ADHD: a critical update for educational professionals

ABSTRACT

A medical approach towards behavioural problems could make professionals without a medical background, like teachers and other educational professionals feel inapt. In this article, we raise six scientifically grounded considerations regarding ADHD, currently the most prevalent childhood psychiatric diagnosis. These “need to knows” show just how misguided and potentially stigmatizing current conceptualizations of unruly behaviour have become. Some examples are given of how teachers are misinformed, and alternative ways of reporting about neuropsychological research are suggested. A reinvigorated conceptual understanding of ADHD could help educational institutions to avoid the expensive outsourcing of behavioural problems that could also—and justifiably better—be framed as part of education’s primary mission of professionalized socialization.

Introduction

Attention deficit hyperactivity disorder (ADHD) is one of the syndromes defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM). In the DSM-5 (American Psychiatric Association, 2013 American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5™ (5th ed.). Arlington, VA: Author. [Google Scholar]) it is described as a neuro-developmental disorder with a persistent behavioural pattern of severe inattention and/or hyperactivity/impulsivity. The behaviours must be uncharacteristic for the developmental age of the child, be manifest in different settings (for example at home and at school), have started before the age of 12, be present for at least 6 months, and interfere with social and academic performance.

ADHD is currently the most prevalent parent-reported diagnosis among children in the USA (Visser et al., 2014 Visser, S., Danielson, M., Bitsko, R. H., Holbrook, J., Kogan, M., Ghandour, R., … Blumberg, S. (2014). Trends in the parent-report of health care provider-diagnosed and medicated attention-deficit/hyperactivity disorder: United States, 2003–2011. Journal of the American Academy of Child & Adolescent Psychiatry, 53(1), 34–46. doi:10.1016/j.jaac.2013.09.001 [Google Scholar]). When DSM-IV was published in 1994 (American Psychiatric Association, 1994 American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (DSM-IV). Arlington, VA: Author. [Google Scholar]) the prevalence of ADHD was an estimated 3% (Goldman, Genel, Bezman, & Slanetz, 1998 Goldman, L. S., Genel, M., Bezman, R. J., & Slanetz, P. J. (1998). Diagnosis and treatment of attention-deficit/hyperactivity disorder in children and adolescents. council on scientific affairs, american medical association. JAMA: The Journal of the American Medical Association, 279(14), 1100–1107. doi:10.1001/jama.279.14.1100 [Google Scholar]). Since then, the percentage of children with a parent-reported ADHD diagnosis increased substantially, from 7.8% in 2003 to 9.5% in 2007 to 11.0% in 2011. In 2011, nearly one in five high school boys had been diagnosed with ADHD and about 13.3% of all 11-year-old boys were medicated for ADHD (Visser et al., 2014 Visser, S., Danielson, M., Bitsko, R. H., Holbrook, J., Kogan, M., Ghandour, R., … Blumberg, S. (2014). Trends in the parent-report of health care provider-diagnosed and medicated attention-deficit/hyperactivity disorder: United States, 2003–2011. Journal of the American Academy of Child & Adolescent Psychiatry, 53(1), 34–46. doi:10.1016/j.jaac.2013.09.001 [Google Scholar]).

In the USA, the total number of children on ADHD medication skyrocketed from 1.5 million in 1995 (Safer & Zito, 1996 Safer, D. J., & Zito, J. M. (1996). Increased methylphenidate usage for attention deficit disorder in the 1990s. Pediatrics, 98(6), 1084. [Google Scholar]) to 3.5 million in 2011 (Visser et al., 2014 Visser, S., Danielson, M., Bitsko, R. H., Holbrook, J., Kogan, M., Ghandour, R., … Blumberg, S. (2014). Trends in the parent-report of health care provider-diagnosed and medicated attention-deficit/hyperactivity disorder: United States, 2003–2011. Journal of the American Academy of Child & Adolescent Psychiatry, 53(1), 34–46. doi:10.1016/j.jaac.2013.09.001 [Google Scholar]). Sales of prescription stimulants have quintupled in the last decade (Schwarz, 2013 Schwarz, A. (2013, December 15). The selling of attention deficit disorder. New York Times, pp. A1. [Google Scholar]), to well over 11 billion in 2015 (www.jsonline.com, accessed 23 September 2016).

