Wk8 Discussion SOCW 6443: The Use of Stimulants in the Treatment ADHD
Wk8 Discussion SOCW 6443: The Use of Stimulants in the Treatment ADHD
Stimulant medications have been used since the mid-1900s to treat ADHD. More recently, medical professionals recognize a degree of complicity in the development of addiction in many of their clients with ADHD in connection with the use of stimulant treatment medications such as dextroamphetamine, levoamphetamine, and methylphenidate. As members of medical treatment teams, mental health professionals recognize their responsibility to treat current clients who have developed this comorbid condition as well as to work to prevent future problems of addiction that might arise from use of stimulant treatment. Clients deserve encompassing, accurate information in order to sort through potentially mixed messages from medical professionals, school personnel, family members, and others. Mental health professionals can provide or point to educational materials to help clients make informed choices, provide information about alternatives based on sound research, and help monitor for misuse of potentially addictive medications (Preston, O’Neal, & Talaga, 2013).
For this Discussion, review the media titled “Attention-Deficit/Hyperactivity Disorder Counseling Session” and consider the medications a psychiatrist might prescribe to treat ADHD. Conduct an Internet search or a Walden Library search for at least one peer-reviewed journal article that addresses issues related to the use of stimulants for the treatment of ADHD as it relates to the client in the media program.
All questions in bold then the answers 300 to 500 words not including the questions
The “Attention-Deficit/Hyperactivity Disorder Counseling Session” transcript has been uploaded
Must use and reference the DSM-5
Post a brief description of the client’s current presentation in the media program.
Choose a medication that a psychiatrist might prescribe to treat ADHD and explain in detail the major action, intended effects, neurotransmitters implicated in its use, and side effects.
Explain why you think this medication might be the most effective for treatment.
Explain how you might address any issues related to the use of stimulants for the treatment of ADHD. Justify your choice based on the client’s presentation and support your position with the Learning Resources and your journal article.
Explain an alternative approach to treating ADHD.
Be sure to support your postings and responses with specific references to the Learning Resources in text citations and full references APA 7th addition format
Recourses
Lichtblau, L. (2011). Psychopharmacology demystified. Clifton Park, NY: Delmar, Cengage Learning.
Chapter 5, “Cognitive Enhancers” (pp. 65–74)
Preston, J. D., O’Neal, J. H., & Talaga, M. C. (2017). Handbook of clinical psychopharmacology for therapists (8th ed.). Oakland, CA: New Harbinger.
Chapter 23, “Child and Adolescent Psychopharmacology” (pp. 255-276)
Attention Deficit: Hyperactivity Disorder Counseling Session
Attention Deficit: Hyperactivity Disorder Counseling Session
Program Transcript
[MUSIC PLAYING]
TANYA: Oh! I used to have one of these action figures at home. That’s cool.
Have you ever played Halo? How about Grand Theft Auto? That’s another one of
my favorite games. Do you have any good games we can play here?
COUNSELOR: Well, Tanya, I love your energy. And I have this pink Play-Doh
that has never been touched. And so I’m wondering if we could talk for a couple
of minutes, and then maybe we could get to some games later. Would you like to
give that a try?
TANYA: OK. Cool.
COUNSELOR: I’m going to get some, too. I think I’m going to get the other pink.
And so you and your mom and dad and I met for a few minutes before. And we
decided that it would be good for you and I to have some time together, just to
spend time.
We can do some playing. We can hang out with each other and talk. And we can
do Play-Doh. And so we can do all sorts of things.
But the thing I want you to know first, before we do anything else, is that what
you say in here stays in here. It’s private. It’s our stuff we’re talking about.
Now, your mom and dad and I will have some conversations. But I won’t say
anything about you behind your back to them. And I do have to let them know if
you were going to do something dangerous. We would talk about that, obviously,
but not that I think that’s the case. Does that make sense? So now, let’s talk
about what kinds of things you would like to have better in your life.
TANYA: What do you mean?
COUNSELOR: Well, let’s say you had three wishes. And you can make three
wishes, one about yourself, one about school, one about home. What would you
like to have different?
TANYA: Can I wish for more wishes?
COUNSELOR: No, but that’s a very smart question to ask, because if you could,
you would have wishes forever. So we have a limit on that. So it’s just really only
three, one about you, one about school, and one about home.
© 2014 Laureate Education, Inc. 1
Attention Deficit: Hyperactivity Disorder Counseling Session
TANYA: Well, I wish I would never have any more homework. And I wish my
parents would get off my case about playing too many computer games. And I
wish I could be invisible and get away with whatever I want without annoying
anybody.
COUNSELOR: Wow, that is a perfect response. So you’d get rid of homework.
You’d make it so your parents wouldn’t be on your case about video or computer
games. And you would be invisible. You could get away with anything.
So Tanya, I’m just interested. It sounds like you would use a whole wish—and
you’ve only got three—on homework.
TANYA: Yep, no homework the rest of my life and my life would be way better.
COUNSELOR: Getting rid of homework would make your life better. And that
makes me think maybe homework is pretty miserable and feels awful right now.
FEMALE SPEAKER: Yep. So poof. I make it disappear.
Attention Deficit: Hyperactivity Disorder Counseling Session
Additional Content Attribution
Creative Support Services
Los Angeles, CA
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Newnan, GA
Narrator Tracks Music Library
Stevens Point, WI
Signature Music, Inc.
Chesterton, IN
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Carrollton, TX
© 2014 Laureate Education, Inc. 2
ARTICLEPEDIATRICS Volume 138 , number 3 , September 2016 :e 20160407
Racial and Ethnic Disparities in
ADHD Diagnosis and Treatment
Tumaini R. Coker, MD, MBA, a, b Marc N. Elliott, PhD, b Sara L. Toomey, MD, MPhil, MPH, MSc, c
David C. Schwebel, PhD, d Paula Cuccaro, PhD, e Susan Tortolero Emery, PhD, e Susan L.
Davies, PhD, f Susanna N. Visser, DrPH, MS, g Mark A. Schuster, MD, PhDb, c
abstractOBJECTIVES: We examined racial/ethnic disparities in attention-deficit/hyperactivity disorder
(ADHD) diagnosis and medication use and determined whether medication disparities
were more likely due to underdiagnosis or undertreatment of
African-American and Latino
children, or overdiagnosis
or overtreatment of white children.
METHODS: We used a population-based, multisite sample of 4297 children and parents
surveyed over 3 waves (fifth, seventh, and 10th grades). Multivariate logistic regression
examined disparities in parent-reported ADHD
diagnosis and medication use in the
following analyses: (1) using the total sample; (2) limited to children with an ADHD
diagnosis or symptoms; and (3) limited to children without a diagnosis or symptoms.
RESULTS: Across all waves, African-American and Latino children, compared with white
children, had lower odds of having an ADHD diagnosis and of taking ADHD medication,
controlling for sociodemographics, ADHD symptoms, and other potential comorbid mental
health symptoms. Among children with an ADHD diagnosis or symptoms, African-American
children had lower odds of medication use at fifth, seventh, and 10th grades, and Latino
children had lower odds at fifth and 10th grades. Among children who had neither ADHD
symptoms nor ADHD diagnosis by fifth grade (and thus would not likely meet ADHD
diagnostic criteria at any age), medication use did not vary by race/ethnicity in adjusted
analysis.
