Missouri doctors might be diagnosing too many children with attention deficit and hyperactivity disorder, according to a new federal report.
Close to 9 percent of kids in Missouri have been diagnosed with ADHD, and about 80 percent of them take prescription drugs for the behavioral disorder. Only Mississippi has a higher rate of children with ADHD who are medicated, according to data released last month by the Centers for Disease Control and Prevention.
In the 1990s CDC researchers started tracking ADHD diagnosis and treatment rates for children ages 4 to 17. Diagnoses spiked 22 percent between 2003 and 2007. The disorder is now the most common behavioral problem in children, affecting more than 4 million school-age kids nationwide.
Debates have long raged about ADHD, with critics saying the disorder was dreamed up by pharmaceutical companies or used as a label for otherwise healthy children with high energy levels. A common perception is that the disorder has been overdiagnosed since it was introduced as a psychiatric diagnosis in 1980. Although there is a lack of scientific study on whether current ADHD rates are accurate, evidence does show that some children have been incorrectly diagnosed. But those numbers could be offset by the underreporting of the disorder among girls and children in rural areas who have limited access to mental health care, experts say.
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COMMON IN THE SOUTH
The disorder is most common in southern states, for reasons researchers don’t fully understand. Rates of ADHD range from 13 percent of children in North Carolina to 4 percent in Nevada. Fewer than 5 percent of children in Illinois have been diagnosed with ADHD, under the national average of 7 percent. Missouri ranks in the upper third for diagnosis rates.
The geographic swing could indicate consistency problems with the sample of parents surveyed, issues with access to health care or, as some experts fear, a sign of false negatives and positives. The data suggest that some children may be inappropriately medicated, said Susanna Visser of the National Center on Birth Defects and Developmental Disabilities, the lead author on the report.
“States that are at upper end of distribution are at the point where 7, 8, 9 percent of the population is taking medication,” Visser said. “It’s really a state’s responsibility to question whether or not this is an appropriate level of intervention.”
Visser said the CDC is working with Patsy Carter with the Missouri Department of Mental Health to determine why the state’s rate is high. Officials in the department said Carter was unavailable for an interview for this story.
Scientists have identified some factors that could be influencing ADHD rates. Communities with higher Hispanic populations have lower rates of ADHD. Children on the government’s Medicaid health insurance are more likely to be diagnosed with the disorder. The age of the doctor plays a role, with younger physicians diagnosing ADHD at higher rates. Access to mental health care is another factor, because psychiatrists are more likely to diagnose ADHD compared to pediatricians.
Children who start school at an earlier age than their peers are more likely to be medicated for ADHD, when their impairment in school could instead be attributed to immaturity, according to a report published last year in the journal Pediatrics.
Because ADHD is not considered a disability category for educational purposes, it is difficult to know how many local students have been diagnosed, according to Paul Bauer, assistant superintendent for learning and assessment for the Special School District of St. Louis County. Teachers don’t encourage parents to seek medical treatment if they suspect ADHD in a student, he said.
“If a student is having difficulties focusing on their work, typically we will have a care team meeting of the school staff with the parents,” Bauer said. “The teacher might suggest that the parent take the student to the doctor, but we wouldn’t make a recommendation that the parent take the student to the doctor.”
WHAT TO DO FIRST
When parents seek a diagnosis of ADHD for a child who has problems in school, other explanations should first be ruled out, including hearing and vision impairments, learning disabilities, sleep apnea, anxiety, poor nutrition or high blood lead levels, doctors said. Diagnosing ADHD is harder, since it requires evidence of behavioral problems beyond the classroom. The doctor must compare the child’s behavior to what is considered normal for his or her age group, lending some subjectivity to the process.
“If your child has the flu, they can do a biological test, but for ADHD it’s really a list of 18 behaviors and whether this child demonstrates these behaviors to a greater degree than other children,” said Jill Isenberg, a psychologist at St. Louis Children’s Hospital. “It’s a tricky thing and in a good, well-done ADHD evaluation the person is getting information from multiple sources — the parents, teachers or day care providers.”
Stimulant drugs work well for moderate to severe cases of ADHD, doctors said. But the medications can have side effects including high blood pressure, reduced appetite, insomnia and in rare cases, psychotic thoughts. They are also classified as addictive by the federal drug administration.
That’s a concern for doctors, especially when children and teenagers take the drugs without a thorough exam and proper diagnosis. Anecdotal evidence indicates some high school and college students without ADHD use stimulants like Adderall or Ritalin for extra focus during exams, and some reports show the trend moving toward elementary school students.
Prescription drugs are sometimes the only tool available to doctors for treating children who struggle in school, said Dr. Ramesh Raghavan, an associate professor of psychiatry at Washington University who studies mental health care among low-income children. It’s easier to prescribe the drugs, which are covered by government and private insurance, than to make neighborhoods safe and healthy for kids, Raghavan said.
“It’s unconscionable in a country that’s as wealthy and powerful as America that we don’t have the investments required to support children in their educational achievement and help them become productive members of our society,” Raghavan said.
The CDC study and Raghavan’s work show that a child’s likelihood of getting prescribed mind-altering drugs depends more on where they live, and not their mental health.
“Unless you know that the child has ADHD, it is unwise to prescribe meds for ADHD,” he said. “Before we treat we should know what it is that we’re treating.”