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Myths and Misconceptions About ADHD:
Science over Cynicism
By Phyllis Anne Teeter Ellison, Ed.D.

(Click here to download this article.)

Myth # 1: ADHD is Not a Real Disorder
Myth # 2: ADHD is a Disorder of Childhood
Myth # 3: ADHD is Over-Diagnosed
Myth # 4: Children with ADHD are Over-medicated
Myth # 5: Poor Parenting Causes ADHD
Myth # 6: Minority Children are Over-Diagnosed with ADHD and are Over-Medicated
Myth # 7: Girls Have Lower Rates and Less Severe ADHD than Boys

Public perceptions of attention-deficit hyperactivity disorder (ADHD) are replete with myths, misconceptions and misinformation about the nature, course and treatment of the disorder. Popular misconceptions assert that ADHD is not a disorder or at minimum, is a benign one that is over-diagnosed. Critics often claim that children are needlessly medicated by parents who have not properly managed their unruly, unmotivated or underachieving children, or who are looking for an academic advantage (e.g., testing or classroom accommodations) in competitive, high-stakes educational environments. Some suggest that "a growing intolerance of childhood playfulness may in fact be leading to more and more children being labeled with ADHD" (Panksepp, 1998, p. 91). Critics rarely present evidence-based arguments and frequently allege that professionals are harming otherwise normal children by diagnosing and treating ADHD.

While barriers to treatment have been reduced in recent years, there is a climate of blame, shame, embarrassment and stigmatism that discourages some from seeking help for debilitating mental health disorders, including ADHD. There is compelling evidence that a large number of youths with a variety of mental disorders, including ADHD, are not being served, are inadequately served, or are inappropriately served (US Surgeon General's Report on Mental Health, 2001; Jensen et al., 1999; MTA, 1999). The Executive Summary on Mental Health: Culture, Race and Ethnicity, a Supplement to the Surgeon General's Report (2001) indicates that 75-80 percent of children and youths with mental health illnesses do not receive needed services. Misinformation often demonizes those in need of treatment for ADHD and may discourage individuals from seeking appropriate care. Parents may avoid professional help because they fear accusations of being labeled poor parents, individuals who needlessly medicate their children. Parents of children with ADHD are often accused of seeking to medicate overly playful, non-compliant or mildly disruptive children. More likely, parents are struggling to help their children cope with a serious constellation of problems and are seeking help because previous attempts to reduce the impact of ADHD have failed. Chronic, untreated disorders such as ADHD are costly to the individual, family and society (Leibson et al., 2001). Parents generally seek professional help for ADHD after a great deal of deliberation, consternation and past failures. We will summarize and attempt to dispel some of the common misconceptions about ADHD.

Myth # 1: ADHD is Not a Real Disorder

This is a common refrain expressed by individuals who assert that the psychiatric community, in concert with pharmaceutical companies, created ADHD to drum up business for private practices and to increase profits for drug companies. According to the National Institutes of Health, the Surgeon General of the United States, and an international community of clinical researchers, psychiatrists and physicians, there is general consensus that ADHD is a valid disorder with severe, lifelong consequences (NIH, 2000; U.S. Surgeon General's Report, 2001). Studies over the past 100 years demonstrate that ADHD is a chronic disorder that has a negative impact on virtually every aspect of daily social, emotional, academic and work functioning (Barkley, 1998). Studies show that children with ADHD have higher rates of other psychiatric disorders, higher frequency of hospitalizations, emergency room visits and total medical costs compared to individuals without ADHD (Liebson et al., 2001).

