ADHD: Underdiagnosed and Undermedicated?

[APSJ]

This is not a new issue(I'm sure its been raised here before) and the quotes below are not from a new article, but since the 'common wisdom', even among those who acknowledge ADHD's existence, continues to be that it is overdiagnosed, and medication prescribed for it more often than it should, I thought it would be worthwhile to raise it.

http://www.washingtonpost.com/wp-dyn...090300729.html

"There is a perception that ADHD is overdiagnosed and overtreated," said lead researcher Dr. Tanya E. Froehlich, a developmental-behavioral pediatrician at Cincinnati Children's Medical Center. "But our study shows that for those who meet the criteria for ADHD, the opposite problem -- underdiagnosis and undertreatment -- seems to be occurring."

To arrive at their findings, Froehlich and her colleagues collected data on 3,082 children who participated in the National Health and Nutrition Examination Survey. Using interviews, the researchers were able to establish the presence of ADHD. They also used data from doctors and the numbers of ADHD medications being used to establish diagnosis and treatment patterns, according to the report.

The researchers found that of the 8.7 percent of children who met the criteria for ADHD, only 47.9 percent had been diagnosed with the condition and only 32 percent were treated consistently with medications.

Here, I think, it may be worth noting that the third of these statistics, the fact that only 32% of students meeting the criteria for ADHD received medication consistently, may not seem alarming given the prevailing wisdom regarding medication.

One might think that since every person is different, and there are all kinds of treatments available, those not receiving medication, but who are diagnosed, may just be receiving a different treatment better suited to them. There are a few problems with this.

First, although I am not ambitious enough to track down actual studies right now, this excerpt from Russel Barkley's website regarding the efficacy of stimulant medication, versus alternate approaches, in the treatment of ADHD is both consistent with this article, and what I have gleaned from many other sources:

No treatments have been found to cure this disorder, but many treatments exist which can effectively assist with its management. Chief among these treatments is the education of the family and school staff about the nature of the disorder and its management, in the case of children with the disorder, and the education and counseling of the adult with ADHD and their family members. But among the treatments that results in the greatest degree of improvement in the symptoms of the disorder, research overwhelmingly supports the use of the stimulant medications for this disorder

(emphasis mine)

Second, it is important to keep in mind that, while this study does not offer statistics on the use of alternate treatment approaches, the probability that a statistically significant portion of those diagnosed, but unmedicated, are being treated with other proven techniques, like therapy, is quite low. Medication is expensive, but for many it is covered, at least to some degree, by insurance. Therapy, in general, is both more expensive and less likely to be covered by insurance. The likelihood that a significant number of diagnosed, but unmedicated, children are receiving such alternative treatments is particularly small when the following is considered:

What's more, children from poor families, who have the highest rates of ADHD, were the least likely to have consistent treatment with medication, Froehlich noted. "In addition, children without health insurance were less likely to be diagnosed and treated," she said.

Dr. Jon A. Shaw, director of child and adolescent psychiatry at the University of Miami School of Medicine, agrees that ADHD is underdiagnosed and undertreated.

"The study is confirmatory of the general scientific literature," he said. "ADHD is a highly prevalent disorder, the most common psychiatric diagnosis in children, and that, in general, it is being underdiagnosed and undertreated in our community."

Shaw noted that those children most at risk receive the worst care. "It is clear once again that it is the poorest of our community who are deprived of the benefits of the most effective treatment -- psychopharmacology for this condition," he said.

The perception that ADHD is overdiagnosed, and overmedicated, may be, at least in part, a result of the fact that(at least according to the following two studies, and several others I found) diagnosis and medication rates seem to vary widely based on numerous factors, some of which would not seem to have any possible link to the actual prevalence of the disorder:

A total of 5.44% of children were reported to have received an ADHD diagnosis. Girls, black children, and Hispanic children were less likely to have the diagnosis even after controlling for other characteristics. Living with one's biological father was negatively associated with ADHD diagnosis. We also found regional variation in diagnosis with the western region of the United States having significantly lower instances of ADHD cases. Higher diagnosis rates were associated with having an older teacher, and lower rates were associated with having a white teacher, relative to a nonwhite teacher. In schools that were subject to stricter state-level performance accountability laws, we found higher odds of ADHD diagnoses, but we found no differences associated with larger class sizes or the presence of state laws that restrict school personnel from discussing ADHD treatment options with parents.

