Reforms

California ranks low in rates of attention deficit disorder



California has one of the lowest rates of diagnosis in the nation of attention deficit hyperactivity disorder in children, raising questions about the role of regional, economic and cultural differences in identifying what scientists regard as a brain disorder.

Over-diagnosing ADHD and over-prescribing medication to children has been the cause of considerable concern in education and other circles. But some researchers interviewed by EdSource Today say that the state’s relatively low rates may indicate that the condition is being under-diagnosed among some demographic groups. They suggest that some students aren’t getting the treatment they need to succeed in school.

California ranks fifth lowest in the nation – tied with Alaska – in the percentage of children diagnosed with ADHD, according to newly released data from the 2011-12 National Survey of Children’s Health. (Click here to see a map of ADHD rates by state.) In part, California’s ranking reflects low rates of diagnosis among Latinos, who make up 38 percent of the state’s population, and even lower rates of diagnosis among Californians of Asian descent, who make up 14 percent of the state’s population.

It’s not the state’s overall rate of childhood ADHD that raises questions, with 5.2 percent of California children, or 1 in 20, receiving the diagnosis. Rather it is the wide variation in diagnostic rates among different racial and ethnic groups.

Kaiser Permanente researchers found that the rates of childhood ADHD in California were 5.6 percent for whites and 4.1 percent for blacks, but only 2.5 percent among Latino children, and 1.9 percent among children of Asian descent.

The very low rates for Latino and Asian American children stand out as anomalous, said Joshua Israel, associate clinical professor of psychiatry at UC San Francisco. “In just about every country that has been looked at, including China, the rates have been about the same for children – between 3 and 9 percent, with the average closer to 5,” he said. “It’s likely that the true rates for Asians in California would not be 1.9 percent.”

Chart

The six states ranked the lowest in percentage of children diagnosed with ADHD.

“We know that there are relatively dramatic differences between ethnic groups in rates of diagnosis,” said Ruth Hughes, chief executive officer of the Maryland-based advocacy group Children and Adults with Attention Deficit Hyperactivity Disorder. “Part of it is cultural, part of it is economic, and all of it has to do with the school system and the medical system.”

Under-diagnosing ADHD has serious consequences, said Sandra Loo, an ADHD researcher and assistant professor of psychiatry at the David Geffen School of Medicine at UCLA.

“There is a common perception that ADHD is not as severe as other disorders, when in fact the long-term outcomes of people with untreated ADHD are really horrible,” she said, including high rates of dropping out of school.

In fact, nearly one-third of children with ADHD drop out or delay high school graduation, according to research conducted at the UC Davis School of Medicine.

The American Psychiatric Association’s Diagnostic and Statistical Manual-IV describes the condition as a “persistent pattern of inattention and/or hyperactivity-impulsivity.”

A child must show clear evidence of “clinically significant impairment” in the ability to function in two major settings – school and home – for at least six months, according to ADHD diagnostic guidelines by the American Academy of Pediatrics. In addition, the child must have at least six symptoms of inattention or hyperactivity to an extent that is “disruptive and inappropriate” for the child’s developmental level. Evidence of impairment should be documented in written reports from teachers and parents, and may include an observation of the child by a mental health professional.

Epidemiological studies of brain disorders find that prevalence is fairly constant across geographic regions, which means that rates of childhood ADHD should be roughly the same across the nation. But they’re not. In Kentucky, which has the highest prevalence, the rate is 13.1 percent, while Nevada has the lowest rate of childhood ADHD, with nearly 4 percent of children diagnosed. The national average is 8 percent, according to the survey. Diagnosis rates also vary broadly by region, with the South reporting higher rates and the West reporting lower rates.

How to account for the differences? It’s all about the beliefs and practices of parents, teachers and doctors, researchers say.

Top 5 states with highest rates of ADHD diagnoses in children

Top 5 states with highest rates of ADHD diagnoses in children

“Regional differences generally have to do with how parents interact with the education system and health providers, as well as with the prevailing attitudes of local health providers,” said Samuel Zuvekas, a senior economist at the Agency for Healthcare Research and Quality in the U.S. Department of Health and Human Services. “It’s a complicated dynamic.”

To avoid over- or under-diagnosis of ADHD, the evaluation process is supposed to be thorough. Yet at every step of the way the process can go awry, subject to pressures from schools, doctors and families.

