by Pamelynn Esperanza MD, and John T. Walkup, MD
THE PREVALENCE OF ADHD has been steadily increasing over the last three decades. The CDC’s best prevalence estimate is between nine and eleven percent for children and adolescents. A recent study of parent-report of a clinician-diagnosed case of ADHD indicates that eleven percent of children have received a diagnosis of ADHD at some time, 8.8 percent currently carry the diagnosis, and 6.1 percent—about seventy percent of those currently diagnosed—are receiving medication. Increases in all three categories have occurred since the CDC started collecting these data early in 2000. As a result, ADHD is now the second most frequent long-term diagnosis made in children, narrowly trailing asthma.
The reported rise in the rates of diagnosis and treatment is controversial. Many experts and the public strongly suspect overdiagnosis due to a variety of factors, but often cite direct marketing to doctors and consumers by the pharmaceutical industry. For instance, a well-publicized New York Times article argues that ADHD is being overdiagnosed, stating that up to fifteen percent of high school children now carry the diagnosis and that the number medicated has grown to 3.5 million, up from only 600,000 in 1990.
However, an alternative interpretation of the CDC data is also possible. The increase in ADHD diagnosis and treatment may reflect progress from the enormous effort by the federal government, advocacy organizations like CHADD, and the training of primary care providers to improve recognition and treatment of ADHD. Rather than a cause for shock and alarm, the recent data may indicate that we may be reaching a point where children and adolescents with ADHD have a chance to be identified and treated with an evidence-based medication early in the course of ADHD.
Although substantial increases in the rate of diagnosis and treatment of ADHD have occurred over the past decade, the CDC’s rate of clinician-diagnosed prevalence (8.8 percent) is very close to the community-based prevalence (nine to eleven percent), ascertained in high-quality epidemiologic studies. Further, the data seem to indicate undertreatment, rather than systematic overtreatment. The rate of stimulant-treated children with ADHD is actually lower (6.1 percent) than the currently diagnosed prevalence of ADHD (8.1 percent), suggesting that only seventy percent of diagnosed cases are on medication. That leaves approximately thirty percent of children and adolescents diagnosed with ADHD who are not receiving medication treatment. Critically, though not every child with ADHD requires medication therapy, it remains the main evidence-based treatment for the condition.
The media and the public have focused attention on the change in the rates of diagnosis and treatment. If we consider the similarity between the current diagnostic/treatment rates and community- based prevalence rates, it becomes clear that rather than being alarmed, we should be grateful that our efforts to spread the word about ADHD and improve the rate of recognition and treatment are largely successful. That said, are some children getting the diagnosis and being treated with medication who don’t have ADHD? The answer to that is likely “yes.” But the historical problem of under-recognition and undertreatment may be a thing of the past.
We may be approaching a time when all children and adolescents with this illness will receive proper disease assessment and appropriate evidence-based therapy. And this, of course, is the goal of all well-intentioned parents and providers: to identify ADHD, treat it effectively, and maximize each child’s well-being.
Pamelynn Esperanza, MD, is assistant professor of psychiatry at Weill Cornell Medical College and an assistant attending psychiatrist at New York- Presbyterian Hospital. She is both a pediatrician and child, adolescent, and adult psychiatrist.
John T. Walkup, MD, is professor of psychiatry, vice chair of psychiatry, and director of the division of child and adolescent psychiatry at Weill Cornell Medical College and New York-Presbyterian Hospital.