http://pediatrics.aappublications.or...act/117/4/e601

Rates of medication treatment for ADHD followed the same pattern noted for ADHD diagnosis, such that males of all ages were more likely to have a reported history of ADHD diagnosis and to currently take medication for the disorder. More males aged 6 years were taking medication for ADHD (4.3%) than females at any age. The highest rates of medication treatment for ADHD by sex and age were reported among males aged 12 years (9.3%) and among females aged 11 years (3.7%). Medication treatment rates were significantly higher among non-Hispanic, primarily English-speaking, and insured children. Geographic variability in prevalence of medication treatment ranged from a low of 2.1% in California to a high of 6.5% in Arkansas.

Nationally, 56.3% of children with reported ADHD diagnoses were being treated with medication at the time of the survey. The frequency of medication treatment among males and females with reported ADHD diagnoses was not significantly different (56.8% versus 55.0%, respectively). Rates of medication treatment among those with a reported diagnosis varied by state, ranging from 40.6% in California to 68.5% in Nebraska (median: [57.6%]).

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5434a2.htm

It seems plausible that there are communities in which ADHD is overdiagnosed, and that this could be creating the misconception that it is overdiagnosed generally. This seems particularly plausible since there would appear to be some correlation between the resources of the parents and the rates of diagnosis.

It is also important to note two related issues, both of which I've seen raised elsewhere on the forum. One, alluded to in the studies, is the fact that girls seem to be diagnosed at lower rates than boys. This does not, in itself, mean that ADHD is underdiagnosed among girls, but there is other evidence that does support that conclusion.

Also, the article, and the studies, deal only with children, and underdiagnosis among adults may be particularly high given the disconnect between the DSMIV criteria and adult ADHD symptoms.

One thing that I feel this issue illustrates is the importance of being precise, and avoiding unwarranted generalizations, when discussing topics of such significance to people's lives. One can easily imagine that a study conducted entirely in one locale might find a very high rate of ADHD diagnosis there, yet be reported as finding that "ADHD is overdiagnosed" instead of "ADHD is overdiagnosed in X community."

[ginniebean]

One of the myths about ADHD is that boys are more likely to have adhd than girls, but the sad truth is that there are just as many girls as boys who have adhd. The girls often remain undiagnosed.

Myth #4: ADHD affects only boys

Girls are just as likely to have ADHD as are boys, and gender makes no difference in the symptoms caused by the disorder. But because this myth persists, boys are more likely to be diagnosed than girls.

http://www.additudemag.com/adhd/article/873.html

[Imnapl]

This topic bears repeating until we all get it.

I would also like to add that the stats shown for kids taking stimulant medication do not differentiate those diagnosed with ADHD and those who are taking medication off label for other conditions.

After years of monitoring the use of Ritalin with triplicate copy prescriptions, the province I live in concluded that Ritalin prescriptions were not being abused, contrary to reports by media and private interest groups.

[Dizfriz]

Originally Posted by ginniebean

Girls are just as likely to have ADHD as are boys, and gender makes no difference in the symptoms caused by the disorder. But because this myth persists, boys are more likely to be diagnosed than girls.

I might disagree with Attitude magazine on this point.

One of the problems leading to the discrepancy of diagnosis is that the DSM was normed mostly on boys (84%). While symptoms are the same in boys and girls, the expression of those symptoms are often different. Boys tend to show more aggressive behavior in expressing their ADHD and thus are referred more for assessment by the schools. Girls, on the other hand tend to be more "Chatty Cathys" bouncing from desk to desk.

While this is often seen as a pain in the neck by teachers is often not disruptive enough for referral although the incident rate of ADHD is the same especially if you compare girls with girls.

Barkley spent a lot of time on this in a week long workshop a number of years ago (I bought the tapes). My experience tends to support this viewpoint. Most clinicians will see many more boys than girls referred for assessment. The statistics reflect this. The "myth" is not the cause for this phenomenon, it may be a factor but it is, in my opinion, a simplistic answer to a complex situation.

