As of 2011, 6.4 million children in the United States were diagnosed with attention deficit/hyperactivity disorder (ADHD). From 2003 to 2013 alone, America saw a 41 percent increase in ADHD diagnoses in children aged 4 through 17. These statistics are shocking, but they raise a crucial question: Is the prevalence of ADHD rising, or are doctors making the diagnosis more frequently?
This question is complicated by the fact that there are no recognized neurological markers of ADHD to date. The Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric Association (APA) instead relies on a set of behavioral patterns for diagnosis. The DSM specifies that children younger than 16 must display six or more symptoms of inattention and/or hyperactivity with persistent recurrence for at least six months; adolescents or adults who are 17 or older need only display five or more of these symptoms. Symptoms of inattention include careless mistakes, organizational problems, distractibility, and forgetfulness. Symptoms of hyperactivity-impulsivity include fidgeting, restlessness, excessive talkativeness, and impatience.
The APA formally recognized ADHD as a mental disorder in the late 1960s, but in the last decade, diagnoses rates have skyrocketed. The absence of concrete symptoms or neurological markers, compounded by a sudden rise in diagnosis rates raises a controversial question: does ADHD actually exist?
Most physicians say yes. “The science speaks for itself,” says Dr. Russell Barkley, professor of psychiatry at the University of Massachusetts Medical Center in Worcester and prominent author on the subject of ADHD. “The science is overwhelming that the answer to these questions is in the affirmative: it’s a real disorder; it’s valid; and it can be managed, in many cases, by using stimulant medication in combination with other treatments,” Barkley added in his interview with Frontline.
Dr. Richard Saul, a behavioral neurologist with fifty years of experience, on the other hand, argues against the existence of ADHD.
“How many of us can claim that we have difficulty with organization or a tendency to lose things; that we are frequently forgetful or distracted or fail to play close attention to details? Under these subjective criteria, the entire U.S. population could potentially qualify. We’ve all had these moments, and in moderate amounts they’re a normal part of the human condition,” writes Dr. Saul in an article for TIME.
“The absence of concrete symptoms or neurological markers, compounded by a sudden rise in diagnosis rates raises a controversial question: does ADHD actually exist?”
Although some patients might actually need stimulants to function well in daily life, the lumping together of many vague and subjective symptoms could be causing a national phenomenon of misdiagnosis and over-prescription of stimulants, argues Dr. Saul.
One of the biggest cases made against the existence of ADHD focuses on the subjective diagnosis of hyperactivity or inattentiveness. Many physicians point out that the symptoms associated with ADHD are also linked to or indicative of a variety of other pathologies, including bipolar disorder, autism, hypoglycemia, sensory processing disorders, sleep disorders, and hearing problems. Furthermore, these symptoms can also indicate completely normal behaviors, including personality tendencies and typical age-appropriate behavior. Ambiguous symptoms leave physicians with a lot of room for subjective diagnosis — or misdiagnosis.
One study from Michigan State University estimates that one million kids are potentially misdiagnosed with ADHD because they are younger than their classmates. The study — which used a sample of 12,000 students — found that the youngest kindergarteners were 60 percent more likely to be diagnosed with ADHD than the oldest in the same grade.
Symptoms of ADHD were found to align with symptoms of youthfulness: “If a child is behaving poorly, if he’s inattentive, if he can’t sit still, it may simply be because he’s 5 and the other kids are 6,” says Dr. Todd Elder, who led the study.
Symptoms associated with ADHD “can also indicate completely normal behaviors, including personality tendencies and typical age-appropriate behavior.”
Another study, which is to be presented at the American Academy of Pediatrics 2015 National Conference & Exhibition in Washington, D.C., found that children in foster care were three times more likely than others to be diagnosed with ADHD. Researchers also found that children with ADHD who were in foster care were also more likely to have another disorder, such as depression or anxiety. This finding certainly reveals the need for medical and behavioral services for these children, but it could also prove the indistinguishable nature of symptoms of ADHD: symptoms of anxiety, depression, or even an altered state (such as being in foster care) can easily be mistaken for symptoms of ADHD. The possibility of misdiagnosis continues to pervade cases of ADHD cases.
