorder, will cling to — and report to survey-wielding researchers — just the banal-sounding ADHD label?

And, much more troublingly, are children who don’t have the disorder now being diagnosed and treated for it? And, if so, where is this happening, how is it happening, and why?

The raw, unanalyzed, not-yet-peer-reviewed numbers that the New York Times, bizarrely, led the paper with last week don’t answer any of those questions. And since the CDC won’t verify their accuracy (precisely because they haven’t yet finished processing their own numbers), I’m not going to repeat them here. And I don’t need to. Previous surveys have shown a steady rise in the rate of ADHD diagnoses over the years. Previous research has also raised disturbing questions about the possibility that some children without actual ADHD are now being diagnosed and medicated for it.

But again, that research, for now, hasn’t provided any clear indication of what’s happening with those kids. Another recent CDC study — one of the largest, community-based, epidemiological studies ever conducted on ADHD prevalence — found last fall that that only about one-third of the children taking medication for ADHD met stringent criteria for the disorder . Exactly what that troubling finding means remains a mystery, Susanna Visser, the lead epidemiologist for the Child Development Studies team in the National Center on Birth Defects and Developmental Disabilities at the CDC, and one of the study’s co-authors, told me last week. It may, she said, mean that the medicated children who didn’t meet the study’s ADHD criteria did, in fact, have the disorder, and were having their symptoms controlled so well by meds that they were no longer discernible. Or it could mean that they were just misdiagnosed. “One group may have been appropriately treated and no longer met criteria and one group may have been inappropriately treated,” Visser said. The medicated children, over all, she added, “had a higher symptom count than those who were not medicated and didn’t meet criteria.” Visser’s CDC team is investigating those possibilities right now, and expects answers in the not-too-distant future.

In the meantime, given the paucity of truly meaningful information, we might pause a moment to consider the effect — the actual, lived effect — of our current cultural obsession with ADHD and the stimulants used to treat it. Let’s take, for example, Alan Schwarz’s comment in the New York Times last Monday that “an A.D.H.D. diagnosis often results in a family’s paying for a child’s repeated visits to doctors for assessments or prescription renewals. Taxpayers assume this cost for children covered by Medicaid, who, according to the C.D.C. data, have among the highest rates of A.D.H.D. diagnoses.” Will this lead to a new round of Congressional hearings on the Medicated Child? Will those hearings comprise any real discussion of the toxic stressors of poverty — conditions long-known to contribute to mental health disorders, including ADHD — or, even more unlikely, to policy solutions that could reduce stress for impoverished families? Or will the focus on the pill-popping young poor simply lead to more roadblocks to treatment for a particularly vulnerable group of children — and parents — already deprived of access to good mental health care?

I wonder, too, what will happen to the children who don’t exhibit the most extreme forms of disruptive, socially and academically debilitating, ADHD: the big temper outbursts, the potentially dangerous, running-into-traffic hyperactivity, the bully-bait social cluelessness. I wonder, if, soon, insurers will decide they’re not entitled to treatment (especially the more expensive, non-drug treatments). I wonder if school districts will decide they don’t qualify for accommodations.

Many of us, myself included, worry deeply about the culture in which our children are growing up. We worry about the pressures, the competition and the class sizes, the lack of free time, the cloistered indoor time, the screen time, the stress. And we worry about the extreme measures some kids are using to cope with that stress: whether it’s cutting, or binge-drinking, or abusing stimulant meds. But ADHD isn’t about all that. It’s a developmental disorder — and while it’s true that its precise definition is linked to all sorts of values and understandings unique to our time, it is not a symptom of social pathology. It is a medical condition, not a metaphor.

If we truly care about kids — all kids — we’d do well to keep our stories straight.

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Rise in ADHD Diagnoses Discussed on NPR's Science Friday

During Talk of the Nation on NPR last week, the rise in ADHD diagnosis was discussed. The audio broadcast can be found here.

IRA FLATOW, HOST:

This is SCIENCE FRIDAY, I'm Ira Flatow. Earlier this week, the New York Times reported new CDC data on diagnosis of attention deficit hyperactivity disorder, ADHD, in kids. And the numbers are startling, with 11 percent of the parents surveyed reporting a diagnosis of ADHD for their school-age kids, higher numbers for some sub-groups of age and gender. That's a big jump. Estimates before that had been that ADHD affected somewhere from three to seven percent of children.