Simple answers for complex problems are almost always wrong answers....Dizfriz

[Fraz_2006]

It's not that more boys have ADHD than girls.

It's just that boys tend to display more hyperactive symptoms due to there "boisterous" nature....

Girls on the other tend to desplay more inattentive symptoms.... because when you think about it.... women are relyed on more for remembering things and keeping organised.

But we all know that hyperactive symptoms are far more easier to diagnose that inattentive ones.... because still too many people out there (even professionals) still believe that ADHD means hyperactive little child.

[scarygreengiant]

I think it's too complex to declare that ADHD is over/undiagnosed as a whole. It depends on what population you're talking about and which community you're talking about. People from certain socioeconomic classes or various cultures might have a disproportionately high/low rate of ADHD diagnoses.

I think in New Orleans it might be overdiagnosed. I work for a children's mental health agency and I have a handful of clients who were diagnosed with ADHD shortly after Hurricane Katrina. That strikes me as suspicious. And apparently I'm not the only one who feels this way. Interestingly, Tulane University is conducting a study about the effect of trauma/stress on children's ability to pay attention. I think stress and trauma can definitely produce ADHD-like symptoms in people but that doesn't mean they have ADHD.

[blueroo]

Originally Posted by scarygreengiant

I think it's too complex to declare that ADHD is over/undiagnosed as a whole. It depends on what population you're talking about and which community you're talking about. People from certain socioeconomic classes or various cultures might have a disproportionately high/low ADHD diagnoses. I work for a children's mental health agency and I have a handful of clients who were diagnosed with ADHD shortly after Hurricane Katrina. That strikes me as suspicious. And apparently I'm not the only one who feels this way. Tulane is conducting a study about the effect of trauma/stress on children's ability to pay attention.

Everything you just said was already stated in the original post.

[scarygreengiant]

Originally Posted by blueroo

Everything you just said was already stated in the original post.

But not the stuff about New Orleans. And I was much more concise than ASPJ.

[ginniebean]

Originally Posted by Dizfriz

While this is often seen as a pain in the neck by teachers is often not disruptive enough for referral although the incident rate of ADHD is the same especially if you compare girls with girls.

I am aware that there is symptom disparity and girls tend to be less extreme in behaviours I've seen it said on this forum without anyone countering it that the rate of boys with Adhd is much higher than that of girls with ADHD. I felt it worthy of inclusion for that very reason.

If ADHD was merely an issue of classroom disruption that would be reasonable, but it's not, so efforts do need to be made to assure that girls do get early treatment so they don't have the often disastrous life results of girls who remain undiagnosed. There is much research that the lives of girls are more severely impacted as adults than boys.

They why's and the wherefore's I'll leave to those who deal with implentation of identification programs.

[Imnapl]

Originally Posted by blueroo

Everything you just said was already stated in the original post.

I'm not sure what motivated you to say that; an inside joke perhaps?

I gave SCG rep points for her real life example of an increase of ADHD diagnoses in New Orleans after Katrina. Members posting about a real life example to back up the thread starter's topic is what the original poster hopes for when they start a thread.

Already stated in the thread? I don't know how you function on ADDForums, but I have ADHD and this is often how I participate on the forums: I start reading a thread which makes me want to research more on that topic so I open another window and do just that. I come back to the thread and start posting a reply and get distracted by things like laundry, letting the dog out, letting the cats out, fresh water at all the stations inside and out, lunch, etc. Between distractions, I will still be adding to my post or editing it without refreshing the page to see if any new posts have been made to the thread. Very often, I have posted the same response as someone else only seconds apart and miss the post because I assumed I was the last poster in the thread. Great minds think alike.

Back to the topic re: boys and girls. I am privileged to be able to observe how siblings behave on campus and in the classroom. Often when a male sibling is diagnosed with ADHD, staff will invariably make a comment about his sister being nothing like him and yet, if they really knew what to look for, they would see that the sister has ADHD too.

[Dizfriz]

Originally Posted by ginniebean

I am aware that there is symptom disparity and girls tend to be less extreme in behaviours I've seen it said on this forum without anyone countering it that the rate of boys with Adhd is much higher than that of girls with ADHD. I felt it worthy of inclusion for that very reason.