Adolescent outcomes of children with ADHD show that they are more likely to drop out of school, to rarely complete college, to have fewer friends and to participate in antisocial activities more than children without ADHD (Barkley, Fischer, Edelbrock, & Smallish, 1990). Rates of cigarette, alcohol and marijuana use appear more often in those with both ADHD and conduct disorders, and were two to five times more frequent than in adolescents with ADHD alone or for those without it. Later in life, adults with ADHD have employment difficulties, suffer from depression and personality disorders, have multiple auto accidents, and have high rates of sexually transmitted diseases and teen pregnancies compared to individuals without ADHD (Fischer, Barkley, Smallish, & Fletcher, 2002). Overwhelming evidence suggests that ADHD is a real disorder with serious consequences. Back to Top

Myth # 2: ADHD is a Disorder of Childhood

Early discussions of ADHD theorized that individuals outgrew the disorder (Ingram, Hechtman, & Morgenstein, 1999). This notion has been dispelled by long-term studies showing that anywhere from 70-80 percent of children with ADHD exhibit significant signs of restlessness and distractibility into adolescence and young adulthood, while a large percentage suffer co-morbid psychiatric disorders, academic failure, and social isolation and/or rejection (Barkley et al., 1990; Barkley, 1998). Research estimates that 1.5 to 2 percent of adults have ADHD (Hunt, 1997), and between two and six percent of adolescents have ADHD (Murphy & Barkley, 1996). Cuffe et al. (2001) found that children with persistent ADHD have more severe ADHD and adverse risk factors later in life. Adverse factors impact the expression of ADHD and increase the risk for associated disorders that compromise adjustment over the lifespan. Thus, ADHD is a lifelong disorder that requires a developmental framework for appropriate diagnosis and treatment (Teeter, 1998). Back to Top

Myth # 3: ADHD is Over-Diagnosed

Critics claim that ADHD is over-diagnosed and many children with the diagnosis do not have ADHD. Despite these claims, it is difficult to find evidence that ADHD is over-diagnosed or that stimulant medications are over-prescribed (Jensen et al., 1999). Moreover, Jensen et al. (1999) suggest that in "some cases ADHD may be undiagnosed and/or untreated" (p. 798). Although this is a complex problem, prevalence rates of ADHD range from two to nine percent (Barkley, 1998). Rates vary depending on the rating scales employed, the criteria used to make a diagnosis, the use of cut-off scores, and changes in diagnostic criteria. Prevalence rates increased when ADHD -- primarily inattentive type (ADHD-PI) -- was added to the DSM-IV (Wolraich et al., 1996).

Changes in special education legislation in the early 1990s increased general awareness of ADHD as a handicapping condition and provided the legal basis for the diagnosis and treatment of ADHD in the school setting. These legal mandates have increased the number of school-based services available to children with ADHD and may have inadvertently led some to conclude that ADHD is a new disorder that is over-diagnosed. Back to Top

Myth # 4: Children with ADHD are Over-medicated

"Critics of stimulant treatment for youths with attention-deficit hyperactivity disorder (ADHD) have increased their rhetoric of late, contending that the leading medication for it, Ritalin, is vastly over-prescribed" (Safer, 2000, p. 55). There are seemingly contradictory data that contribute to this confusion -- e.g., a steady increase in stimulant use, although most school-aged children with ADHD are not medicated in the community (Jensen et al., 1999).

Although there has been an increase in the rate of prescriptions for stimulants and an increase in the production of methylphenidate, "little is known about why these increases are occurring" (Jensen et al., 1999, p. 797). "Most researchers believe that much of the increased use of stimulants reflects better diagnosis and more effective treatment of a prevalent disorder." (Surgeon General's Report, 2001, p. 149). Others suggest that the changes may be a function of increased prescription rates for girls and teens with ADHD (Safer, 2000). The percentage of children who receive medication of any kind is small. Goldman et al. (1998) reported that 2.8 percent of elementary-aged students were on medication, and that stimulants accounted for 99 percent of the prescribed medications. So while there has been an increase in the number of prescriptions, a relatively low overall rate of stimulant use is reported in school-aged children. Physicians in the community tend to use less than optimal doses, have fewer follow-up monitoring sessions, and less medication compliance than recommended by the MTA study (Jensen et al., 2001). Back to Top

