The study’s findings are striking: About one in 10 kids in the U.S. has a diagnosis of attention-deficit hyperactivity disorder (ADHD).
That’s a big jump from some 20 years ago when 6.1% of kids were believed to have ADHD. The current rate is higher than other nations, and it means that in every American classroom, several students will have the disorder that can overwhelm them — and their teachers, parents and peers.
But, as the study – published in JAMA Pediatrics – shows, there’s a nuanced story to be told about ADHD and much we don’t know. The disorder can impair a child’s ability to focus, lead him to act on impulse and put him constantly on the move. Grades, confidence and relationships can all be impacted. A child with ADHD may even receive punishment for behaviors over which there’s little control. Yet, no one really knows the cause of ADHD, why it’s on the rise, why its rates are higher in the U.S. than in other nations and whether its current treatments are the best ones.
For insight into these questions, I spoke with Lane Strathearn, a co-author of the study and the physician director of the Center for Disabilities and Development at the University of Iowa Hospitals & Clinics.
It sounds like there’s a mushrooming of cases. How would you describe what’s going on?
There’s a consistent picture across a long period of time — about 20 years — of ongoing increase. It’s not just a fad. Of course, what the paper can’t tell us is why there’s that increase. That’s the interesting part.
Could it be that we’re finding what was already there — that we’re just better at looking for and identifying ADHD?
I think that’s definitely part of the picture. It’s very similar to autism, where you’ve also got rising rates. The question there is effectively the same question: Is it just that we’re recognizing it more? Is it just that we’re diagnosing it on paper more now? Or, is there an actual increase in the number of children who are living with it? That is a really critical question.
With both ADHD and autism, the predominant thought is that there are genetic causes. In ADHD, we believe there are some children who have a genetic variation that leads to increased difficulty paying attention, hyperactivity and difficulty concentrating and focusing. If that’s true, then genes don’t change this fast. If there is a true increase in the number of children with ADHD, then we’ve got to be looking beyond genetics.
So, it’s believed that a person may be genetically predisposed, but then there may be triggers that make ADHD come out?
Yes, that’s my thinking and I think there are other people who think that way as well.
What are your thoughts on the U.S. having higher rates than other nations?
My particular bias in this is I’m a developmental pediatrician. I do research on early infancy and parent-infant relationships. Early experience to an attachment relationship is a predictor of attention and concentration. It’s an environmental factor relating to early care-giving and parenting. Seeing this rise in ADHD makes me wonder about what we’ve noticed on a societal level — changes and patterns in infant care-giving — and whether that may be playing a role. But that’s a little out there. There’s not a whole lot of research backing up my hypothesis.
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ADHD is often diagnosed with another condition. Do you think it’s possible that, say, 20 years ago, a child may have been diagnosed with, say, autism and now would be diagnosed with autism and ADHD?
That could be. When you’re dealing with conditions that are diagnosed based on a checklist of behaviors, which is the case with ADHD and autism, you’re simply observing behaviors and rating whether they meet certain criteria. There are no blood tests, there’s no brain scan, there’s no other physiological measurement that says that this child has ADHD, and this child doesn’t. It’s sort of like a headache. It can be caused by stress, lack of sleep or a brain tumor. The manifesting symptom doesn’t tell you very much at all about what might be leading to that symptom.
Children who have experienced trauma, abuse or neglect, for example, often exhibit symptoms that are indistinguishable from ADHD. They are hyper-aroused, hyperactive and less attentive because their brains have developed to be alert to any danger cues in their environment. When these kids get in the classroom, learning how to spell or do math is low on their priority list. Their brain is organized to respond to threat. In most cases, putting these children on medication does them a great disservice because we’re not addressing the core problem. We’re actually giving them medication that counteracts their survival mechanism. That’s just a simple example, and I’m not saying every child with ADHD has experienced abuse or trauma.
A lot of people almost equate an ADHD diagnosis with a Ritalin prescription. What are your thoughts?
There is absolutely no doubt that medication such as Ritalin improves attention and concentration. You take the medication and within a half hour you see a dramatic change in behavior. That’s why it’s become so widespread. It does the job. And, of course, we’ve been using stimulants for a long time. There have been a lot of studies and there haven’t been any major red flags, so that’s reassuring. But, there’s still a lot of unanswered questions.
What isn’t so clear is what are the long-term benefits, and are there any?
People assume that if the child is able to sit and pay attention, that they’re going to do better in school. But that isn’t really borne out by the research. It’s not that clear. Their behavior is better, but is it actually helping them developmentally in the long run? That’s a little bit more murky. It leads us to the question of who or what are we treating? Are we treating the child? Are we treating the parents? Are we treating the teacher to make their life easier in the classroom? Who is getting the benefit from this in the long run?
Another option is behavioral therapy, correct?
That’s correct, but obtaining behavioral therapy is challenging — finding the resources, finding the practitioners. It’s expensive. It takes a long time. It may be months of working with the therapist versus instantaneously with one pill, which would you rather do?
And medication is cheaper than providing therapy.
But, in the long run, maybe it’s not that cheap. You still end up with kids who become adults that still have the same difficulties. To me, if therapy can actually provide a coping mechanism for the child that can support them in the future, that is more important and valuable than a solution that kicks in and then in four to eight hours is gone.