This week the American Academy of Pediatrics (AAP) began recommending that "any child 4 through 18 who has school or behavioral problems and symptoms of inattention, hyperactivity, or impulsivity" be evaluated for attention deficit hyperactivity disorder (ADHD). Previously the AAP's guidelines applied only to kids between 6 and 12. An ADHD diagnosis is considered confirmed if a patient meets the criteria in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders, which lists characteristics that are very common in children but tries to narrow the label's reach by requiring that the "symptoms" last for at least six months "to a degree that is maladaptive and inconsistent with developmental level." It looks like that caveat has been somewhat successful, since far less than 100 percent of American 4-to-17-year-olds have been diagnosed with ADHD—only about 10 percent, according to the National Survey of Children's Health. One in 10 is still a pretty impressive number, of course, and the AAP's new guidelines can be expected to boost it further.
The measured prevalence of ADHD has risen as the diagnostic criteria for it have have evolved. In 1994, when the DSM-IIIr prevailed, the American Psychiatric Association said 3 percent to 5 percent of school-aged children had ADHD, less than half the current rate. There are also substantial variations in ADHD prevalence across states, with 2007 rates ranging from a low of 5.6 percent in Nevada to a high of 14.3 percent in Alabama, and across countries, which a 2007 review in The American Journal of Psychiatry found was due largely to differences in diagnostic criteria.
An ADHD diagnosis often means a prescription for a stimulant such as Ritalin, Adderall, Vyvanse, or Provigil. The share of American children taking such drugs by prescription rose from less than 1 percent in 1987 to 3.5 percent in 2008. Stimulants do indeed help children (and adults) pay attention and remain focused on tasks, although whether that means they are a treatment for a disease remains a matter of substantial debate and in practice hinges on a magical slip of paper from an M.D. According to the new AAP guidelines, "behavioral interventions should be considered first-line therapy" for "preschool-age children," while "for children 6 to 11, the AAP recommends combination treatment with medication and behavioral therapy if feasible." Children 12 and older "should begin treatment with medication, and physicians might also prescribe behavioral therapy." Confusingly, the AAP urges doctors to "carefully weigh the risks of drug therapy at an early [prepubescent] age with those associated with delayed diagnosis and treatment" even though "evidence for use of stimulants in this age group is particularly strong." By contrast, doctors should go straight to speed for adolescents, even though "the evidence in this age group is not as strong as in the younger patients."
For more on how psychiatrists create diseases by defining them, see my essay on the continuing relevance of Thomas Szasz in the October issue of Reason. For more on medical vs. nonmedical use of psychoactive substances, see my 2008 essay "No Bad Drugs."
[Thanks to Nicolas Martin for the tip.]
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