Journal of the American Academy of Child & Adolescent Psychiatry
PRESIDENTIAL ADDRESSComparison of Diagnostic Criteria for Attention-Deficit Hyperactivity Disorder in a County-Wide Sample
ABSTRACT
Objective
To examine teacher-reported prevalence rates for attention-deficit hyperactivity disorder (ADHD) based on DSM-III-R and DSM-IV in the same population.
Method
Teachers completed questionnaires in which they rated all their students on all DSM-III-R and DSM-IV symptoms for disruptive behavior disorders except for seven conduct disorder symptoms but including seven symptoms screening for anxiety or depression. This constituted all children in kindergarten through fifth grade in a middle Tennessee county during the 1993–1994 academic year (16 schools, 398 teachers, and 8,258 children). Also included were questions about the children's diagnosis of ADHD, treatment with stimulants, and the presence of behavior or academic problems.
Results
The prevalence rates were 7.3% for ADHD (DSM-III-R); 11.4% for ADHD, total (TOT); 5.4% for ADHD, inattentive type (AD); 2.4% for ADHD, hyperactive-impulsive type (HI); and 3.6% for ADHD, combined type (CT). Factor analysis identified five fartors: opposition/defiance-conduct, inattention, hyperactivity/impulsivity, anxiety/depression, and stealing-truancy. The rates of problems differed mostly between ADHD-AD and ADHD-HI (40% versus 80%) for behavior and (75% versus 23%) for academics. Few (15% to 40%) had an ADHD diagnosis or stimulant treatment (21% to 32%).
Conclusion
DSM-IV criteria are likely to increase the prevalence of this disorder in comparison with DSM-III-R rates, but they may better characterize its heterogeneity. J. Am. Acad. Child Adolesc. Psychiatry, 1996, 35(3):319–324.
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Cited by (431)
Prevalence, diagnosis and medication of hyperactivity/ADHD in France
2022, Annales Medico-PsychologiquesLa prévalence de l’hyperactivité/TDAH fait l’objet d’intenses débats au niveau international. En France, la seule étude disponible pointe un taux de prévalence du TDAH de 3,5 à 5,6 % des enfants âgés de 6 à 12 ans. Les auteurs estiment également que 3,48 % des 6–12 ans sont traités par psychostimulant. Notre article s’appuie sur les données de l’Assurance Maladie pour discuter ces résultats.
Il est possible de procéder à une étude rigoureuse du taux diagnostic et du niveau de prescription du méthylphénidate en France en analysant les données de l’Assurance Maladie. Dans cette perspective, nous avons utilisé les informations extraites de la base du Système National d’Information Inter-Régime de l’Assurance Maladie (SNIIRAM) présentées en 2017 dans un rapport de l’Agence Nationale de Sécurité du Médicament et des produits de santé (ANSM).
Les données de l’Assurance maladie permettent d’établir une estimation de la prévalence du TDAH de 0,3 % en France.
Ce résultat appelle des investigations plus approfondies dans la base du SNIIRAM. Il questionne les raisons du faible taux de médication du TDAH en France en comparaison d’autres pays occidentaux. Il interroge les biais méthodologiques et les conflits d’intérêts susceptibles d’orienter les études de prévalence du TDAH en France et au niveau international.
Prevalence estimates for ADHD have therefore been at the core of an international debate in the last two decades. In France, the only available study carried out telephone inquiries in 2008 from a 7912 randomly selected sample of households. The researchers estimated 3.5% children suffered from ADHD, while 2.2% other children were treated with psychostimulants for attention deficit or hyperactivity symptoms without having formally been diagnosed. The use of a rigorous scientific approach and a strong methodology let the authors conclude the prevalence rate of children suffering from ADHD in France ranged from 3.5 to 5.6%. They also noted that among the 3.5% of children who were diagnosed with ADHD, 36.5% were being treated with methylphenidate. Therefore, they estimated 3.48% of children aged 6–12 were effectively treated with psychostimulants. In 2017, a report was issued by the National Agency for Medicines and Health Products Safety using data from The French National Social Security System (SNIIRAM) concerning methylphenidate consumption among children aged 6–11. This report showed 19,613 children aged 6–11 were effectively treated with methylphenidate in 2014. The study also states the prescription rate for methylphenidate increased by 44% between 2008 and 2012, then again by 13% between 2013 and 2014, though 34.2% of the children being treated with methylphenidate are not diagnosed as suffering from ADHD but from other psychiatric pathologies. Our paper compares these two data sets: one concerning ADHD prevalence and the ratio of ADHD children treated with methylphenidate in France, the other regarding the provision of methylphenidate-based medication among children. We highlight the gap between the two studies’ results and call for supplementary investigations of the French Healthcare Insurance database as a way to obtain better information on ADHD diagnosis and medication in France.
