One-third of children diagnosed with ADHD were diagnosed young — before the age of 6 — according to a new national snapshot from the U.S. Centers for Disease Control and Prevention.
Earlier, the CDC found that based on parental reports, 1 in 10 school-aged children, or 6.4 million kids in the U.S., have received a diagnosis of ADHD, a condition marked by symptoms including difficulty staying focused and paying attention, out of control behavior and over-activity or impulsivity.
The percentage of children diagnosed with ADHD has increased steadily since the late 1990s and jumped 42 percent from 2003-2004 to 2011-2012, the CDC says. Last year, concerns flared when a report found that thousands of toddlers are being medicated for ADHD outside of established pediatric practice guidelines.
In the current analysis, also based on parental reporting, and using data drawn from the 2014 National Survey of the Diagnosis and Treatment of Attention-Deficit/Hyperactivity Disorder and Tourette Syndrome, the CDC also found:
•The median age at which children with ADHD were first diagnosed with the disorder was 7 years old
•The majority of children (53.1%) were first diagnosed by a primary care physician
•Children diagnosed before age 6 were more likely to have been diagnosed by a psychiatrist
•Children diagnosed at age 6 or older were more likely to have been diagnosed by a psychologist
•Among children diagnosed with ADHD, the initial concern about a child’s behavior was most commonly expressed by a family member (64.7%)
•Someone from school or daycare first expressed concern for about one-third of children later diagnosed with ADHD (30.1%)
•For approximately one out of five children (18.1%), only family members provided information to the child’s doctor during the ADHD assessment
What are we — parents, educators, doctors — to make of all this? In particular, what does it mean that so many very young kids are being diagnosed with an attention disorder? (Has anyone ever encountered a 4- or 5-year-old child who is not hyperactive, impulsive and inattentive??)
I asked two doctors — a pediatrician and a psychiatrist — for their impressions of the CDC report. Both agreed that we seem to have two problems when it comes to ADHD: over-diagnosing and under-diagnosing. Here, lightly edited, are their responses.
First, the pediatrician:
James M. Perrin, MD, is a professor of pediatrics at Harvard Medical School and associate chair of MassGeneral Hospital for Children. Dr. Perrin is also the immediate past president of the American Academy of Pediatrics and chaired the 1990s committee that wrote the first practice guidelines for ADHD (and he was on the committee for the 2011 revision).
RZ: How difficult is it to diagnose ADHD in children under 6 years old?
JP: In the pediatric community, we have worked over last 15 years to train general pediatricians to make diagnoses of ADHD reliably and follow very clear, specific guidelines on how to do so. In 2011, the AAP revised its practice guidelines for ADHD and included the opportunity to diagnose children ages 4 and 5 years old.
At the same time we recognize it’s very hard to do that well in that age group…because a lot of children are inattentive at 4 — you don’t expect them to work hard and read a Hardy boys book for an hour and half. Five is often impulsive, active, so it’s not unusual to have symptoms that children with ADHD would also have at age 4, 5. So, it’s not easy.
We did say [in the guidelines] pretty clearly that you shouldn’t make the diagnoses without significant impairment of normal behavior. What we mean by that is a child whose symptoms impair her ability to play with other children, or whose behavior is so out of control that it’s dangerous, for instance she runs out in front of cars, or has many accidents, that’s when the symptoms become impairing.
The other thing is that we have worked for the past 15, 18 years on how pediatricians address ADHD — the diagnosis, the treatment and the followup. But insurers don’t pay for these time-consuming evaluations. If you are dealing with a 7-year-old, you want to get information from the school so it’s best to have direct contact from a principal, a teacher, a nurse, if there is one. And that takes time to gather.
Ideally, you want much more than just information from the parents, in fact, the DSM requires that to diagnose both 4- and 5-year-olds, the child must exhibit symptoms in more than one place, not just at home, and that’s true for older children too.
But if you think about a 4-year-old, it’s not always easy to get input from another place in addition to a parent report. It’s harder to make the diagnosis in younger children and I’d be worried about cutting corners to make the diagnosis.
Does this also mean that increasingly, 4- and 5-year-olds exhibiting these symptoms are seeing psychiatrists and other mental health professionals?