So what's behind the surge in numbers? Is the spike real, or is it just a reporting error? And what does that increase in diagnoses mean? Joining us now to talk about it is William Graf, he's a professor of pediatrics and neurology at Yale School of Medicine in New Haven. Welcome to SCIENCE FRIDAY.

WILLIAM GRAF: Hi Ira, thanks for inviting me.

FLATOW: Were you surprised by these numbers?

GRAF: Yeah, these numbers are pretty high, and it is surprising, and I think that on one hand they're sort of real because we've seen this change over the last two decades as the rates have slowly gone up, and on the other hand they're inflated a little bit, probably because of the way they were obtained.

These are - the CDC did a study, which is like polling data. They - it's called the National Representative randomized Cross-sectional Survey. And it's - this particular trial supposedly was done with land line and cell phone telephone surveys of all households who have children.

There was a similar study just published a couple weeks ago that was on autism, which showed the rate of autism was two percent of the population, which is also very high and was discussed just in the same way. But these are epidemiological survey data, and they're worth something. We have other data to show that the numbers are indeed going up.

FLATOW: Give us an idea again what actually ADHD is, real ADHD.

GRAF: Yeah, I think that's one of the points of the discussion. Probably ADHD is three to seven percent of the population, and we're talking about a rise now, but it has an interesting history. It probably dates back 40 or 50 years. It was called, you know, minimal brain damage a long time ago in the '70s.

The Diagnostic and Statistical Manual III, DSM-III, called it ADD with or without hyperactivity. And then the name sort of changed. DSM-IV called it ADHD. DSM-V will change it slightly differently. You have to remember that ADHD overlaps with other minor neurological - relatively minor. They can cause impairment.

And the three classic symptoms are inattentiveness, impulsiveness, hyperactivity, and we can talk about what that is. And that has to lead to impairment. And there's a couple of reasons why this diagnosis would be controversial, and that is because there's no biological marker for it, because the diagnostic criteria are somewhat subjective and because different people will interpret the impairments and the symptoms differently even in the same child.

FLATOW: Could this not be one of the reasons for over-diagnosis, that these are vague ways of diagnosing some of the symptoms.

GRAF: There's probably a lot of social reasons why and environmental reasons why it could be over-diagnosed. There are also these co-morbidities with ADHD. Probably half of the kids have - who really have ADHD have some form of a learning disability. There are different names that are out there like auditory processing disorder, and the latest is something called executive function disorder. That's the most popular right now.

And I can well see that there'll be a shift in ADHD diagnosis to something else, just like the terms for autism have changed in the last 10 years to spectrum disorders and things like that. So you have changes in the names we give, the labels that we give for these conditions.

FLATOW: Is the diagnoses coming from the parents, the doctors, the teachers? Where are we seeing this increase coming from?

GRAF: So I can list a couple of possible explanations for why the numbers are going up. First of all, it could be that kids are actually changing, and there is actually more ADHD out there. But most people probably don't believe that. Kids are spending more time in front of their computers, and they might be exercising less than in the past. Those are probably true. But whether or not that translates to a diagnosis of ADHD is less clear.

I think some of the reasons, that there's a lot of surveillance for this, so people are looking for it. There's greater awareness and acceptance of the disorder and in part because the pharma industry has direct-to-consumer advertising, and they've succeeded in selling this.

And then adolescents are way up, and that's an interesting sub-group here because the boys in high school, their numbers have jumped, and there's got to be an explanation for why the diagnosis is being made so late. And then lastly we just recently published a position paper through the American Academy of Neurology on pediatric neural enhancement, which is a sub-group that might be taking stimulants and might be coded as ADHD, but actually it's healthy children who are using stimulant medications as study drugs. And that probably explains some of the jump.

FLATOW: You know, there is - if you just think about it, it seems like the jump is occurring at the same time we hear about the epidemic of obesity in children, of type 2 diabetes, of sugar consumption. Have these things been controlled for or thought about as perhaps having some connection?

