Children at Risk ADHD

According to the American Psychiatric Association, Attention-deficit/Hyperactivity Disorder (or ADHD) is one of the most common mental disorders affecting children (1). However, that was not always the case. This paper will demonstrate how ADHD diagnosis is climbing at a steady rate without concrete evidence that the disorder is actually any more prevalent today than it was just a few decades ago. Furthermore, this paper will attempt to show why the disorder is being diagnosed now more than in the past, and what groups are particularly at risk for diagnosis.

With this information, the paper will face the debate of whether or not overdiagnosis is or is not an issue by relating the phenomen to Bronfenbrenner's ecological model by taking a strong look at the current treatment methods for the disorder.

To begin, it is important to understand what Attention-deficit/Hyperactivity disorder actually entails. The Mayo Clinic states that ADHD includes a combination of persistent problems, such as difficulty sustaining attention, hyperactivity, and impulsive behavior (Mayo Clinic 1). The problem is usually first recognized in school-aged children when it leads to disruption in the classroom or problems with schoolwork. However, while teachers and staff are usually among the first involved in recognizing a child may have a problem, they have no say in whether a child has to seek treatment or take medication to attend school. This is a task left to parents and pediatricians. Children who have the disorder may also struggle with low self-esteem, troubled relationships, and poor performance in school (2).

While ADHD has been a diagnosis since the early 1900's, the risk factors for developing the disorder have remained unclear over time. The one risk factor that is most universally accepted is that the disorder occurs more often in boys than in girls, as well as with differing symptoms. Boys tend to be more hyperactive, whereas girls tend to be more quietly inattentive (Mayo Clinic 2). Next, there is some evidence that the disorder could be genetic. For instance, 3 out of 4 children diagnosed with the disorder also have a relative with the disorder (American Psychiatric Association 1). However, it is unclear what genes the disorder would act on, and there are plenty of cases where a diagnosed child has no relatives with the disorder. There is also evidence to suggest that the disorder can come about in other ways. These other risk factors include exposure to environmental toxins like lead, maternal drug or alcohol use during pregnancy, and premature birth (Mayo Clinic 1). Of these risk factors, there has been the most studies on the effect of maternal smoking to suggest that this could lead to a heightened risk for ADHD (He et al. 1). There is also debate about whether poverty is a risk factor for the disorder. The research suggests that this cannot yet be confirmed, but it is possible to conclude that poverty can make the disorder more difficult to treat due to a lack of funds to seek a specialist or pay for medication. It is also important to note that while there are other factors that can lead to a difficulty sustaining attention such as sugar consumption, playing video games, and watching tv, these are not the same as ADHD (CHADD 2). As such, the treatment for ADHD differs significantly.

Treatment for ADHD is usually "multimodal. This means that a combination of treatments are utilized with focuses ranging between medical, educational, behavioural, and psychological options (NIMH 2). Because ADHD is not the same for every individual, personalized treatment options are usually implemented. For the purposes of this paper, there will be a focus on the medication used to treat the disorder as it has a clearer impact on the different systems of Bronfenbrenner's model which will be discussed later. The most common medications prescribed for the treatment of ADHD fall under the category of stimulants. These are administered either once or twice a day depending on the medication. These medicines include methylphenidate (with brand names that include Ritalin, Concerta, Daytrana, and Focalin), and amphetamines (with brand names that include Adderall, Dexedrine, Vyvanse) (2). These medicines aim to improve attention by helping normal brain chemicals work better. The medicines mainly target two brain chemicals, dopamine and norepinephrine. These chemicals are important to the disorder as they play a key role in controlling attention and concentration (Gulf Bend 1). As people respond differently to different medications, doctors will often prescribe these medications in different doses and may sometimes prescribe a combination of medicines to a single individual. The initial process of standardizing a patient's medicinal schedule may take weeks or months to try and find the proper balance. As with any other medication, these drugs may have side effects. The most common side effects are loss of appetite and trouble sleeping. Other ADHD medicine side effects include jitteriness, irritability, moodiness, headaches, stomach aches, increased heart rate, and high blood pressure (Mayo Clinic 2).

As far as preventive measures go, the research is limited on how to prevent the disorder from arising. While there are no confirmed actions to prevent the disorder, avoiding maternal smoking and drug use, as well as keeping children away from toxins may be helpful for lowering the risk of developing the disorder. As preventive measures are limited, the research tends to focus on the treatment methods described above rather than complete prevention.

