Overdiagnosis: Schools Under Pressure on ADHD

    • May 9, 2014

Any parent who has struggled to help a child through an Attention Deficit Hyperactivity Disorder (ADHD) diagnosis and treatment can tell you that the process is a marathon, not a sprint. Janice Lynch Schuster, an Alexandria, Va., mom of six, vividly remembers her struggles with her eldest son.

“He was a very smart, precocious 6-year-old boy who could not sit still in class and he did not follow social cues well. He was always in trouble. At first, we tried cognitive behavioral therapy to see if that would help. We also had the support of a guidance counselor who went above and beyond to help him make friends. It was not a quick diagnosis. We had many teachers and family members complete observational studies of him. After more than 18 months of trying different things, we learned enough to get an accurate ADHD diagnosis with the help of the organization Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD),” Schuster says.

Her son was diagnosed 18 years ago. That kids today may not be given the benefit of such a long and careful assessment is at the center of the work of Stephen Hinshaw, PhD, and Richard Scheffler, PhD, recipients of a Robert Wood Johnson Foundation (RWJF) Investigator Award in Health Policy Research.

In their new book The ADHD Explosion: Myths, Medication, Money, and Today's Push for Performance, Hinshaw and Scheffler report startling findings about how millions of kids are diagnosed with ADHD, and possibly placed on medication, after a process that lasts minutes, not months. “There is no simple blood test or brain scan for ADHD. Most kids get a diagnosis and a prescription after a 15-minute interview in a pediatrician’s office,” Hinshaw says.

Profit, Performance and ADHD

At a time when 11 percent of American children have been diagnosed with ADHD and 70 percent of those diagnosed receive medication, scientists around the world are exploring the controversy over the accuracy of ADHD diagnosis and treatment. Hinshaw and Scheffler’s analysis of the forces that often come together to foist an incorrect ADHD diagnosis on unsuspecting children and parents adds a powerful voice to the debate.  

For their investigation into swiftly rising ADHD rates in public schools, Hinshaw, a professor of psychology at the University of California, Berkeley and Scheffler, a professor of health economics and public policy at the school, compared 30 states that passed educational accountability laws before the No Child Left Behind Act went into effect in 2002 to 20 states that did not have a policy until afterward. These laws prioritize standardized test scores as the basis for school funding.

Among states with the most recent accountability laws, Hinshaw and Scheffler found that over four years—2003 to 2007—ADHD diagnoses increased 59 percent among children in families with incomes within 200 percent of the federal poverty level. Among the middle-class and upper-class children in those 20 states, there was only a 5 percent increase. In the 30 states that had accountability legislation before No Child Left Behind, the ADHD diagnosis rate was about 20 percent—close to the national average—and there was no significant difference between low-income and high-income kids. Similarly, in private schools (not subject to the accountability laws) there was no differential increase in diagnosis by income.

“By any measure, 59 percent is a huge number,” Hinshaw says. “We checked the analysis in every possible way and the numbers remained the same. It is not possible for there to be such a dramatic biological or genetic change in these kids over four years.” Implicating school policies, along with quick-and-dirty diagnostic practices as the culprit, he adds, “policy analysts call these kinds of results the ’unintended effects’ of legislation.”

While Hinshaw and Scheffler support expanded pre-K programs and other measures to help students achieve academic success, along with early (age 4) and appropriate diagnosis for children with ADHD, they are concerned about the growing tendency to label every fidgety, distracted child who may struggle with tests with the disorder.  

“With the accountability push, administrators are impatient. There are penalties for underperforming schools. Performance matters big time in terms of test scores,” Hinshaw explains.

Education Equals a Healthier Nation

As the debate over how to evaluate children continues, the latest public health research gives some idea of what’s at stake. In the 2013 RWJF Commission to Build a Healthier America report experts suggest that one of the most important ways to improve health is to emphasize high-quality early childhood education. 

That begs the question, what happens to a child’s health if that educational experience is marred by an inappropriate ADHD diagnosis? “There is a stigma attached to the diagnosis,” Schuster says. “My son’s teachers pigeonholed him as ‘one of those kids’ and it was very detrimental to him. The medications also affected his sleep and his appetite.”

She adds: “The focus on medication is also a mistake. There’s a tendency with ADHD to think you just give the kid a pill and that’s it. But if you really want to help a child with ADHD succeed, it’s an ongoing process of working with teachers, schools and counselors to make sure they get the services they need.” 

Hinshaw also expresses concern over the increasingly common use of ADHD drugs such as the stimulant Ritalin (and related compounds) within the general population. “Although youth with ADHD show academic as well as behavioral benefits from medication, the pills do not enhance learning in people who do not have ADHD. The general population is at risk for becoming addicted to stimulants when the drugs are used as performance enhancers,” he says.  

With the new emphasis on pre-K and the Common Core curriculum now taking the place of No Child Left Behind, educators are not likely to shift their focus away from tests and scores. So part of the answer, Hinshaw advises, is for parents to learn more and take control of the diagnostic process.

Putting Parents in Control

This is sometimes difficult because “there are not enough child psychiatrists, but a parent should ensure that their child is evaluated by a mental health professional trained in behavioral health,” Hinshaw says.

He also advocates seeking out support groups. “It’s important to talk to other parents of children with similar issues,” he adds, suggesting that parents, teachers and schools will have to work together on behavioral strategies and other methods to give kids the help they really need. “In fact,” he says, “the biggest gains occur when medications are combined with skill-building approaches.”