CONCLUSIONS: Racial/ethnic disparities in parent-reported medication use for ADHD are
robust, persisting from fifth grade to 10th grade. These findings suggest that disparities
may be more likely related to underdiagnosis and undertreatment of African-American and
Latino children as opposed to
overdiagnosis or overtreatment of white children.
aDepartment of Pediatrics, Mattel Children’s Hospital, David Geffen School of Medicine at UCLA, Los Angeles,
California; bRAND, Santa Monica, California; cDivision of General Pediatrics, Boston Children’s Hospital and
Department of Pediatrics, Harvard Medical School, Boston, Massachusetts; Departments of dPsychology and
fHealth Behavior, University of Alabama at Birmingham, Birmingham, Alabama; eCenter for Health Promotion
and Prevention Research, University of Texas–Houston, School of Public Health, Houston, Texas; and gCenters
for Disease Control and Prevention, Atlanta, Georgia
Dr Coker was responsible for study conception and design, data analysis, interpretation of
fi ndings, and writing of the manuscript; Dr Elliott contributed to study conception and survey
development, obtained funding, and participated in study design, analysis, and interpretation;
he also revised manuscript drafts; Dr Schwebel contributed to study conception and survey
development, obtained funding, participated in study design and interpretation, and revised
manuscript drafts; Drs Toomey, Tortolero Emery, Cuccaro, and Davies contributed to study
conception and survey development, obtained funding, participated in study design, and revised
manuscript drafts; Dr Visser contributed to study conception, study design, and revision of
manuscript drafts; and Dr Schuster contributed to study conception and survey development,
To cite: Coker TR, Elliott MN, Toomey SL, et al. Racial
and Ethnic Disparities in ADHD Diagnosis and Treatment.
Pediatrics. 2016;138(3):e2016040
7
WHAT’S KNOWN ON THIS SUBJECT: There are
racial/ethnic disparities in medication use for
attention-defi cit/hyperactivity disorder (ADHD), but
it is unknown if the disparity is more likely due to
an underdiagnosis
or undertreatment of African-
American and Latino children, or an overdiagnosis
or overtreatment of white children.
WHAT THIS STUDY ADDS: Racial/ethnic disparities
in medication use for ADHD are robust, persist
from fi fth to 10th grade, and seem to be more
related to underdiagnosis and undertreatment of
African-American and Latino children as opposed to
overdiagnosis or overtreatment of white children.
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Attention-deficit/hyperactivity
disorder (ADHD) diagnoses have
been increasing in the United States.
Parent-reported rates of ever
receiving a diagnosis for children
aged 4 to 17 years increased from
7.8% in 2003 to 11.0% in 2011,
and rates of ADHD medication use
increased from 4.8% in 2007 to
6.1% in 2011. 1 Studies also describe
racial/ethnic disparities in diagnosis
and medical treatment of ADHD,
indicating that African-American
and Latino children may have lower
rates of receiving a diagnosis and
medication compared with white
children. 2 – 7
These differences in diagnosis and
treatment are generally interpreted
as reflecting underdiagnosis and
undertreatment of African-American
and Latino children. 5, 6 In light of
the increasing prevalence, however,
researchers have recognized that
overdiagnosis or overtreatment
of white children is a possible
alternative explanation for the
disparity, 3, 8 although previous
studies have not examined which
explanation is most likely.
The current study was conducted
to help address this question: Is
the disparity in ADHD diagnosis
and medication treatment more
likely due to an underdiagnosis
or undertreatment of African-
American and Latino children or
an overdiagnosis or overtreatment
of white children? A population-
based, multisite longitudinal survey
was used to examine racial/ethnic
disparities in the diagnosis of ADHD
and in ADHD medication treatment
among children. We also examined
whether the disparity and the likely
main drivers of the disparity changed
from fifth grade to 10th grade.
METHODS
Healthy Passages is a longitudinal
study of a cohort of 5147 fifth-
graders and their parents (2004–
2006), with follow-up in seventh
grade (2006–2008) and 10th grade
(2009–2011). 9, 10 Institutional review
board approval was obtained at each
study site and the Centers for Disease
Prevention and Control.
Study Population and Sampling
Procedure
Participants were recruited from
public schools in the following
districts: 10 contiguous public school
districts in and around Birmingham,
Alabama; 25 contiguous public school
districts in Los Angeles County,
California; and the largest public
school district in Houston, Texas.
Eligible schools had an enrollment
of ≥25 fifth-graders, representing
>99% of students enrolled in regular
classrooms. To ensure adequate
sample sizes of African-American,
Latino, and white students, a 2-stage
probability sampling procedure,
detailed elsewhere, 9 was used. The
sampling procedure included the
following: (1) random sampling of
schools using probabilities that were
a function of how closely a school’s
racial/ethnic mix corresponded to
the site’s racial/ethnic target; and (2)
invitation to participate to all fifth-
grade students in regular classrooms
of sampled schools.
The 118 sampled schools had 11 532
enrolled fifth-graders. A primary
caregiver (henceforth referred to as
“parent”) for each student received
a letter requesting permission for
contact by study personnel. Of the
11 532 parents, 6663 who either
agreed to be contacted or who were
unsure were invited to participate;
5147 completed an interview at
baseline (fifth grade), and 4297
parent–child dyads participated in
all 3 waves (at fifth grade and ∼2 and
5 years later, when most children
were in seventh and 10th grades,
respectively).
Our sample size reached the
predetermined sample size targets;
details of statistical power are
described elsewhere. 9 Interviews
were conducted at the home, a study
center, or another preferred location.
Parents provided informed consent
for participation, and children gave
assent.
Measures
ADHD Symptoms
Questions from the Diagnostic
Interview
Schedule for Children
Predictive Scales (DPS) were used
to assess the presence of parent-
reported symptoms of ADHD and
other mental health conditions that
may be comorbidities which could
affect whether a child receives a
diagnosis or medication for ADHD.
These comorbidities included
oppositional defiant disorder,
conduct disorder, and depression.