GRAF: I don't know if the data is so clear on the connection there. But kids are definitely getting heavier. Looking at movement and physical activity and then human activity, the need to move, and this thing called hyperactivity, most studies actually don't show that children with ADHD are moving that much more. They're just fidgeting more. So that's sort of an interesting part of this disorder.

Most kids that I see who have ADHD are actually quite thin. And I don't know if that's a national trend or not.

FLATOW: How about the link to medication? Do we see more kids with the disorder and more medication of those kids?

GRAF: That's where the data comes through beyond the survey science, there are more doctor visits coded for ADHD management. There's more stimulants being prescribed. There's more drug being manufactured, and there's more drug being consumed. And actually last year there was a national shortage of methylphenidate for a while, which means it's actually being consumed.

Another question that comes up periodically is whether people might be motivated to have the ADHD label because of privileges or rights that they might get to take longer for tests. So it would be a diagnostic label which would have some sort of benefit to them, even if they're not taking stimulant medication.

FLATOW: Is there any federal funding for parents or schools or people like that for children who have ADHD? And if so, might that be a motivation?

GRAF: Oh, whether - I think to get Social Security income for a child would depend on the parents' income, and I've heard of that as a possibility, but I don't think it's very common. Certainly the services for children that are publicly funded through public schools are there, the ability to have children be assessed in school.

And that's usually where the assessment takes place. It's not in the doctor's office. It's - these are kids that are not doing well in school, and then the teachers and the school psychologists gather data on that child and bring it back to the physician.

FLATOW: So they're - yeah, are they capable, are they trained enough to be able to actually bring that data to assess, to make the assessment?

GRAF: Again there's - this is a complicated disorder. It's a brain-based disorder when it's real. And then the real question here is, like you say, these numbers are rising, so are these just milder cases. What are the other explanations for that? I think by definition of ADHD, the problem is bad enough that it's causing functional impairment, and that means the child has to be struggling in school. And usually the data is there.

With the milder cases of the kids that are actually normal who are accounting for part of the increase by getting a label of ADHD and then potentially getting stimulants as study drugs, we don't have any data on that because it's not legal, and it's - we believe as the American Academy of Neurology that it's also not ethical to give children medications who are healthy.

FLATOW: So you look at this study, and what's your takeaway message on this?

GRAF: It's sort of the same as the autism that came out a few weeks ago. I don't believe that two percent of children with autism - two percent of children have autism. And I don't think one in five boys in high school has ADHD. But this is a wonderful opportunity to talk about these changes over the course of the last two decades.

This is a national discussion we should be having. Why has this happened, and where are we going with the next two decades? Is this the new normal, that everybody's going to have a label and a medicine in school? This is sort of a sociopolitical discussion that one might have in terms of the competition that kids are forced to have, the school pressures, the No Child Left Behind and the other measures that would put schools under pressure to have better test scores and things like that.

FLATOW: Dr. Graf, thank you for taking time to be with us today. We'll be following this issue with you.

GRAF: Thank you, Ira.

FLATOW: William Graf is a professor of pediatrics and neurology at Yale School of Medicine in New Haven.

The audio broadcast can be found here.

DNA Chip Confirms ADHD Diagnosis in Children

A DNA chip can help to confirm the diagnosis of ADHD in children, and may also provide future treatment strategies. 

While this is super interesting research....its not ready for clinical prime time. JR

Attention Deficit Hyperactivity Disorder (ADHD) is the most common childhood neuropsychiatric disorder. Yet there is currently no tool that will confirm the diagnosis of ADHD. In her thesis entitled "Development of a genotyping system to be applied in Attention Deficit Hyperactivity Disorder and its Pharmacogenetics," the researcher Alaitz Molano, a graduate in biochemistry and PhD holder in Pharmacology from the UPV/EHU-University of the Basque Country, presents a tool that could improve not only the diagnosis of but also the therapeutics for this disorder.

The prevalence of ADHD is between 8% and 12% among the infant-adolescent population worldwide, and 50% continue with the symptoms into adult life. Children with ADHD have difficulty paying attention, do not complete the tasks they have been assigned and are frequently distracted. They may also display impulsive behaviour and excessive, inappropriate activity in the context they find themselves in, and experience great difficulty restraining their impulses. "All these symptoms seriously affect the social, academic and working life of the individuals, and impact greatly upon their families and milieu close to them," says Molano.

