LETTERS TO THE EDITOR
A Different Approach to Rising Rates of ADHD
Diagnosis
To the Editor:
I
n “Beyond Rising Rates,” published in the
January 2014 issue, Walkup et al.1 take a con-
trarian position, suggesting that readers should
view the recent Centers for Disease Control and
Prevention (CDC) report on the prevalence of
the diagnosis of attention-deficit/hyperactivity
disorder (ADHD) as a sign of progress rather
than a cause for alarm. They note that “the
CDC’s prevalence estimate of ADHD diagnosis
is very close to the community-based prevalence
of ADHD as ascertained in high-quality epide-
miologic studies.”1 Walkup et al.1 suggest that
the increase in the rate of diagnosis of ADHD in-
dicates progress because diagnostic rates are
finally beginning to reach the true prevalence
of the disorder, and thus treatment may be
reaching those who previously went untreated.
I respectfully disagree with this conclusion.
Epidemiologic studies have not uniformly indi-
cated that the true prevalence of ADHD in chil-
dren is 11%.2,3 Two recent meta-analyses have
indicated that the rate of ADHD is closer to
5% to 7%.2,3 Importantly, prevalence estimates
of ADHD vary greatly depending on the diag-
nostic method used.2 Although some epidemio-
logic studies have indicated that the prevalence
of ADHD may approach the level reported by
the CDC, these studies have depended largely on
a single, nonclinical observation of symptoms—
namely, parent or teacher reports.4,5 Conversely,
studies that have drawn on observations of
ADHD symptoms from parent and teacher re-
ports have suggested a much lower prevalence
of ADHD, a rate closer to 5% to 7%.
Child psychiatrists recognize that relying
solely on 1 adult, such as a parent, is an inade-
quate approach to diagnosing ADHD. My read-
ing of the CDC report is that the increase in the
diagnosis of ADHD reflects not better recogni-
tion of the disorder, but rather, sadly, that a
substandard approach to diagnosing ADHD has
become the norm.
Jonathan Posner,
Columbia University
New York
posnerj@childpsych.columbia.edu
JOURNAL OF THE AMERICAN ACADEMY OF C HILD & ADOLESCENT PSYCHIATRY
VOLUME 53 NUMBER 6 JUNE 2014
This work was funded in part by National Institute of Mental Health
grants K23-MH091249 (to J.P.) and R01-MH101172 (to J.P.) and by
funding from the Edwin S. Webster Foundation.
Disclosure: Dr. Posner is a principal investigator on an investigator-
initiated grant from Shire Pharmaceuticals.
0890-8567/$36.00/ª2014 American Academy of Child and
Adolescent Psychiatry
http://dx.doi.org/10.1016/j.jaac.2014.02.006
REFERENCES
1. Walkup JT, Stossel L, Rendleman R. Beyond rising rates: person-
alized medicine and public health approaches to the diagnosis and
treatment of attention-deficit/hyperactivity disorder. J Am Acad
Child Adolesc Psychiatry. 2014;53:14-16.
2. Willcutt EG. The prevalence of DSM-IV attention-deficit/hyperac-
tivity disorder: a meta-analytic review. Neurotherapeutics. 2012;9:
490-499.
3. Polanczyk G, de Lima M, Horta B, Biederman J, Rohde L. The
worldwide prevalence of ADHD: a systematic review and meta-
regression analysis. Am J Psychiatry. 2007;164:942-948.
4. Amiri S, Fakhari A, Maheri M. Mohammadpoor Asl A. Attention
deficit/hyperactivity disorder in primary school children of Tabriz,
North-West Iran. Paediatr Perinat Epidemiol. 2010;24:597-601.
5. Canino G, Shrout PE, Rubio-Stipec M, et al. The DSM-IV rates
of child and adolescent disorders in Puerto Rico: prevalence,
correlates, service use, and the effects of impairment. Arch Gen
Psychiatry. 2004;61:85.
Drs. Walkup and Rendleman reply:
T
hank you very much for your comments.
Your position is one that we believe is
shared by many, which is why we wrote the
piece. Although we respect your and others’
opinions, we find it difficult to support the
statement that rising rates are due largely to
substandard assessment of ADHD—it is just
too simplistic an explanation. The solution that
you allude to is likely not tenable for a high-
prevalence condition such as ADHD, because
there just aren’t enough child psychiatrist pro-
viders to do it all. We are not advocating poor-
quality diagnosis or inappropriate treatment;
rather, the goal of the editorial was to understand
the role of advocacy and education in rising rates,
the importance of a public health approach to
high-prevalence conditions, and to help child
and adolescent psychiatrists come to terms with
the fact that our traditional model of care, which
is time intensive and highly personalized, is not
MD
likely to be able to address the public health
burden of ADHD. We certainly do not want to
inhibit the pediatric prescriber from taking on
the challenge. They need our support to do it well.
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