The DPS is a screening tool based on
the Diagnostic Interview Schedule
for Children; it relies on parent-
reported symptoms (reported as
present or not) of ADHD (7 yes/
no items), oppositional defiant
disorder (12 yes/no items), and
conduct disorder (8 yes/no items),
as well as child-reported symptoms
of depression (6 yes/no items)
during the previous 12 months
(sensitivities and specificities for
ADHD, oppositional defiant disorder,
conduct disorder, and depression,
≥0.89). 11 The 7 ADHD symptoms
in the DPS align with 5 inattentive
symptoms (eg, Has your child often
had trouble finishing his or her
homework or other things he or she
is supposed to?) and 2 hyperactivity/
impulsivity symptoms (eg, Has your
child often left his or her seat when
he or she was not supposed to?) on
the Diagnostic and Statistical Manual
of Mental Disorders, Fifth Edition. 12
A dichotomous variable was created
for symptoms consistent with
ADHD, defined by a score (sum of
symptoms) above the sample 90th
percentile. We used this cutoff value,
which was more stringent than cutoff
values used in a previously studied
community sample, 11 because data
on level of impairment or symptom
severity were not collected. For
2
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PEDIATRICS Volume 138 , number 3 , September 2016
fifth- and seventh-grade surveys,
the 90th percentile corresponds
to positive responses on ≥6 of 7
possible ADHD symptoms. For
the 10th-grade surveys, the 90th
percentile corresponds to ≥5 of 7
possible symptoms. Of note, the
Diagnostic and Statistical Manual
of Mental Disorders, Fifth Edition,
requires ≥6 symptoms of inattention
and/or hyperactivity-impulsivity for
youth aged ≤16 years or ≥5 for youth
aged ≥17 years. 12 We also created a
continuous variable for symptoms
consistent with ADHD and each of
the other mental health disorders,
defined by the total symptom score
for each scale. Higher symptom
scores reflect more symptoms.
ADHD Diagnosis
In survey waves 1 and 3, parents
were asked if a physician or health
professional had ever told them
that their child had hyperactivity or
attention-deficit disorder (wave 1
question) or hyperactivity, attention-
deficit disorder, or ADHD (wave 3
question) (response options, yes or
no). This question was not asked in
wave 2.
ADHD Medication Use
In waves 1 through 3, parents were
asked if during the last year (wave 1)
or past 12 months (waves 2 and 3)
their child had taken medication for
being overactive, being hyperactive,
or having trouble paying attention
(yes or no).
Other Variables
Data were collected on several child
and parent wave 1 characteristics
previously hypothesized to influence
mental health care use. 13 – 15 Child
sociodemographic covariates
included study city (Birmingham,
Houston, and Los Angeles), child
race/ethnicity (non-Latino black
[henceforth, African-American],
Latino, non-Latino white, and other
race/ethnicity), age at fifth grade
survey (<11, 11, and ≥12 years), sex (male or female), insurance status
(uninsured or insured), annual
household income (less than $20 000,
$20 000–$34 000, $35 000–$69 999,
$70 000 or higher), and household
composition (2-parent, 1-parent, or
other). Parent sociodemographic
covariates included highest
household education level (no high
school diploma, high school diploma,
some college, and college degree
or greater) and English language
proficiency (speaks English very well
versus less than very well). Because
no significant differences were
found in results when accounting for
household size in the income variable
(by using the federal poverty level),
we used annual household income.
We also included child symptoms
of oppositional defiant disorder,
conduct disorder, and depression
(each as continuous variables),
and the child’s school functioning,
using the Pediatric Quality of Life
Inventory version 4.0 at each wave.
This inventory tool is a well-validated
instrument designed to measure
health-related quality of life in 2- to
18-year-olds. 16 It measures school
functioning by using 5 child-reported
items (hard to pay attention in class,
forgets things, trouble keeping up
with school work, missed school
because not feeling well, and missed
school to go to physician/hospital);
respondents report how much of a
problem each item has been during
the past month, with 5 response
options (never, almost never,
sometimes, often, and almost always
a problem). Items are reverse scored
(ie, higher scores represent better
school functioning) and linearly
transformed to a 0 to 100 range.
We included a dichotomous measure
of receipt of family-centered care
(FCC) collected by wave 3 parental
report. FCC is a key element of
the medical home, is less likely to
be reported by African-American
and Latino parents, and may be
associated with having fewer unmet
medical needs. 17 – 19 Although FCC
was only measured in wave 3, it was
used as a covariate in analyses of
all waves, as a general indicator of
access to FCC. FCC was indicated as
received if the parent reported that
their child’s physicians “always”
or “usually” spent enough time,
listened carefully, were sensitive
to the family’s values and customs,
provided specific information that
the parent needed, and helped
the parent feel like a partner in
their child’s care; this method of
assessing FCC has been used in
multiple studies. FCC is included in
the National Survey of Children’s
Health and the National Survey of
Children with Special Health Care
Needs, 20, 21 and it has been shown
to be stable over multiple waves of
these national surveys. 22 However,
because we cannot know whether
FCC measured at wave 3 is indicative
of care received at waves 1 and 2, a
sensitivity analysis was conducted
to determine whether inclusion of
FCC as a covariate in adjusted models
significantly changed our results.
Statistical Methods
All analyses use design and
nonresponse weights and account
for the effects of weights and
clustering of children within sites by
using Stata SE 10. 23 – 25 Our sample
included 4297 parent–child dyads
that participated in all 3 waves.
We used χ2 tests of homogeneity
and t tests to describe the wave
1 characteristics of children and
parents in the study sample. Bivariate
analyses were also used to describe
the proportion of children with
symptoms consistent with ADHD,
parent-reported diagnosis of ADHD,
and a history of parent-reported
medication for ADHD according to
child race/ethnicity and survey wave.
The proportion of children receiving
ADHD medication was examined
according to race/ethnicity at each
wave, stratified according to number
of ADHD symptoms (0 symptoms,
1–2 symptoms, 3–5 symptoms, and
6–7 symptoms). Logistic regression
3
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was used to examine the unadjusted
and adjusted odds of ADHD diagnosis
and medication use according to
race/ethnicity over the 3 survey
waves. To determine the disparity
in medication use among children
who had received a diagnosis, odds
of medication use were calculated
according to race/ethnicity among
children with a diagnosis of ADHD
(with or without symptoms).
Finally, we looked for racial/ethnic
disparities in medication use among
2 groups of children: (1) those with a
presumed need for ADHD medication
(either an ADHD diagnosis or
symptoms suspicious for ADHD); and
(2) those with no presumed need
for ADHD medication (no diagnosis
of or symptoms consistent with
ADHD by fifth grade). Racial ethnic/
disparities in medication use that
persist in this first group of children
would suggest underdiagnosis or
undertreatment of African-American
and Latino children. Disparities
that persist in the second group of
children would suggest overdiagnosis
or overtreatment of white children,
which could be the result of multiple
factors (eg, differential provider or
parental expectations for medication
use among children based on child
race/ethnicity).
RESULTS
Table 1 describes the sample. In fifth
grade, parents reported that 8% of
children had symptoms of ADHD, 8%
had ever received an ADHD diagnosis,
and 7% had taken medication for
ADHD over the past year. By 10th
grade, those percentages increased
to 9%, 9%, and 8%, respectively. In
fifth, seventh, and 10th grades, higher
percentages of African-American
children compared with white
children had symptoms suggestive
of ADHD (fifth grade, 12% vs 7%;
seventh grade, 11% vs 6%; and 10th
grade, 13% vs 9%). Latino children
were just as likely to have ADHD
symptoms as white children at each
wave ( Table 2).