Myth # 5: Poor Parenting Causes ADHD

This misconception may be the most difficult to dispel because parenting characteristics (i.e., being critical, commanding, negative) and poor management do exacerbate ADHD and increase the risk for comorbid disorders (e.g., oppositional defiance and conduct disorders; Barkley, 1998). Twin studies exploring the contribution of environmental factors (e.g., parenting practices, parental psychopathology) find that genetic factors and not a shared environment account for the greatest variance in ADHD symptoms -- about 80 percent (Goodman & Stevenson, 1989). While management difficulties influence parent-child conflicts and the maintenance of hyperactivity and oppositional problems in young children (Barkley et al., 1990), Barkley (1998) concludes that "theories of causation of ADHD can no longer be based solely or even primarily on social factors, such as parental characteristics, caregiving abilities, child management, or other family environmental factors" (p. 176).

Other factors may play a causal role in the individual differences in symptoms of ADHD, including exposure to environmental toxins (e.g., elevated blood lead, prenatal exposure to alcohol and tobacco smoke), but not all children exposed to these risk factors have high rates of hyperactivity, nor do all children with ADHD have these risk factors (Barkley, 1998). Furthermore, pregnancy and birth complications are not more frequent in children with ADHD compared to normal children. Although other factors (e.g., family adversity, poverty, educational/occupational status, home environment, poor nutrition, environmental toxins, ineffective childrearing practices) do not appear to have a significant contribution to the development of ADHD symptoms (see Barkley, 1998 for a review) these factors contribute to comorbid disorders and complicate treatment effectiveness.

Johnston and Freeman (2002) identified a number of inaccurate or non-scientifically-based parent beliefs about the causes of ADHD including: allergic reactions or sensitivity to foods, family problems like alcoholism or marital discord, high sugar consumption, ineffective discipline, lazy learning habits, a lack of motivation, etc. In this study, inaccurate or "false beliefs" were associated with parental attributions that children were responsible for their ADHD symptoms (symptoms are intentional and children can control their symptoms), and with the use of less effective treatment (e.g., diet control). Parent perceptions and beliefs about the nature of ADHD are related to treatment outcome (Hoza et al., 2000). Furthermore, attributions that ADHD symptoms are intentional and controllable often result in harsh, critical and punitive parenting practices (Johnston & Patenaude, 1994). These misperceptions are frequently addressed in parent training components of multimodal treatment plans. Back to Top

Myth # 6: Minority Children are Over-Diagnosed with ADHD and are Over-Medicated

Access to diagnosis and treatment of mental health illnesses varies depending on gender, race and social economic status (SES), but not in the way one might predict. The Executive Summary on Mental Health: Culture, Race and Ethnicity from the Report of the Surgeon General (2001) shows that African American youths are over-represented in arrests, detentions, incarcerations, classes for emotional disturbance and the child welfare system. However, African Americans do not appear to receive needed treatment for ADHD or for other mental health disorders.

Research investigating ADHD in African American youths is also sparse. In a study of public school children and youths in Florida, Bussing et al. (1998) found that service delivery to African American children was deficient even though there was no evidence that the incidence rate of ADHD was lower than those reported in whites. Bussing et al. (1998) found that: (1) only 50 percent of children with ADHD were receiving treatment, (2) girls were underserved at a rate three times lower than boys, and (3) whites were three times more likely to be referred compared to African American children. In the few studies exploring medication rates across races, ethnic minority children are 2 to 2.5 times less likely to be medicated for ADHD compared to white children (Safer & Malever, 2000).