Co-author Allen Frances, who was chair of the DSM-IV, as well as the chair of the DSM-5, David Kupfer, have called the rise in childhood ADHD an “unreal epidemic” (Frances, 2011Frances, A. (2011). The epidemic of attention deficit disorder: Real or fad? Retrieved from http://www.psychiatrictimes.com/display/article/10168/1864222 [Google Scholar]; Verhoeff, 2010 Verhoeff, B. (2010). Drawing borders of mental disorders: An interview with David Kupfer. BioSocieties, 5(4), 467–475. doi:10.1057/biosoc.2010.24 [Google Scholar]). In an interview in the New York Times (Schwarz, 2013 Schwarz, A. (2013, December 15). The selling of attention deficit disorder. New York Times, pp. A1. [Google Scholar]), Keith Conners, a professor emeritus at Duke University who spent much of his career in legitimizing the diagnosis of ADHD, named the rising rates of the ADHD diagnosis in the USA “a national disaster of dangerous proportions”.

Teachers and other school personnel are often the first to suggest the diagnosis of ADHD in a child (Phillips, 2006 Phillips, C. B. (2006). Medicine goes to school: Teachers as sickness brokers for ADHD. Plos Medicine, 3(4), e182–e182. doi:10.1371/journal.pmed.0030182 [Google Scholar]; Sax & Kautz, 2003 Sax, L., & Kautz, K. J. (2003). Who first suggest the diagnosis of attention-deficit/hyperactivity disorder? Annals of Family Medicine, 1(3), 171. doi:10.1370/afm.3 [Google Scholar]). Previous research suggests that teachers tend to feel insecure about dealing with behavioural problems (Walter, Gouze, & Lim, 2006 Walter, H. J., Gouze, K., & Lim, K. G. (2006). Teachers’ beliefs about mental health needs in inner city elementary schools. Journal of the American Academy of Child & Adolescent Psychiatry, 45(1), 61–68. doi:10.1097/01.chi.0000187243.17824.6c [Google Scholar]) and hesitant to accept responsibility for students with special needs (Pijl, 2010 Pijl, S. J. (2010). Preparing teachers for inclusive education: Some reflections from the netherlands. Journal of Research in Special Educational Needs, 10(1), 197–201. doi:10.1111/j.1471-3802.2010.01165.x [Google Scholar]). In this article, we present six scientifically grounded “need to knows” that unravel misconceptions about ADHD. These topics are selected from a wide array of issues surrounding ADHD because we believe they are the most effective in revealing the catch-all (Singh, 2011 Singh, I. (2011). A disorder of anger and aggression: Children’s perspectives on attention deficit/hyperactivity disorder in the UK. Social Science & Medicine, 73(6), 889–896. doi:10.1016/j.socscimed.2011.03.049 [Google Scholar]) nature of the ADHD classification, and/or the most exemplary of the adverse effects related to the misunderstandings regarding ADHD. We draw mostly from research and practices in the USA, as the “iMO” of ADHD (Lloyd, Stead, & Cohen, 2006 Lloyd, G., Stead, J., & Cohen, D. (2006). Critical new perspectives on ADHD. New York: Routledge. [Google Scholar], p. 3). However, we concur with Richards (2013 Richards, L. M. (2013). It is time for a more integrated bio-psycho-social approach to ADHD. Clinical Child Psychology and Psychiatry, 18(4), 483–503. doi:10.1177/1359104512458228 [Google Scholar]) that in general “Europe has followed the USA’s lead” by using the DSM-IV and its successor and will also refer to European studies if deemed appropriate. The topics we address are meaningful to teachers and other educational professionals, but certainly also to others such as policy makers who decide on society’s investments in schools.