In fifth and 10th grades, white
children were much more likely
to have ever received a diagnosis
of ADHD (16% in fifth grade and
19% in 10th grade) than African-
American children (9% and 10%,
respectively), Latino children (4%
and 4%), and children of other race/
ethnicity (10% and 10%) ( Tables
2 and 3). White children were also
more likely to have a parental report
of taking medication for ADHD in the
last year at all 3 waves, compared
with African-American, Latino, and
other children ( Table 3). Results for
differences in medication use were
similar when stratified according
to number of ADHD symptoms. At
all symptom levels above zero, a
higher proportion of white children,
compared with African-American
and Latino children, had a parental
report of ADHD medication (see
Supplemental Table 6). This disparity
persisted even among children at
the highest symptom levels. For
example, among 10th grade children
at the highest symptom level, 65%
4
TABLE 1 Fifth Grade Characteristics
Characteristic Unweighted N Weighted % or Mean ± SD
Child race/ethnicity
African-American 1497 29.1
Latino 1512 44.4
Othera 248 4.4
White 1039 22.1
Male sex 2097 51.1
Age (child age at fi fth grade)
≤10 y (most aged 10; n = 16 are 8–9 y) 1989 44.0
11 y 2048 48.9
≥12 y 260 7.1
Highest household education
Some high school 755 23.
5
High school graduate 850 21.
8
Some college 1159 25.2
College graduate 1474 29.5
Household income, $
<20 000 1306 35.4
20 000–34 000 865 23.0
35 000–69 000 857 20.1
≥70 000 1059 21.5
Family household composition
Two-parent 2400 58.1
Single-parent 1685 37.7
Other (nonparent, foster) 190 4.2
Insurance type (child)
Private 2063 42.5
Medicaid/CHIP 1664 42.3
Other insurance type (military, IHS) 80 2.0
Uninsured 472 13.2
Study site
Birmingham, AL 1350 31.0
Houston, TX 1462 34.
6
Los Angeles, CA 1485 34.4
Mental health symptoms
Oppositional defi ant disorder 329 7.8
Conduct disorder 350 8.2
Depression 307 7.5
FCC 2176 48.9
School functioning (PedsQL subscale) — 75.0 ± 20.6
CHIP, Children’s Health Insurance Program; IHS, Indian Health Service; PedsQL, Pediatric Quality of Life Inventory; —,
continuous variable.
a The other category includes multiracial (n = 131), American Indian/Alaska Native (n = 7), and Asian or Pacifi c Islander
(n = 110).
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PEDIATRICS Volume 138 , number 3 , September 2016
of white children were taking ADHD
medication according to parental
report, compared with 36% of
African-American children and 30%
of Latino children.
Across all waves, African-American
children had significantly lower
adjusted odds of both ever having
a diagnosis of ADHD (fifth grade
adjusted odds ratio [aOR], 0.40 [95%
confidence interval (CI), 0.27–0.59];
10th grade aOR, 0.42 [95% CI,
0.27–0.67]) and of taking ADHD
medication in the past year (fifth
grade aOR, 0.43 [95% CI, 0.29–0.65];
seventh grade aOR, 0.41 [95% CI,
0.28–0.62]; 10th grade aOR, 0.44
[95% CI, 0.28–0.71]) compared with
white children. A similar pattern was
observed when comparing Latino
children versus white children
on adjusted odds of ever having a
diagnosis of ADHD (fifth grade aOR,
0.37 [95% CI, 0.22–0.60]; 10th grade
aOR, 0.46 [95% CI, 0.26–0.79]) and
of taking ADHD medication (fifth
grade aOR, 0.40 [95% CI, 0.23–0.70];
seventh grade aOR, 0.43 [95% CI,
0.25–0.74]; 10th grade aOR, 0.41
[95% CI, 0.21–0.79]) ( Table 3). Of
note, male sex was consistently
associated in these models with
receiving an ADHD diagnosis and
medication.
Disparities in Medication Rates
Among Children With ADHD
According to Symptoms or Diagnosis
Among children ever having a
diagnosis of ADHD or past-year
symptoms of ADHD, African-American
children had lower adjusted odds
of past-year ADHD medication,
compared with white children at
fifth grade (aOR, 0.33 [95% CI,
0.17–0.62]), seventh grade (aOR,
0.34 [95% CI, 0.18–0.64]), and 10th
grade (aOR, 0.41 [95% CI, 0.22–0.75]).
Latino children had decreased odds
compared with white children at fifth
grade (aOR, 0.38 [95% CI, 0.16–0.90])
and 10th grade (aOR, 0.42 [95% CI,
0.20-0.86]) only ( Table 4).
When examining disparities in
medication use among children who
had been diagnosed with ADHD
(whether they had symptoms),
African-American children (fifth
grade odds ratio [OR], 0.46 [95% CI,
0.22–0.97]; 10th grade OR, 0.42 [95%
CI, 0.24–0.74]) and Latino children
(fifth grade OR, 0.17 [95% CI, 0.07–
0.39]; 10th grade OR, 0.28 [95% CI,
0.14–0.57]) had lower unadjusted
5
TABLE 2 ADHD Symptoms, Diagnosis, and Medication Use According to Race/Ethnicity Over 3 Waves
Variable Fifth Grade Seventh Grade 10th Grade
ADHD, by symptoms
Total 8 (350) 7 (324) 9 (400)
White 7 (68) 6 (67) 9 (87)
African-American 12 (176) 11 (154) 13 (195)
Latino 6 (90) 6 (89) 6 (95)
Other 7 (16) 6 (14) 9 (23)
P <.001 <.001 <.001
ADHD, by diagnosis
Total 8 (368) NA 9 (422)
White 16 (152) NA 19 (191)
African-American 9 (131) NA 10 (139)
Latino 4 (62) NA 4 (69)
Other 10 (23) NA 10 (23)
P <.001 <.001 Took medication for ADHD (past 12 mo)
Total 7 (314) 7 (336) 8 (341)
White 14 (132) 14 (142) 16 (155)
African-American 9 (123) 9 (124) 8 (110)
Latino 3 (44) 3 (55) 4 (60)
Other 7 (15) 6 (15) 7 (16)
P <.001 <.001 <.001
Unless otherwise indicated, data are presented as n (%). NA, not applicable.