Access to treatment is affected by a number of factors unrelated to need including: (1) a lack of perceived need; (2) system barriers including availability, cost and language; (3) concerns that their children would be taken from the home if parents seek services; (4) stigma associated with seeking help for mental illnesses; and, (5) cost of treatment, lack of adequate reimbursement, length of treatment and cost of medication (Bussing et al., 1998). Furthermore, African Americans are more likely to leave mental health treatment prematurely, and are less likely to receive care. Evidence suggests that minority children are not over medicated and may be underserved for ADHD. Back to Top

Myth # 7: Girls Have Lower Rates and Less Severe ADHD than Boys

According to the Surgeon General's Report on Mental Health (2001) girls are less likely to receive a diagnosis of and treatment for ADHD compared to boys despite need. Gaub and Carlson (1997) found that girls with ADHD have greater intellectual impairment, but lower rates of hyperactivity and externalizing disorders compared to boys. Girls with ADHD have more severe internalizing disorders than boys, and both show more similarities than differences in symptoms and treatment needs. Biederman et al. (1999) found that girls with ADHD were more likely to have conduct problems, mood and anxiety disorders, lower IQ, and more impairment on social, family and school functioning than non-referred girls. However, conduct problems were lower in girls than in males with ADHD, which may account for lower referral rates in community and school samples. Girls in clinic samples also had high rates of substance abuse, alcohol, drug and cigarette use, and were at an increased risk for panic and obsessive compulsive disorders (Biederman et al., 1999).

Finally, Rucklidge and Tanner (2001) found that girls with ADHD were more impaired than a control group on measures of depression, anxiety, self-esteem, overall symptom distress and stress. Girls with ADHD reported strained relationships with teachers, thoughts of suicide, and past episodes of self-harm. Compared to boys with ADHD, girls with ADHD reported higher rates of overall distress, anxiety and depression, and demonstrated more hyperactivity, conduct and cognitive deficits. Parents and teachers noted higher rates of inattention, hyperactivity, oppositional defiance, conduct problems, social difficulties, depression and anxiety. Girls may report more distress than boys, and they "may be more affected by environmental factors than males with ADHD" (Rucklidge & Tanner, 2001). Thus, gender differences need to be more fully addressed in longitudinal and treatment studies.

Myths and inaccurate information about ADHD should be dispelled by scientific findings. However, popularly held "false beliefs," which are often perpetuated by emotional or unexamined arguments, do more harm than good. They do little to advance our knowledge and do a lot to discourage individuals from seeking help and from using effective treatments for ADHD that have undergone rigorous scientific scrutiny. Back to Top

Phyllis Anne Teeter Ellison, Ed.D., is chair of the editorial advisory board and a member of CHADD's executive committee.

References

Barkley, R. A., (1998). Attention-deficit hyperactivity disorder: A handbook for diagnosis and treatment. New York: Guildford Press.

Barkley, R. A., Fischer, M., Edelbrock, C., & Smallish, L. (1990). The adolescent outcome of hyperactive children diagnosed by research criteria: I. An 8-year prospective follow-up study. Journal of the American Academy of Child & Adolescent Psychiatry, 29, 546-557.

Biederman, J., Faraone, S., Mick, E., Williamson, S., Wilens, T., Spencer, T., Weber, W., Jettson, J. Kraus, I., Pert, J., Zallen, B. (1999). Clinical correlates of AD/HD in females: Findings from a large group of girls ascertained from pediatric and psychiatric referral sources. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 966-975.

Bussing, R., Zima, B.T., Perwien, A.R., Belin, T.R., & Widawski, M. (1998). Children in special education programs: Attention deficit hyperactivity disorder, use of services and unmet needs. American Journal of Public Health, 88, 880-886.

Cuffe, S.P., McKeown, R., Jackson, K., Addy, S., Abramson, R., & Garrison, C. (2001). Prevalence of attention-deficit/hyperactivity disorder in a community of older adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 1037-1044.

Fischer, M., Barkley, R. A., Smallish, L., & Fletcher, K. (2002). Young adult follow-up of hyperactive children: Self-reported psychiatric disorders, comorbidity, and the role of childhood conduct problems and teen CD. Journal of Abnormal Child Psychology, 30, 463-475.

Goldman, L.S., Genel, M., Bezman, R.J., & Slanetz, P.J. (1998). Diagnosis and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Council on Scientific Affairs, American Medical Association. Journal of the American Medical Association, 297, 1100-1107.

