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Fact: The rates with which ADHD is diagnosed vary so much primarily due to diagnostic criteria and measurement methods used.

by Eric Taylor, FRCP FRCPsych(Hon) FMedSci

When people say that “ADHD is overdiagnosed” they are usually referring to the routine practice in a particular region or country.

The rates with which ADHD is diagnosed do indeed vary so much in different places that it is natural to consider the possibilities both of over- and under- diagnosis. Both can apply in different countries and at different times.

In Europe, the rates for diagnosis have mostly been rising, often from a very low level in the 1980s.

• In the UK, when families are asked if their child has ever received a diagnosis from any source, the rates for children of school age are around 1.2%. However, from the analysis of a primary care database the rate is only 0.51%.
• In Germany, the equivalent rate has been estimated at 2.2% for full diagnosis and 4.8% for “ADHD features.”
• In France, a representative population survey found that 3.5% of children had been treated for inattention and/or hyperactivity.

In the USA, by contrast, rates are rather higher and vary from state to state. In 2007, a national survey of parents found that 9.5% of children aged 4 to 17 had received a diagnosis.

How do these rates compare with the actual rates of ADHD in the populations?

Does this mean that ADHD is overdiagnosed in the USA and underdiagnosed in Europe? Not necessarily. To answer that, we must ask how these rates compare with the actual rates of ADHD in the populations.
The true rates are not so easy to define.

Inattention and hyperactivity-impulsiveness are distributed as dimensions in the community. There is no unchallengeable neurobiological cut off to establish what levels should or should not be regarded as a disorder. Accordingly, the research diagnosis of ADHD is based on international consensus and longitudinal research.

Many studies in many countries have agreed that this research diagnosis represents a valid medical syndrome, with characteristic predictions to neurobiology, psychological function, course and treatment outcome.
Epidemiological research has found prevalence does not vary much between countries. The most authoritative reviews of studies put its prevalence at about 7% of children internationally. The differences are based mainly on the exact diagnostic criteria and measurement methods adopted.

These figures for rates of research disorder can be seen in more detail in a recent review .

In short, in Europe there are much higher figures for the actual rates of ADHD (the research prevalence) than for the rates with which ADHD is recognised (the administrative prevalence). The conservative implication is that more than half of the affected children at any one time have never been identified as such – or, even if they have been, the information has not reached the family. This obviously does not imply over-diagnosis.

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ABOUT THE AUTHOR

Eric Taylor FRCP FRCPsych(Hon) FMedSci is Emeritus Professor of Child and Adolescent Psychiatry at King’s College London Institute of Psychiatry, Psychology and Neuroscience. He has received the Ruane Prize from NARSAD, the Heinrich Hoffman medal from the World ADHD Federation, an ADDISS Award, and the inaugural President’s Medal from ACAMH.

Read more myths about living with ADHD

References

Taylor, E. (2017). Attention deficit hyperactivity disorder: overdiagnosed or diagnoses missed?. Archives of Disease in Childhood, 102(4), 376-379.

FACT: Researchers do not yet know exactly what causes ADHD.
Brain-imaging studies show that differences in brain structure and wiring cause problems with attention, impulse control and motivation.

by Elaine Taylor-Klaus

For parents of kids with ADHD, the struggle is real. As an invisible condition, ADHD is difficult to diagnose and treat. In addition, children are often stigmatized as ‘behavioral problems’ because their underlying neurological condition is not evident to the outside world.

Parents of kids with ADHD encounter a wide range of unexpected behaviors from their children, whose brains are wired to be impulsive, disorganized, hyperactive, distracted and/or emotionally intense. They are required to manage complicated medical, academic and emotional problems, and, more often than not, with minimal guidance. To add insult to injury, traditional paradigms for parenting are often not only ineffective, but counter-productive for children with ADHD.

It’s a vicious cycle.

We generally set expectations for children based on their age. As a result, a child who is lagging developmentally can appear willfully rude, disobedient or lazy. For children with ADHD, developmental delays in certain areas of the brain only show up by about three years of age compounding the problem.

When we hold children with ADHD to a level of performance that is not appropriate to where they are developmentally, we set them, and ourselves, up for failure. We fail to recognize that:

• Challenges in working memory make it difficult for our kids to learn from their mistakes.
• Challenges with impulsivity make it difficult for them to stop and think before they act.
• Challenges with frustration intolerance make it difficult for them to behave with respect.