TABLE 3 Unadjusted ORs and aORs of ADHD Diagnosis and Medication Use According to Race/
Ethnicity Over 3 Waves
Variable Fifth Grade Seventh Grade 10th Grade
ADHD, diagnosis
White Ref NA Ref
African-American
OR (95% CI) 0.54 (0.43–0.69)*** NA 0.46 (0.36-0.60)***
aOR (95% CI) 0.40 (0.27–0.59)*** NA 0.42 (0.27–0.67)***
Latino
OR (95% CI) 0.21 (0.15–0.30)*** NA 0.18 (0.13–0.26)***
aOR (95% CI) 0.37 (0.22–0.60)*** NA 0.46 (0.26–0.79)**
Other
OR (95% CI) 0.63 (0.38–1.03) NA 0.45 (0.29–0.72)**
aOR (95% CI) 0.76 (0.40–1.41) NA 0.56 (0.30–1.03)
ADHD, medication
White Ref Ref Ref
African-American
OR (95% CI) 0.57 (0.43–0.75)*** 0.58 (0.45–0.75)*** 0.48 (0.35–0.66)***
aOR (95% CI) 0.43 (0.29–0.65)*** 0.41 (0.28–0.62)*** 0.44 (0.28–0.71)**
Latino
OR (95% CI) 0.18 (0.12–0.25)*** 0.21 (0.15–0.29)*** 0.23 (0.17–0.31)***
aOR (95% CI) 0.40 (0.23–0.70)** 0.43 (0.25–0.74)** 0.41 (0.21–0.79)**
Other
OR (95% CI) 0.45 (0.25–0.80)** 0.39 (0.23–0.67)** 0.42 (0.22–0.79)**
aOR (95% CI) 0.60 (0.31–1.18) 0.46 (0.25–0.86)* 0.45 (0.21–0.98)*
Adjusted for child age, sex, health insurance, mental health symptoms, and school functioning; household composition,
income, and highest parental educational attainment; parent English profi ciency and reported receipt of FCC in child’s
health care; and study site. NA, not applicable.
* P < .05.
** P < .01.
*** P < .001.
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COKER et al
odds of medication use compared
with white children. This sample
limited to children with a diagnosis
did not have adequate numbers to
support adjusted analysis (n = 328
for fifth grade; n = 368 for 10th
grade); results not shown in table.
Medication Rates Among Children
Without ADHD According to
Symptoms or Diagnosis by Fifth
Grade
Among children who had neither
past-year symptoms consistent with
ADHD nor an ADHD diagnosis by fifth
grade (and thus would not likely meet
ADHD diagnostic criteria at any age),
there was no statistically significant
difference in past-year medication use
according to race/ethnicity (1%–2%
of white, African-American, and
Latino children were taking ADHD
medication at fifth grade and 2%–3%
at seventh grade). By 10th grade,
the difference in medication use was
statistically significant (P = .004);
7% of white children without ADHD
according to symptoms or diagnosis in
fifth grade took ADHD medication in
the past year, compared with 4% for
African-American children and 3% for
Latino children. In adjusted analyses,
however, the odds of medication use
were not statistically significant for
African-American and Latino children
compared with white children at fifth,
seventh, and 10th grades ( Table 5).
Findings were not sensitive to
inclusion of FCC care as a covariate.
DISCUSSION
In this longitudinal, multisite study,
African-American and Latino
children were less likely to have a
parental report of ever receiving an
ADHD diagnosis or of taking ADHD
medication in the past year compared
with white children; the disparity
in medication use persisted among
children with either a diagnosis of
ADHD or with symptoms of ADHD.
The disparity was not observed in
adjusted analysis among children who
had no history of ADHD according to
diagnosis or symptoms by fifth grade.
Other large studies have found similar
disparities in ADHD diagnosis for
African-American and/or Latino
children, including the 2003–2004 and
2007 National Survey of Children’s
Health, 7, 26, 27 the Early Childhood
Longitudinal Survey–Kindergarten
Cohort, 2, 3 the 1997 to 2001 National
Health Interview Survey, 6 and the 1997
to 2005 Medical Expenditure Panel
survey. 5 Similar disparities have also
been reported in medication use for
ADHD, finding that African-American
and/or Latino children are less likely
to take a medication for ADHD. 1, 3, 5, 6, 27
Reports from 3 waves of the National
Survey of Children’s Health (2003,
2007, and 2011–2012) suggest that
racial/ethnic disparities in diagnosis
and medication treatment continued to
emerge over time, reflecting the trends
of increasing parent-reported ADHD
diagnosis and medication use in the
United States from 2003 to 2011. 1, 27
Not all studies, however, have found
racial/ethnic disparities in ADHD
diagnosis or medication use. 28, 29
For example, Froehlich et al, 29
using 2001–2004 National Health
and Nutrition Examination Survey
data, found no such disparities
among children meeting Diagnostic
and Statistical Manual of Mental
6
TABLE 4 aORs of ADHD Medication Use by Race/Ethnicity Over 3 Waves Among Children With a Diagnosis or Symptoms of ADHD
Child Race/Ethnicity Fifth Grade (n = 577) Seventh Grade (n = 721) 10th Grade (n = 645)
% (N) aOR (95% CI) % (N) aOR (95% CI) % (N) aOR (95% CI)
Total 47 (270) 36 (261) 45 (282)
White 73 (125) Ref 61 (118) Ref 67 (143) Ref
African-American 41 (101) 0.33 (0.17–0.62)a 33 (97) 0.34 (0.18–0.64)a 35 (88) 0.41 (0.22–0.75)a
Latino 24 (31) 0.38 (0.16–0.90)a 19 (35) 0.51 (0.23–1.15) 29 (36) 0.42 (0.20–0.86)a
Other 45 (13) 0.37 (0.12–1.10) 29 (11) 0.24 (0.11–0.56)a 44 (15) 0.33 (0.11–0.96)a
Adjusted for child age, sex, health insurance, mental health symptoms, and school functioning; household composition, income, and highest parental educational attainment; parent
English profi ciency and reported receipt of FCC in child’s health care; and study site. Signifi cant fi ndings are bolded. Fifth grade analysis was limited to children with ADHD symptoms or
diagnosis at wave 1. Seventh grade analysis was limited to children with ADHD symptoms or diagnosis at wave 1 or with symptoms at wave 2 (diagnosis not reported at wave 2). Tenth
grade analysis was limited to children with ADHD symptoms or diagnosis at wave 3.
a Signifi cant fi ndings.
TABLE 5 aORs of ADHD Medication Use According to Race/Ethnicity Over 3 Waves Among Children With No Diagnosis or Symptoms of ADHD at Wave 1
Child Race/Ethnicity Fifth Grade (n = 3628) Seventh Grade (n = 3628) 10th Grade (n = 3596)
% (N) aOR (95% CI) % (N) aOR (95% CI) % (N) aOR (95% CI)
Total 1 (44) 2 (86) 4 (138)
White 1 (7) Ref 3 (25) Ref 7 (56) Ref
African-American 2 (22) 1.03 (0.27–3.96) 3 (33) 0.73 (0.30–1.74) 4 (39) 0.59 (0.28–1.22)
Latino 1 (13) 0.51 (0.12–2.23) 2 (23) 0.85 (0.31–2.34) 3 (38) 0.55 (0.24–1.29)
Other 1 (2) 1.23 (0.13–11.64) 2 (5) 1.08 (0.30–3.92) 4 (5) 0.70 (0.25–2.02)
Adjusted for child age, sex, health insurance, mental health symptoms, and school functioning; household composition, income, and highest parental educational attainment; parent
English profi ciency and reported receipt of FCC in child’s health care; and study site.
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PEDIATRICS Volume 138 , number 3 , September 2016
Disorders, Fourth Edition, criteria
for ADHD. Differences in study
findings may relate to such factors as
relative distribution of white versus
nonwhite participants, or the breadth
of socioeconomic covariates included
in adjusted analyses.
