COMMENTARY

Is ADHD Really Increasing?

William T. Basco, Jr., MD, MS

Disclosures

December 04, 2018

Two Decades of Trends in ADHD

Previous estimates of the prevalence of attention-deficit /hyperactivity disorder (ADHD) in the United States suggested that the prevalence was increasing. The last time national data were examined was in 2011. Xu and colleagues[1] used updated information from the National Health Interview Survey conducted by the National Center for Health Statistics of the Centers for Disease Control and Prevention to estimate the most recent prevalence of ADHD among US children and adolescents. This survey samples approximately 35,000 households. The data are collected through in-person interviews, with a parent providing the child's medical history. The main question of interest was the parental response to the question, "Has a doctor or health professional ever told you that your child has had attention-deficit/hyperactivity disorder or attention-deficit disorder (ADD)?"

Extensive demographic data are available, along with race and ethnicity. The children were aged 4 to 17 years at the time of participation. In the 2015-2016 data, the prevalence of ADHD was 10.2% (95% confidence interval, 9.6%-10.8%). Boys comprised 68.9% of the children with ADHD in 2015-2016.

The incidence of ADHD increased with age (7.7% among children aged 4 to 11 years, 13.5% among children aged 12 to 17 years). The prevalence of an ADHD diagnosis increased over time (6.1% in 1997-1998, 10.2% in 2015-2016), a trend that was statistically significant. The trends were noted in both age groups but the increase (from 7.2% to 13.5%) was highest in children aged 12 to 17. The prevalence of the diagnosis among boys increased from 9% to 14% over the years studied. Among girls, it increased from 3.1% to 6.3% over the same years. Every racial or ethnic subgroup likewise experienced significant increases over time. The rising prevalence occurred regardless of family income measures or geographic region. The conclusion of the study is that the estimated prevalence of ADHD/ADD has increased between 1997 and 2016.

Viewpoint

There are many possible reasons for the increasing prevalence of ADHD/ADD during the study years. Perhaps of greatest importance was ascertainment bias across multiple settings—increased awareness by parents and by teachers and school systems, as well as (hopefully) more systematic and appropriate evaluation by providers. Most busy clinicians will view the 10% increase as clinically believable, because behavioral concerns occupy a disproportionate amount of their patient care time. That said, there is always room for improvement by providers.

This study reminds me of a study[2] I reviewed in 2015, which demonstrated that pediatricians make about 39% of the diagnoses of ADHD but that in 18% of the cases parents were the only adults to provide information about their child's behavior; there was no input from the child's school or from objective behavior-rating scales. As I argued then, taking a more careful approach to making the diagnosis in the first place is never a bad idea.

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