Schools are on the front lines of identifying children who may have ADHD, working with their families and doctors and creating educational plans or accommodations if necessary. It’s a task that school systems don’t uniformly embrace, said Hughes of Children and Adults with Attention Deficit Hyperactivity Disorder. Some teachers and administrators may find the process overwhelming or may balk at the idea of suggesting that a child’s behavior is atypical, while others may be quick to spot a potential case of ADHD.

“There can be subtle, powerful messages in schools about whether kids get identified,” Hughes said. “The same kid who was never identified as having ADHD in one school system can move to another school system and be identified.”

Families, too, vary in their willingness to consider that their child might have a brain disorder, and their willingness to discuss the matter with teachers and doctors.

Another obstacle is that pediatricians, who make the bulk of diagnoses of childhood ADHD, typically aren’t reimbursed for the time it takes to conduct a rigorous evaluation, making the process “particularly challenging for primary care clinicians,” the American Academy of Pediatrics noted.

The need for appropriate diagnosis is considerable, researchers said, given risks at both ends of the spectrum: medicating children who don’t have ADHD or under-treating children who suffer from a disorder that may seriously impair their social and educational functioning.

“I am a researcher, but I am also a medical doctor, and I see the benefit of a carefully made diagnosis,” said Darios Getahun, lead author of the Kaiser Permanente study. “If you identify a child with ADHD in a timely way, and initiate treatment, the outcome will be better learning and better functioning in social situations.”

 

Filed under: Reforms, Student Health

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10 Responses to “California ranks low in rates of attention deficit disorder”

  1. CarolineSF said

    on April 22, 2014 at 11:08 am

    Totally un-PC alert.

    It’s clear to anyone who’s been involved in a diverse school district that attitudes toward identifying disabilities vary widely among demographics. The clear one to me is that I’ve consistently seen middle- and upper-middle-class white families struggling to get their kids identified with and treated for disabilities — outraged sometimes that the particular diagnosed disability doesn’t qualify, and so forth. Meanwhile, the culture in low-income African-American communities tends to view special-ed identification as a racist insult. The former see this as a way to get extra, specialized treatment and accommodations for their children, while the latter view it as a way for their children to be branded and isolated in ineffective or damaging programs.

    And very often mainstream commentators — and certainly leftist commentators — adopt and encourage that latter view, when it comes to African-American kids. I’m pretty sure I’ve seen it reflected on this very site.

    Although my involvement as an engaged parent and volunteer has been a district with a plurality of Asian students and a large Latino population, I haven’t perceived such clear cultural attitudes among those groups in my experience. But cultural attitudes seem likely to have an impact.

  2. Marita Dietz said

    on April 21, 2014 at 6:57 pm

    California’s low diagnostic rate of ADHD has a lot to do with its poor school funding. It has one of the lowest per child spending of all 50 states. Although California is just as bound to the federal disability law that requires Child Find- the identification and evaluation of all disabled students, local school districts cannot afford to dip into general funds to include this fairly new disabled classification.

    In my school district, for example, if the parent of a child who is in constant trouble for disruptive behavior says, “Gee I wonder if my child has ADHD,” we changed the subject. Teachers have been warned that it is inappropriate to recommend that the parent write a letter requesting an evaluation. We are told that parents must get an outside evaluation on their own and follow their health care provider’s advice. In other words, “Don’t go there!” I have been directly told that special education already encroaches on our general fund so we can’t accommodate any more cases.

    Teacher recommendations to their principal that a child be tested are outright ignored. I’ve now worked for this particular district long enough to see the long-term effects of ignoring this fairly severe disability. I did file a complaint with the CDE. They came and investigated and found my complaint to be valid. Then nothing. The CDE did not follow up to be sure any changes occurred. What a waste of taxpayer money!

  3. Don said

    on April 20, 2014 at 7:19 pm

    Worldwide identification rates will be smaller as ADHD is a relatively new medical issue. You are much more likely to be diagnosed here in the US than in most other countries. I have seen first hand the bias many California cultures have towards identification.

    I have a child diagnosed with ADHD. Without medication he was unable to meaningfully participate in school. With it he excels. To this day my experience is that most teachers do not understand the problem and therefore don’t know how to deal with it. I’m not implying that my son would not need medication otherwise, but it doesn’t help that teachers don’t get the professional training they need, especially considering the prevalence of the condition. Not one of his teachers has ever attended an ADHD-oriented professional development day.