In view of the problems existing in diagnosing ADHD patients and deciding about their treatment, this PhD thesis set out to develop and clinically validate a genotyping tool that could help to confirm the diagnosis, to predict how it will evolve, and to select the most suitable pharmacological treatment in each case.

Molano studied how genetic polymorphisms (variations in the DNA sequence between different individuals) are associated with ADHD. "We looked for all the associations that had been described previously in the literature worldwide, and did a clinical study to see whether these polymorphisms also occurred in the Spanish population; the reason is that genetic associations vary a lot between some populations and others."

About 400 saliva samples of patients with ADHD and a further 400 samples from healthy controls without a history of psychiatric diseases were analysed. And the use of over 250 polymorphisms led to the discovery of 32 polymorphisms associated not only with the diagnosis of ADHD but also with the evolution of the disorder, with the ADHD subtype, the symptomatological severity and the presence of comorbidities.

On the basis of these results, Molano is proposing a DNA chip with these 32 polymorphisms, which could be updated with new polymorphisms, as a tool not only for diagnosing but also for calculating genetic susceptibility to different variables (responding well to drugs, normalisation of symptoms, etc.).

The study has also confirmed the existence of the 3 ADHD subtypes: lack of attention, hyperactivity, and a combination. "It can be seen that on the basis of genetics the children that belong to one subtype or another are different," explains Molano.

By contrast, no direct associations were found between the polymorphisms analysed and the response to pharmacological treatment (atomoxetine and methylphenidate). Molano believes that this could be due to the fact that "in many cases the data on drugs we had available were not rigorous," due to the difficulty in collecting data of this kind. Molano will in fact be pursuing her research along this line: "We want to concentrate on the drug response aspect, obtain more, better characterised samples, and monitor the variables in the taking of drugs very closely, whether they were actually being taken or not, etc."

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Childhood Diagnosis of ADHD Dramatically Increased Over Last 9 Years

This article discusses the surge in ADHD diagnoses in children and reasons for why the increase may be happening.

The rate of children diagnosed with Attention Deficit Hyperactivity Disorder rose dramatically between 2001 and 2010, with non-Hispanic white children having the highest diagnosis rates, according to a Kaiser Permanente study published in the journal JAMA Pediatrics(formerly Archives of Pediatrics and Adolescent Medicine). The study also showed there was a 90 percent increase in the diagnosis of ADHD among non-Hispanic black girls during the same nine-year period.

The study examined the electronic health records of nearly 850,000 ethnically diverse children, aged 5 to 11 years, who received care at Kaiser Permanente Southern California between 2001 and 2010. It found that among these children, 4.9 percent, or 39,200, had a diagnosis of ADHD, with white and black children more likely to be diagnosed with the neurobehavioral disorder than Hispanics and Asian/Pacific Islander children. For instance, in 2010, 5.6 percent of white children in the study had an ADHD diagnosis; 4.1 percent of blacks; 2.5 percent of Hispanics; and 1.2 percent of Asian/Pacific Islanders.

The study also examined increases in the rates of first-time ADHD diagnosis. Researchers found that the incidence of newly diagnosed ADHD cases rose from 2.5 percent in 2001 to 3.1 percent in 2010 -- a relative increase of 24 percent. Black children showed the greatest increase in ADHD incidence, from 2.6 percent of all black children 5 to 11 years of age in 2001 to 4.1 percent in 2010, a 70 percent relative increase. Rates among Hispanic children showed a 60 percent relative increase, from 1.7 percent in 2001 to 2.5 percent in 2010. White children showed a 30 percent relative increase, from 4.7 percent in 2001 to 5.6 percent in 2010, while rates for Asian/Pacific Islander children and other racial groups remained unchanged over time.

"Our study findings suggest that there may be a large number of factors that affect ADHD diagnosis rates, including cultural factors that may influence the treatment-seeking behavior of some groups," said study lead author Darios Getahun, MD, PhD, from Kaiser Permanente Southern California's Department of Research & Evaluation. "These findings are particularly solid given that our study relied on clinical diagnoses of ADHD based on the criteria specified within the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders and that it represents a large and ethnically diverse population that can be generalized to other populations."

