Stimulated Youth: ADHD Overdiagnosis in America

The video starts off like many YouTube videos do: a young girl of the newest generation Z, holding her phone selfie-style and smiling into the camera as the world flies past through the closed window of her parents’ SUV.

She has dark curly hair and a fresh face; a silver friendship necklace dangles from her neck. She is just a teenager; wide-eyed, excited. She is hosting a comparison video on her newly declared YouTube page, though she’s not comparing an old iPhone to a newly purchased Android, or even designer shampoo to the drug store version. She is comparing her experience with Adderall to her experience with Concerta. She has ADHD, and she is letting you know which psychostimulant works best for her with the least amount of side effects.

“The first time I had Adderall it was like holy nuts, I feel alive! It literally gave me such an energy boost and a rush. People were looking at me and were like, ‘Kate, what are you on?’ And I’m like, ‘Adderall!’ It literally was like heaven in a pill,” the young girl told her audience.

Kate is like many U.S. teens who have been diagnosed with ADHD and prescribed a stimulant medication. Concentrating on tasks can be difficult without first popping that magic pill. What follows is a burst of energy and the ability to focus sharply, intensely. But like many people who take stimulants, the positive effects can be short-lived.adderall vs. concerta

“Each day it started wearing off sooner and sooner and it started affecting me less and less,” Kate continued. “When it was wearing off I was really moody and got angry pretty fast. I was really irritable and I’m like what is going on?”

Kate may have been experiencing withdrawals. Similar to the withdrawals addicts feel when they can’t get their next fix. It’s similar, because stimulants are drugs. Schedule II controlled substances to be exact. Kate is one of millions of U.S. children taking these controlled substances for her ADHD.

The rise of ADHD

The number of kids diagnosed with Attention Deficit Hyperactivity Disorder, or ADHD, has skyrocketed since the turn of the 21st century, prompting many researchers and medical health professionals to look for an explanation.

About 11% of kids aged 4 to 17 in the United States had been diagnosed with ADHD in 2011, a number that increased 40% between 2003 and 2013 alone, according to the Centers for Disease Control (CDC).

ADHD, now the most prevalent childhood disorder next to obesity, is a behavioral disorder distinguished by three main characteristics: inattention, impulsivity and hyperactivity. Children with ADHD may have difficulty paying attention or sitting still long enough to focus on tasks, which can negatively affect their performance in school.

ADHD can also interfere at home and put stress on a child’s relationship with his or her family and friends. Children with ADHD may have low self-esteem and are more likely to abuse drugs and alcohol. In about three-quarters of cases, ADHD follows children into adulthood, making a comprehensive treatment program vital for success in life.

Doctors recommend using a combination of behavioral therapy and medication to treat kids and teens with ADHD, though the first line of treatment recommended for preschoolers is behavioral therapy alone. In some cases children are treated only with medication, and as the CDC points out, as much as 17.5% of children with current ADHD are not being treated with either medication or behavioral therapy.

There are several different types of medication used to treat ADHD, though the most commonly prescribed are stimulants.

Stimulants are extremely potent and highly addictive medications classified by the U.S. Drug Enforcement Agency as schedule II controlled substances due to their “high potential for abuse.” Other schedule II narcotics include cocaine, methadone and opium.

Doctors have been using stimulants to treat children diagnosed with ADHD since they were first introduced in the 1930s. Benzedrine, a type of amphetamine, was the first stimulant used in the treatment of ADHD, a behavioral disorder first described in 1902.

In 1943, Desoxyn was introduced. The brand name for prescription methamphetamine, Desoxyn is still available today though rarely prescribed. Instead, methamphetamine is found most often on the streets in its crystalline form.

In 1955, the Food and Drug Administration (FDA) approved Ritalin, another type of amphetamine stimulant. Ritalin held much of the ADHD prescription drug market share until the introduction of new medications called methylphenidates 40 years later. Methylphenidates work similarly to amphetamines in the brain (they increase the availability of the neurotransmitters dopamine and norepinephrine) but generally last longer in the body. The most well-known methylphenidate, and one of the most prescribed, is Adderall.

Following the introduction of Adderall in the 1990s, extended release versions of methylphenidates were introduced. The first of these was Concerta in 2000, but extended release versions of other ADHD stimulants, including Adderall and Ritalin, soon came to market. These extended release versions made it possible to take one pill per day, instead of three pills three times a day, eliminating the need for kids to take their medication at school.concerta lawsuits

2.8 million kids take prescription stimulants

Stimulants can be highly effective in the treatment of ADHD, but they carry the risk of serious side effects, some of which include sudden death in children with underlying (and in some cases undetected) heart problems, prolonged and painful erections that can cause permanent erectile dysfunction, and new or worse psychiatric problems, such as hearing voices, believing things that are not true or being overly suspicious. Stimulants can also cause hostile and aggressive behavior and bipolar illness, whether those mental problems existed before treatment or not.

