Everyone seems to be talking about ADHD at the moment – and how we need more diagnoses and more medication, and how the prevalence has significantly increased over the last 1-2 decades. But is ADHD increasing – and are we asking the right questions about how we recognise and treat it. One major international news outlet recently asked that exact question.
Everyone seems to be talking about ADHD at the moment – and how we need more diagnoses and more medication.
And how the prevalence has significantly increased over the last 1-2 decades.
But is ADHD increasing – and are we asking the right questions about how we recognise and treat it. One major international news outlet recently asked that exact question.
Here in New Zealand the Government via the Ministry of Health released a new policy two weeks ago on diagnosing and treating ADHD.
GPs and nurse practitioners will be able to diagnose and treat ADHD from February next year, the Ministry of Health says. The change has been long called for by GP groups and advocates as a way of increasing access and reducing huge wait times for patients seeking a diagnosis.
“Seeking a diagnosis.” That’s an interesting phrase, isn’t it. It’s almost sounds like the patient – or in the case of a child, the parents – has already determined the diagnosis and simply wants treatment, or in this case, medication.
At present, GPs can only prescribe ADHD stimulant medications to patients on the recommendation of a psychiatrist or paediatrician. The wait times for specialists can be up to a year, or longer for children.
….Royal College of General Practitioners NZ medical director Dr Luke Bradford said GPs were now upskilling to be able to be able to provide the new service. The rule change would improve access to diagnosis, he said. But it was a complicated field and patients should not expect quick answers. “It’s not going to be, I’m going to the doctor about my sore knee, and by the way, I always thought I’m not very good at concentrating. Do you think I’ve got ADHD? Can I have some Ritalin? That’s not what is going to happen.”
….Consultant clinical psychologist Dr Melanie Woodfield welcomed the decision to keep ADHD assessment of young people within child health or mental health services. “Assessing ADHD in children is a complex process that aligns well with specialist expertise and resources,” she said. “Of course, we must balance comprehensive, high-quality assessments with timely, appropriate support and this can be challenging given the demands on both specialist and primary care services. “However, assessing ADHD in children requires a thorough understanding of the child’s functioning across different settings (looking wide) and developmental history (looking back).
Now this was an interesting announcement because a specialist GP was censured and suspended last year for breaching the current regulation around prescribing medication for attention deficit hyperactivity disorder (ADHD).
Now the NZ media have been fascinated with this topic. Here’s the stories on the NZ Herald website just this year
Seven lifestyle and environmental triggers that makes ADHD worse.
Five rules every woman with ADHD should know.
ADHD advice – insight into neurodiversity.
Five signs you’re unknowingly masking ADHD.
Study tool helps ADHD students in university success.
I have autism and ADHD – and no friends.
Focusing on a child’s strength after ADHD, autism assessment.
Wild ride into ADHD.
Guy Williams talks about ADHD.
The age of diagnosis – have we got it wrong on ADHD.
I realised I had ADHD at 42.
ADHD – why the right diagnosis matters.
How to explain to someone you have ADHD.
What are the core ADHD symptoms.
This is just since the beginning of the year – just on the NZ Herald website.
But a major newspaper publication The New York Times recently ran a major piece in April which I haven’t seen reprinted in NZ even though the NYT articles are often republished here.
Have we been thinking about ADHD all wrong – By Paul Tough, a contributing writer for the magazine who, for the last two decades, has written articles and books about education and child development.
… The number of American children diagnosed with A.D.H.D. more than doubled in the early 1990s, from fewer than a million patients in 1990 to more than two million in 1993, almost two-thirds of whom were prescribed Ritalin. To Swanson, at the time, that increase seemed entirely appropriate. Those two million children represented about 3 percent of the nation’s child population, and 3 percent was the rate that he and many other scientists believed was an accurate measure of A.D.H.D. among children.
I was interested in the NZ stats for children and ADHD
So this is 2024 – by gender and ethnicity. Maori boys 5x more likely than Asian boys.
But before Te Pati Maori shouts “colonisation!!!”, Maori girls are less than European girls.
Here’s the trend though.
Male 3% – 8% 167% increase.
So is ADHD primarily a condition affecting boys.
OR do we attribute boy’s behaviour to ADHD.
And interestingly, looking at deprivation, boys from richer households are more likely to have ADHD than poorer households – or is that just that the poorer families can’t access healthcare for these types of assessment.
These figures are backed up by research in the NZ Medical Journal which looked at the dispensing of attention-deficit hyperactivity disorder medications, and it showed the same hike – the blue line is the children under 18 – and a three-fold increase. But note this is dispensing of medication. The previous graphs were diagnoses – but may not have been prescribed Ritalin.
And it’s not just the US or NZ.
Here’s some other countries – and you’ll note that at 8% we’re at Canada’s rate (out the right).