In addition, the study found that boys were three times more likely to be diagnosed with ADHD than girls. Higher family incomes also were associated with the likelihood of ADHD diagnosis; children from families with a household income of more than $30,000 a year were nearly 20 percent more likely to be diagnosed with ADHD than children from families making less $30,000.

According to the Centers for Disease Control and Prevention, ADHD is one of the most common neurobehavioral disorders of childhood. The CDC estimates that between 4 percent and 12 percent of school-aged children have the disorder, which generates health care costs of between $36 billion and $52 billion per year. Children with ADHD are more likely to experience learning problems, miss school, become injured and experience troublesome relationships with family members and peers, according to the researchers.

"While the reasons for increasing ADHD rates are not well understood, contributing factors may include heightened awareness of ADHD among parents and physicians, which could have led to increased screening and treatment," said Dr. Getahun. "This variability may indicate the need for different allocation of resources for ADHD prevention programs, and may point to new risk factors or inequalities in care."

This study is part of Kaiser Permanente's broader efforts to deliver transformational health research regarding the impacts of ADHD. One recent Kaiser Permanente study found an association between conditions in which the prenatal brain is deprived of oxygen and the risk of ADHD in children and adults.

And last December, a Kaiser Permanente study found little evidence of increased risk of heart attack, sudden cardiac death or stroke associated with use of medications used primarily to treat ADHD. The population-based study included more than 150,000 adults aged 25 to 64 years who used ADHD medications.

These studies are made possible in part by Kaiser Permanente's extensive electronic health record system, one of the largest private systems in the world. The organization's integrated model and electronic health record system securely connects 9 million people, 611 medical offices, and 37 hospitals, linking patients with their health care teams, their personal health information and the latest medical knowledge. The system coordinates patient care between the physician's office, the hospital, radiology, the laboratory and the pharmacy, and helps eliminate the pitfalls of incomplete, missing, or unreadable charts. It also connects Kaiser Permanente's researchers to one of the most extensive collections of longitudinal and de-identified medical data available, facilitating studies and important medical discoveries that shape the future of health and care delivery for patients and the medical community.

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Consequences of Mistaking OCD for ADHD

This article discusses how similar symptoms of OCD and ADHD are, and the consequences if they are misdiagnosed for each other.

On the surface, obsessive compulsive disorder (OCD) and attention deficit/hyperactivity disorder (ADHD) appear very similar, with impaired attention, memory, or behavioral control. But Prof. Reuven Dar of Tel Aviv University's School of Psychological Sciences argues that these two neuropsychological disorders have very different roots -- and there are enormous consequences if they are mistaken for each other.

Prof. Dar and fellow researcher Dr. Amitai Abramovitch, who completed his PhD under Prof. Dar's supervision, have determined that despite appearances, OCD and ACHD are far more different than alike. While groups of both OCD and ADHD patients were found to have difficulty controlling their abnormal impulses in a laboratory setting, only the ADHD group had significant problems with these impulses in the real world.

According to Prof. Dar, this shows that while OCD and ADHD may appear similar on a behavioral level, the mechanism behind the two disorders differs greatly. People with ADHD are impulsive risk-takers, rarely reflecting on the consequences of their actions. In contrast, people with OCD are all too concerned with consequences, causing hesitancy, difficulty in decision-making, and the tendency to over-control and over-plan.

Their findings, published in theJournal of Neuropsychology, draw a clear distinction between OCD and ADHD and provide more accurate guidelines for correct diagnosis. Confusing the two threatens successful patient care, warns Prof. Dar, noting that treatment plans for the two disorders can differ dramatically. Ritalin, a psychostimulant commonly prescribed to ADHD patients, can actually exacerbate OCD behaviors, for example. Prescribed to an OCD patient, it will only worsen symptoms.

Separating cause from effect

To determine the relationship between OCD and ADHD, the researchers studied three groups of subjects: 30 diagnosed with OCD, 30 diagnosed with ADHD, and 30 with no psychiatric diagnosis. All subjects were male with a mean age of 30. Comprehensive neuropsychological tests and questionnaires were used to study cognitive functions that control memory, attention, and problem-solving, as well as those that inhibit the arbitrary impulses that OCD and ADHD patients seem to have difficulty controlling.

