Scientific Evidence in Support of ADHD Prevention Program

Wellplace, Michigan functions as the Access Center for Detroit Wayne Mental Health Authority (DWMHA). As the Access Center, Wellplace serves as the front door for individuals seeking mental health or substance abuse information and services in Detroit-Wayne County.

Attention Deficit Hyperactivity disorder remains the most commonly diagnosed disorder in children from ages 7 through 17. In addition, it is associated with the development of other behavior disorders such as oppositional defiant disorder (Report of the Surgeon General’s Conference on Children’s Mental Health, 1999). Clinical data shows attention deficit disorder (ADHD) and oppositional defiant disorder (ODD) consistently competing for the number one spot as the most frequently diagnosed behavioral health condition for children ages 7-17. Attempts at establishing a true prevalence rate has been made difficult due to the variation in diagnostic practices, and reported outcome studies have placed it anywhere from 1% to 20% and has led to a debate about whether ADHD is over or under diagnosed.

Presenting at a public health conference in 1999 (ADHD: A Public Health Perspective) Stephen Hinshaw of the University of California-Berkley, discussed the need for further evaluation of the “individual, social, and economic burden of ADHD at a population level,” and voiced concern that “the United States has few epidemiologic-scale data relevant to ADHD, making inference to population–level impact nearly impossible to ascertain.” One of the problems that epidemiologic researchers are facing is “how to screen large numbers of children and still assess the psychopathology as well.” (Rowland, Lesenne, Abramowitz, 2000). Most researchers suggest that using a standard screening method such as those based on the DSM-IV would be imperative. However, unless combined with expert assessment “methods for combining symptom reports from different respondants or defining impairment would still need to be addressed.” (Rowland, Lesenne, Abramowitz, 2002).

One pilot program screened all children in four elementary schools from grades 1-5. The DSM-IV provided the measurement (survey) standard. Its aim was to study ADHD prevalence rate by screening a large population of children, the vast majority of whom had never been screened. It was concluded that: “…the DSM-IV presence of ADHD had been substantially underestimated…..beyond the number of children already diagnosed with ADHD, and another 39% had not been previously identified.” (Rowland, Umbach, Catoe, Long, Rabiner, Panke, Naftel, Faulk, Sandler, 2001). The authors concluded that “Population-based studies of ADHD are feasible and may provide important information about practice and treatment patterns in community settings.”

Perhaps the most complete study of the prevalence of ADHD was done by a group (Barbaresi, Katusic, Colligan, Pankrantz, Weaver, Weber, Marzek, Jacobsen, 2002) who used a population based, birth cohort study. They found that the highest cumulative incidence for children 0-18 was 16% with the lowest at 7.4%. This is fairly consistent with more recent research that suggests the general prevalence rate to be 3%-9% of the school age population (Hoagwood, Kelleher, Feil, Comer, 2000). Both of these studies would consider the DSM IV prevalence rate as estimated at 3%-5% of school age children far too modest.

In 2001, Brown, RT. Freeman, WS. Perrin, JM, et al., conducted an extensive review and analysis of all literature and studies focused on prevalence rates of ADHD. Criteria for inclusion included symptomatic adherence to the DSM III and DSM III-R, as well as DSM IV, and represented both school-based and community-based screening. Results were published in Pediatrics 2001:107 entitled “Prevalence and assessment of attention-deficit/hyperactivity disorder in primary care settings.” Overall prevalence rates ranged from a low of 9.5% to 16.1%, with the highest rate belonging to studies utilizing the DSM IV. The average across all versions of the DSM was 9.2% to 13.63% with a mean of 11.5%. Of particular note is that prevalence rates were higher when symptoms alone was the basis for diagnosis, and decreased when symptoms were combined with functional impairment.

In 2003 the Department of Health and Human Services Centers for Disease Control conducted a state by state national survey with the objective of trying to determine the prevalence of ADHD among school age children ages 7-17. The survey relied upon parents completing an ADHD screening tool as its primary method of data collection. The results of that survey showed rates ranging from 6% to 11.9% with the average being 7.8%. The survey also showed the rate being 2.5 times higher for males than females, which is consistent with earlier research. The results of this survey were reported in the CDC Morbidity and Mortality Weekly Report (MMWR) Sept. 2, 2005.

Many authors have sought answers for accurately identifying children with ADHD while preventing mis-diagnosis. One problem identified by many, is that the diagnosis is made in children who meet some, but not all of the criteria listed in the DSM-IV. (Rowland, Umbach, Catoe, Stallone, Long, Rabiner, Naftel, Panke, Faulk, Sandler, 2001). Researchers including the Surgeon General are convinced that children require a complete, multi-modal evaluation, which assesses the family, school behavior, and peer relationships. The children who are less hyperactive but largely inattentive may be missed due to lack of serious behavior problems. Over diagnosis is a legitimate concern because children are being placed on medication for hyperactive or belligerent behavior without appropriate differential diagnosis (Surgeon General, 1999).

Risk factors for ADHD include inheritence, environmental factors such as lead poisoning, and parent/child relations that are characterized by significant intrusiveness and over control. These factors, whether they help create ADHD, or exist as a consequence of ADHD, may result in the diagnosis of oppositional defiant disorder as well. In fact, rates of comorbidity run about “25%-40% for oppositional defiant disorder/conduct disorder.” (Rowland, Lesesne, Abramovitz, 2002).

One of the complicating factors in sceening for ADHD is that ADHD is not a simple one stop diagnosis. Children can be diagnosed as inattentive without hyperactivity, hyperactive without being inattentive, or have a mixed symptom complex of both. Professional diagnosis will rely not only on screening instruments, but also parent and teacher rating scales, and personal interview to draw a correct conclusion.

Wellplace, Michigan feels that a great service can be rendered by providing educational material aimed at early identification and intervention. To this end Pioneer Counseling Centers ADHD Prevention Program is focused on helping parents of children ages 7-17 learn to identify targeted symptoms that may be suggestive of ADHD in its various forms. Given the multimodal approach that is needed to make an accurate diagnosis, this prevention program’s aim is to first help parents identify whether their child may be struggling with ADHD, and second to refer its members to an appropriate licensed, clinical professional who can further screen the child and come to an accurate assessment, and determine if services are needed.