And you’ll also note that boys are more likely to be diagnosed with ADHD.
I found this graph fascinating – once I understood it. On the right, it shows the % INCREASE each year. Purple is female. So while boys lead the girls, the growth in the number of girls being prescribed drugs like Ritalin are outpacing the boys.
And you’ll also see the explosion in diagnoses between 20 – 60 year olds. Here in NZ, ADHD medication prescription rates have risen tenfold for adults in the past 16 years.
So it’s not just a childhood issue. Although that’s probably my main focus for this episode.
Continuing with the NYT article:
Despite Ritalin’s rapid growth [in the 90s], no one knew exactly how the medication worked or whether it really was the best way to treat children’s attention issues. Anecdotally, doctors and parents would observe that when many children began taking stimulant medications like Ritalin, their behavior would improve almost overnight, but no one had measured in a careful, large-scale scientific study how common that positive response was or, for that matter, what the effects were on a child of taking Ritalin over the long term. And so [researcher] Swanson and a team of researchers, with funding from the National Institute of Mental Health, began a vast, multisite randomized controlled trial comparing stimulant treatment for A.D.H.D. with nonpharmaceutical approaches like parent training and behavioral coaching.
Good idea. But remember, this is back in the 90s.
The initial results of the M.T.A. study, published in 1999, underscored the case for stimulant medication. After 14 months of treatment, the children who took Ritalin every day had significantly fewer symptoms than the ones who received only behavioral training. Word went out to clinics and pediatricians’ offices around the country: Ritalin worked. This was good news not only for families with children who struggled with attention issues but also for the corporations that offered them pharmaceutical solutions.
…Though Swanson had welcomed that initial increase in the diagnosis rate, he expected it to plateau at 3 percent. Instead, it kept rising, hitting 5.5 percent of American children in 1997, then 6.6 percent in 2000. As time passed, Swanson began to grow uneasy. He and his colleagues were continuing to follow the almost 600 children in the M.T.A. study, and by the mid-2000s, they realized that the new data they were collecting was telling a different — and less hopeful — story than the one they initially reported. It was still true that after 14 months of treatment, the children taking Ritalin behaved better than those in the other groups. But by 36 months, that advantage had faded completely, and children in every group, including the comparison group, displayed exactly the same level of symptoms.
So the benefit wears off. Does that mean the condition wears off?
[The reporter] spent the last year speaking with some of the leading A.D.H.D. researchers in the United States and abroad, and many of them, like Swanson, express concern over what they see as a disconnect between the emerging scientific understanding of A.D.H.D. and the way the condition is being treated in clinics and doctors’ offices. Edmund Sonuga-Barke, a researcher in psychiatry and neuroscience at King’s College London, described the situation in personal terms. “I’ve invested 35 years of my life trying to identify the causes of A.D.H.D., and somehow we seem to be farther away from our goal than we were when we started,” he told me.
“We have a clinical definition of A.D.H.D. that is increasingly unanchored from what we’re finding in our science.”
He then discusses the increasing diagnoses and medication for ADHD – similar to NZ – and says:
That ever-expanding mountain of pills rests on certain assumptions: that A.D.H.D. is a medical disorder that demands a medical solution; that it is caused by inherent deficits in children’s brains; and that the medications we give them repair those deficits. Scientists who study A.D.H.D. are now challenging each one of those assumptions — and uncovering new evidence for the role of a child’s environment in the progression of his symptoms. They don’t question the very real problems that lead families to seek treatment for A.D.H.D., but many believe that our current approach isn’t doing enough to help — and that we can do better.
…A.D.H.D. has always been a controversial diagnosis. Skeptics argue that many of the classic symptoms of the disorder — fidgeting, losing things, not following instructions — are simply typical, if annoying, behaviours of childhood. In response, others point to the serious consequences that can result when those symptoms grow more intense, including school failure, social rejection and serious emotional distress.
So where do you draw the line? How do you tell a normally rambunctious kid from a child with A.D.H.D.? The tool that clinicians use to make that distinction is the Diagnostic and Statistical Manual of Mental Disorders, or D.S.M., which provides a checklist of symptoms to use in diagnosing patients, including nine potential symptoms for inattention and nine for hyperactivity/impulsivity. To qualify for the diagnosis, a child must display six symptoms from either category, of sufficient severity and level of impairment, for at least six months, starting before age 12, and those symptoms must be present in two different settings (like home and school).
That seems pretty scientific — six symptoms, two settings, six months, age 12 — and it reflects a longstanding effort by many in the field to portray A.D.H.D. as a straightforward medical condition with clear diagnostic boundaries….
Now, however, some scientists have begun to argue that the traditional conception of A.D.H.D. as an unchanging, essential fact about you — something you simply have or don’t have, something wired deep in your brain — is both inaccurate and unhelpful.