When we judge children with ADHD as naughty, we miss the opportunity to help them learn self-management with their self-esteem intact.

FACT: Parents are essential to a child’s treatment plan.

According to the CDC, parents rarely receive referrals or encouragement to seek parent training, support and guidance.

Back to the vicious cycle. When parents follow the guidance of traditional parenting “experts,” and they don’t see improvement, they begin to feel like they are failing as parents. Their stress rises, which leads to a more reactive approach to parenting.

This is exacerbated by friends and family who judge their parenting with well-meaning suggestions like:

• “You’ve got to stop babying him.”
• “If you would only set some guidelines, she would be fine.”
• “You just need to be more consistent.”
• “They just need you to discipline them.”

When parents accept the accusation that they are bad parents, they lose confidence in their intuition. They miss opportunities to stay connected with their kids so that they can help them get to know and manage themselves.

As many leading experts will tell you, while ADHD is certainly not caused by bad parenting, it can definitely cause bad parenting. Excessive stress and aggravation create a negative cycle of behaviors that are unhelpful to the child, and eventually damage the relationship between parent and child, and often between spouses.

Contrary to popular opinion, children with ADHD are not misbehaving because they’re naughty; their parents are usually doing the best they can under extremely difficult circumstances.

Call to Action

Rather than judging parents as the cause of their children’s behaviors, professionals must take a more active role in following medical protocol. Every parent of a child diagnosed with ADHD should be informed that they play a key role in their child’s treatment.

Parent training in behavior management (also known as “behavior therapy”) is a first-line recommended treatment, alongside medication, for any child with ADHD.

Until parents are routinely encouraged to seek support, training and guidance that goes beyond basic information about the condition, the myth that ADHD is caused by poor parenting will be perpetuated.

Adapted from Elaine Taylor-Klaus’ upcoming book, The Essential Guide to Raising Complex Kids with ADHD, Anxiety and More, Quarto Press, July, 2020. Elaine is the CEO and co-founder of ImpactADHD.com

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ABOUT THE AUTHOR

Elaine Taylor-Klaus is the co-founder of ImpactADHD.com, the creator of Sanity School®, and the co-author of Parenting ADHD Now! Easy Intervention Strategies to Empower Kids with ADHD.

This article was adapted from Elaine Taylor-Klaus’ upcoming book, The Essential Guide to Raising Complex Kids with ADHD, Anxiety and More, Quarto Press, July, 2020.

Read more myths about living with ADHD

References

• What is Recommended Treatment for ADHD?
• What is Behavior Therapy? (part 1)
• What to Look for in a Behavior Therapy Program (part 2)
• CDC Report Says Doctors Aren’t Following Guidelines for Treatment of Children with ADHD
• Recommended Treatment

FACT: Boys are diagnosed two to three times as often as girls, but about 4.2% of girls have received a diagnosis of ADHD at some point in their life (and that’s not none!).

By Michelle Frank, Psy.D.

Since ADHD was first studied in the late 1700’s, it has predominantly been studied in boys: white, hyperactive, school-aged boys, to be specific. While research on girls and women is growing at exponential rates, the myth that ADHD is a condition of boyhood has gotten in the way of adequate diagnostic and treatment services for millions of girls and women with ADHD over the centuries (yes, centuries).

According to a prominent study by the National Institute for Mental Health in 2011, about 4.2% of females have received a diagnosis of ADHD at some point in their life. However, we are still learning whether these numbers actually reflect incidence or whether rates of diagnosis for girls and women continued to be under reported.

Boys are diagnosed two to three times as often as girls, and they are also more likely to be diagnosed early in life. Researchers are currently investigating whether there is a true difference in incidence of the condition between males and females, or whether differences in rates of diagnoses are due to other factors such as gender bias or variations in presentation of symptoms.

Overall, however, women and girls are less likely to be properly diagnosed with ADHD, with boys and men being more likely than girls and women to be referred for services even when their symptom profiles are exactly the same.

Not all people with ADHD are hyperactive

The myth that all people with ADHD are hyperactive likely accounts for another reason that girls and women with the condition go overlooked.

Girls and women are less likely to present with hyperactive or externalizing behaviors compared to boys and are more likely to be diagnosed with the Predominantly Inattentive Presentation of the condition. Inattentive symptoms can easily be overlooked or misperceived and are less likely to lead to a referral for evaluation. Inattentive symptoms, for instance, are less likely to cause a classroom disturbance that gets the teachers’ attention. Further, clinicians and researchers are beginning to wonder if current diagnostic criteria accurately reflect the condition for girls and women.