The reason treatment for ADHD is important is because the disorder has a number of associated negative outcomes. These include problems with education, relationships, employment, and quality of life. With education, it has been demonstrated that children and adolescents with the disorder may struggle with school-related assignments in comparison to control-groups (American Psychiatric Association 1). With relationships, ADHD symptoms can contribute to misunderstandings in social situations that can put a strain on relationships with peers, family, and teachers (2). With employment, it has been demonstrated that ADHD in adults can lead to difficulty with workplace productivity and makes it difficult to maintain employment. With quality of life, people with ADHD and their families have reported poorer quality of life than control groups in several studies (CHADD 3). There are also negative outcomes that stem from the medication used to treat the disorder. The medication may cause cardiac disruptions such tachycardia, arrhythmia, and murmurs which may pose threats to the child's overall health (2). These stimulants also force the body to rapidly produce dopamine, which can create a dependency within the brain. Thus, if or when an individual stops taking, or loses access to their prescription for their medication, extreme withdrawal can occur. Studies suggest it is common for stimulant addiction to lead to future tobacco, alcohol, or other street and prescription drug addiction (CDC 1). Because of these associated negative outcomes, it is crucial to find out why diagnoses are increasing at such an alarming rate.

In 2012, the Center for Disease Control announced that 11% of all children between the ages of 4 and 17 had been diagnosed with ADHD. This roughly 1-in-10 risk of being diagnosed equates to 6.4 million children being affected by the disorder (2). While this statistic on its own is staggering, it is important to note how this number has climbed over time. In 2007, 7.8% of children were diagnosed. In 2009, the number was up to 9.5%. Dr. David Rabiner, a child clinical psychologist and director of undergraduate studies in the department of psychology and neuroscience at Duke University has also weighed in on the growing rate of diagnosis. He reports that between 1992 and 2008, boys' visits to a doctor that led to an ADHD diagnosis rose from an average of 39.5 diagnoses for every 1000 visits to an average of 144.6 diagnoses for every 1000 visits. For girls, the rate increased from an average of 12.3 diagnoses for every 1000 visits to an average of 68.5 diagnoses for every 1000 visits (Rabner 1). While there is clear consensus that diagnosing rates are increasing, the more difficult question to answer is why.

One explanation for the rapid growth in diagnosis has to do with who is doing the diagnosing. While diagnoses were largely coming from psychiatrists and clinical psychologists in the past, today primary care physicians are mainly the ones making these diagnoses (Leslie 1). The problem with this is that pediatricians are not nearly as qualified as psychiatrists and clinical psychologists to make these diagnoses. Primary care pediatricians simply lack the amount of training in the field that these other mental health experts have. So while psychiatrists and clinical psychologists have dedicated their lives to the practice, pediatricians are only working with roughly two months of psychiatric training during residency but end up making over 90% of the ADHD diagnoses today (2). In an ideal situation, a child would visit their primary care physician and would then be referred to either a psychiatrist or clinical psychologist to receive a proper diagnosis. However, this is becoming increasingly rare. A suggested reason for this could be that parents are not willing to spend additional money to see a specialist with increasing healthcare costs when a primary care physician is willing to make the diagnosis and write out the prescription. Part of the problem with overdiagnosis stems from parents thinking that medication is the quick fix and again not wanting to spend the time and money of sending their child to a specialist to receive alternative forms of treatment. It is important to note that there is no quick fix for ADHD. Any kind of treatment only masks the underlying issue, it never ceases the symptoms permanently.

Now, to incorporate Bronfenbrenner's model to explain the branching impacts of the disorder, it is important to understand what this model actually is. Bronfenbrenner developed his ecological systems theory, which outlines the overall environment into several subcategories, in which different systems within society have a distancing impact on the individual. By utilizing his model, the impacts of an exponentially increased rate of diagnosis may be discussed within multiple layers of society, starting with the direct impact on the individual child, and gradually radiating into the greater impact on society.

At the center of Bronfenbrenner's model is the individual. A mere diagnosis of ADHD can have serious side effects. For example, diagnosis is capable of distorting and changing a child's self- image. If sever enough, it could lead to Borderline Personality Disorder (or BPD). Of those diagnosed with ADHD, 25% of the population has a comorbid diagnosis of both ADHD and BPD (SAGE 1). With this, there is a lost contact between an individual and their self-image which can lead to further self-confidence issues. There are cases where the medication prescribed to mediate behavior unintentionally leads the child to see themself as crazy making them shy, upset, or outraged.