… The diagnostic criteria in the D.S.M. often require subjective judgment, and historically those criteria have been quite fluid, shifting with each revision of the manual.
A.D.H.D. is defined in the D.S.M. as a neurodevelopmental disorder, but the symptoms of A.D.H.D. can be produced by a variety of environmental causes as well. Difficulty sitting still and sustaining attention can also be symptoms of a serious head injury, fetal alcohol syndrome, childhood lead exposure, early trauma and more. There is also a high rate of overlap between the symptoms of A.D.H.D. and those of other psychiatric disorders, including depression, anxiety, dyslexia and autism. Although the D.S.M. specifies that clinicians shouldn’t diagnose children with A.D.H.D. if their symptoms are better explained by another mental disorder, more than three quarters of children diagnosed with A.D.H.D. do have another mental-health condition as well, according to the C.D.C. More than a third have a diagnosis of anxiety, and a similar fraction have a diagnosed learning disorder. Forty-four percent have been diagnosed with a behavioral disorder like oppositional defiant disorder.
“There is no single-gene story,” says John Gabrieli, an M.I.T. neuroscientist. ‘There literally is no natural cutting point where you could say, “This person has got A.D.H.D., and this person hasn’t got it.”’
F. Xavier Castellanos, a neuroscience researcher at New York University, says
‘There’s a real disconnect between the almost awesome effects on behavior and the minimal effects on academic achievement or attainment.’ What bothers me is that the kids do more seatwork — you can see that they’ve done more problems — but then when you test them a week or two later, their scores barely budge. Or they don’t budge at all. That’s the thing that really frustrates me.”
This effect has turned up in a number of studies over the years, but there are two relatively recent ones that illustrate it well. One was published in 2023 by Elizabeth Bowman, an Australian neuroscientist, and David Coghill, a British psychiatrist. They recruited 40 young adults in Australia, gave some of them stimulant A.D.H.D. medications and others a placebo and then asked them to solve a series of complex tests…
The subjects who were given stimulants worked more quickly and intensely than the ones who took the placebo… In the end, though, their scores … were no better than the placebo group. The reason? Their strategies for choosing items became significantly worse under the medication. Their choices didn’t make much sense — they just kept pulling random items in and out of the backpack. To an observer, they appeared to be focused, well behaved, on task. But in fact, they weren’t accomplishing anything of much value.
A Florida researcher named William Pelham Jr. found something similar in a study published in 2022. … the children taking Ritalin worked faster and behaved better in the classroom than those in the placebo group. But again, they didn’t learn any more than the control group. “Although it has been believed for decades that medication effects on academic seatwork productivity and classroom behaviour would translate into improved learning of new academic material,” the scientists wrote, “we found no such translation.”
So what’s going on? If these studies are accurate, stimulant medications don’t do much to improve cognitive ability or academic performance. And yet millions of young Americans (and their parents) feel that the pills are essential to their success in school. Why?
‘There is no long-term effect. The only long-term effect that I know of has been the suppression of growth.’
There was another distressing result they noticed in their data — a physiological one. The children who took Ritalin for an extended period grew less quickly than the nonmedicated children did. By the end of those 36 months, subjects who had consistently taken stimulant medication were, on average, more than an inch shorter than the ones who had never received medication. Many of the scientists in the M.T.A. group assumed that this height suppression in childhood would be temporary — that the shorter children would catch up during adolescence — but when data was collected again nine years after the initial experiment, the height gap remained.
The author then spoke to students across the country, and asked this question
Can changing a person’s environment really alter their symptoms? In 2016, the M.T.A. research group published a paper that suggested that for many young people, the answer is yes. At that point in the history of the study, the subjects were adults in their mid-20s, able to speak for themselves. So rather than simply collecting data on their symptoms or their height, the scientists asked them questions. They conducted long interviews with 125 of these young adults, all of whom were diagnosed with A.D.H.D. as children.
What the researchers noticed was that their subjects weren’t particularly interested in talking about the specifics of their disorder. Instead, they wanted to talk about the context in which they were now living and how that context had affected their symptoms. Subject after subject spontaneously brought up the importance of finding their “niche,” or the right “fit,” in school or in the workplace. As adults, they had more freedom than they did as children to control the parameters of their lives — whether to go to college, what to study, what kind of career to pursue. Many of them had sensibly chosen contexts that were a better match for their personalities than what they experienced in school, and as a result, they reported that their A.D.H.D. symptoms had essentially disappeared. In fact, some of them were questioning whether they had ever had a disorder at all — or if they had just been in the wrong environment as children.
‘Characterizing A.D.H.D. as a personality trait rather than a disorder, they saw themselves as different rather than defective.’
…A hairstylist told the researchers that her inability to concentrate in school vanished when she began studying hair.
