Over 20 years of practicing general and behavioral pediatrics leads me to a completely different conclusion. The increase is due to the vast oversimplification of complex behavioral and emotional problems in the face of influence of the pharmaceutical and health insurance industries who together point us in the direction of the quick fix over thoughtful evaluation and treatment.The two other events will, I believe, support this position.

First in my AAP SmartBrief, the daily listing I receive via email of important news stories related to pediatrics, I read this item Youngest in Class Get ADHD Label in USA today. The article states:

Kids who are the youngest in their grades are 60% more likely to be diagnosed with ADHD than the oldest children, according to a study out today from Michigan State University, given exclusively to USA TODAY. A second study, by researchers at North Carolina State University and elsewhere, came to similar conclusions. Both are scheduled for publication in the Journal of Health Economics.

In my previous job,when the majority of my work consisted of seeing children who had been referred for "evaluation of ADHD" I commonly encountered children who were having their first structured school experienced. Many were among the youngest in their class. They were described as "impulsive." They found difficult to sit at circle time, and unfathomable to sit at a desk to do a written assignment. Yet parents would frequently tell me that the teacher had confided that while she wasn't supposed to make diagnoses, she was sure this child must have ADHD. The findings reported in this article confirm my suspicion that for many of these "ADHD evaluations" referred to me, it was the environment that didn't fit the child, rather than that the child had a "problem."

A few hours after reading this article, I received a phone call from the office manager from the pediatric practice I recently left. As I have written about in my blog, I changed practices to focus on working with young children and their parents in the setting of a community health center. This was in part because I was struggling with the expectation, in keeping with the standard of care in pediatric treatment of ADHD, that I fill many,many prescriptions without any opportunity to understand the complex life experience of these children.

I was sure to refer every child I had been seeing to an appropriate provider. Many of them would be followed, in keeping with the standard of care in pediatrics, by the other primary care clinicians in the practice. Some, who I felt needed more intensive help, I referred to an excellent child psychiatrist in my community. Just before I left, I learned that she had a new policy that she would only see patients for medication evaluation if they were engaged in psychotherapy. I thought this policy was very wise.

One patient, the office manager called to tell me, was very unhappy with this plan (details,as always, have been changed to protect privacy.) "He's never been in therapy before," his irate mother apparently told the office manager. I had a vivid flashback. Mother and father at opposite ends of the room, tense and angry. A small, thin 9 year old boy slumped into the corner of the exam table nervously chewing his nails. As his parents argued about his "laziness" he seemed to want to disappear into the wall. At our last visit together, however, his parents agreed that things were perhaps more complex than simply inattentive ADHD. They accepted my referral to the psychiatrist.

But apparently they had a change of heart. Just getting the prescription filled by their pediatrician was their preference. "He doesn't need any therapy." his mother said. Perhaps he doesn't. But I can be sure of what he does need. He needs someone to listen to him.

I am sad for these many children whose voices are not heard. It causes me great agitation to think about the state of affairs in children's mental health care that has led to a situation where countless children are labeled with a psychiatric diagnosis, their complex life experience tucked into vastly oversimplified categories. 

My new book Keeping Your Child in Mind (now available on Amazon-in bookstores August 30th) offers an alternative way of thinking about children currently being labeled with the diagnosis of ADHD. In it I describe a model of child development, supported by over 30 years of research, that shows how by letting children's voices be heard and by recognizing the meaning of their behavior, we can facilitate their healthy emotional development. The book covers birth through adolescence, with many examples from my practice of children who were referred to me for "ADHD" evaluation. I place their symptoms in developmental context and make sense of them in light of the child's primary relationships and life history.

Articles like the one reported on in Psychcentral cause my blood pressure to shoot through the roof. Looking at the cover of my book, a marvelous achievement by an artist who clearly grasped the central concept, helps me to feel calm. Now that it is launched out into the world, I am hopeful that it will help to bring about a change in the way we as a society understand and support young children and families.