The Scandal of ADHD Diagnosis in the U.S.

The majority of ADHD diagnoses are made with the kind of attention you wouldn’t accept from an automobile service department. And our kids are the ones getting hurt by the fractured process. Things need to change.
Speak Up, Please | posted by Stephen Hinshaw, Ph.D., Katherine Ellison
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If you think a lot of American children are being over-diagnosed with ADHD, and perhaps over-medicated, you're right. And if you think a lot of American children aren't being diagnosed with ADHD and not given treatment when they should — guess what? You're also right.

The reason for both of these potentially serious problems is the same—and it's a scandal. Despite the best wisdom of our mental health profession, the majority of ADHD diagnoses are made with the kind of attention you wouldn't accept from an automobile service department.

Research shows that the most common way children are being diagnosed with ADHD is during a 15-minute appointment with a pediatrician —just 15 minutes! — well short of the thorough evaluation recommended by respected organizations such as the American Academy of Pediatrics and the American Academy of Child and Adolescent Psychiatry.

The gold standard needed for a valid diagnosis includes not merely conversations with a patient and his or her parents, but a thorough medical history, and, ideally, systematic ratings from teachers and family members, to know for sure if the chief problem is ADHD or whether any one of a host of other possible distraction-causing problems, from anxiety to trauma to a head injury, is the culprit.

A short office visit is usually insufficient to rule out these other problems. Moreover, a simple office assessment that doesn't gather other perspectives can easily miss serious problems that arise in other contexts. In other words, a youth having major ADHD-related problems at school might look just fine when in a one-on-one situation in a new environment, with a doctor wearing a white coat.

I wouldn't argue that there aren't some talented, intuitive pediatricians out there who can quickly spot signs of the neurobiological disorder, whose chief symptoms are distraction and impulsivity. But the odds are strong that this quick-and-dirty approach to a major public health issue is taking a serious toll. Many children are being over-treated — unnecessarily labeled and prescribed medication that can sometimes have serious side effects, from insomnia to tics to mood changes.

The consequences of under-diagnosis and under-treatment for ADHD are equally serious: longitudinal research shows the disorder can result in many more accidents, injuries, academic and professional failures, and divorces, compared to the rest of the population. This isn't just a problem for families raising children with ADHD: Taxpayers are paying more than $100 billion a year to clean up the mess.

Let's pause here for a short refresher on what's been happening with ADHD diagnosis rates in this country. The most recent survey by the Centers for Disease Control and Prevention showed that the ADHD diagnosis rate for children and adolescents skyrocketed by 41 percent between 2003 and 2012. Today one in nine youth, or more than 6 million in all, have received a diagnosis. More than two-thirds of them — nearly 4 million children and teens — are taking medication. These numbers are significantly higher than anywhere else in the world, and they are well above the estimated global prevalence rate of between five and seven percent. What's more, they are much higher in some parts of the nation than in others, suggesting that factors other than accurate diagnoses — including pressures from schools to get high scores on standardized tests, although that's a whole other discussion — are contributing.

The rise in U.S. rates may now be starting to slow, but it is certain to continue at least for some years. Among the reasons: Obamacare is making doctors' visits more accessible to millions of Americans who previously lacked health insurance, while a push for early childhood education means more children are starting school earlier, and being noticed by teachers when they can't keep still. In fact, professional medical associations now recommend that children with ADHD be identified and treated by as early as age four—even as, in those tender years, the need for thorough evaluations is even greater.

All this makes the recent findings of researchers including Jeffrey Epstein, at the University of Cincinnati, extremely worrisome. Epstein has found that half of pediatricians in his Ohio sample failed to gather the kind of feedback from parents and teachers that is so vital to an accurate diagnosis. If that doesn't surprise you, imagine how you might react if you were told that 50 percent of cancer patients weren't being diagnosed with the best, evidence-based techniques.

Moreover, whereas more than 90 percent of the diagnosed children Epstein tracked were prescribed medication, only 13 percent were offered the kinds of behavioral therapy — including parent-training and classroom supports — backed by solid evidence as helpful to seriously distracted children. Even worse, the doctors very rarely — at most, 10 percent of the time — followed up their treatments with systematic monitoring, a recipe for failure. As is the case with all mental health problems, there’s still no objective test—a blood sample, computer assessment, or brain scan—that can objectively and accurately tell who does or does not have ADHD. Such a test may exist in our future, but right now there's no alternative to devoting what all of us, diagnosed or not, have less and less of today: time and attention.

It's time we face the facts: ADHD is a genuine medical ailment, and an exceptionally expensive one. But investing time, bandwidth, and money before the problem gets worse, as it almost always will, can save considerable time and money down the line. We need more specialists, including child and adolescent psychiatrists, as well as developmental-behavioral pediatricians. We need medical schools to include evidence-based approaches in their training. And most importantly, we need reimbursements that fully compensate doctors who take the time to do it right.

Stephen Hinshaw is professor of psychology at the University of California, Berkeley, and vice-chair for psychology within the psychiatry department at the University of California, San Francisco. He is the co-author, with journalist Katherine Ellison, of "ADHD: What Everyone Needs to Know."

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