This past Sunday, the New York Times ran a lengthy feature article that created quite the stir in our professional community. The article, titled The Selling of Attention Deficit Disorder, spelled out in great detail the marketing practices the pharmaceutical industry has employed over the last twenty years in promoting the use of medications in kids and adults primarily indicated for ADHD, with a focus on the strategies of the company (Shire) that has been the market leader in ADHD for the past ten years.

There’s a study coming out in the January issue of the Journal of the American Academy of Child and Adolescent Psychiatry (JAACAP) that reinforces the extent to which ADHD diagnosis is truly reaching epidemic proportions. Here’s a portion of the abstract…

Results

In 2011, 11% of children/adolescents aged 4 to 17 years had ever received an ADHD diagnosis (6.4 million children). Among those with a history of ADHD diagnosis, 83% were reported as currently having ADHD (8.8%); 69% of children with current ADHD were taking medication for ADHD (6.1%, 3.5 million children). A parent-reported history of ADHD increased by 42% from 2003 to 2011. Prevalence of a history of ADHD, current ADHD, medicated ADHD, and moderate/severe ADHD increased significantly from 2007 estimates. Prevalence of medicated ADHD increased by 28% from 2007 to 2011.

Conclusions

Approximately 2 million more U.S. children/adolescents aged 4 to 17 years had been diagnosed with ADHD in 2011, compared to 2003. More than two-thirds of those with current ADHD were taking medication for treatment in 2011. This suggests an increasing burden of ADHD on the U.S. health care system. Efforts to further understand ADHD diagnostic and treatment patterns are warranted.

The journal editors ran a commentary by Dr. John Walkup (head of child psychiatry at Cornell) to accompany the study. Quoting from Dr. Walkup…

If the CDC’s data are consistent with other epidemiologic studies and the prevalence of treated ADHD is less than the current prevalence of ADHD, why is there such concern about overdiagnosis and overtreatment of ADHD? Several factors drive this reaction. First, the change in rates of diagnosis and treatment are emphasized, rather than the proportion of cases in the community who are diagnosed and treated. The CDC’s report of a 42% increase in diagnosis in less than a decade and a 28% increase in treatment in 4 years sounds shocking. However, when considering the similarity between the current diagnostic and treatment rates and community-based prevalence rates, the issue is much more clear—the CDC data suggest that we are getting to a point when children with ADHD in the United States may actually be getting an opportunity for a diagnostic assessment and appropriate evidence-based treatment.

What Dr. Walkup didn’t address in his commentary is the question of why so many of our kids are struggling to function in school, at home, in peer relationships and in community activities to the extent that parents sense the need to seek out professional help.

Allow me to point out the elephant in the living room…

I’ve seen 55 kids so far this month in our practice with an ADHD diagnosis. For ten of the 55, problems with impulse control or behavior are a primary focus of treatment. For 55 out of 55, educational struggles are a primary focus of treatment. Is the ADHD epidemic really a product of drug company marketing, or is it a result of our culture and our educational system imposing expectations upon a large segment of our child and teen population that they’re not developmentally prepared to meet? Perhaps a classic case of pounding square pegs into round holes?

Let’s start with the educational system. We need to consider the possibility that the demands and expectations of the environments where our kids and teens spend much of the time are a big part of the problem and question whether we need to rethink our expectations for academic productivity and the design of the learning environments where our kids spend much of their day.

Here’s an interesting review article examining the research literature on homework. The article quotes a study in which 80% of U.S. teachers see homework as a tool for teaching organizational skills. But at what age should we expect kids to be able to master organizational skills? In our area, it’s not at all unusual to see first graders with planners. Has anyone asked… Is it a good idea for first graders to have planners? First graders should go to school, learn to read, learn their math facts, have recess, come home, play in the snow with their friends and read with their parents before they go to bed. Their brains aren’t yet wired for multitasking.  Another difference between the U.S. and other countries is the extent to which homework is used to determine grades. In one study, 82% of U.S. teachers graded homework vs. 14% in Japan and 6% in Germany. What happens to kids who are outliers in the sense that they require more time to generate the expected volume of academic product compared to their peers? What happens to family life when harried parents and stressed out kids are at one another’s throats as a result of homework expectations?

I was speaking earlier this week to to a special educator in a very prestigious school system who has referred families to our practice. She told me to expect another wave of referrals shortly because of the sheer number of kids struggling to master the content of the new curriculum imposed by our state. While some parents receive lots of support from their local schools when their kids struggle academically and require educational assessment and specialized intervention, other families all too frequently encounter resistance. When  parents don’t know where else to turn, they turn to the pediatrician, or sometimes, a specialty practice like ours.

Here’s the other elephant in the living room…We elect the folks in Washington, the state legislators and the local school board members who decide upon the expectations for our kids in school and the environments in which they will learn. Are our elected representatives giving us what we want…and are lots of kids with relative weaknesses in attention, focus, drive and organizational skills getting steamrollered in the process?

As the father of a high school senior waist-deep in the college application process and a clinician who sees several hundred kids over the course of a year, the pressures our kids are under to be academically successful are exponentially different than those my generation experienced. The first difference is that our kids are competing against peers from throughout the world for positions in the most highly regarded schools. When I was a senior, a recruiter from Harvard walked into my high school’s guidance department and offered to provide half the cost of attending for four years on the spot…if I applied there today with the grades and test scores I had in 1979, someone in the admissions office would hit the “delete” button on my application. I didn’t have a “coach” to prepare me for my SATs…I got up on the designated Saturday morning and took the test.

The other difference is that many parents are very afraid of what the future holds for their kids. Membership in an increasingly narrow societal elite defined by educational accomplishment is seen to offer a measure of security in uncertain times. I don’t find it at all surprising that increasing numbers of parents are seeking to identify any and all potential obstacles to their child’s academic success, especially when kids have a condition that results in difficulty functioning in the environments that hold the key to “success” in our culture.

I think the rise in the prevalence of ADHD treatment has far more to do with what we as parents desire for our children and the ways in which our educational environments pose obstacles to the future success of those kids with relative weaknesses in attention, focus, organizational skills, motivation and speed of processing new information than it reflects the effectiveness of drug company marketing strategies.

What’s really important for our kids to be successful in life, and how can we best support our kids in becoming who they were created to be?

Disclosures: I’ve done no promotional speaking for pharmaceutical companies in the last seven plus years. 100% of honoraria I received for pharmaceutical industry consulting in 2008 and 2009 were contributed to Key Ministry (no consulting since 2010). All research funding our practice has received since 2007 related to ADHD was derived from the National Institute of Mental Health through our practice’s participation in the CAPTN (Child and Adolescent Psychiatry Trials Network) Network, in partnership with Duke University. I was involved in research, consulting and speaking on behalf of Richwood (later Shire) Pharmaceuticals from 1997-2006.

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Key Ministry offers a resource center on ADHD, including helpful links, video and a blog series on the impact of ADHD upon spiritual development in kids and teens. Check it out today and share the link with others caring for children and youth with ADHD.