    As for Navigio’s contention that ADHD is nothing more than normal behavior in contrast with a sedentary society, as a parent of a child with ADHD I’m sure that is incorrect. Being rambunctious is not the same as being hyperactive.

  4. Tammy Lentine said

    on April 20, 2014 at 9:03 am

    Please don’t blame each other. I am the same mom but I behave differently when I suffer from sleep derivation. This is my observation.

    I highly suspect its the time zones that are contributing to or causing the children to have ADHD. We wake and sleep by the sun it is natural.

    I live in Indiana EDT we have to get up two or three hours before the sunrise because of the time zoning laws. I have two boys with ADHD, learning disabilities in reading and a daughter with no disability. My 7th grader could read 2.4 reading level. We moved to Nashville TN for 2 years and both boys were straight A students. my daughter (1st)grade could read 2.8 reading level when we left IN Dec. 2008 by June 1, 2008 she was reading a 3.6 level when we moved from TN she was writing 5.8 grade level and reading 9.0 level books. The 7th grader could read and write at the 9.5 grade level by 8th grade. He has a trophy for AR points. We moved back to IN 2010 and today Apr 2014 he is a Jr. in High school and he is failing again and his progress has diminished. He is reading 4.3 grade level and writing is impossible. ADHD is back with vengeance and my daughter 6th grade reads 6th grade books and writes at grade level. Nobody understands the tragedy. I am taking ADHD medication now so I can stay awake and get through my own degree.

  5. Gary Ravani said

    on April 26, 2013 at 4:59 pm

    Got a problem with “shooting off your mouth” do ya? Hmmmm

    As i was in school in the 60s and started my 35 year teaching career in the 70s I know of no empirical data supporting the treatment of kids in a “horrendous” manner.

    The information I cited on the rates of ADHD did come from a very comprehensive scientific study.

    Appreciate your comments about “not blaming teachers” though.

  6. Betty said

    on April 25, 2013 at 5:14 pm

    One of the reasons we didn’t see more ADHD diagnoses in the 60s and 70s is because scientists didn’t know as much about the disorder nor were there the variety of treatment options we have today. Instead of getting the appropriate treatments and education, these poor children were labeled as behavioral problems or bad kids. Many were treated horrendously. As adults, they live with the scars of those memories. It makes me physically sick when I hear people smugly blame the parents for their child’s behavior. If you have a child with special learning needs or any disability, it’s hard. Really hard. Did you ever look at a child’s strengths instead of painting them as a problem? So many of these kids and adults have great talent, but are stuck in a system that can’t provide them the appropriate learning environment to meet their needs. Not everybody has the same brain or learning style. It’s very complex.

    I wish people would stop adding to the stigma and setting the bar too low. Sure, there’s a place for vocational workers. And no there is nothing wrong with that….as long as that is what a person wants. Everybody has different values and motivations. What if that vocational worker has dreams of pursuing his or her own business? There are certain skills that would allow that individual to be more successful given the appropriate education…Even in vocational or tech school. And if that person has ADHD or a learning disability as defined by the law, that person is entitled to certain accomodations so that the playing field is leveled. Research has shown that individuals with ADHD who are given accommodations such as extended time on tests don’t have scores higher their neuro-typical aged peers. It makes me wonder if the individuals who make claims like these are saying it for self serving reasons of their own. Screw the disabled! If it makes my kid next on the list for an opportunity….who cares, right? Think about it. Or maybe instead of going through the motions of getting legitimate prescriptions for a legitamate disorder, we’ll just let give the whole class pot to settle everybody down. Why don’t we give it to the teachers too. Let’s completely ignore the underlying issues and the reality of the situation. Let’s continue to promote stigma and shame. Thanks, but no thanks.

    I do think that the expectation of today’s children are a little over the top. Kids use technology as an escape. They win there. It’s someplace they can feel confident. Educational programs all over the country are pushing technology. Didn’t you know our kids are going to have to compete in the global community with kids from China? This is what some of us are being told. It puts parents in a tough spot. Parents have a lot of anxiety because they see what they consider a normal childhood (running and playing outside) slipping out of their children’s fingers. If the child has a disabity, due to the pace of today’s society, they can fall behind much more quickly. However, there are some wonderful tech support and devices out there for kids with special needs. But….they’re expensive. Money is limited on both sides. There are no easy asnwers and solutions here. Complicating matters, technology in the field of disability for disorders such as ADHD is relatively new. There needs to be more research so that some of these “helpful technologies” are research validated and reliable for use in teaching.

