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The danger of overdiagnosis amid the childhood ADHD epidemic

Oxford University Press USA

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In barely a decade, the number of U.S. children and adolescents diagnosed with attention-deficit hyperactivity disorder (ADHD) has risen by more than 40 percent, note authors Stephen Hinshaw and Katherine Ellison in their new book, "ADHD: What Everyone Needs to Know". Today, more than six million youths have received diagnoses, amounting to one in nine children aged 4-17. For those older than nine years of age, more than one boy in five has received a diagnosis. Among diagnosed youth, nearly 70 percent receive medication.

The rise in awareness about ADHD -- a sometimes disabling condition involving distraction and impulsivity -- is good news in the sense that many more children are now receiving the attention and treatment they need, say the authors. Yet the rapidly rising rates also point to a danger of over-diagnosis -- and over-medication -- which Hinshaw and Ellison believe may be largely due to clinical carelessness.

"Too many diagnoses are made during a 15-minute appointment in the pediatrician's office," said Hinshaw, a professor at the University of California at Berkeley and a leading international expert on ADHD, who added: "These quick-and-dirty evaluations are a leading factor in overdiagnosis and overtreatment."

ADHD cannot be diagnosed by a blood test or brain scan, as is also true of all other mental-health disorders. Instead, the most accurate way to determine if a child has the disorder is to take a thorough medical history, interview the patient about symptoms, and gather feedback from parents and teachers. It's important in particular to distinguish whether a child has become distracted due to ADHD or several other possible reasons, such as anxiety, trauma, or a sleep disorder. And when ADHD is diagnosed, it's essential for doctors to have follow-up appointments to monitor therapy and adjust medication, if prescribed, as needed.

All of this takes more time and patience than many doctors can spare, especially under constraints from patients' medical insurance. Nonetheless, respected organizations such as the American Academy of Pediatrics and the American Academy of Child and Adolescent Psychiatry support thorough evaluations as the gold standard of diagnosis.

As the authors point out, hasty and incomplete evaluations not only can fuel over-diagnosis but can also prevent clinicians from recognizing ADHD when it does exist. "A child may be able to hold it together without showing any symptoms in a doctor's office for a limited time, so if the doctor doesn't get good information from parents or teachers, it may be easy to decide there's no problem," said Ellison, a Pulitzer Prize-winning journalist and author and co-author of three books about ADHD.

Some of the first indicators of ADHD may include problems with speech and language, forgetfulness, an inability to follow directions, lack of focus during play or while listening to a story, and early pre-reading issues, the authors note.

Professional groups including the American Academy of Pediatrics are now calling for recognition and treatment of ADHD as early as age 4. The goal of such early intervention is to help keep families calm and supportive, reduce injury rates from accidents, which are more common among people with ADHD, and ultimately head off what could be years of failure and demoralization.

Still, as the new guidelines inevitably will lead to even more diagnoses, clinicians must push back against a system that encourages them to rush, say the authors. The risk if they don't is that many children will needlessly suffer side-effects from medication while others will struggle with ADHD without support. "We have to figure out a way to change the incentives so that doctors can give this disorder the attention it demands," said Hinshaw.

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About Hinshaw and Ellison:

STEPHEN P. HINSHAW, PhD, is co-author of the new book, "ADHD: What Everyone Needs to Know" (Oxford Press, Nov 2015). He is an internationally recognized research investigator of child and adolescent disorders, an award-winning teacher, and the author of more than 280 research articles and chapters plus 12 books. He is a professor of psychology at UC Berkeley and vice chair for psychology in the department of psychiatry at UC San Francisco.

KATHERINE ELLISON is co-author of the new book "ADHD: What Everyone Needs to Know" (Oxford Press, Nov 2015). She is a Pulitzer-prize winning reporter and author of several books. She specializes in writing about neuroscience, learning disorders, and education.

Note to Reporters:

For any additional information, or to speak with either Hinshaw or Ellison, please contact: Katherine Cooney, Katherine.cooney@oup.com, 212-726-6111

Any mention or reporting of data from this article should be attributed to the book: ADHD: What Everyone Needs to Know.

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