Few previously published studies
have empirically addressed the
question of whether ADHD medication
disparities are primarily due to
underdiagnosis/undertreatment of
African-American and Latino children
or overdiagnosis/overtreatment of
white children. One commentary
addressed the question of
overdiagnosis but without empirical
data. 30 Another study focused on
whether overdiagnosis of ADHD
was a problem, based on previously
published ADHD prevalence data. 8
We found that, among children with a
potential need for ADHD medication
(ie, ADHD symptoms or diagnosis),
African-American and Latino children
were less likely to take ADHD
medication than white children;
however, among children with no
apparent need for ADHD medication
(ie, no ADHD symptoms or diagnosis),
white children were not significantly
more likely to take medication. Our
study does not have an objective
measure of ADHD prevalence, and
thus we are unable to directly address
this question of overdiagnosis and
overtreatment. However, our findings
do indirectly suggest that these
disparities are more likely from the
underdiagnosis/undertreatment of
African-American and Latino children
than the overdiagnosis/overtreatment
of white children. It may be that
African-American and Latino children
are less likely to report taking a
medication for ADHD because they
are less likely to receive a diagnosis
of ADHD, or because when diagnosed,
they are less like to receive (or accept)
a medication for ADHD.
In fifth and seventh grades, only
small percentages of children
with neither symptoms nor a
diagnosis of ADHD by fifth grade
were taking ADHD medication
(across all racial/ethnic groups of
children); the implication of this
finding is that overdiagnosis and
overtreatment likely contribute
only minimally to the disparity
in medication treatment. This
proportion increased for 10th
grade, particularly among white
children, and in unadjusted analysis,
there was a significant difference
between white children compared
with African-American and Latino
children. We found no statistically
significant differences in adjusted
odds, which may be due to the small
number of children with medication
use in those models.
This study has limitations. First,
parent-reported data may introduce
reporting bias; however, a recent
study reported similarities between
parent-reported ADHD estimates and
administrative claims data estimates. 31
In addition, we were unable to include
reports from teachers or schools
on school functioning, which is an
important element of ADHD symptom
reporting. Our child-reported school
functioning measures are limited
in that they focused on behavior,
were not validated against teacher
ratings, and may not accurately reflect
academic achievement. It is also
possible that there are racial/ethnic
differences in parental reporting of
symptoms for which we are not able to
account; these differences in reporting
could potentially lead to either an
underestimation or overestimation
of the disparities in our findings. Data
collection was limited to children in
public school settings in 3 metropolitan
areas, and our sample’s racial/
ethnic composition is different from
the US composition because it was
designed to have a balanced sample of
African-American, Latino, and white
children; thus, caution should be used
in generalizing our findings to other
populations. We also lacked detailed
information on ADHD medication
use (eg, type and dose of medication,
duration of use); these data should be
considered for future studies.
CONCLUSIONS
Our findings have implications for the
diagnosis and treatment of ADHD.
There are various improvements in
care that may help in closing this gap in
diagnosis and treatment. These include
actively and universally eliciting
parental concerns about child behavior
and academic performance (at home
and school) at well-visits, 32, 33 providing
care that is culturally relevant in
families’ preferred languages, 34 and
linking with community resources
to provide mental health education,
guidance, and services to families (eg,
parent training courses for parents of
children with ADHD). 35 – 39 Pediatric
clinicians also may need to consider
universal behavioral health screening
tools for children to improve diagnostic
capabilities and recognize when a
child has ADHD symptoms, even if
the problem is not recognized by the
parent.
Because the rates of diagnosis
and treatment are rising in the
general population of US children, a
significant need remains to identify
and treat African-American and
Latino children who have ADHD and
avoid a widening of these disparities.
ACKNOWLEDGMENTS
We thank the Healthy Passages team,
staff, and participants for making the
study possible.
7
ABBREVIATIONS
aOR: adjusted odds ratio
ADHD: attention-deficit/
hyperactivity disorder
CI: confidence interval
DPS: Diagnostic Interview
Schedule for Children
Predictive Scales
OR: odds ratio
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COKER et al
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obtained funding, participated in study design and interpretation of fi ndings, revised manuscript drafts, and contributed to overall supervision; and all authors
provided fi nal approval for the submitted manuscript.
DOI: 10.1542/peds.2016-0407
Accepted for publication Jun 30,
2016
Address correspondence to Tumaini R. Coker, MD, MBA, Mattel Children’s Hospital, David Geffen School of Medicine at UCLA, 10833 Le Conte Ave, Room 12-436, Los
Angeles, CA 90095. E-mail: tcoker@mednet.ucla.edu
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2016 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have no fi nancial relationships relevant to this article to disclose.
FUNDING: The Healthy Passages Study was funded by the Centers for Disease Control and Prevention, Prevention Research Centers (Cooperative Agreements
CCU409679, CCU609653, CCU915773, U48DP000046, U48DP000057, U48DP000056, U19DP002663, U19DP002664, and U19DP002665). The fi ndings and conclusions in
this report are those of the authors and do not necessarily represent the offi cial position of the Centers for Disease Control and Prevention.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential confl icts of interest to disclose.
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O R I G I N A L A R T I C L E
Is ADHD a ‘real’ disorder?
MICHAEL QUINN and ANDREA LYNCH
In many western countries, attention deficit hyperactivity disorder (ADHD)
has achieved celebrity status, such that it probably no longer requires intro-
duction. The disorder is a global phenomenon, spreading rapidly as result of
the increasing dominance internationally of US psychiatric models, the need
for new markets for major pharmaceutical companies, increasing use of the
internet by parents and professionals and changing approaches to schooling.
There is a broad consensus among international experts and organisations
that ADHD is a genuine neurodevelopmental disorder based on empirical
research. However, many critics have questioned the legitimacy of ADHD.
This paper reviews the arguments for and against the ADHD construct. First,
the review examines the literature and research endorsing ADHD as a ‘real’
disorder. Second, the criticisms levelled against the ADHD construct are
examined.
Key words: ADHD, support, science, criticisms.
Introduction
According to the American Psychiatric Association (2013), ADHD is a neurode-
velopmental disorder characterised by a persistent pattern of inattention and
hyperactivity–impulsivity. Symptoms of this nature persist into adulthood and
can cause several impairments in social, academic and occupational functioning
(Gapin et al., 2011). Globally, the disorder affects 5.3% of children (Polanczyk
et al., 2007). This figure was reported following a review of 102 prevalence
VC 2016 NASEN
DOI: 10.1111/1467-9604.12114
studies from seven regions, including North America, South America, Europe,
Africa, the Middle East, Asia and Oceania. The disorder is more commonly
diagnosed in males than in females in the general population, with a ratio of 2:1
in children (American Psychiatric Association, 2013). In the United States, and
increasingly in Europe, psychostimulants are first-line treatments for ADHD
(Singh, 2008) and since the 1950s, medications for ADHD have been used
(Kewley, 2011).
