September 2, 2011

A Matter of Focus

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Joseph V. Madia, MD By:

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What's behind increase in ADHD diagnoses

Even as a toddler, a little boy named Lee was super active. He didn't have time for crawling. No, he started walking at about 9 months.

And he took off after that. Literally. The boy preferred to zoom through the world. Taking naps during his preschool years just didn't happen. Then sitting in a chair at school was almost tortuous.

And it wasn't just his body that seemed to be in constant motion - except when watching television. His mind was everywhere. Playing with a pencil was far more fascinating than doing math problems.

To say he was a challenge for his teachers and parents is sort of an understatement.

His fourth grade teacher knew what was wrong.  Lee was diagnosed with attention deficit hyperactivity disorder (ADHD) and prescribed medication that year.

The boy's behavior both in and out of the classroom and his grades improved measurably.

This youngster is one of millions of children, adolescents and adults who wrestle with ADHD.

A new study suggests that ADHD is more prevalent than ever, and dailyRx.com talked with an expert in the field about the latest findings.

What is ADHD and how is it diagnosed?

Attention deficit hyperactivity disorder is one of the most common and well-studied of all childhood conditions. Its symptoms are fairly obvious and include trouble paying attention and focusing, impulsive behavior and hyperactivity.

Symptoms can begin in childhood and persist into adolescence and adulthood. ADHD can - and usually does - impact a person's family, school, social and professional lives.

Diagnosing ADHD involves a number of steps, which include:

  • A medical exam
  • An assessment checklist that identifies and rates ADHD symptoms
  • For children, this checklist is completed by parents, teachers, and sometimes the child.
  • Identifying and evaluating other mental health conditions that may be present such as anxiety, depression, etc.

ADHD diagnoses on the rise

A recently published report by the Centers for Disease Control and Prevention (CDC) shows a marked increase in the number of children who are being diagnosed with ADHD between the ages of 5 and 17.

Here's what the National Health Interview Survey, 1998–2009 found:

  • The number of children diagnosed with ADHD rose from 7 percent in 1998–2000 to 9 percent in 2007–2009.
  • From 1998 through 2009, prevalence of ADHD rose to 10 percent of children from families whose income fell below the poverty line.
  • Prevalence rose to 11 percent for those with family incomes of between 100-199 percent of the poverty level.
  • ADHD diagnoses increased to 10 percent of children living in the Midwest and Southern regions of the United States.
  • These statistics held true for both boys and girls.
  • ADHD is consistently less prevalent in Mexican children than in other racial and ethnic groups.

What has changed?

While these statistics suggest that ADHD is becoming a more common condition, a nationally known ADHD expert looks at the numbers differently.

Glen R. Elliott, PhD, MD, is the Chief Psychiatrist and Medical Director at Children’s Health Council, a not-for-profit child and adolescent mental health facility affiliated with Stanford University.

According to Dr. Elliott, "There is little to no evidence to suggest that there are more children with ADHD. What has changed is the threshold at which the diagnosis is being made," he said.

"Historically, back in the 60’s, estimates of what was then called hyperactivity ranged as high as 15-20 percent of school-aged children. The lowest estimated prevalence was in the early 90’s, with the introduction of the DSM-IV (mental health diagnostic manual), when formal estimates were 3 percent," Dr. Elliott said.

He says that the problem really has to do with the fact that there are no clinical or objective ways to diagnose ADHD. This causes confusion and difficulty in arriving at a definitive diagnosis.

"Many of the behaviors we use to make the diagnosis blend into normal behaviors, so one has to decide, for example, how much physical activity is 'too much?'"

Changing criteria and perspectives

Dr. Elliott, who is an affiliated clinical professor at Stanford’s Department of Psychiatry and Behavioral Sciences, says the guidelines for diagnosing ADHD have changed over the past 10 years.

"Experts in the field have reached consensus that the previous criteria were simply too strict and were missing children who could benefit from treatments for ADHD," said Dr. Elliott.