Women and girls with ADHD have a higher incidence of depression and anxiety. This could, in part, be due to a tendency of girls and women to exhibit internalizing behavior while boys and men in general are more likely to display behaviors that are more externalizing.

Many are initially referred for treatment due to symptoms of anxiety and depression, while symptoms of ADHD are missed. A number of complex and nuanced factors further influence the female experience of ADHD, including fluctuating estrogen levels impacting symptoms and gendered expectations of behavior that might complicate how symptoms are perceived.

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ABOUT THE AUTHOR

Dr. Frank is a licensed clinical psychologist specializing in providing diagnostic and treatment services to individuals with ADHD. Dr. Frank is the co-author of A Radical Guide for Women with ADHD: Embrace Neurodiversity, Love Boldly, and Break Through Barriers, written in collaboration with Sari Solden and published by New Harbinger. Dr. Frank has been an active member of both ADDA and CHADD and has presented both locally and nationally on ADHD, women’s issues, and neurodiversity.

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References

https://www.nimh.nih.gov/health/statistics/attention-deficit-hyperactivity-disorder-adhd.shtml

https://www.tandfonline.com/doi/abs/10.1080/15374410903103627

https://link.springer.com/article/10.1007/s00787-018-1211-3

Fact: Everyone does not have a physical difference in their brain.

by the Attention Deficit Disorder Association (ADDA)

When people say things like, “Everyone has a little bit of ADHD these days!” they mean everyone exhibits some behaviors like the symptoms of ADHD.

They don’t mean everyone has a physical difference in their brains. It’s more like, “Everyone is a little distractible, forgetful or impulsive these days!”

They probably don’t make these comments to be mean. They’re trying to “normalize” challenges. But declaring “everyone” has a “little bit” of ADHD is inaccurate. It is also hurtful and dismissive of the real struggles people with ADHD go through every day.

The symptoms of ADHD exist within a continuum of typical human behavior. Most people lose their keys from time to time. They tune out in meetings. They’re late to class. And they have trouble delaying gratification. But these behaviors are not the same as ADHD. They are human behaviors or experiences that occur for many reasons. With ADHD, the reason is neurological in origin. It is not a choice, a fluke, or a bad day.

ADHD is a brain-based, often chronic, lifelong syndrome.

It gets in the way of the smooth operation of self-regulatory functions of the brain. Ongoing neurological studies find many differences in the ADHD brain. The structure, volume, chemical activity and communication pathways in the brains of people with ADHD are different than those without.[1] [2] Scientists have linked several genes to the condition.[3]

People with ADHD show behaviors resulting from this inner dysregulation. These behaviors include forgetfulness, distractibility, impulsivity and an inability to focus. For people with ADHD, these behaviors are disruptive. And they happen more often, with greater intensity, severity, and chronicity than for people without ADHD.

Further, when people with ADHD try to change, they often can’t course-correct the way others can. People with ADHD have more negative consequences from their challenges than the average. They earn less and incur more debt. They struggle with academic and workplace performance. They even face greater risk of physical injury.[4]

It is true everyone can be forgetful and distracted sometimes; and it’s also true that the vast majority of people – around 90-95% – do NOT have ADHD[5].

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About the Author

ADDA is the world’s leading adult ADHD organization. An international 501(c)3 non-profit organization, we were founded over twenty-five years ago to help adults with Attention Deficit Hyperactivity Disorder (ADHD) lead better lives. ADDA has become the source for information and resources exclusively for and about adult ADHD. We bring together scientific perspectives and the human experience to generate hope, awareness, empowerment and connections worldwide in the field of ADHD. If you’re an adult with ADHD, (or you love one), discover how we can help make your (or their) life better at add.org.

Resources

[1] Friedman, L.A., and Rapoport, J.L. Brain development in ADHD. Current Opinion in Neurobiology, Volume 30, 2015, Pages 106-111. https://doi.org/10.1016/j.conb.2014.11.007.

[2] Tang C, Wei Y, Zhao J, Nie J: Different Developmental Pattern of Brain Activities in ADHD: A Study of Resting-State fMRI. Dev Neurosci 2018;40:246-257. doi: 10.1159/000490289

[3] https://www.bbrfoundation.org/content/first-robust-genetic-markers-adhd-are-reported

[4] Matza, L. S., Paramore, C., & Prasad, M. (2005). A review of the economic burden of ADHD. Cost effectiveness and resource allocation : C/E, 3, 5. doi:10.1186/1478-7547-3-5

[5] https://www.cdc.gov/ncbddd/adhd/data.html

FACT: Parents do not cause ADHD. The disorder comes from the accumulation of many environmental and genetic risk factors.