As Prof. Dar and Dr. Abramovitch predicted, both the OCD and ADHD groups performed less than a comparison group in terms of memory, reaction time, attention and other cognitive tests. Both groups were also found to have abnormalities in their ability to inhibit or control impulses, but in very different ways. In real-world situations, the ADHD group had far more difficulty controlling their impulses, while the OCD group was better able to control these impulses than even the control group.

When people with OCD describe themselves as being impulsive, this is a subjective description and can mean that they haven't planned to the usual high degree, explains Prof. Dar.

Offering the right treatment

It's understandable why OCD symptoms can be mistaken for ADHD, Prof. Dar says. For example, a student in a classroom could be inattentive and restless, and assumed to have ADHD. In reality, the student could be distracted by obsessive thoughts or acting out compulsive behaviors that look like fidgeting.

"It's more likely that a young student will be diagnosed with ADHD instead of OCD because teachers see so many people with attention problems and not many with OCD. If you don't look carefully enough, you could make a mistake," cautions Prof. Dar. Currently, 5.2 million children in the US between the ages of 3 and 17 are diagnosed with ADHD, according to the Centers for Disease Control and Prevention, making it one of the most commonly diagnosed neuro-developmental disorders in children.

The correct diagnosis is crucial for the well-being and future trajectory of the patient, not just for the choice of medication, but also for psychological and behavioral treatment, and awareness and education for families and teachers.

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Youngest Kids in Class May Be More Likely to Get ADHD Diagnosis, Study Claims

A study claims that the youngest children in the class may be incorrectly diagnosed with ADHD and medicated due to a natural lack in maturity.

A new study from Iceland adds to existing evidence that kids are more likely to be diagnosed with attention deficit hyperactivity disorder if they're among the youngest in their grade at school.

The findings suggest -- but don't prove -- that some children are diagnosed with attention deficit hyperactivity disorder (ADHD) when they're just less mature than their peers.

"Educators and health-care providers should take children's ages in relation to their [classmates] into account when evaluating academic performance and other criteria for ADHD diagnosis," said study author Helga Zoega, a postdoctoral fellow at Mount Sinai School of Medicine in New York City. "Parents can use these findings to help inform their decisions about school readiness for children born close to cutoff dates for school entry."

Debate has erupted in recent years about whether ADHD is overdiagnosed in children who are naturally rambunctious and don't need to be medicated.

Earlier this year, a Canadian study found that more boys aged 6 to 12 were diagnosed with ADHD if they were the youngest in their grade levels: the percentages were 7.4 percent among the youngest boys and 5.7 percent among the oldest.

There also was a gap between older and younger girls, although they're much less likely than boys to be diagnosed with ADHD.

The new study tracked nearly 12,000 children born between 1994 and 1996 in Iceland, where there's also been a debate over the diagnosis of the condition and the use of stimulants to treat it, Zoega said. The researchers looked at the children's test scores at ages 9 and 12, and examined whether they were prescribed drugs for ADHD.

Overall, 740 children -- about 6 percent of the total -- were prescribed ADHD drugs at some point from 2003 to 2009.

Children in the youngest third of their classes were 50 percent more likely than those in the oldest third to be prescribed ADHD medications from ages 7 to 14.

The study also found that "being younger relative to one's classmates affects academic performance throughout childhood," Zoega said.

Richard Morrow, a health research analyst at the University of British Columbia who studies ADHD, said the findings are consistent with those from other countries.

"In the education system, it leads to the question, 'What strategies or resources do we need to help ensure the well-being of all children in the classroom, where children vary in age by up to a year?' " he asked. "Parents need to be aware that if behavioral issues arise for their child, this may be related to their child's relative age in the classroom.

"Similarly, doctors need to consider a child's relative age in school or other settings such as athletics before making a diagnosis or writing a prescription," Morrow added. "Lastly, we may need to revisit how the diagnosis is defined to lessen the risk of inappropriate diagnosis."

The findings appear online Nov. 19 and in the December print issue of the journal Pediatrics.

So what can be done?

"Children behave and perform according to their own maturity level within the classroom," Zoega said. "Being younger relative to one's classmates affects academic performance throughout childhood. When evaluating whether a child has ADHD, this should be taken into account to prevent unnecessary diagnoses and prescribing of stimulants."

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