…A young man who was training to be an auto technician said that in his new career, his A.D.H.D. was no longer an issue…If people with A.D.H.D. are directed into areas where their strengths and interests lie, he went on, “I’m pretty sure that they can naturally just go about dealing with it, instead of having to give people medications.”
…[H]igh school can be really boring, and without medication, they have a low tolerance for boring stuff. For some children, a different school, or a different kind of school, might produce the same profound shift that the M.T.A. subjects experienced when they enrolled in film school or began studying hair styling. For others, a prescription for Ritalin or Adderall might help make school feel like a better fit. But for them and their parents, the experience of taking medication might feel quite different if it was presented to them not as a medicine to fix their defective brain but as a tool to make an inhospitable environment more tolerable.
Edmund Sonuga-Barke graduated from Bangor University in Wales, collected a master’s degree and a Ph.D. and then went on to positions of academic prestige, including being elected to the Academy of Medical Sciences and named editor in chief of The Journal of Child Psychology and Psychiatry.
“The simple model has always been, basically, ‘A.D.H.D. plus medication equals no A.D.H.D.,’” he says. “But that’s not true. Medication is not a silver bullet. It never will be.” What medication can sometimes do, he believes, is allow families more room to communicate. “At its best,” he says, “medication can provide a window for parents to engage with their kids,” by moderating children’s behaviour, at least temporarily, so that family life can become more than just endless fights about overdue homework and lost lunchboxes. “If you have a more positive relationship with your child, they’re going to have a better outcome. Not for their A.D.H.D. — it’s probably going to be just the same. But in terms of dealing with the self-hatred and low self-esteem that often goes along with A.D.H.D.”
Here’s an interesting question though. Does the diagnosis help or hinder?
An Australian psychologist named Luise Kazda has studied this very question. In a 2021 review paper, she and her colleagues found 14 studies in which receiving an A.D.H.D. diagnosis created a sense of “empowerment” by “supporting a sense of legitimacy accompanied by understanding and sympathy as well as decreased guilt, blame and anger.” But in 22 other studies, Kazda wrote, “a biomedical view of difficulties was shown to be associated with disempowerment. By providing an excuse for problems, a decrease in responsibility by all involved can occur, often followed by inaction and stagnation.” An additional 14 studies found that the diagnosis increased feelings of stigmatization.
“The diagnosis can create an identity that enhances prejudice and judgment,” Kazda reported, “which are associated with even greater feelings of isolation, exclusion and shame.”
…For some parents, it may indeed be less stigmatizing, and more comfortable, to be able to say, “My child has A.D.H.D., a medical condition, so he needs to take this medicine every day,” rather than, “I want my kid to succeed in environments for which he’s not well suited, so therefore I want him to take these pills.” For many children, however, a diagnosis of A.D.H.D. that is communicated via the dominant medical model can feel like more than a stigma; it can feel like a life sentence. The message to children is often that A.D.H.D. is a binary, biological category, and if your symptoms place you in that category, your brain has a deficit, and you have a disorder.
The alternative model, by contrast, tells a child a very different story: that his A.D.H.D. symptoms exist on a continuum, one on which we all find ourselves; that he may be experiencing those symptoms as much because of where he is as because of who he is; and that next year, if things change in his surroundings, those symptoms might change as well. Armed with that understanding, he and his family can decide whether medication makes sense — whether for him, the benefits are likely to outweigh the drawbacks. At the same time, they can consider whether there are changes in his situation, at school or at home, that might help alleviate his symptoms. If he is also experiencing other psychological conditions — anxiety or depression or post-traumatic stress — they can take steps to address those deeper issues, independent of his inability to focus in math class.
Admittedly, that version of A.D.H.D. has certain drawbacks. It denies parents the clear, definitive explanation for their children’s problems that can come as such a relief, especially after months or years of frustration and uncertainty. It often requires a lot of flexibility and experimentation on the part of patients, families and doctors. But it has two important advantages as well: First, the new model more accurately reflects the latest scientific understanding of A.D.H.D. And second, it gives children a vision of their future in which things might actually improve — not because their brains are chemically refashioned in a way that makes them better able to fit into the world, but because they find a way to make the world fit better around their complicated and distinctive brains.
That was a long read but I’d encourage you to access the full article if you can.
My real questions are – how much of this is ADHD. But how much of this is increasing screentime. How much of this is diet and increasing sugar and artificial stuff in food. How much of this is bad sleep patterns. How much of this is just an active child. Or even a naughty child that simply needs boundaries. A child that needs a radically new diet and structure to the day – and appropriate bed time – with no computers or screens in the bedroom.
And is ADHD stimulant medications the answer?
I’m not a doctor. I just hope that we’re asking those questions.
Credit to the New York Times for asking those exact questions. It’s an important discussion.