In many western countries, ADHD has achieved celebrity status, such that it
probably no longer requires introduction (Graham, 2010). It is a global phenom-
enon, spreading rapidly as result of the increasing dominance internationally of
US psychiatric models, the need for new markets for major pharmaceutical com-
panies, increasing use of the internet by parents and professionals and changing
approaches to schooling (Stead et al., 2006). Campbell (2000) asserts it is safe
to argue that we likely know more about ADHD than any other childhood con-
dition. Yet, despite the existing plethora of research and skyrocketing increases
in the number of persons diagnosed with ADHD, it is clear that this topic is
highly misunderstood (Kewley, 1999).
Support for ADHD
The symptoms of ADHD do not represent a new phenomenon (Goldstein and
Goldstein, 1998): the British physician George Still made reference to a disorder
we now recognise as ADHD in 1902 (Cooper and Bilton, 2002). Descriptions of
inattention, impulsive and hyperactive behaviour in childhood have appeared in
texts as old as the Bible (Goldstein and Goldstein, 1998). Many international
experts and organisations have endorsed ADHD as a valid medical disorder (e.g.
Barkley, 2013; DuPaul and Stoner, 2014; Mash and Wolfe, 2015; Tannock,
1998; Kewley, 2011; Goldstein and Goldstein, 1998; American Psychiatric
Association, 2013; National Institute of Mental Health, 2008; British Psycholog-
ical Society, 2000; National Institute of Clinical Excellence, 2013). Many of
these organisations, among others, have published comprehensive guidelines
that provide evidence-based recommendations for the diagnosis and treatment of
ADHD. In 2002, Professor Russell Barkley and a consortium of medical practi-
tioners and researchers published an International Consensus Statement on
ADHD (Barkley et al., 2002). This document is significant in the context of the
current article because it confirmed the status of the scientific findings
60 Support for Learning � Volume 31 � Number 1 � 2016 VC 2016 NASEN
concerning the validity of the disorder, and its adverse impact on the lives of
those living with ADHD.
Science and ADHD
Findings from genetic and neurological studies have given weight to the argu-
ment that ADHD is a valid disorder. For example, Tannock (1998) reviewed
several studies and identified the following findings which support a genetic
basis for ADHD:
� Over the past 30 years, numerous family-genetic studies have reported a
higher prevalence rate of psychopathology, particularly ADHD, in parents
and other relatives of children with ADHD.
� In twin and adoption studies, reports have consistently shown a much
greater incidence of ADHD among identical monozygotic (MZ) twins than
among non-identical dizygotic (DZ) twins. Passmore (2014) also adds that
MZ twins share 100 per cent of their genes, whereas DZ twins only share
50 per cent of their genes: ‘Scientists have found that if one twin has
symptoms of ADHD, the risk that the other will have the disorder is as
high as 75-90%’ (Barkley, 2013).
� In the dopamine system, molecular genetic research has identified genetic
abnormalities. Dopamine is one of many neurotransmitters found in the
brain and is essential for attention among other things (Ratey and Hager-
man, 2008).
There have also been suggestions that ADHD may have its roots in neurological
causes (Buckley et al., 2009; Barkley and Murphy, 2006; Jacobs and Wendel,
2010). Neurotransmitter chemicals such as dopamine, norepinephrine and sero-
tonin play a vital role in regulating human behaviour (Reynolds et al., 2012;
Parker, 1998). These neurotransmitters carry messages between brain cells dur-
ing mental tasks – rather like workers moving around and putting things together
in a factory (Munden and Arcelus, 1999). Ratey and Hagerman (2008) explain
why these particular neurotransmitters are so important in the case of children
with ADHD. First, the neurotransmitter dopamine is essential for attention,
among other things. Second, norepinephrine affects arousal, alertness, attention
and mood. Third, serotonin regulates many functions, including mood, impulsiv-
ity, learning and self-esteem. Professionals maintain that children with ADHD
have a deficiency in these neurotransmitter chemicals (Barkley, 2013; Ratey and
VC 2016 NASEN Support for Learning � Volume 31 � Number 1 � 2016 61
Hagerman, 2008; Reiff and Tippins, 2004). Studies have discovered particularly
low levels of activity in the neurotransmitters located in the frontal lobes of the
brain (Wheeler, 2007). Findings from various studies support the argument that
neurological factors are a key contributor to ADHD. Neuro-imaging studies
involving children with ADHD have shown a decreased size of the prefrontal
cortex (e.g. Mostofsky et al., 2002), resulting in expected deficits in certain pre-
frontal executive functions, such as response inhibition and working memory
(Barkley, 1997; Tannock, 1998). In the United States, one study that deserves
particular attention was carried out at the National Institute of Mental Health by
Zametkin et al. (1990). This study has been described as a landmark piece of
research (Ratey and Hagerman, 2008). Using a type of brain scan referred to as
Positron Emission Tomography (PET) scans, the study focused on the rate at
which the brain uses glucose, which is the brain’s main energy source. Results
illustrated that during an attention test, participants with ADHD displayed 10
per cent less brain activity than the control group. The largest deficit was within
the prefrontal cortex, an area of the brain which plays a crucial role in regulating
behaviour, and is also prone to positive reinforcement through physical activity
(Ratey and Hagerman, 2008).
Medicalising ‘annoying’ behaviour
Some critics of the ADHD construct question the possibility that ADHD is per-
haps nothing more than an example of the ‘medicalisation’ of behaviours in
children which are the most annoying and problematic for adults to control. As
Bromfield proclaims, the condition is implicated in ‘all sorts of abuses, hypoc-
risies, neglects, and other society ills that have nothing to do with ADHD’
(Bromfield, 1996, p. 3; cited in Conrad and Potter, 2000, p. 570). Indeed, those
who are critical of ADHD as a medicalised construct often cite ADHD as ‘a
means of labelling and controlling children who exhibit difficult behaviours’
(Mather, 2012, p. 19). Child neurologist Fred Baughman has been one of the
most outspoken critics of ADHD, calling it a ‘fraud’. As Baughman (2006)
argues:
‘Virtually all the symptoms of ADHD relate to classroom behaviour. Children
who don’t do homework, fidget, squirm, interrupt, and are forgetful and disor-
ganized are assumed to have a biochemical imbalance in their brain. These chil-
dren can be difficult to control in a classroom and in many cases are more
62 Support for Learning � Volume 31 � Number 1 � 2016 VC 2016 NASEN
compliant when drugged. However, there is absolutely no scientifically valid
evidence that compliant –drugged students learn faster.’ (2006, p. xiii)
He goes on to conclude: ‘ADHD is a disorder manufactured to match our times.
It is a quick catch-all diagnosis with a magic bullet treatment’ (2006, p. xiii).
Other critics view ADHD as a social construct which is the result of our
performance-driven cultures and societies, citing the prolific increase of Ritalin
and other stimulants to ‘treat’ ADHD as nothing more than a method of perform-
ance enhancement. According to Lawrence Diller (1998), the ADHD label is ‘sal-
vation’ for some, allowing them to avoid feelings of ‘failure’ as they blame their
behaviour and related issues on brain functioning or genetics, rather than accepting
personal responsibility for their problems. The same author contends that the
increased numbers of those diagnosed with ADHD has led to the development of
supportive communities which provide a sense of belonging to people whose
behaviour has otherwise made them outsiders in the dominant culture.
