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I am an MD, board-certified in family practice; and also a PhD psychologist. Over the past 25 years, I have signed off on more than 90,000 patient visits. I have seen first-hand the explosion in the diagnosis of ADHD and the prescribing of medications. So, like other parents and other practitioners, I was concerned when I read this week about new data from the Centers for Disease Control and Prevention which documents a continued rise in the proportion of children and teenagers diagnosed with ADHD. According to this most recent analysis, fully 20% of high school boys in the United States today have been diagnosed with ADHD, and the majority of those diagnosed have been treated with powerful prescription stimulants such as Adderall, Concerta, Metadate, or Vyvanse. Overall, 11% of American kids in grades K-12 have now been diagnosed with ADHD: 7% of girls, and 15% of boys.
But I noticed also something peculiar in the data, something which has so far escaped notice. And that peculiar something may be the key to a strategy which parents can use to turn this trend around.
When I first began studying what we now call ADHD, 35 years ago – back in 1978 – it was called “hyperkinetic reaction of childhood.” The name change from "hyperkinetic reaction of childhood" to ADD/ADHD came with the publication of DSM-III in 1980. In that era, most experts agreed that ADHD was most common in early childhood, less common in adolescence, and rare in adults. A British study from 1970 suggested that only 1 in 1,000 children had this condition. The American consensus in 1979 was that the figure, at least in our country, was closer to 1 in 100 (e.g. the review article by Gabrielle Weiss and Lily Hechtman in Science, September 28 1979). Even back then, physicians recognized that the American reaction was to label a student’s behavior as “attention deficit” and treat with medication, while the British reaction was to label the same behavior as “conduct disorder” and tell the boy (it was nearly always a boy) to shape up or ship out. In 1979, the male-to-female ratio among those diagnosed was believed to be anywhere from 5:1 to 9:1.
The CDC data published this week include two peculiar features which have so far gone unnoticed. First, there has been a flip in the natural history of ADHD: ADHD used to be more common in young children, who then outgrew it as they moved into adolescence. The new data show that ADHD is at least twice as common in high school students compared with elementary-school kids. Second, there has been a disproportionate surge in the number of GIRLS being diagnosed, so that the male-to-female ratio, formerly 5:1 or higher, has now dropped to 2:1. Rates of diagnosis have increased for boys as well as girls, but the rate of increase over the past decade has been much faster for girls than for boys. How come?
I think these two unexpected findings are related. In addition to my 90,000+ encounters with patients in the office, I have also visited more than 360 communities over the past 12 years, meeting with students, listening to teachers, and talking with parents. Here’s what I think has happened over that time:
- Kids are getting less sleep. Boys are staying up past midnight firing photon torpedoes at the enemy. Girls are staying up past midnight texting and Tweeting, and Photoshopping their pics for their Flickr page. This problem is seen more often with high school kids than with younger kids, in part because parents insist on “lights out and devices off” for 9-year-olds earlier and more emphatically than for 16-year-olds. But this problem is just as acute with girls as with boys.
- Sleep deprivation is being mistaken for ADHD. The sleep-deprived teen is indistinguishable from the teen who truly has severe ADHD. If you just watch a kid in the classroom, as I have done on many occasions, there's no way you can distinguish a sleep-deprived teen from the teen with ADHD of the Inattentive type. Both kids are having trouble focusing and concentrating; both kids are drifting off in worlds of their own. The only way to make the distinction is to know how much sleep the kid is getting. And most parents have no idea what their kids are doing in the bedroom between 10 PM and 6 AM. They could be sleeping. Or Tweeting. Or exchanging texts. Or surfing the Net for pornography.
- The response to medication is taken to confirm the diagnosis. The teen reports difficulty concentrating and paying attention. The doctor says, “Let’s try Adderall /Concerta / Vyvanse and see whether it helps.” The first dose is given Monday morning. Monday at noon, the teacher calls the parent to say, “My goodness what a genius your Emily / Justin / Sonia / Tyrone is! I had no idea! How sharp! How focused!” The medication was prescribed for ADHD. The medication helps. Therefore my kid must have ADHD. That’s what many parents think.
But the parent is mistaken. Adderall and Vyvanse are amphetamines. They’re speed. They are powerful stimulants. These medications compensate for the kid’s sleep deprivation. Concerta / Metadate / Focalin / Daytrana / Ritalin all are methylphenidate, which works in exactly the same way as the amphetamines in Adderall and Vyvanse: both amphetamine and methylphenidate bind to dopamine receptors in the brain, just as cocaine does. Yuppies in the 1980s discovered that they could party all night, do a line of coke the next morning, and be bright and alert in the office the next day. Teenagers today have discovered that they can stay up till 3 in the morning playing video games or tweeking their Tumblr page or posting photos on Instagram or Snapchat, take 30mg of Adderall at 6 AM, and be bright and alert in class the next day. The difference is that Adderall is much cheaper than cocaine. And it’s covered by your health insurance.
Some of the problems kids are facing today do not have easy solutions. But this problem does have an easy solution. No devices in the bedroom. No child or teen should have a device with Internet access behind a closed door without a responsible adult in the room. That means no iPads in the bedroom. No laptops. And especially, no smartphones. At 9:00 at night, you (the parent) take the device and you plug it into the charger, which stays in your bedroom, the parent’s bedroom. Your kid can have it back the next morning.
This is your job. It’s not reasonable to put this burden on your teen. What is she supposed to say, when her friend asks her tomorrow in school, “Hey I texted you last night at midnight, how come you didn't answer?” Do you expect your teen to say, “Well, I thought it was more important for me to get a good night’s sleep than to answer your text?” Or is your teen supposed to say, “Recent research from Dr. Dement’s group at Stanford suggests that sleep deprivation can mimic symptoms of ADHD, and I don’t want my concentration to be impaired in Spanish class.” It’s not plausible to expect a teenager to say such things. You have to allow her to say, “My evil parents take my phone every night at 9:00 and they don’t let me have it back until the next morning!”
You have to be the evil parent. Turn the devices off at 9:00 PM. Devices with Internet access – the laptop, the iPad, and the smartphone – should be used in a public space, such as the kitchen. The bedroom should be primarily for reading and for sleeping.
Doctors in 1979 understood something which is still in the rule book but which many of my colleagues today seem to have forgotten: true ADHD is a disorder which always manifests in childhood, by definition, usually before 7 years of age, always before 12 years of age. If your kid has developed a serious problem with attention only at 14 or 15 or 16 years of age, then ADHD is unlikely to be the diagnosis.
Try turning off the devices first.
Leonard Sax MD PhD is a family physician, psychologist, and the author of Boys Adrift: the five factors driving the growing epidemic of unmotivated boys and underachieving young men (Basic Books), and Girls on the Edge: the four factors driving the new crisis for girls (Basic Books). You can reach Dr. Sax directly via his web site, www.leonardsax.com.
