by Regan D. Sarmento, BS
American Day Treatment Centers

Educators, medical professionals, and parents alike are questioning the alarming rate at which the diagnosis of Attention Deficit Hyperactivity Disorder (ADHD) is being given to our youth.  Many in the academic and professional communities believe that ADHD is being over-diagnosed and worry that many children who do not truly have ADHD are being treated with medications.  Has ADHD become the "flavor of the day"? Or could there be other circumstances that explain the symptoms rather than a general diagnosis of ADHD? 

According to the DSM-IV (APA, 1994) the defining feature of ADHD "is a persistent pattern of inattention and/or hyperactivity-impulsivity that is more frequent and severe than is typically observed in individuals at a comparable level of development", the symptoms of which must have been present after the age of 7 years old.  Additional criteria that must be met are impairment in at least two settings, such as home and school, and there must be clear evidence that the impairment is interfering with daily functioning.  Lastly, the symptoms may not occur as a result of other mental disorders.  The DSM-IV continues with diagnostic criteria that must be met in order to diagnose a subtype of ADHD.  As you can see, the criteria are very specific and stipulate that the presenting symptoms must be "severe" and "more frequent" than peers of the same age.  The words severe and more frequent could be open to interpretation in order to fit the child.
 
Research by way of neuro-imaging is finding that children diagnosed with ADHD do not possess the typical asymmetry in the frontal lobe area of the brain (Barabasz & Barabasz, 1999).  The frontal lobe is responsible for controlling motor behavior and decreasing focus on stimuli that are irrelevant or distracting.  This information can be diagnosed through EEG's; however; it is rarely done and is contra-indicated in guidelines for diagnosing ADHD.  As a result, the diagnosis may be based solely upon subjective reports.

According to the CDC, in 2003 almost four million children in America ages 3 through 17 were diagnosed with ADHD.  Of those four million, children with fair to poor health were three times as likely to be diagnosed with ADHD.  One has to question if stereotypes of children play into the diagnostic process.  Writing in the journal Pediatrics, Schneider and Eisenberg (2006) found that a diagnosis of ADHD was more likely to be influenced by a student's home and school environment.  For example, a child living with their biological father was less likely to receive a diagnosis of ADHD.  If the child's family was in the lowest income quintile they were more likely to receive a diagnosis of ADHD.  Higher diagnosis rates were found among students who had older teachers.  Perhaps a child with an older teacher is unable to grasp concepts due to outdated teaching methods or a teacher's unwillingness to adopt new strategies.  Are teachers stereotyping students based upon environment and developing a misguided perception of the student's behavior as a result?  Unfortunately, there is no definitive answer but it does invite speculation. 

Half of all marriages today end in divorce.  As a result, approximately one million children are suffering from the stressors of divorce.   Children of divorced parents are often the recipients of inconsistent affection and discipline and are exposed to arguments, possible threats, monetary pressures, and in some cases violence.  As a result, they may begin to display behaviors such as inability to focus. They may be easily distracted, impulsive, more likely to engage in risky behavior, or they may be oppositional to authority figures.  These behaviors resemble the characteristics of a child with ADHD; however; they are acute and directly related to the divorce of the parents.  In addition, when a doctor is evaluating a child of divorced parents for a diagnosis of ADHD, one parent is usually absent.  Thus, it may be unclear if the behaviors presented are a result of ADHD or an acute stress reaction (Stein, Diller & Resnikoff, 2001).

Peg Dawson, a psychologist on staff at Seacoast Mental Health Center in New Hampshire, wrote an article describing the poor sleep patterns of adolescents and the effect of poor sleep.  Most teenagers require 8.5 to 9.25 hours of sleep each night however 25% report that they sleep less than 6.5 hours a night (Dawson, 2005).Lack of sleep is associated with irritability, reduced alertness, tardiness, impulsivity, hyperactivity, behavior and academic problems (Dawson, 2005).  Researchers have suggested that 15% to 30% of children will experience sleep disturbances at some point during their childhood and up to 75% of all adolescents have sleep problems (Dawson, 2005).  These are astounding numbers!  The symptoms mentioned above are synonymous with the general criteria of ADHD.  Is it possible that children and adolescents are being diagnosed with ADHD when in fact they have an undiagnosed sleep disorder? 

