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ADHD Rising in the U.S., but Why?

child with ADHD

Nov. 20, 2018 -- Scott Young distinctly remembers the first teacher who tried to talk with him about attention deficit hyperactivity disorder (ADHD) in connection with his oldest son, Jonathan. The stay-at-home dad in Charlotte, NC, says the teacher reached out several times but he consistently and purposely blew her off.

“One of Jonathan’s preschool teachers had tried to talk with me when he was about 4 1/2 and I wouldn’t listen,” Young says. “She always wanted to get together and talk about issues, and one day she caught me in the carpool line and said I would love to get together with you and talk about some things I’ve seen with Jonathan. I knew what she was getting at and I didn’t want to hear it. I didn’t believe ADHD existed.”

But by the time his son was in kindergarten, Young says there was no avoiding the conversation. He and his wife knew their son was smart but could see him falling behind in school as he struggled with academics, focus, and behavior. The parents reached out to a psychologist to have their son evaluated, and that doctor finally helped the couple understand and come to terms with what was going on with their boy.

“As soon as we sat down, he made his case and I was a believer,” Young recalls. “It was a quick flip, and in 30 minutes I went from not wanting Jonathan to have ADHD and not believing it existed, to knowing this was exactly what he had and understanding that with a diagnosis came a treatment plan to help him.”

That was 14 years ago. Since then, Young’s two other sons -- now 14 and 18 -- have been diagnosed with ADHD, and his wife has, too. All are now on medication to treat the condition. The family has also worked on behavior modification and gotten accommodations at school to help their sons. Young says as his family has become more educated about ADHD, the condition seems to have become more common and the world has become more accepting of it, too.

“My children grew up during a time when ADHD was just starting to gain acceptance. Now everywhere we turn it seems people have children with ADHD. We have definitely seen an increase, and there isn’t the stigma that there used to be -- where our child was the only one in a class not invited to a birthday party or told he couldn’t go on a field trip because he was too active,” Young says.

A flurry of new research is, in fact, showing an increase in both diagnoses and treatment of ADHD. Researchers are looking to better understand the cause of the condition, but many questions remain.

Latest Research on ADHD

A new study published Aug. 31 finds ADHD diagnoses in children between the ages of 4 and 17 increased from 6.1% in 1997-1998 to 10.2% in 2015-2016.

“This is a dramatic change,” explains study researcher Wei Bao, MD, PhD, an assistant professor in the College of Public Health at the University of Iowa. “ADHD was already a common condition in children in the past, and it is becoming even more common. Now 1 in 10 children are affected. This is really high.”

Different studies and groups have reported different ADHD numbers through the years, but Bao’s study, which relied on parent reports, is in line with data that have showed a sharp increase in the disorder that the American Psychiatric Association (APA) says is one of the most common in children. The CDC in 2016 found that 6.1 million children between the ages of 2 and 17 had been diagnosed with ADHD. The agency previously reported a 42% jump in ADHD diagnoses by a health care professional between 2003 and 2011.

The cause of ADHD isn’t known. Genetics certainly play a role. The APA points out that 3 out of 4 children with ADHD have a relative who also has the disorder.  Bao’s study didn’t look at the cause of the rise in ADHD diagnoses, but he says there are likely a number of factors, including increased recognition by doctors about the condition and rising awareness about the disorder among parents and schools.

He says increased rates of diagnosed ADHD among black and Hispanic youths may be a result of increased access to care and decreased stigma in those communities for receiving an ADHD diagnosis. And he says changes in how diagnoses are made likely also contribute to the increased number of children being diagnosed with ADHD.

Researchers have long suspected a variety of other factors contribute, too. They range from chemical imbalances, brain changes or injuries, and habits during pregnancy that affect a child’s development like maternal smoking and drinking alcohol, as well as exposure to pesticides and nutritional deficiencies. Several recent studies have explored other possible environmental factors, too.

Adam Leventhal, PhD, a researcher of the screen time study and a professor of preventive medicine and psychology at the University of Southern California, says the difference in risk was clearer when you compared low users, who had a 4.6% ADHD symptom rate, to high users, who had an ADHD rate of 10.5%. But he stresses this observational study doesn’t lay out a clear cause and effect.

“On one hand, it could be that youth with ADHD are drawn to digital media because they seek out stimulation. On the other hand, it could be the opposite -- digital media exposure could increase risk for ADHD symptoms, which is what we focused on in our study. The reason we hypothesize that media could play a role in ADHD symptoms is because during this time in life, the brain circuits underlying impulse control and ability to maintain focus and sustain attention are developing. Excessive exposure to highly stimulating digital content could alter the natural course of brain development,” Leventhal explains.

“As far as screen time and its impact on ADHD, the chicken or the egg issue is difficult to discern,” says Ghassan N. Atiyeh, MD, a pediatrician in Alexandria, VA. “However, we see in all age groups that even with very significant ADHD symptoms, all these patients are able to remain very attentive to the flashing lights and moving pictures on screens. That stimulation somehow calms the hyperactive/impulsive/inattentive tendencies. Parents, however, very often report that interrupting the screen time leads to anger and outbursts.”

ADHD Basics

ADHD is marked by deficiencies of certain neurotransmitters or chemicals in the brain. As research into the disorder has increased, awareness of the condition has risen, too. It was the most googled medical condition in the first half of 2018.

“ADHD has become common terminology. It has become part of the culture as well as part of the medical world,” explains Peter Conrad, PhD, a sociologist at Brandeis University who has researched ADHD since 1975.

Atiyeh says it’s certainly a condition he is seeing more often in his practice.