Methylphenidate is the only psychostimulant which prescription is authorized in the case of an ADHD diagnosis in France. To determine the prevalence of methylphenidate-based medication use in children aged 6–11, we first collected data concerning methylphenidate consumption from the SNIIRAM database and analyzed them in regard to the 2008 demographic survey issued by the National Institute for Statistics and Economic Studies (INSEE). Using this information and ADHD prevalence data, we secondly inferred an ADHD diagnosis rate in France. Consequently: Since methylphenidate is the only drug precription in France for ADHD, without any other therapeutic authorization; By taking into account (1) the ratio of children diagnosed ADHD and treated with methylphenidate in France (36.5%) and (2) the data concerning methylphenidate consumption in France (19,613 children aged 6–11 in 2014); It is possible to obtain accurate information on ADHD diagnosis in France from the provision of methylphenidate-based medication. We finally compared the prevalence rate of methylphenidate prescription and the estimation of ADHD diagnosis as reported in the SNIIRAM database, to the psychostimulant consumption level and the ADHD prevalence rate as highlighted in the initial prevalence study.
Figures extracted from the SNIIRAM database show 19,613 children aged 6–11 were effectively treated with methylphenidate in 2014. Knowing the prescription rate for this molecule and this population increased by 44% between 2008 and 2012, then again by 13% between 2013 and 2014, we calculated methyphenidate consumption concerned 9555 of children aged 6–11 in 2008. Comparing this number to the National Institute of Statistics and Economic Studies (INSEE) children census, which reported 4,752,571 French children in 20081, one can estimate about 0,2% of children aged 6–11 were effectively given methylphenidate that year. If 9555 of children aged 6–11 were treated by methylphenidate in 2008 according to the French National healthcare insurance system, and if 36.5% of ADHD children are treated with methylphenidate in France, then a correct estimate of the number of children who had been diagnosed with ADHD in 2008 would be 9555 + 9.555 × 0.635 = 15,622 children. This would mean around 0.3% of this population was diagnosed with ADHD in France in 2008.
The real methylphenidate consumption rate among 6–11 children in France is at best 17 times lower than the estimation initially provided by the Lecendreux et al. prevalence study (0.2% the 6–11 children versus 3.48% of the 6–12 aged children). The discrepancy we highlight in this paper questions conflicts of interest and methodological biases at work in telephone inquiries or in any indirect methodology willing to establish ADHD prevalence rates.
The results we present in this communication support more in-depth investigations of the SNIIRAM database when it comes to determining precise ADHD diagnosis and methylphenidate prescription rates in France. Accessing national, official databases would give researchers relevant information concerning potential variations in diagnosis and prescription rates over time, according to regions and hospitals, the age of the child at the time of diagnosis or treatment initiation, multiple co-morbidities and prescriptions outside of recommendations, associated therapeutic practices (psychotherapy), etc. Such complementary studies could also shed light on the factors contributing to the low rate of prescription drugs in the treatment of ADHD in France.
Using Large Aggregated De-Identified Electronic Health Record Data to Determine the Prevalence of Common Chronic Diseases in Pediatric Patients Who Visited Primary Care Clinics
2021, Academic PediatricsWe used de-identified clinical data from multiple health care systems using different electronic health records (EHRs) to 1) quantify the prevalence of common pediatric chronic diseases, 2) investigate patent characteristics associated with common pediatric chronic diseases, and 3) compare the results of our methodology to determine chronic disease prevalence with traditional approaches.
We used a HIPAA-compliant and de-identified web application (Explorys; IBM Watson Health Explorys Inc.) to identify patients 17 years old or younger from multiple health care systems in the US who were seen in primary care clinics between 2016-2018 to determine the most common chronic conditions in this age group. The prevalence of chronic conditions was compared between different age groups, genders, races/ethnicities, and insurance; odds ratios and confidence intervals were calculated and reported.
The top 6 chronic conditions identified by prevalence were: obesity/overweight (36.7%), eczema (15.8%), asthma (12.7%), food allergies (4.7%), attention deficit-hyperactivity disorder (4.09%) and hypertension (4.07%). Chronic conditions were generally more prevalent among relatively older pediatric patients, males, and African-American and multiracial groups.
Approximately 40% of children and adolescents have at least one chronic disease. Obesity/overweight, eczema, and asthma are the most common chronic diseases of childhood, in the US, among those seeking care in health care systems with EHRs. The work compiled herein demonstrates that aggregated, standardized, normalized and de-identified population-level EHR data can provide both sufficient insight and statistical power to calculate the prevalence of chronic diseases and the odds ratio of various risk factors.