I think its relatively unusual for [young children] to see a mental health person without going through a pediatrician…but increasingly, we are seeing young children being kicked out of daycare for behavior — fighting, biting, uncontrollable behavior. So there are kids, 3, 4, 5 years old referred to mental health. I’ve been looking at ADHD for 20-plus years and I’m not comfortable diagnosing ADHD in a 4-year-old without help.
What we are dealing with in ADHD is a condition where there is no blood test, no X-ray test, no test that is diagnostic. It’s different from diabetes, or many other conditions. So what we [look out for] is when the symptoms are exaggerated so much, for instance, the child’s lack of attention is way out of the normal range. But that has to be determined, we are dealing with a spectrum here.
What about medication for children under 6?
Evidence on the use of medication for 4-, 5-year-olds isn’t great. The 2011 guidelines recommend behavior interventions as a first line treatment, involving parents in active parent training programs. For ages 6 and up, it’s a combination behavior and medication; the recommendation is starting a combination of both at the same time.
It’s hard not to read these statistics and wonder if we’re not pathologizing fairly normal kid behavior. After all, as you said, 4-year-olds simply aren’t terribly attentive.
There was an interesting study in China [presented at a scientific meeting but unpublished] where researchers studied diagnoses of ADHD in boys, and they found that children who started school younger had higher rates of diagnosis of ADHD. But once they aged, many of those diagnoses were inaccurate. The point is that maybe we are rushing children too far too soon, and some of these children may have what look like symptoms of ADHD but what they really have are symptoms of being immature. All of which makes it more complicated as to how you diagnose ADHD in 4- and 5-year-olds.
So it sounds like there’s both over-diagnosing and under-diagnosing going on?
The evidence indicates that some children who have the diagnosis of ADHD do not actually have the condition and that many children with ADHD are never diagnosed.
Now, the psychiatrist:
Ned Hallowell, MD, is a nationally recognized child and adult psychiatrist who specializes in ADHD. He is based in Sudbury, Mass and New York City.
RZ: What do you make of the CDC data?
NH: I think it’s good news and bad news. There’s greater awareness in the general public and among mental health professionals of ADHD. But the not-so-good news is we don’t have enough clinicians, particularly primary care, who have enough training to make the diagnoses…they are on the front lines. It’s very understandable that some kids, a number of kids under age 6, may look like like they have ADHD and they don’t.
What’s the problem?
In my view it’s the combination of electronic overstimulation, too much screen time, with not enough family connection — family dinners, going for a picnic, it’s the human moment, compared to the electronic moment. And that can look like symptoms that look like ADHD.
The hallmarks of ADHD are distractibility, impulsivity, impatience, trouble with organizing and planning, getting your stuff together, those also can be caused by having too much time in front of the screen and not enough time with a human being.
We have a social problem masquerading as a medical one. So many primary care providers have neither the time or the training to do the job they’d like to do. Child psychiatrists are as rare as hen’s teeth, but we we have the most training in diagnosing this condition.
So what’s the takeaway here?
To me the big point is this modern paradox, the over-connection to electronics and under-connection to people — as you get younger, 5, 4, 3, it’s usually social problems that can look like ADHD, stress in the family, conflict in the family, poverty, violence.
What is the key to diagnosing this disorder in very young kids?
There are several several factors in diagnosing ADHD in these younger children. It’s intensity — how much more distractible are they, for example.
And the teacher observations are so important, parents don’t have a big cohort to compare to, you need several sources of information. Does this kid stand out? Another key thing is, does it occur in multiple settings, is it just at home, or daycare too?
You also want to be sure to rule out medical causes, lead poisoning, fetal alcohol syndrome, you want to make sure you check the medical causes.
Do you think the actual number of kids with ADHD is rising, or is it simply greater awareness of the condition?
I think two things: It’s increasing awareness and training, more accurate diagnosis and inaccurate diagnosis. The solution is to have people really trained and to have information from multiple sources.
My personal thing that I keep trying to stress is the need for human connection. I like to say it’s a vitamin C deficiency — a vitamin connect deficiency, connection to friends, neighborhoods, pets, nature, to heroes and dreams. I think it produces what can look like ADD or even failure to thrive, it’s a lack of sparkle, zest. The good news is that connection is free…that’s why I prescribe dogs all the time.