The outcry this week in response to the American Academy of Pediatrics’ decision to publish new treatment guidelines for Attention-Deficity/Hyperactivity Disorder in children ages 4 to 18 (as opposed to age 6 to 12, as was the case previously,) has been largely focused on the fear that the change will vastly increase the number of very young children being diagnosed with ADHD and pump younger and younger kids full of medication.
Yet the guidelines contain no indication that this was the intent or will prove to be the case. Instead, they seem most likely destined to have the opposite effect: toughening the criteria doctors use before diagnosing ADHD in very young children and dissuading them from being quick to write prescriptions for stimulants like Ritalin.
For one thing, the new guidelines advise doctors to ascertain that the core symptoms that generally lead kids to be diagnosed with ADHD – inattention, hyperactivity, and impulsivity, most notably – have been present, in more than one situation, for nine months, rather than the six months currently specified by the psychiatric Bible, the DSM-IV. For another, they strongly recommend that medication be used only as a last resort for very young children (and then only in cases where the child’s symptoms are causing “moderate-to-severe continuing disturbance” in his or her life). They instead recommend behavior modification as a first-line treatment.
(MORE: Children Can Outgrow ADHD)
Given the plethora of therapists who claim they can treat ADHD without drugs, they detail which behavioral therapies have a strong evidence base behind them, make suggestions as to how parents and doctors might try to find therapists trained in those techniques, and make very detailed suggestions for how doctors might alter their pediatric practices to provide their young ADHD patients with the most comprehensive sort of care. These suggestions include: “spending more time with patients and families, developing a system of contacts with school and other personnel, and providing continuous, coordinated care.”
The takeaway is that if the new American Academy of Pediatrics guidelines are followed – and that’s a complicated if – it’s very likely that fewer very young children will be diagnosed with the disorder and more will, if diagnosed, be treated with non-drug interventions.
Surprised?
I wish I could be. But I’ve spent the past eight years now reading about ADHD and comparing the differences between what specialists in the disorder say and what the public hears. Researchers, practitioners, advocates for helping children and adults with ADHD tend, when they speak about the disorder, to be shouting into the wind, their words quickly lost in the storm of sensationalism, irrationality, and unavowed prejudice that’s unleashed at the mere mention of the diagnosis. Indeed, I’ve come to think that the discussion of ADHD in our country has now reached a level of hysteria we haven’t seen since the debate over working motherhood in the late 1980s and 1990s.
That is to say: back then, there was fear-mongering, finger-pointing and vilification. There was a real social change that had occurred – women had, in a relatively short period of time, reached critical mass in the workplace. But the public’s readiness to accept this change had not kept pace. And our institutions had not – still have not – changed to accommodate them and make life better for their families. The should-she, should-she not of working versus stay-at-home motherhood kept our media busy and made countless women miserable – and the core social problems that lay behind all the verbiage went all but unaddressed.
(MORE: Depression and the Mommy Wars: Who’s Worst Off?)
A very similar process has happened with ADHD. There was a real change in the practice of psychiatry, away from psychoanalysis, toward a focus on neurobiology and a greatly expanded idea of environment. But public attitudes didn’t keep pace; parent-blaming persisted, and still largely continues today. As the definition and understanding of ADHD shifted, more children were diagnosed; inattention emerged as a characteristic as important as hyperactivity; girls got attention, teenagers, too. Yet just as the diagnostic categories were expanding – doctors were “seeing” more ADHD in the children brought to them – our system of medical care changed in ways that were inimical to giving these children the best possible standard of care. Thanks to managed care, the length of the average pediatrician visit was squeezed to a mere 11 minutes. Insurance companies greatly limited reimbursement for all but the briefest, and cheapest, sort of specialized mental health care visits.
There’s no evidence to indicate that the actual prevalence of ADHD in kids has increased over the past few decades. But diagnoses have soared. Maybe it’s because doctors diagnose what they have the eyes to see; maybe it’s because doctors diagnose what they have the tools to treat; maybe it’s because school demands have gotten higher so kids who would have muddled through a generation ago now trip up; maybe it’s because something in our culture is keeping kids from knowing how better to keep themselves self-regulated; maybe it’s that we no longer fatalistically accept that some kids are going to flame out and fail; maybe our belief now that every child has the right to reach his or her potential has led us to identify and try to help them overcome the roadblocks that get in their way. In any case – a real change – a vast increase in ADHD diagnoses, has, once again, been accompanied by a lag in public attitudes and an absolute refusal to deal systematically with changing our institutions to accommodate the needs of children and families.
While strongly supporting behavioral therapy for young children with ADHD, the American Academy of Pediatrics authors make clear to note that good behavior therapy is hard to find. In fact, they write, finding good mental health care at all is hard to find. In many parts of the country, they add, you can’t find any specialized mental health care for kids at all. And if you can, good luck getting insurers to pay for it – especially critically important parts, like detailed psychoeducational evaluations by psychologists, which can help prevent false diagnoses of ADHD.
What the new guidelines really are is an action plan for better mental health care for kids. It’s time they were read that way.