Goodman, R. & Stevenson, J. (1989). A twin study of hyperactivity: II. The aetiological role of genes, family relationships, and perinatal adversity. Journal of Child Psychology and Psychiatry, 30, 691-709.

Gaub, M., & Carlson, C. L. (1997). Gender differences in AD/HD: A meta-analysis and critical review. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 1036-1045.

Hoza, B., Owens, J.S., Pelham, W.E., Swanson, J.M., Conners, C.K., Hinshaw, S., Arnold, L., & Kraemer, H.C. (2000). Parent cognitions as predictors of child treatment response in attention-deficit/hyperactivity disorder. Journal of Abnormal Child Psychology, 28, 569- 583.

Hunt, R.D. (1997). Nosology, neurobiology, and clinical patterns of AD/HD in adults. Psychiatry Annuls, 27, 572-581.

Ingram, S., Hechtman, L., & Morgenstern, G. (1999). Outcome issues in AD/HD: Adolescent and adult long-term outcome. Mental Retardation and Developmental Disabilities Research Reviews, 5, 243-250.

Jensen, P.S., Hinshaw, S., Swanson, J., Greenhill, L., Conners, K., Arnold, E. et al. (2001). Findings from the NIMH multimodal treatment study of AD/HD (MTA): Implications and applications for primary care providers. Developmental and Behavioral Pediatrics, 22, 60-73.

Jensen, P.S., Kettle, L., Roper, M.T., Sloan, M.T., Dulcan, M.K., Hoven, C., Bird, H., Bauermister, J., & Payne, J. (1999). Are stimulants overprescribed? Treatment of AD/HD in four U.S. communities. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 797-804.

Johnston, C., & Freeman, W. (2002). Parent's beliefs about AD/HD: Implications for assessment and treatment. AD/HD Report, 10, (6-9).

Johnston, C., & Paternaude, R. (1994). Parent attributions for inattentive-overactive and oppositional-defiant child behaviors. Cognitive Therapy and Research, 18, 261-275.

Leibson, C.L., Katusic, S. K., Barbaresi, W.J., Ransom, J., & O?Brien, P.C. (2001). Use and cost of medical care for children and adolescents with and without attention- deficit/hyperactivity disorder. JAMA, 285, 60-66.

MTA Cooperative Group. (1999). A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder. Archives of General Psychiatry, 56, 1073- 1086.

Murphy, K., & Barkley, R. A. (1996). Attention deficit hyperactivity disorder in adults. Comprehensive Psychiatry, 37, 393-401.

National Institutes of Health Consensus Development Conference Statement: Diagnosis and Treatment of Attention Deficit/Hyperactivity Disorder (AD/HD) (2000). Journal of the American Academy of Child and Adolescent Psychiatry, 39, 182-193.

Panksepp, J. (1998). Attention deficit hyperactivity disorders, psychostimulants, and intolerance of child playfulness: A tragedy in the making? Current Directions in Psychological Science, 7, 91-98.

Rucklidge, J., & Tanner, R. (2001). Psychiatric, psychosocial, and cognitive functioning of Female adolescents with AD/HD. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 530-540.

Safer, D. (2000). Are stiumulants overprescribed for youths with AD/HD? Annals of Clinical Psychiatry, 12, 55- 62.

Safer, D.J., & Malever, M. (2000). Stimulant treatment in Maryland public schools. Pediatrics, 106, 533-539. Surgeon General?s Report, (2001). Report of the Surgeon General?s Conference on Children?s mental Health: A National Action Agenda. Department of Health and Human Services.

Teeter, P. A., (1998). Interventions for AD/HD: Treatment in developmental context. New York: Guilford Press.

Wolraich, M.L., Hannah, J.N., Pinnock, T.Y., Baumgaertel, A., & Brown, J. (1996). Comparison of diagnostic criteria for attention-deficit hyperactivity disorder in a county-wide sample. Journal of American Academy of Child and Adolescent Psychiatry, 35, 319-324.

This article originally appeared in the June 2003 issue of Attention! magazine.

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