    Quit blaming teachers too. Many just don’t get the training they need in their teaching programs to be able to handle kids with disabilities as well as they’d like to. The same goes for our medical schools. They’re also limited by the times…grant money is drying up, some states are going broke…

    The people that refer to other parents as “helicopter parents” must not be educated on disability and special education law. Parents are often forced into heavily advocating for their children because their kids aren’t always getting the appropriate services they need. The “helicopter belief” Could come from a cultural, political, religious, or some other perspective. This may be your opinion, but it doesn’t mean you’re correct in your assumptions.

    Most if all, quit blaming kids. They’re innocent.

    Before you go shooting off your mouth with your opinion, why don’t you actually read up on some reputable research validated sources of information on disability, special education, psychology, positive behavioral intervention, and special education law. You’ll need years to learn.

  7. Gary Ravani said

    on April 25, 2013 at 11:52 am

    The most comprehensive study I could locate suggests CA’s rate of identification aligns with scientific projections for the rest of the country and also aligns with international rates. This means about 1 in 20 kids are identified with the characteristics defined as ADHD.

    So, CA’s rate of identification seems to be in line with worldwide identification rates. This suggests other states are likely over-identifying kids.

    There is a caveat: Kids from the Ukraine who were caught up in the Chernobyl disaster seem to exhibit symptoms at about four times the international average, so “stress” seems indicated as a factor. What might be happening in some of our other states? And Navigio’s point is well taken. Averages can hide areas where symptoms are concentrated and/or found relatively rarely.

    There were also anecdotal reports on certain “helicopter parents” pushing to get their kids diagnosed ADHD to allow accommodations in certain testing situations. Could not find a study on this.

    • CarolineSF replied

      on April 25, 2013 at 1:22 pm

      The L.A. Times did a fairly large story on that issue (upper-income parents pushing to get kids diagnosed) some years ago. I don’t remember if it had studies as sources or just anecdotes.

  8. AHW said

    on April 24, 2013 at 9:44 pm

    You make an excellent point, navigio (hope I chose the right letter-i vs. l). As a former college educator (English, Writing, Art History), I cringe when I consider how many of my students suffered horribly when they reached college. Many had been taught few basic skills, and they seemed frustrated and confused after having had their meds curtailed. Some turned to other drugs, which did not help their struggles. Some schools had counseling services that would practically write these students’ essays for them. Many had inflated expectations about future careers, despite scarcely being able to write a coherent sentence, let alone a solid paragraph or essay. I do not remember so many “super-hyper” or “unfocused” students when I was attending primary school during the late 60s and secondary school during the 70s. Those few who had profound behavioral issues were educated at a separate school, while the ones who could not thrive in academic subjects eventually branched off to Vo-tech schools where they could learn trades. We seem to have gone off the rails when too many parents expected all their children to attend college. There is absolutely nothing wrong with a technical degree/certificate, etc.; our country needs good technicians, plumbers, electricians, etc. more than ever. College was never meant to be a universal experience. I also blame the inability of education to attract more of the best and the brightest to the profession. Too many mediocre students who just want a steady paycheck and summers off go into teaching today; too many lack passion for and detailed knowledge of their subjects to instill the lifelong excitement about learning we should value in much of our population. It’s no wonder students become restless and bored. Too many parents also fail to teach children how to behave in public. We seem to swing between overly permissive and overly strict parents, which in turn creates issues in classrooms. Drugging kids into submission seems awfully Draconian and reckless. At the same time, we make it more difficult for many parents of profoundly mentally ill (schizophrenia, etc) young people to secure help for their loved ones, who can pose a danger to themselves and others. We need to do better for children and adults.

  9. navigio said

    on April 23, 2013 at 9:56 am

    It’s too bad the study’s granularity was only state-level or above. It would be interesting to understand the how diagnosis differs by urban/suburban distinction, home environment, even start of school time.
    I personally think ADHD is largely a side-effect of our culture’s attempt to be more sedentary, and to impose that state on children. Its too bad we’ve gotten to the point where we seem to want to ‘efficiencize’ even the process of growing up.

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