ADHD medication also can have a severe impact on the individual. For example, a stimulant like Adderall leads to an extreme loss in appetite. The most critical time period for a child to be eating properly is between the ages of 4 and 17. Proper eating provides the body with necessary nutrients, minerals, proteins, and carbohydrates to support rapid growth. A lack of proper nutrition can prevent the body from fully maturing. A sudden loss of appetite caused by ADHD medication can lead a child to not eating properly (American Psychiatric Association 3). This can lead to significant losses in weight that can increase the potential for an eating disorder, while simultaneously stunting growth and putting the child at other health risks.

To move onto the microsystem, this is the system that entails the relationship in which an individual affects and is affected by their immediate environment. As mentioned earlier, ADHD can lead a child into a disturbed emotional state. This disturbed emotional state can lead to difficulties with relationships with peers, teachers, and family. Furthermore, if those in the immediate environment of the diagnosed are not ready to cope with the needs of the child, it can lead to improper disciplining of the child or general backlash that will only heighten the disturbed emotional state. This can lead into the mesosystem where we see an interaction between microsystems. With children who have ADHD, there is a strong interaction between the microsystem of the home and the microsystem of the school. If a teacher has a problem with the behaviour of a student, they may go to the parents to try and resolve the issue. If properly handled, this may be an opportunity for a parent to bring their child to a specialist to receive proper treatment for ADHD. However, it can also lead to harsh punishment for a child for behaving in a manner they cannot control. Thus, family/school interactions can be helpful or harmful depending on the situation. Unfortunately, these interactions tend to be more harmful for families of lower socioeconomic status as they do not have the funds to provide proper treatment to the child.

The interactions on the mesosystem can relate to similar advantages or disadvantages at the exosystem. Here, different environments are again involved, but this time there is some kind of indirect effect on the child. For example, problems at a parent's job can affect the treatment of a child with ADHD. A raise for a parent can increase a child's access to treatment options. On the contrary, if a parent is fired from work he or she may be unable to fill a prescription for their child for a period of time. If a teen with ADHD is unable to receive their usual medication, they may turn to street drugs as an alternative.

Taking things even more broadly, the effects at the macrosystem can be seen as an effect on the nation. For example, ADHD is covered under the Rehabilitation Act of 1973 and the Americans with Disabilities Act. This means that in the United States an employer cannot discriminate against someone with ADHD. Furthermore, they must provide reasonable accommodations in the workplace (Tudisco 1). However, a diagnosis of ADHD is not enough to qualify for protection under the ADHD. In order to qualify for coverage, "the disorder must significantly impact an individual's ability to perform major life activities or functions and the individual must be regarded as having a disability and have a record of having been viewed as disabled (Noor 1). Therefore, an individual who may have been incorrectly diagnosed with the disorder would likely fail to receive these accommodations.

At the chronosystem, changes over time stand out more for a disorder like ADHD than others. This can be a result of the increasing diagnoses of the disorder. While a child in the past may have simply been seen as a misbehaved kid, increased diagnoses have created more knowledge of the disorder around the globe and provided more credibility for the need of treatment. Thus, it helps tear down stereotypes and may make it easier and more acceptable for a child to receive adequate treatment without judgement from others over time.

ADHD is a serious disorder that has more recently received the recognition it deserves. While increasing rates of diagnosis are alarming, it is clear the negative outcomes of the disorder need to be quelmed in some fashion. Thus, it is still unclear whether overdiagnosis is a serious concern, or a necessary consequence of ensuring those who actually have the disorder receive the proper treatment. One of the most effective methods for helping resolve the risk factors associated with the disorder is to use as many behavioral therapy techniques as possible before concluding that a child needs to be switched over to medication. This could help prevent later substance abuse problems and prevent children who do not need medication, especially those who are incorrectly diagnosed, from developing a dependence on stimulants, Furthermore, there should be an emphasis on having psychiatrists and clinical psychologists making ADHD diagnoses in place of primary care physicians. On its own, this could help bring down the rates of diagnosis to those more recognizable in the past before healthcare costs began to skyrocket. Through more research into the risk factors for developing ADHD and alternative methods to medication, ADHD can become a problem psycho

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