Monday, May 5, 2014

What It Will Take to Decrease ADHD Rates, Part 2

In my last post, I enumerated some of the reasons why I thought the high rates of ADHD diagnosis and treatment were not about to fade. Here, I will discuss several steps that I think would need to take place in order to quell the ADHD "epidemic" in America.

Education Reform

Back in October, the New York Times published a very interesting article examining possible causes behind the rising rates of ADHD diagnosis:
Hinshaw, as well as sociologists like Rafalovich and Peter Conrad of Brandeis University, argues that such numbers are evidence of sociological influences on the rise in A.D.H.D. diagnoses. In trying to narrow down what those influences might be, Hinshaw evaluated differences between diagnostic tools, types of health insurance, cultural values and public perceptions of mental illness. Nothing seemed to explain the difference — until he looked at educational policies.

The No Child Left Behind Act, signed into law by President George W. Bush, was the first federal effort to link school financing to standardized-test performance. But various states had been slowly rolling out similar policies for the last three decades. North Carolina was one of the first to adopt such a program; California was one of the last. The correlations between the implementation of these laws and the rates of A.D.H.D. diagnosis matched on a regional scale as well. When Hinshaw compared the rollout of these school policies with incidences of A.D.H.D., he found that when a state passed laws punishing or rewarding schools for their standardized-test scores, A.D.H.D. diagnoses in that state would increase not long afterward. Nationwide, the rates of A.D.H.D. diagnosis increased by 22 percent in the first four years after No Child Left Behind was implemented.
And now, with the implementation of the Common Core, things may get even worse. As the philosopher-comedian Louis C.K. tweeted:

I am no education specialist, but it's fairly obvious that our education system is not working, and things like NCLB and the Common Core do not address the most pressing need, which is better teachers. This is a problem that is parallel to the emphasis in my profession on useless things like "quality of care", maintenance of certification, and patient satisfaction surveys, rather than increasing professionalism and training better clinicians.

Changes in Professional Training/Culture

Speaking of training better clinicians, blindly applying diagnostic criteria without regard to context is one of the biggest problems in American psychiatry. It leads to situations like this one noted by Dr. Allen Frances on Twitter:
In that study, parents completed a structured interview, designed to cover all of the ADHD diagnostic criteria. This approach is the gold standard in research, yet if you look at the document I linked to, there is no mention of the word "sleep" at all in there. So if a teenager is up all night playing video games and then struggles with focusing at school and doing homework, this approach would flag that teen as having ADHD. Sadly, many doctors, especially those with limited time to spend with patients, use a similar approach when they give parents a questionnaire like the Vanderbilt and then diagnose the child with ADHD if enough 2's and 3's were circled.

If a child does get diagnosed with ADHD, both the American Academic of Pediatrics and the American Academy of Child and Adolescent Psychiatry have published guidelines that say first-line treatment is medication "and/or" behavior therapy. Yet it is very hard for most families to actually find someone who offers this type of therapy; plus, behavioral therapy is much more demanding of parents' time and effort than simply medicating a child, a point I'll address in the next section. Still, increasing access to behavioral therapy can potentially help reduce the reliance on meds. I'm not sure how this is going to happen, but obviously we as a society would have to make it a priority to increase the numbers and the quality of training of those therapists.

As another example of the lack of holistic thinking, there are multiple studies showing a link between certain artificial food colorings and hyperactive behavior in school-aged children. During my child psychiatry training, I heard about these studies from a lecturer who emphasized that the effect size was small. However, a small average effect can mask large effects in individuals who are susceptible to certain insults. Or it may slowly lead to larger effects over long periods of time. In Europe, foods containing those dyes are required to have a warning label that they "may have an adverse effect on activity and attention in children," so most manufacturers have switched to using natural colors so they don't have to show the warning label. Not surprisingly, the FDA decided not to act, citing the need for more research.

Societal/Demographic Changes

One of my previous posts examined the geographical differences in the distribution of ADHD in the U.S. Clearly, societal factors like higher rates of single parenthood, lower social mobility, etc. have an impact on which children get diagnosed with ADHD.

One of the biggest issues I come across is how everyone is super-busy all the time, especially parents with young children who have to juggle their jobs and child-raising responsibilities. Not surprisingly, given how exhausted many American parents are, it is easy to give in to the temptation of having television or an iPad be a babysitter/pacifier. This of course comes at a huge cost to the relationship between parents and their children. Child in Mind is an excellent blog that has many posts on how parent-child interactions are critically important for the development of self-regulation skills in children, which significantly impact emotions, behaviors, and the ability to concentrate. There is also evidence that parents and schools can effectively teach self-control to children in ways that do not require harsh treatment or bribery.

Thus, measures that take stress off parents and increase the time that they can spend with their children is something that our society needs to invest in. Universal daycare/preschool is just one example. According to this article, "the U.S. ranks third to last among OECD countries on public spending on family benefits." If you don't think that has anything to do with why we lead the world in ADHD, then I'd love to hear your explanation.

In conclusion, there are no easy fixes to the problem of ADHD over-diagnosis/treatment in America, because it is in large part a reflection of some thorny societal/cultural problems. But that doesn't mean there are no solutions. The problem does require addressing issues on multiple levels, and not simply prescribing more pills.
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