Identifying comorbid ADHD in autism: Attending to the inattentive presentation
2020, Research in Autism Spectrum DisordersThere are high rates of comorbidity between ADHD and ASD; however, there has been limited work parsing rates by ADHD presentation. In addition, commonly used questionnaires have demonstrated reduced utility in capturing ADHD symptoms in individuals with ASD. We examined the prevalence of comorbid Attention-Deficit/Hyperactivity Disorder (ADHD) parsed by DSM-5 presentation in clinic-referred youth with Autism Spectrum Disorder (ASD) without intellectual disability (ID). We compared common rating scales to determine which most effectively identified comorbid ADHD.
We examined comorbid ADHD diagnoses from archival assessment data for 419 youth with ASD without ID. We examined diagnostic discriminability of the parent and teacher ADHD Rating Scale (ADHD R-S), and Attention and ADH Problems Scales of the Child Behavior Checklist and Teacher Report Form using receiver operating characteristic (ROC) curves. Hierarchical logistic regression was used to examine measures’ unique contribution to ADHD diagnosis.
Sixty-one percent of the study sample met DSM-5 criteria for an attention disorder. ADHD, Combined (ADHD-C) represented the largest proportion of ADHD diagnoses (76.8%), followed by Inattentive (ADHD-I;19.7%), Hyperactive/Impulsive (.02%), and Un-/Other Specified (.02%). Measures provided greater diagnostic discriminability in identifying ADHD-C relative to ADHD-I. The ADHD R-S inattentive symptom count provided the greatest discriminability for both subtypes and was the only scale that provided clinically meaningful differentiation between those with ASD only and ASD + ADHD-I.
These results support using the ADHD R-S to capture comorbid ADHD symptoms in ASD. The findings underscore the need for more thorough examination of inattentive symptoms to rule out ADHD-I.
Zebrafish models for attention deficit hyperactivity disorder (ADHD)
2019, Neuroscience and Biobehavioral ReviewsAttention deficit hyperactivity disorder (ADHD) is a common, debilitating neurodevelopmental disorder associated with inattentiveness, pathological hyperactivity and impulsivity. Despite the mounting human and animal evidence, the neurological pathways underlying ADHD remain poorly understood. Novel translational model organisms, such as the zebrafish (Danio rerio), are becoming important tools to investigate genetic and pathophysiological mechanisms of various neuropsychiatric disorders. Here, we discuss ADHD etiology, existing animal models and their limitations, and emphasize the advantages of using zebrafish to model ADHD. Overall, the growing utility of zebrafish models may improve our understanding of ADHD and facilitate drug discovery to prevent or treat this disorder.
Sex differences in stress regulation of arousal and cognition
2018, Physiology and BehaviorThere are sex differences in the prevalence and presentation of many psychiatric disorders. For example, posttraumatic stress disorder (PTSD) and major depression are more common in women than men, and women with these disorders present with more hyperarousal symptoms than men. In contrast, attention deficit hyperactivity disorder (ADHD) and schizophrenia are more common in men than women, and men with these disorders have increased cognitive deficits compared to women. A shared feature of the aforementioned psychiatric disorders is the contribution of stressful events to their onset and/or severity. Here we propose that sex differences in stress responses bias females towards hyperarousal and males towards cognitive deficits. Evidence from clinical and preclinical studies is detailed. We also describe underlying neurobiological mechanisms. For example, sex differences in stress receptor signaling and trafficking in the locus coeruleus-arousal center are detailed. In learning circuits, evidence for sex differences in dendritic morphology is provided. Finally, we describe how evaluating sex-specific mechanisms for responding to stress in female and male rodents can lead to better treatments for stress-related psychiatric disorders.
ADHD in children and young people: prevalence, care pathways, and service provision
2018, The Lancet PsychiatryAttention-deficit hyperactivity disorder (ADHD) is a common childhood behavioural disorder. Systematic reviews indicate that the community prevalence globally is between 2% and 7%, with an average of around 5%. At least a further 5% of children have substantial difficulties with overactivity, inattention, and impulsivity that are just under the threshold to meet full diagnostic criteria for ADHD. Estimates of the administrative prevalence (clinically diagnosed or recorded) vary worldwide, and have been increasing over time. However, ADHD is still relatively under-recognised and underdiagnosed in most countries, particularly in girls and older children. ADHD often persists into adulthood and is a risk factor for other mental health disorders and negative outcomes, including educational underachievement, difficulties with employment and relationships, and criminality. The timely recognition and treatment of children with ADHD-type difficulties provides an opportunity to improve long-term outcomes. This Review includes a systematic review of the community and administrative prevalence of ADHD in children and adolescents, an overview of barriers to accessing care, a description of associated costs, and a discussion of evidence-based pathways for the delivery of clinical care, including a focus on key issues for two specific age groups—younger children (aged ≤6 years) and adolescents requiring transition of care from child to adult services.
The project was supported in part by the United Way of the designated county.