Stephen V. Faraone, PhD.

The idea that parents cause ADHD arose from the naïve observation that children with ADHD frequently misbehaved, along with the belief that misbehavior was a sign of poor parenting.

Although it is true that lax parenting can lead to misbehavior, there is no evidence that lax parenting leads to the inattention, hyperactivity and impulsivity that define ADHD.

The myth that bad parenting causes ADHD also comes from the fact that when psychologists teach parenting skills to parents, the behavior of the child improves. While this is true, it is also true that teaching parenting skills does not markedly improve the symptoms of ADHD.

Another reason for not blaming parents is that a very large body of scientific studies has discovered the causes of ADHD symptoms

• the genes we inherit from our parents and
• adverse environments to which we are exposed.

We initially suspected genetic causes of ADHD from the simple observation that ADHD runs in families. If one child has ADHD, their brothers and sisters and more likely to also have ADHD compared with the average child.

Twin Studies

There have also been many twin studies of ADHD from Europe, the United States and Australia. There are two types of twins. Identical twins are genetic copies of one another. They share 100 percent of their genes. Fraternal twins are like regular brothers and sisters. They only share 50 percent of their genes.

All of the twin studies show that if one twin has ADHD, the probability that the other twin has ADHD is much greater if the twins are identical. This is very strong evidence that genes are involved in causing ADHD.

Very recently, I worked with an international group of over 100 scientists and clinicians to study the genetic material (DNA) of 20,183 people diagnosed with ADHD and 35,191 not diagnosed with ADHD. When we compared these two groups, we found convincing evidence that 12 areas of the human genome harbored risk genes for ADHD. These data also proved that there were many more risk genes to discover. The total number is unknown but it could be in the thousands. The data also showed us that each gene had only a very small impact on the risk for ADHD.

The twin studies also proved that there must be some environmental risk factors for ADHD. We know that because if one identical twin has ADHD, the risk to the co-twin is not 100 percent. Scientists have discovered many environmental risk factors for ADHD. Most of these risks occur very early in the development of the brain. For example, children who have complicated births are at higher risk for ADHD, especially if the complication affects the flow of oxygen to the brain. When children are exposed to toxins (e.g., lead, pesticide, pollution), that can also increase the risk for ADHD.  Like the genetic risk factors, the environmental risks each, individually have a very small effect on the probability of developing ADHD.

In rare cases, ADHD can arrive from a single cause. Examples are extreme environmental deprivation or large re-arrangements of the chromosomes. But I and other scientists who study ADHD have concluded that most cases of ADHD are due to the accumulation and interaction of many environmental effects that change the brain in a manner that leads to the symptoms of ADHD. So, let’s not blame parents for the ADHD in their children. That simply does not square with the facts.

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ABOUT THE AUTHOR

Stephen Faraone, PhD, is a Distinguished Professor in the Departments of Psychiatry and Neuroscience & Physiology at SUNY Upstate Medical University, President of the World Federation of ADHD and Program Director for www.ADHDinAdults.com. His research studies of ADHD include epidemiology, neurobiology, and psychopharmacology.

Read more myths about living with ADHD

References

Faraone, S. V. & Larsson, H. (2019). Genetics of attention deficit hyperactivity disorder. Mol Psychiatry 24, 562-575.

Faraone, S. V., Asherson, P., Banaschewski, T., Biederman, J., Buitelaar, J. K., Ramos-Quiroga, J. A., Rohde, L. A., Sonuga-Barke, E. J., Tannock, R. & Franke, B. (2015). Attention-deficit/hyperactivity disorder. Nat Rev Dis Primers 1, 15020.

FACT: The therapeutic use of stimulant medications for ADHD prevents addiction

By Stephen V. Faraone, PhD

There are two classes of stimulant medications for ADHD: methylphenidate (MPH) and amphetamine (AMP). Each of these medications is available in several long and short acting formulations, the availability of which differs among countries. Examples of MPH products are Ritalin, Concerta and Medikinet. Examples of AMP projects are Lysdexamfetamine, Dyanavel XR and Evekeo.

The different formulations affect how the drug is delivered to the brain and are designed to modulate the speed of uptake and the length of time the drugs work during the day.

