ADHD: Why Do the Numbers Keep Growing?

Thomas J. Power, PhD from Medscape

   A recent New York Times analysis of data from the most recent National Survey of Children's Health concluded that almost 1 in 5 teenage boys and 11% of all school-aged children have been diagnosed with attention-deficit/hyperactivity disorder (ADHD). Medscape asked Dr. Thomas Power, from the Children's Hospital of Philadelphia (CHOP), to discuss some theories to explain this increase.
   My name is Tom Power. I'm a psychologist and Director of the Center for Management of ADHD at CHOP. I want to make a few comments about the rising rates of ADHD. At this point, a number of people are commenting that the rates of ADHD may be over 10%. People are asking about factors that may be contributing to that [increase]. Probably the main reason is that providers generally are doing a better job of screening for ADHD. In particular, primary providers and school professionals are doing a better screening for ADHD and bringing to the attention of parents potential concerns about their children.
   The real estimates of ADHD, based upon a number of studies conducted by independent researchers, would suggest that the prevalence is probably in the 5% to 10% range. The best guess may be about 7%, which raises the question as to whether ADHD may be overdiagnosed at this point. I think that these are legitimate questions. Particularly in suburban communities in which more affluent, middle-class and upper-middle-class families reside, there may very well be an overdiagnosis of ADHD. The reasons for that are that a diagnosis of ADHD may be assigned after only a brief screening, which typically would not be appropriate. A comprehensive evaluation is necessary.
   In our center, the approach that we use includes parent and teacher rating scales, as well as a thorough parent interview, consisting of a good medical and developmental history. We strongly recommend that approach to providers in the community.
   Another potential concern is that children with mild problems may be assigned a diagnosis of ADHD. The presence of mildly elevated symptoms of inattention or hyperactivity is typically not sufficient to render a diagnosis of ADHD. There has to be a relatively high level of symptomatology, as well as significant impairment in 2 or more settings to render the diagnosis. I do want to mention that underdiagnosis is also still occurring in certain regions of the country -- in particular, rural areas and underserved inner-city locales. Urban areas are places in which the diagnosis of ADHD may not be made often enough and services may not be provided as much as they should.
   What can we do about the problem of overdiagnosis? First, we need to be conducting more comprehensive assessments, as I described. Second, when children have mild problems, they often need services. They may not need intensive services. They typically would not need medication. We would typically recommend brief parent training using behavioral strategies, perhaps consisting of 2-4 sessions, and school consultation using behavioral strategies. If those methods are not sufficient and the problems get to be more concerning, then more intensive behavioral treatments -- again, using parent training and school consultation -- would be indicated. In some cases, medication, in particular with stimulants, is necessary.