Disagreement on how to ‘define’ ADHD
A review of literature shows there is no consensus on an agreed definition for the
disorder. For the example, in the Diagnostic and Statistical Manual of Mental Dis-
orders, Fifth Edition (DSM-5) published by the American Psychiatric Association
(2013), ADHD is defined as a ‘neurodevelopmental disorder’, and the Interna-
tional Classification of Diseases and Related Health Problems refers to it as a
‘hyperkinetic disorder’ (World Health Organization, 1992). ADHD is also defined
in a wide variety of ways within the research literature, and each definition can
give some insight into the author’s philosophical position concerning the nature of
ADHD. It is not uncommon to see ADHD defined as a neurobiologic condition
(Quinn, 2008), a neurodevelopmental disorder (Mrug et al., 2012), a mental disor-
der (Benkert et al., 2010) and a heterogeneous condition (Newcorn et al., 2001;
Faraone and Biederman, 1998). In addition, the following terms have also been
historically applied to ADHD: ‘attention deficit disorder (ADD), hyperkinetic dis-
order (HKD), hyperkinesis, minimal brain dysfunction, minimal brain damage
(MBD), and disorder of attention, motor control, and perception (DAMP)’ (Carr,
2006, p. 421). Regardless of the kind of term used, children with ADHD continue
to present with severe and pervasive symptoms of inattention, hyperactivity and
impulsivity.
VC 2016 NASEN Support for Learning � Volume 31 � Number 1 � 2016 63
Lack of a biological marker and unknown etiology
Despite copious amounts of medical and psychological research, science has yet
to discover a biological marker or characteristic for ADHD. Unlike other medi-
cal conditions which have clear and identifiable markers that indicate the pres-
ence of disorder, in the case of ADHD, ‘No biological marker is diagnostic’
(American Psychiatric Association, 2013, p. 61). Also, there are no objective
medical ‘tests’ which can detect the presence of ADHD (Timimi and Taylor,
2004). Science remains unable to identify the exact causes or etiology of
ADHD, and prominent researchers like Faraone and Biederman admit that we
have yet to achieve this goal (Faraone et al., 1995). The inability to conclusively
identify causes of ADHD calls into serious question the legitimacy of ADHD as
a medical disorder (Visser and Jehan, 2009). Not surprisingly, several theories
exist concerning the causes of ADHD in the individual.
The biological theory of impaired brain functioning is perhaps the most widely
accepted of all theories (Tidefors and Strand, 2012), as it suggests that ADHD is
the result of malfunction in brain processes and/or structures (Qiu et al., 2011;
Castellanos et al., 2002; Taylor, 1999). Genetic factors have also been strongly
linked to ADHD causation (Tannock, 1998; Hawi et al., 2013; Park et al., 2010;
Thapar et al., 2007; Faraone and Biederman, 1998), as have ‘deficits’ in the
individual, such as deficits in executive functioning (Shoemaker et al., 2012), in
executive inhibition (Nigg, 2001) and in behavioural inhibition (Barkley, 1997).
ADHD has also been linked to a host of sources outside of the individual, such
as conditions before, during and after gestation, psychosocial influences and
environmental factors (Thapar et al., 2013; Taylor and Sonuga-Barke, 2008).
The existing body of research is not without its critics. Researchers such as
Ongel (2006) take a more sceptical view of such studies, warning us that associ-
ation between variables (such as abnormal behaviour and brain abnormalities)
does not automatically signify causation.
Diagnosis of ADHD: subjectivity and checklists
The subjective nature of the ADHD diagnosis is another cause for criticism.
Senior (2009) argues that ADHD is so contested precisely because of the subjec-
tive nature of the diagnostic process. ADHD diagnosis is based largely on the
characteristic criteria established in the DSM-5 (American Psychiatric Associa-
tion, 2013) and the International Classification of Diseases and Related Health
64 Support for Learning � Volume 31 � Number 1 � 2016 VC 2016 NASEN
Problems (World Health Organization, 1992), and is subjectively identified by
medical professionals through use of behavioural checklists and rating scales
(Stead et al., 2006). There is no one standardised checklist in use for ADHD
diagnosis; rather, there are at least two dozen, if not more (Cohen, 2006). Often,
whether a person obtains a diagnosis of ADHD can be a matter of degree and
personal opinion.
Over-diagnosis and use of psychotropic drugs in children
Critics of the ADHD construct also question the ever increasing diagnosis of
ADHD along with skyrocketing rates of psychostimulant drug usage in children.
It is estimated that in the UK during the ten-year period from 1994 to 2004, the
prescription of methylphenidate increased by an astonishing 7,600% (Cohen,
2006). As Cormier (2008) explains, we should be extremely concerned regard-
ing the ever increasing numbers of pre-schoolers who are diagnosed with
ADHD, as well as the ‘sevenfold’ increase in the prescription and use of stimu-
lant medications in children. Statistics such as this raise questions regarding the
possibility of the ‘over-diagnosis’ of ADHD. In their research, Bruchmuller
et al. (2012, p.128) determined that therapists commonly fail to diagnose in
strict accordance with manuals and that ‘overdiagnosis of ADHD occurs in the
clinical routine’. However, others argue against the concept of overdiagnosis,
claiming this is a misperception which has simply taken hold in public percep-
tion and media coverage (Sciutto and Eisenberg, 2007).
Questions have also been raised regarding the influence and motives of the phar-
maceutical industry in the race to ADHD diagnosis (Conrad and Bergey, 2014;
Ongel, 2006). While much of the research literature strongly asserts the efficacy
of psychostimulant drugs in treating and controlling symptoms associated with
ADHD (Benkert et al., 2010; Forness et al., 1999), questions must be raised
regarding the potential for bias, especially in cases where pharmaceutical com-
panies are backing research into the efficacy of pharmacological treatments for
ADHD. One example of such research is the Survey of ADHD in Irish Children
(Fitzgerald, 2007) which was directly supported by the pharmaceutical company
Eli Lilly and Co. (Ireland) Ltd. Interestingly, many of the questions in this ‘sur-
vey’ of parents of children with ADHD highlight strongly positive outcomes
reported by parents when their children were on medication, as opposed to
when they were not.
VC 2016 NASEN Support for Learning � Volume 31 � Number 1 � 2016 65
Conclusion
The authors of this paper reviewed the literature and research supporting ADHD
as a valid disorder. They also explored the many criticisms levelled against the
ADHD construct. Research literature on both sides of the ADHD argument
presents clear and compelling evidence for their theories and positions and it is
clear that the debate surrounding the legitimacy of ADHD as a medical condi-
tion is far from over. Although the ADHD construct has been scientifically
explored, it has gathered limited medical support, and admittedly, serious gaps
in knowledge remain unanswered. This highlights the need for further research
and exploration of this controversial and contested condition, with which many
of our children and students continue to be diagnosed and labelled in the present
day.
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Correspondence
Michael Quinn
School of Education
University College Dublin (UCD)
Ireland
Email: michael.quinn@ucdconnect.ie
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