Despite these differences, medications in each class contain the same drug, either MPH or AMP. Both drugs are potentially addictive but their ability to cause addiction depends on how they are used.

Drug addicts enjoy drugs when they reach the brain quickly. For that reason, they prefer forms of MPH or AMP that can be injected or snorted (sniffed through the nose).

In the 1960s and 1970s, many animal model studies showed that MPH and AMP would cause addiction. This caused much concern until researchers realized that they had made a crucial error. They had injected large quantities of the drug into the animal (usually a rat or a mouse) rather than giving the drug orally in the way it is used therapeutically for ADHD.

When researchers at the University of California in San Diego gave these drugs orally with doses that were comparable to therapeutic doses, they found no evidence for addiction. That finding is now widely accepted.

Importantly, the finding is also consistent with the fact that physicians do not observe addiction among their patients with ADHD who use the drug in oral, therapeutic doses.

Concerns have also been raised about the non-medical use of stimulant medications, especially among young adult college students who will use these medications in the hopes that they will improve their studying ability (e.g. by staying up late) or for mixing with alcohol at parties to say awake. This is indeed a problem, but it is not related to the prescribed use of these medications by patients with ADHD. Nonetheless, it has contributed to the perception that these medications cause addiction.

About 15 years ago, I realized that the longitudinal studies of patients with ADHD (i.e. repeated observations of people over short or long periods of time) could help us better understand whether the prescribed use of stimulant medications caused addiction.

Stimulant medication in childhood does not lead to addictive disorders later

With my colleagues at Harvard Medical School and the Massachusetts General Hospital, I reviewed all available studies. We found no evidence that the use of stimulant medications for ADHD in childhood led to addictive disorders in adolescence or adulthood.

Instead, we found some evidence that the stimulant medications for ADHD protected patients from subsequent addictive disorders.

Additional evidence for a protective effect of stimulant medications came from a Swedish study of commercial health care claims from 2,993,887 adolescent and adult ADHD patients. The authors concluded:

These results provide evidence that receiving ADHD medication is unlikely to be associated with greater risk of substance-related problems in adolescence or adulthood. Rather, medication was associated with lower concurrent risk of substance-related events and, at least among men, lower long-term risk of future substance-related events.

This confirmed an earlier report from Sweden based on a study of 26,249 men and 12,504 women with ADHD.

So, the data are clear and unequivocal. When used therapeutically, the stimulant medications for ADHD do not cause addiction. Instead, because these medications control the symptoms of ADHD, they reduce the likelihood that a child with ADHD will, eventually, develop a substance use disorder.

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ABOUT THE AUTHOR

Stephen Faraone, PhD, is a Distinguished Professor in the Departments of Psychiatry and Neuroscience & Physiology at SUNY Upstate Medical University, President of the World Federation of ADHD and Program Director for www.ADHDinAdults.com. His research studies of ADHD include epidemiology, neurobiology, and psychopharmacology.

Read more myths about living with ADHD

References

Kuczenski, R. & Segal, D. S. (2002). Exposure of adolescent rats to oral methylphenidate: preferential effects on extracellular norepinephrine and absence of sensitization and cross-sensitization to methamphetamine. J Neurosci 22, 7264-71.

Wilens, T., Faraone, S. V., Biederman, J. & Gunawardene, S. (2003). Does Stimulant Therapy of Attention Deficit Hyperactivity Disorder Beget Later Substance Abuse? A Meta-Analytic Review of the Literature. Pediatrics 111, 179-185.

Quinn, P. D., Chang, Z., Hur, K., Gibbons, R. D., Lahey, B. B., Rickert, M. E., Sjolander, A., Lichtenstein, P., Larsson, H. & D’Onofrio, B. M. (2017). ADHD Medication and Substance-Related Problems. Am J Psychiatry 174, 877-885.

Chang, Z., Lichtenstein, P., Halldner, L., D’Onofrio, B., Serlachius, E., Fazel, S., Langstrom, N. & Larsson, H. (2014). Stimulant ADHD medication and risk for substance abuse. J Child Psychol Psychiatry 55, 878-85.

Faraone, S. V., Rostain, A. L., Montano, C. B., Mason, O., Antshel, K. M. & Newcorn, J. H. (2019). Systematic Review: Nonmedical Use of Prescription Stimulants: Risk Factors, Outcomes, and Risk Reduction Strategies. J Am Acad Child Adolesc Psychiatry.