Sarah

Jane Beglen
EMR 3

In the media today, there is a lot of talk about special education. New York

Times author Maggie Koerth-Baker who has Attention-Deficit-Hyperattentive-

Disorder wrote The Not-So-Hidden Cause Behind A.D.H.D. Epidemic. She claims the
rise in this disorder is due to sociological factors. She points out that ADHD
diagnoses are not due to environmental factors; but rather how we educate, interact
with doctors, and the expectations which adults have from kids. In school systems
across the nation the expectations for success are higher. Its more of a cut-throat
environment: especially for those trying to get into college (Koerth-Baker, 2013). I
will examine the over diagnosis of ADHD and how education policies, health policies
and gender bias contribute.
Since the implementation of the No Child Left Behind Act (NCLB) the stakes
are higher for school systems, and there is more pressure for teachers to have
successful students. With NCLB, almost every student has had to measure their
academic standing using the same standardized tests. The article claims that some
of the students who did not keep up to the NCLB standards became more at risk to
be diagnosed as having ADHD. When people dont fit in, we react by giving their
behavior a label, either medicalizing, criminalizing it or moralizing it says Professor
Nigg of Psychiatry at the Oregon Health and Science University (Koerth-Baker
2013). Stephen Hinshaw, a Professor of Psychology at the University of California
Berkeley, found a correlation that there is a geographic disparity for kids who have
been diagnosed with ADHD. In 2007, North Carolina reported that 15.6% of
children between ages of 4 and 17 were diagnosed with ADHD. Meanwhile, in the
western part of the nation, California reported just 6.2% of the students ages 4 and

Sarah Jane Beglen

EMR 3

17 had ADHD (Koerth-Baker, 2013). Hinshaw pointed out the reason for this
disparity was that North Carolina was one of the first to include NCLB while
California was one of the last. He claimed that when students are failing the
standards of NCLB they would be recognized as students with ADHD. He predicts
the percentage of ADHD kids in California will increase as time elapses while the
NCLB act is still in effect.

The article also argued a cause behind the increase of ADHD diagnoses is

linked to multiple changes in public policy. First, the Individuals with Disabilities
Education Act (IDEA) incorporated ADHD in 1991 that protected students and
allowed them access to tutors and extra time on standardized tests. Next, the
overhaul of the Food and Drug Administration in 1997 allowed drug companies to
more easily market directly to the public, including ADHD patients. These policy
changes, pointed out by Adam Rafalovich, a sociologist at Pacific University in
Oregon, were highly influential. By the late 1990s, as more parents and teachers
became aware that ADHD existed, and that there were drugs to treat it, the
diagnosis became increasingly normalized, until it was viewed by many as just
another part of the experience of childhood (Koerth-Baker, 2013).

In a scholarly article, the increase in ADHD diagnosis is analyzed. ADHD is

one of the most extensively studied pediatric mental disorder and one of the most
controversial, (Erkulwater, 2008). The increase of ADHD began in the 1990s when
physician visits for stimulant pharmacotherapy increased. The prescribed
treatment of ADHD, which is often Ritalin, Adderall or Concerta, is now more
available because Medicaid and Supplemental Security Income (SSI) cover it.

Sarah Jane Beglen

EMR 3

Medicaid is a federal-state program that offers public health insurance. Through

Supplemental Security Income, a federal program, low-income children can receive
the IDEA-related services such as tutors and extra time on standardized tests. Also,
the SSI program gives a cash benefit to the families of children diagnosed with
ADHD. The disability rights movement sparked these policy changes.

To receive the benefits and protection from IDEA, one has to be medically

diagnosed under the Diagnostic-Standard Manual and also meet the functional
severity standard. The functional severity standards under the IDEA are in the
hands of the teachers. They are the evaluators and the primary consideration
should be given to the teacher reports because of greater familiarity with age-
appropriate norms (Erkulwater, 2008). The increase in ADHD diagnosis also can
be attributed back to the teachers and their higher demands on the student. They
have a lot of influence because the clinicians deciding if a person will receive IDEA
protection rely on the teachers report.
Another peer-reviewed journal article continues the discussion of the
increase of ADHD diagnoses in children. A 2009 study in Germany hypothesized
that clinicians diagnosing ADHD were influenced by the representativeness
heuristic. This means the clinicians base their decisions on the mental shortcuts in
their brain that point to the likelihood of an event by comparing it to the most
recent existing prototype that already exists in their mind. The researchers put this
to the test and sent four separate case vignettes to 1,000 therapists in Germany, of
which 473 were selected in the results (Bruchmller, 2012). The therapists were
asked to diagnose the case given to them, recommend treatment, and provide a