On top of the risk of side effects, many people worry about putting such addictive drugs in the hands of children and teens. These are, after all, controlled substances, and most ADHD medications are approved to treat children as young as 6. ADHD medications are sometimes prescribed to children as young as 3 and 4, though statistics show the number of stimulant prescriptions to children under 6 is declining.

The use of stimulants in American youth is highest among 6 to 12 year olds. A study published in the American Journal of Psychiatry in 2012 indicated that in 2008, about 5.1% of all 6 to 12 years olds were taking a stimulant, up slightly from 4.2% in 1996.

The same study found that while the use of stimulants was highest among 6 to 12 year olds, utilization increased most among 13 to 18 year olds. Researchers found that 2.5% of American 13 to 18 year olds were taking a stimulant in 1996; by 2008 that number had doubled to 5%, an annual rate of increase of 6.5%.

Studies in the UK have shown a similar trend among the union’s adolescents, raising concerns for the potential for misuse.

In the US, a total of 2.8 million kids under the age of 18 were taking a stimulant in 2008. With the rate of ADHD diagnoses expected to continue on its upward trend, that number is also likely to increase.

Perhaps even more frightening is the fact that the increase in ADHD diagnoses is not consistent among the general population.

Diagnoses spiked overall in the last decade or more, but they did not spike consistently across the United States. In Kentucky, for example, the prevalence of ADHD was 14.8% in 2011 — 250% higher than Nevada’s prevalence of 4.2%.

In the 5 states with the highest prevalence rates (Kentucky, Arkansas, Louisiana, Indiana, and South Carolina/Delaware) more than 11% of the states’ youths had been diagnosed with ADHD in 2011 compared to under 6% in the 5 states with the lowest prevalence rates (Nevada, New Jersey, Colorado, Utah and California).

Some of the same 5 states with the highest diagnoses rates also had the highest number of children taking ADHD medications – over 10% in both Kentucky and Louisiana, compared to 2% in Nevada and 3.3% in California.

In an article published in the journal Psychiatry Advisor on July 28, 2015, Dr. Sanford Newmark, head of the Pediatric Integrative Neurodevelopmental Program at the University of California, San Francisco, said there was “no reasonable biological explanation” for the differences between states. “If ADHD is a true neurodevelopmental disease – which it is – then the prevalence of diagnosis and treatment should be consistent,” Dr. Newmark said.

ADHD or Immaturity?

What’s the reason for this increase in ADHD diagnoses and the disparities across states?

Dr. Newmark attributed the rise in ADHD diagnoses to inadequate evaluations, pressures for diagnoses from parents and teachers, and an increase in demands made on children.

According to Dr. Newmark, some doctors are making diagnoses based on superficial examinations. “Making an accurate diagnosis of ADHD takes time,” he said.

Doctors need to rule out other explanations for a child’s symptoms, including learning disabilities, anxiety and posttraumatic stress disorder. “It is important to get an understanding of the child’s entire environment, including his or her school and family situation. One must take the time to speak with and observe the child before rushing to a diagnosis,” he continued.

Dr. Newmark’s contention wasn’t based solely on anecdotal evidence. In a study of 1,000 physicians assessing ADHD, only 15% said they regularly used information from multiple sources and settings, a University of California, Los Angeles report indicated.

Numerous other studies have demonstrated that children are often diagnosed based on their immaturity and not because they have a disorder.ADHD teen

Take a 2010 study published in the Journal of Health Economics that compared the rate of ADHD diagnoses in kindergartners. The study found that 10% of kindergartners born in August (youngest in class) were diagnosed with ADHD compared to 4.5% of kindergartners born in September (oldest in class). The kindergartners born in August were also twice as likely to be treated with stimulants. The study authors estimated this alone could have resulted in 900,000 incorrect diagnoses of ADHD.

Studies have yielded similar results in other countries, as well, including Canada. In Iceland, researchers found the entire youngest third of a class was 50% more likely to be diagnosed with ADHD and prescribed a stimulant.

“What these studies tell us is that we are unable to distinguish those children who have ADHD from those who are simply immature,” said Dr. Newmark.

The pressures put on children to perform well academically at such young ages are also partly to blame, said Dr. Newmark. Kindergartners are now expected to learn to read – a cognitive development that some 5 year olds simply aren’t ready for – and preschoolers are expected to be able to sit quietly in a group.

“A generation or two ago, many children did not go to preschool and sitting still in a group was not one of the requirements of early childhood education,” he commented.

Today, Dr. Newmark said, “the diagnosis and treatment of ADHD in preschoolers is creating one of the most rapidly growing segments of the ADHD population.”

The pressures put on children quickly circle back to the parents when teachers come to them with concerns that their four year old can’t sit still during circle time. Time-strapped working parents turn around and pressure doctors into giving them a diagnosis and medication, and time-strapped doctors are unable to perform a proper examination of the purportedly rowdy child who may simply be immature for his grade.