The American Academy of Pediatrics (AAP) established evidence-based guidelines to aid in proper diagnosis and treatment of patients with ADHD.  The guidelines are utilization of DSM-IV criteria, evidence directly obtained from parents and classroom teacher, and an evaluation for coexisting conditions (Rushton, Fant, & Clark, 2004).  Research was conducted by Jerry Rushton, Kathryn Fant, and Sarah Clark to determine if physicians are utilizing the guidelines set forth by AAP.  The data gathered were extremely concerning.  Of family physicians and pediatricians surveyed to determine routine adherence to the four components of the guidelines, only 34.9% pediatricians and 14.3% of family physicians reported consistent adherence to the AAP guidelines (Rushton et al., 2004). 

ADHD is being diagnosed to an alarming degree.  Today's youth are under great pressure to excel at all costs and are experiencing other disorders such as anxiety and depression, which imitate the well known symptoms of ADHD.  While it may be more acceptable in mainstream society to be diagnosed with ADHD, it is a diagnosis that is often treated with stimulant based medication.  A complete, thorough evaluation and accurate diagnosis is imperative. 

References:

American Psychiatric Association:  Diagnostic and Statistical Manual of Mental Disorders (4th ed.)(1994).  Washington, DC, American Psychiatric Association.

Barabasz, A. & Barabasz, M.  (1999).  Treating ADHD with hypnosis and neurotherapy. (Report No. CG029544).  Pulllman, WA:  Washington State University.  (ERIC Document Reproduction Service No. ED435076).

Brown, R., Freeman, W., Perrin, J., Stein, M., Amler, R., Feldman, H., Peirce, K., & Wolraich, M.  (2001).  Prevalence and assessment of attention-deficit/hyper-activity disorder in primary care settings [Electronic version].  Pediatrics, 107, 43-57.

Dawson, P.  (2005, January).  Sleep and adolescents.  [Electronic version]  Counseling 101, 21-26.

Guevara, J., Lozano, P., Wickizer, T., Mell, L., & Gephart, H. (2001).  Utilization and cost of health care services for children with attention-deficit/hyperactivity disorder [Electronic version].  Pediatrics, 108, 71-78.

Polaha, J., Cooper, S., Meadows, T., & Kratochvil, C.  (2005).  The assessment of attention-deficit/hyperactivity disorder in rural primary care: The portability of the American academy of pediatrics guidelines to the "real world" [Electronic version]. Pediatrics, 115, 120-126.

Rushton, J., Fant, K., & Clark, S.  (2004).  Use of practice guidelines in the primary care of children with attention-deficit/hyperactivity disorder [Electronic version]. Pediatrics, 114, 23-28.

Schneider, H. & Eisenberg, D. (2006).  Who receives a diagnosis of attention-deficit/hyperactivity disorder in the United States elementary school population? [Electronic version].  Pediatrics, 117, 601-609.

Stein, M., Diller, L., & Resnikoff, R. (2001).  ADHD, divorce, and parental disagreement about the diagnosis and treatment [Electronic version].  Pediatrics, 107, 867-872.

U.S. Department of Health and Human Services. (2005).  Summary health statistics for U.S. children: National health interview (Vital and Health Statistics Series 10, No. 223).  Washington, DC. 

Dey, A. & Bloom, B. Visser, S. & Lesesne, C.  (2003).  Mental health in the United States: prevalence of diagnosis and medication treatment for Attention-deficit/hyperactivity disorder-United States.  Journal of the American Medical Association, 294, 2293-2296.