There are three types of ADHD: inattentive, hyperactive/impulsive, and a combined type. There is no medical test to identify the disorder, so it's diagnosed based on symptoms seen over at least 6 months. Diagnoses come from a comprehensive evaluation by a licensed clinician, such as a pediatrician or psychologist, who looks for a series of characteristics on a checklist.

While it’s not uncommon for children to sometimes show behaviors like wandering off task; struggling to focus and pay attention; fidgeting; being restless, hyperactive, or talking too much; and getting easily frustrated; the National Institute of Mental Health (NIMH) says when someone has ADHD, these characteristics are “chronic or long-lasting, impair the person’s functioning, and cause the person to fall behind normal development for his or her age.”

The NIMH says symptoms can appear in children as young as 3 to 6, but plenty of people aren’t diagnosed until they are teens or adults. The agency says symptoms “can be mistaken for emotional or disciplinary problems or missed entirely in quiet, well-behaved children.”

“There used to be a stigma that you were a bad kid, defiant, oppositional, or not smart and can’t learn, and I think the stigma is much less now,” explains Rebecca Siegel, MD, a child psychiatrist practicing in New York City for 15 years. “This is a neurodevelopmental disorder that has been around for many years, and schools and parents and society in general are becoming much more aware.”

Left undiagnosed, the condition generally leads to poor performances at school and work, difficult relationships, and potentially unhealthy attempts at self-medication. “The diagnosis is nothing to run away from. It should be something you address head on so your kids can be helped,” Siegel says. “They shouldn’t feel the deck is stacked against them or that they aren’t smart.” 

The disorder isn’t without controversy though. Some think it’s overdiagnosed and that children are being overly and needlessly labeled for behavior that would have been tolerated in years past with more flexible and less competitive school environments. Bao says his study does not have data to assess the possibility of overdiagnosis.

“There is a common perception that ADHD is overdiagnosed in the United States, but a previous study ... indicated that this perception was not supported by available scientific evidence,” Bao says.

Others think medication is too readily being handed out. An October 2018 study that looked at global medication use for ADHD does find its use is on the rise.

The report found an increase in the use of stimulant and nonstimulant medications to treat ADHD in 13 countries that were part of a retrospective, observational study of more than 150 million people.

The authors say there were geographic differences. In some places like Japan, rates of medication prescriptions were lower while rates of medication prescriptions are higher in the United States. The authors say this should be a cautionary note for clinicians to make sure they aren’t overdiagnosing and medicating children.

“There’s no question some people benefit from medication but whether or not all medications are being given appropriately is another question,” Conrad says.

The NIMH says under proper medical supervision, stimulant medications are considered safe, but there are risks. They can raise blood pressure and heart rate and increase anxiety. There are also questions about how and if they affect a child’s growth. In the long term, people with ADHD may have a higher risk of cardiovascular disease, although it’s not known if that is from ADHD or its treatment, and one new study suggests ADHD patients are more than twice as likely to develop early-onset Parkinson’s disease.

Positive Outcomes

The American Academy of Pediatrics recommends families get children evaluated by their primary care doctors if they are having issues with inattention, hyperactivity, or impulsivity. Atiyeh, the Virginia doctor, says when children are properly identified as having the disorder and then treated with a combination of medication, behavioral and family therapy, school support, and interventions, they can flourish.

“When you do have ADHD and it is impacting you negatively socially and academically, then you bet it is a beneficial thing to be diagnosed,” Atiyeh explains. “We know if you have ADHD with impulsive type, you are more likely to engage in high-risk activities like driving drunk, self-medicating, and having unprotected sex as a teen.”

Properly treated, however, children with ADHD show no signs of engaging in riskier behavior more than the average child, Atiyeh says.

“So from that perspective it is a huge benefit,” Atiyeh says.

Finding Success

Siegel, the New York psychiatrist, doesn’t just help other families manage ADHD. She has seen the benefits of treatment personally, too. Her daughter was diagnosed as a child.

“With my own daughter, her self-esteem and self-confidence grew tremendously from all these accommodations and treatments put into place for her. She blossomed,” Siegel explains. “She is now 18 and going to college next year. My own story is one of such hope and tears of joy.”

Young says his family is a success story, too. Today, Jonathan is in college and doing well. His younger brothers are good, too. Young says that doesn’t mean there aren’t still daily challenges. He says parenting children with ADHD requires a lot of patience, flexibility, fostering of good relationships with teachers, holding schools accountable, and setting aside your own expectations of what you want your child to be doing and instead helping them learn, grow, and succeed in their own way, wherever they are.

“My wife and I have faith in our sons, faith in those who love and support us, and after fully embracing the diagnosis of ADHD, our journey has been an exciting and fulfilling ride,” Young says. “Every child with ADHD I have ever met has blown my socks off with how bright and creative they are. These children have so many skills. They will do big things in society.”

WebMD Article Reviewed by Smitha Bhandari, MD on November 26, 2018

Sources

Peter Conrad, PhD, Brandeis University, Waltham, MA.

Ghassan N. Atiyeh, MD, Children’s Medical Associates, Alexandria, VA.

Wei Bao, MD, PhD, University of Iowa College of Public Health, Iowa City, IA.

Adam Leventhal, PhD, University of Southern California, Los Angeles.

Rebecca Siegel, MD, Amen Clinics, NYC.

Scott Young, Charlotte, NC.

American Psychiatric Association: “What is ADHD?”

CDC: “Key Findings: Trends in the Parent-Report of Health Care Provider-Diagnosis and Medication Treatment for ADHD: United States, 2003—2011,” “Key Findings: National Prevalence of ADHD and Treatment: New statistics for children and adolescents, 2016.”

National Institute of Mental Health: “Attention Deficit Hyperactivity Disorder.”

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