If ADHD was merely an issue of classroom disruption that would be reasonable, but it's not, so efforts do need to be made to assure that girls do get early treatment so they don't have the often disastrous life results of girls who remain undiagnosed. There is much research that the lives of girls are more severely impacted as adults than boys.

They why's and the wherefore's I'll leave to those who deal with implentation of identification programs.

Good post and points.

As I was discussing in my earlier post, the DSM criteria are strongly slanted toward identifying boys who are ADHD. Girls are so often missed due to this. It is not that the rate of boys being ADHD is greater than girls, it is that more boys are identified and diagnosed than girls. The evidence indicates and I much believe that the rate is about the same if corrected for different symptom expression.

This is a subject I have posted on a number of times. Due to the current criteria and the lack of awareness of how ADHD impacts girls, so many are not diagnosed until adulthood if at all. This is one of the problems that needs to be deal with in the new DSM criteria.

It is the nature of what we have right now that many girls are often left to suffer with the disorder not knowing what is happening to them. There are diagnostic instruments such as the DuPaul surveys that compare girls to to girls and help pick up girls with ADHD. The problem is to get professionals to be aware of this and use diagnostic methods that are more likely not to miss ADHD in girls (false negative).

It is a simple observable fact that there are many more boys referred for ADHD evaluations than girls. Therein lies the problem. If girls don't come in for an evaluation, ADHD will not be caught no matter how aware the clinician.

I really know no way of dealing with this except with better criteria and training especially with the education community. I have not seen research on this but it is my observation that most ADHD assessments are a result of the schools suggesting the possibility of the disorder. Few are entirely parent referred so the schools are the "early warning system" that is vital in getting kids treated for ADHD. Again, if girls do not come in, their ADHD cannot be recognized and treated.

Fortunately, the problem is being recognized and steps are being taken to address it. The downside is that these changes take place slowly.

Interesting subject and one for which I mount my soapbox periodically.

Dizfriz

[Brikka]

i'm a woman who was just diagnosed as severe ADHD at 26. i have read that a lot of woman/girls do not know what is going on and often seek help for depression/anxiety.

i was misdiagnosed as bipolar and borderline

my cousin just got diagnosed as severe ADHD at 21, once i was figuring out what was going on with me, i mentioned it to her.

the thing is, now that i look back on my life and my behavior especially in school, every single sign was there, and it was affecting every aspect of my life...and i find it crazy that NOT ONCE did any teacher/coach/parent/friend/doctor bring up anything about it.

i knew plenty of boys in school who were diagnosed as ADHD and medicated, but honestly i can't even think of one girl that i knew who was diagnosed with ADHD.

i also read that women get diagnosed as borderline and men as ADHD

[ysabeau]

i have read that a lot of woman/girls do not know what is going on and often seek help for depression/anxiety.i was misdiagnosed as bipolar and borderline

I recall walking out of a new psychiatrists office chuckling about two years ago after he offered up a diagnosis of bi-polar. (I'd moved, I needed a prescription)

I returned to my original psych, who I have seen since the age of 17 and gave me my first adult or ADD residual diagnosis (original dx age 2).
He couldn't help but laugh and said "He's forever sending me new patients suggesting they have ADD".


The differences in objectivity when gender comes into play is a crying shame

....to assure that girls do get early treatment so they don't have the often disastrous life results of girls who remain undiagnosed. There is much research that the lives of girls are more severely impacted as adults than boys.

Thankyou APSJ

[Imnapl]

My daughter's first assessment for ADHD was when she was 12. Because she was not in trouble at school or with the law, they decided her ADHD was mild and didn't require treatment. When she went to see another psychiatrist at age 18, he spoke with her for 20 minutes and told her she would have outgrown ADHD by her age. In her 20s, she was assessed by a psychologist who charged her a fortune for brain scans and was more interested in getting her to sign on for neurofeedback therapy than diagnosing anything. A few years later, she sought help because she had hit bottom. Her anxiety and depression were so pervasive that the psychiatrist was very concerned that she too had a mood disorder, but wanted to treat the ADHD first to see what happened. Smart lady.

There is something really wrong here and it is hurting our girls.