Perspectives are changing too. The Emeritus Professor of Clinical Psychiatry at the University of California, San Francisco says that how optimistic the public and professionals are about the effectiveness of treatments impact the rates of ADHD diagnosis.

"When optimism is high, diagnoses tend to rise; when worries about treatment safety are high, diagnoses tend to lower," Dr. Elliott says. "That does not in any way mean the 'real' prevalence of ADHD is changing."

ADHD diagnosis very helpful for adolescents and adults

A trend that Dr. Elliott sees is what he calls "the interest in diagnosing ADHD in both younger children (under age 6) and adolescents and adults."

While diagnosing ADHD in young children continues to be challenging and "quite difficult," Dr. Elliott adds, "diagnosing ADHD in adolescents and adults is less difficult and can be a major boon to individuals in those age groups who previously were dismissed as 'lazy' or 'flaky.'"

Other trends affecting ADHD diagnosis

The likelihood of receiving an ADHD diagnosis has to do with the fact that school systems and homes are highly stressed, Dr. Elliott says. These factors include much larger class sizes, fewer support systems both for families and educators and increasing stresses and strains in the home.

"All these kinds of changes are apt to tip the scales for children with relatively milder ADHD from being able to cope to not doing well—and therefore coming to the attention of a mental health or medical professional," Dr. Elliott said.

Getting help for a highly treatable condition

While ADHD is a serious and often chronic condition, Dr. Elliott says it's also "quite treatable with a variety of approaches."

"If parents suspect their child has had sustained problems with any or all of the following functional areas—sustained attention, inability to stay focused even on routine tasks, a high level of physical activity, and high impulsivity—that is causing difficulties at home and school, they should consider an assessment for ADHD with a reputable care provider knowledgeable about behavioral problems," Dr. Elliott urges.

Treatment approaches

Once a child - or an adult - is diagnosed, treatment options for ADHD are plentiful and include both medications and other therapies.

Common medications used to control ADHD in both children and adults include:

Psychostimulants

  • Adderall (amphetamine-Dextroamphetamine)
  • Dexedrine, Dextrostat (dextroamphetamine)
  • Focalin (dexmethylphenidate)
  • Ritalin, Concerta, Metadate, Daytrana (methylphenidate)
  • Vyvanse (lisdexamfetamine)

Most of these are oral medications that come in short- and long-acting forms. Daytrana comes in a patch that's applied to the hip daily.

Other medications

Strattera (altomoxetine) - a non-stimulant
Wellbutrin (bupropion), tricyclics - antidepressants sometimes prescribed for other conditions
Catapres, Tenex (alpha-2 agonists)

Finding the right medicine and dosing sometimes takes a while to finalize. That's why you'll want to have a good relationship with a medical professional who can work with you and/or your child.

Other therapies

Cognitive behavioral therapy is also helpful. Ask your doctor for referrals to a qualified therapist who is experienced in working with individuals living with ADHD.

The little boy grows up

The on-the-go child - Lee - took Concerta for several years in grade school, and then went off the medication due to parental concerns.

His grades and behavior suffered. By the time he reached high school, advancing to the next grade level required summer school. The situation was harrowing for his teachers, counselors and parents.

Finally in his junior year, his mother suggested that his untreated ADHD may be contributing to the crisis. So Lee was re-tested for ADHD. His pediatrician, teachers and parents helped arrive at the diagnosis.

His doctor suggested that Lee begin taking a relatively new medication - Vyvanse - that his doctor felt would be most effective for his type of ADHD.

Taking the medication only on school days, Lee said it did help be able to focus better without making him feel jittery or zoned out.

That he made the best grades of his high school career during his senior year is evidence that it worked.

Lee is now a freshman in college and thriving.

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Reviewed by: 
Joseph V. Madia, MD
Review Date: 
August 31, 2011

Last Updated:
October 4, 2012