While this cycle is certainly tragic, it doesn’t necessarily explain why certain states have more diagnoses than others.

Public education policy drives ADHD spike

To explain the discrepancies between states, Drs. Richard Scheffler and Stephen Hinshaw, both professors at the University of California, Berkley, dove into the data and found that the dramatic rise in ADHD diagnoses coincided with a change in the way states funded their public k-12 schools beginning in the 1990s.

In their book titled, “The ADHD Explosion: Myths, Medication, Money, and Today’s Push for Performance,” Drs. Scheffler and Hinshaw explained how states began allocating school funding based on performance standards like end-of-year exams and graduation rates. In 2002, the federal government signed this way of budgeting into law when it passed the No Child Left Behind Act and tied federal education dollars to performance metrics.

The NCLB Act fundamentally changed the way schools operated – suddenly, the amount of money schools received from the federal government hinged on the performance of their students on standardized tests and other objective measures. The generation of test-takers was born and the increase in ADHD diagnoses began to rise.

Much criticism can be – and has been – placed on the NCLB Act and similar state programs, which essentially shifted the focus off of learning for the betterment of the child to learning for the betterment of the school’s budget.

Scheffler and Hinshaw said with the advent of these programs, schools started looking for kids with possible ADHD and urging parents to seek treatment. Certain states and school districts were even allowed to keep kids with diagnosed ADHD out of the performance scores, further incentivizing ADHD diagnoses in disruptive or poor-performing students.

This point may be demonstrated in a study published in the American Sociological Review in 2014, which found the use of stimulants among children with ADHD was 30% higher during the school year than the summer. The study authors suggested this could indicate students were using stimulants – perhaps at their parents’ behest – as performance enhancing drugs to meet academic demands.

Other explanations for this phenomenon exist, of course. Many parents choose to give their children a “drug holiday” during the summer months because they worry about the potential for serious side effects. Some doctors actually prescribe a drug holiday in order to determine if the child still needs medication as part of their treatment program. Data suggest, however, that children with ADHD benefit more when they stick to their treatment program year-round; unless there is a clear and compelling reason – by doctor’s request, for instance – it is not recommended that children interrupt their treatment.

Let’s assume for a minute, however, that the authors’ fears are true. Let’s assume students – teens, pre-teens and younger – are using these highly addictive, highly dangerous controlled substances to perform better in school.

Because they are required to take not only their regular curriculum tests, mid-terms and final exams, but also a standardized test in math and English every year between third and 8th grades, and once in high school, and at least one standardized science exam in elementary, middle and high school? Because if they don’t perform well on these exams, they risk not only their own academic futures but that of their schools? Because if they don’t perform well on these exams their school may not be able to afford new iPads, or computers, or even textbooks? Because if they don’t perform well on these exams, everything else falls down with them?

When you place a school’s ability to purchase textbooks on exam performance, when you place a teacher’s salary on exam performance, when you place graduation on exam performance, you essentially place the burden of the entire educational system onto the backs of its students. It’s no wonder students, parents, teachers and administrators alike are pushing for ADHD diagnoses and drug treatment. Futures are riding on the students’ abilities to take tests — tests that sometimes take weeks out of the school year to complete. This gives students with ADHD more reason to stick to their stimulant regimen, which isn’t necessarily a bad thing in cases of true ADHD. It is estimated that 70% to 80% of children with ADHD have fewer symptoms when they take these medications.

But what if it isn’t true ADHD?

What if a child taking dangerous stimulants is one of the 900,000 cases of misdiagnosis cited by the 2010 study in Journal of Health Economics? What if a percentage of our nation’s children and teens are taking legal speed because of legislation we passed? Is it coincidence that the United States has the highest rate of diagnosed ADHD?

In his article, Dr. Newmark appealed to his audience and asked where we might go from here.

“I do believe that we have an ‘epidemic’ of overdiagnosis of ADHD, the roots of which are deeply ingrained at many levels in our society. We will have to decide whether to treat more of our children with long-term psychostimulants or work together to find a different approach to this persistent problem,” he said.

Changes to the No Child Left Behind Act came during the Obama Administration. The new Every Student Succeeds Act, passed in 2015, still bases school performance on exams and graduation rates, but passes the baton to the states to determine what to do with its failing schools.

The new law does not address concerns over too much testing – though it does allow states to break up the grueling exams usually taken at the end of the school year into a series of smaller exams.

After nearly a decade and a half under the rule of No Child Left Behind, and with minimal changes made under the new education reform, how long will it take for society to address the “epidemic of overdiagnosis”? How many more children will be needlessly subjected to harsh, highly addictive stimulants because they can’t sit still during circle time or focus long enough to complete a four-hour Scantron test?

Perhaps it’s time we address the negative effects our legislation has on our youngest generation before it’s too late to save our future generations.