Sarah Jane Beglen

EMR 3

therapeutic approach. Vignettes 2 through 4 said 16.7% had ADHD, which was a
false positive diagnosis (Bruchmller, 2012), meaning it was a false diagnosis and it
was positive because it said they did have the disability. Results concluded that
more false positive/negative diagnoses happened in vignettes involving male cases.
In addition, male therapists were more likely to make an ADHD diagnosis than
female therapists. The over-diagnosis leads to overstated levels of recommendation
for medication. Some health care systems are providing free medication for clients
who do not actually have ADHD, which inflates the overall cost of health care. The
study highlighted that not all therapists follow the DSM-IV (and now DSM-V)
requirements. The German study relates to the main article The Not-So-Hidden
Cause Behind A.D.H.D. Epidemic because it raises another cause of the epidemic:
misdiagnosis. It brings up the topic of gender biases. In representative population-
based studies, the male-to-female ratio of ADHD is approximately 3:1 (Bruchmller,
2012).
In the Hallahan book, Chapter 7 is dedicated to ADHD. It describes the
different types of ADHD and characteristics on how to diagnose a student with the
behavior. The increasing amounts of research and defined diagnosis procedures
and guidelines add to the overall increase in awareness of ADHD. The different
types of ADHD include ADHD Predominantly Inattentive, ADHD Predominantly
Hyperactive-Impulsive and ADHD Combined. The different characteristics
highlighted by Barkleys theory of ADHD include problems with behavioral
inhibition, executive functioning, time awareness and management and persistent
goal-directed behavior (Hallahan, 2012).

Sarah Jane Beglen

EMR 3

The textbook states that several conditions can co-exist with ADHD,
therefore, due to similarities there may be confusion and that also adds to the
increase in ADHD diagnoses (Hallahan, 2012). When the Food and Drug
Administration expanded direct marketing by drug companies in 1997, medication
sales increased though not always for the right reasons. Medication was seen as a
quick alternative to full treatment. However, in the Hallahan textbook, it argues
medication should not be first response to problem behavior (Hallahan, 2012).
I agree with Professor Nigg that in our society, if a student is not at the same
level academically as another student, they are far too easily labeled with a disorder
and prescribed medication. I believe the escalation of ADHD diagnoses can be
largely attributed to changes in the aforementioned policies. The No Child Left
Behind Act created increased pressure for teachers to instruct their kids to exceed
the NCLB standards. If students in their class cannot meet those standards, teachers
sometimes misjudge it as having a learning disability. Far too often these
misjudgments lead to a misdiagnosis of a disability like ADHD. Not only do they
mislabel the student but often times when one is diagnosed with ADHD, medication
is prescribed. The students who are using ADHD medication when they do not have
to cause health problems for themselves and waste economic resources in our
health care system which is unethical. Policy changes like SSI and Medicaid, protect
more people and makes the treatment of a disability easier with the assistance of
these programs. These are great policies, everyone should be able to get treatment
for a disability but they should look more closely at the condition they are providing
support for.

Sarah Jane Beglen

EMR 3

I believe that a change is needed in the system of diagnosing a child with

ADHD. I recognize that it is good that teachers are being very observant, but they
should receive more training on how to accurately detect students with possible
learning disabilities. It is necessary for clinicians to further investigate each case
because they cannot rely solely on teachers to report their feelings about the
students progress due to possible bias. 11% of children ages 4 through 17 have
been diagnosed with ADHD and if professionals look more closely, this number
should decrease (Koerth-Baker, 2013). If these changes can be made, the lower
level of diagnosis for ADHD can conserve our health care resources, and concentrate
the care on those who truly need it.

Sarah Jane Beglen

EMR 3

References
Bruchmller, K.M., Jrgen Schneider, S. (2012). Is ADHD diagnosed in accord with
diagnostic criteria? Overdiagnosis and influence of client gender on diagnosis.
Journal of Consulting and Clinical Psychology, Vol 80(1), 128-138.
Erkulwater, J., Mayes, R. (2008). Medicating kids: Pediatric mental health policy and the
tipping point for ADHD and stimulants. Journal of Policy History, Vol. 20 Issue
3, 309-343.
Hallahan, D. P., Kauffman, J. M., Pullen, P. C. (2012). Exceptional learners: An
introduction to special education (12th ed.). Upper Saddle River, New Jersey:
Pearson Education, Inc.
Koerth-Baker, M. (2013). The Not-So-Hidden Cause Behind the A.D.H.D. Epidemic.
New York Times. Retrieved November 10, 2013 from http://www.nytimes.com/