Misdiagnosis isn’t the only concern with ADHD; over-prescription of ADHD medication also incites controversy. The cost of prescription medication for ADHD is enormous. American families shell out $42.5 billion annually for ADHD treatments, and 6.1 percent of American children use ADHD medication stimulants. The pharmaceutical industry has made ADHD treatment a commercial enterprise of marketing and moneymaking that is not always honest — according to an article in The New York Times, the FDA has cited every major ADHD drug at least once since 2000 for false and misleading advertising. Doctors are also a target audience for drug company advertising — medical and psychiatric journals abound with hundreds of pages of ads for ADHD medications, and the companies themselves often compensate doctors who publicly endorse their drugs.
Although ADHD medications generally reduce hyperactivity and impulsivity and heighten focus, these benefits don’t usually last for longer than two years. Additionally, the long-term consequences of taking such stimulants are not fully understood. Stimulant medications, including amphetamines (such as Adderall) and methylphenidate (such as Ritalin and Concerta), are common treatments for children and adults with ADHD. Stimulants gradually increase levels of dopamine, a neurotransmitter associated with pleasure, movement, and attention. This slow and steady increase mimics the natural dopamine production cycle of the brain and ideally creates a therapeutic sensation of calmness and focus.
“American families shell out $42.5 billion annually for ADHD treatments, and 6.1 percent of American children use ADHD medication stimulants.”
All ADHD stimulant medications are associated with rare cases of heart attack, stroke, and sudden death. There are also subtler effects, such as decreased appetite, sleep problems, weight loss, and irritability.
The addictive nature of ADHD medication stimulants is also a concern. Dr. Saul asserts, “addiction to stimulant medication is not rare; it is common. We only need to observe the many patients who are forced to periodically increase their dosage if they want to concentrate. This is because the body stops producing the appropriate levels of neurotransmitters that ADHD meds replace—a trademark of addictive substances.”
Eleven percent (and counting) of American children have been diagnosed with ADHD. ADHD may or may not exist, but it is clear that both our diagnostic standards and treatment methods require further research and development to prevent the misdiagnosis and over-medication of millions of patients.
Akinbami, L. J., Liu, X., Pastor, P. N., & Reuben, C. A. (2011). Attention Deficit Hyperactivity Disorder among Children Aged 5-17 Years in the United States, 1998-2009. NCHS Data Brief. Number 70. Centers for Disease Control and Prevention.
Brody, Blaire. “The Shocking Cost of Your Child’s ADHD.” The Fiscal Times, April 1, 2013.
Consumer Reports. “Pros and Cons of ADHD Medication.” Consumer Reports. Last modified July 2010.
Holland, Kimberly, and Elsbeth Riley. “ADHD by the Numbers: Facts, Statistics, and You.” Healthline. Last modified September 14, 2014.
MediLexicon International. “Children in foster care three times more likely to have ADHD diagnosis.” Medical News Today. Last modified October 23, 2015.
NIH. “DrugFacts: Stimulant ADHD Medications: Methylphenidate and Amphetamines.” National Institute on Drug Abuse. Last modified January 2014.
PBS. “Does ADHD Exist?” Frontline. Accessed November 5, 2015.
Porter, Eloise. “Misdiagnosis: Conditions that Mimic ADHD.” Healthline. Last modified December 17, 2012.
Saul, Richard. “Doctor: ADHD Does Not Exist.” TIME, March 14, 2014.
Schwarz, Alan. “The Selling of Attention Deficit Disorder.” The New York Times, December 14, 2013.
Schwarz, Alan, and Sarah Cohen. “A.D.H.D. Seen in 11% of U.S. Children as Diagnoses Rise.” The New York Times, March 31, 2013.
U.S. Department of Health and Human Services. “Attention-Deficit/Hyperactivity Disorder (ADHD) Data and Statistics.” CDC. Last modified July 8, 2015.
U.S. Department of Health and Human Services. “Attention-Deficit/Hyperactivity Disorder Symptoms and Diagnosis.” CDC. Last modified June 26, 2015.