This is an important issue. According to Centers for Disease Control and Prevention (CDC), the percentage of children with an ADHD diagnosis continues to increase, from 7.8% in 2003 to 9.5% in 2007 and to 11.0% in 2011. The CDC also notes that the base rates for ADHD varies substantially by state ranging from a low of 4.2% in Nevada to a high of 14.8% in Kentucky.
Since the prevailing belief about ADHD is that it is caused by an underlying biogenetic delay, it is imperative for those who ascribe to the biological determinist view to account for the increased prevalence of ADHD by asserting that we are simply getting better at identifying people who possess the disorder. For zealots of biological determinism, we are merely getting better at “discovering” the hidden ADHD which exists out there in the world. However, they caution that diagnosis should always be done by a professional who truly understands the specific criteria necessary to make the diagnosis; it is imperative that evaluations are accurate.
Alternatively, if the increased prevalence of ADHD originates from psychosocial factors, the biological determinist belief system tarnishes. The diagnostic label would no longer imply a diluted biological system spouting from genetics, but an artifact of societal emphasis.
It is therefore not surprising that advocates of ADHD biological determinism assert that the high frequency rates of ADHD are due to improvements in identifying people who “have” ADHD. They believe that there is substantially more ADHD to be found, and that the real problem is getting treatment for people with the disorder who are not yet detected.
A Different View
ADHD has always been a relatively popular diagnosis so it is not surprising that its rate of occurrence is relatively high. However, important socio-political trends may help to explain the sharp increase in the base rates for ADHD that we are currently seeing.
These trends include:
- With so much talk about ADHD in the media, and with doctors, family, and friends, people wonder if the diagnosis pertains to them. And the more people hear about ADHD the more they see it in themselves and others.
- People who struggle want to know why they struggle and they want a remedy. The diagnosis helps to rationalize failures and it permits quicker access to accommodations and services.
- Researchers seek diagnoses to help them organize their investigations of etiologies and treatments for problematic behaviors.
- Pharmaceutical companies seek diagnoses so that they can coordinate medicinal treatments with specific kinds of functional impairments. A diagnosis helps to create a marketplace.
- Schools seek diagnoses to justify giving individuals extra services and to excuse achievement scores that do not meet performance expectations.
- Doctors (and other practitioners) seek diagnoses so they can recommend appropriate therapies (including giving a pill).
- Insurance companies insist on diagnoses to legitimize payments for “medical necessity.” If providers of health care want payment, they must assign a diagnosis.
- With early intervention in mind, many facilities and practitioners are now utilizing “screening tools” to identify unrecognized diagnoses in people. While there are merits to this endeavor, quite often there are high rates of false positives when relying on these tools. The end result is greater numbers of people receiving a diagnosis such as ADHD.
- Many different groups promote the assignment of an ADHD diagnosis, and the outcome is more ADHD. Other ways to classify, understand, and help individuals fall by the wayside. Since diagnosis coordinates with scholarly research, medication, accommodation, and financial reward, there is great interest in utilizing the extant diagnostic system.
- It is not surprising that the base rates for ADHD are exceptionally high. The diagnostic category encompasses behaviors that are prevalent throughout childhood (e.g., negligence of the perspective of others, lack of responsibility, intrusiveness, desperation, antagonism, and avoidance). Since these behaviors occur so frequently with so many people, it is not shocking that large numbers of people qualify for the diagnostic category. And when there are more people finding it difficult to meet societal expectations, there will be more people qualifying for the diagnosis.
A final note: The base rate for ADHD always depends on the criteria employed. If the criteria are lenient, then more people will receive the diagnosis. And if there is societal backlash protesting the excessively high rates of ADHD, then people will advocate for more stringent criteria. However, when that endeavor lowers the frequency rates, we will not be discovering less ADHD, we will simply be changing the rules.
Akinbami, L. J., X. M. Liu, P. N. Pastor, and C. A. Reuben. 2011. “Attention Deficit Hyperactivity Disorder among Children Aged 5–17 Years in the United States, 1998–2009.” NCHS Data Brief No. 70. August.
Are Schools Driving ADHD Diagnoses? How accountability laws may influence the rising rates of kids with the disorder. Child Mind Institute.
Wiener, C., Parenting Your Child with ADHD: A No-Nonsense Guide for Nurturing Self-Reliance and Cooperation. Oakland, CA. New Harbinger Publications. 2012.
Wiener, C. Attention Deficit Hyperactivity Disorder as a Learned Behavioral Pattern: A Return to Psychology. Lanham, MD: University Press of America, 2007.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.
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