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Are standardized tests leading to more ADHD diagnoses?

As a young mother, Robin Richeson was overwhelmed by her son Aaron’s boundless energy. Richeson chalked up his behavior, which included climbing tall trees, running away and an inability to focus in school to boys being boys.

But the teachers at Aaron's school in Ownesboro, Ky., thought something else was going on. “They just said that he was all over the place — he couldn't handle the structure. 'We think he has ADD or ADHD,'” Richeson remembers being told at a parent-teacher meeting.

An evaluation by the family doctor confirmed those suspicions. Aaron has ADHD, a condition marked by inability to focus and impulsive behavior. Today, 7-year-old Aaron takes Ritalin, which helps him focus in school.

Aaron is one of about six million children with ADHD in America. One in nine children between the ages of 4 and 17, or about 11 percent, have an ADHD diagnosis, according to a 2012 study by the Centers for Disease Control. CDC data also show that the rates of ADHD diagnoses have gone up rapidly in the last decade, increasing by 40 percent between 2003 and 2012.

But national averages don’t tell the whole story when it comes to ADHD. CDC data also shows that the likelihood a child will be diagnosed with ADHD depends on which state they live in. In Western states, including Nevada, California, Utah, Colorado and Hawaii, rates of ADHD diagnosis fall between 5.5 and 7 percent of all school-aged children. Compare that to Southern states, including North and South Carolina, Florida and Kentucky, where ADHD diagnosis rates are more than double that — from 12 to 16 percent of all school-aged children.

In their forthcoming book “The ADHD Explosion and Today’s Push for Performance,” Dr. Stephen Hinshaw, professor of Psychology at UC Berkeley and his colleague UC Berkeley economics professor Richard Scheffler, examine what is behind the diverging rates of ADHD in states across the country. Their conclusion: a driving factor behind these trends is state education systems.

ADHD and exit exams

As Hinshaw and Scheffler looked at the numbers they noticed an interesting pattern: states with high school exit exams (tests students must take as a condition for graduation), also tended to have above-average rates of ADHD. “In these states, you don’t get a diploma unless you can show you’ve mastered certain material,” Hinshaw said. The stakes are high for students: “fail the test and you won’t make it to college,” Hinshaw said.

But the tests aren’t just for the students. Many states use exit exam outcomes to measure school and teacher performance. “District funding, not to mention jobs, are contingent on student performance on these exams,” Hinshaw said.

With stakes this high, educators must find ways to get their students’ performance to mandated levels, and an ADHD diagnosis, according to Hinshaw, might be helpful. A child with an ADHD diagnosis will be prescribed medication, which, if taken, tends to improve their ability to function in a structured classroom and, many experts contend, actually can improve a child’s academic performance.

Additionally, in many states children with ADHD diagnoses are offered educational accommodations. For example, because of his ADHD Aaron Richeson has extra time to complete homework assignments and exams, preferential classroom seating, and prompting and cueing from teachers, said his mother, Robin. Some states put kids with ADHD in special education programs, according to Hinshaw, which means they are not required to participate in the exit exams. “It’s a way of not penalizing teachers for kids who can’t focus,” Hinshaw said.

Hinshaw acknowledges that the relationship between ADHD and exit exams isn’t perfect. Both Nevada and California have exit exams, and they have the lowest rates of ADHD diagnosis in the country. Still, he and his colleague maintain the explanatory value of their theory. “This is a natural experiment,” said Hinshaw. “If it’s not a smoking gun, it’s pretty close.”

Diagnosing a problem

Hinshaw doesn’t want his work to be interpreted to mean that ADHD is a myth, a social construction of the American education system. “It’s a real condition and it causes real impairment,” he said. For those who truly have the condition, medication and educational accommodations can dramatically improve their quality of life and academic performance.

On the other hand, there is a strong possibility overdiagnosis of ADHD in some areas of the country and underdiagnosis in other parts is taking place. It’s a potentially worrisome trend because the consequences of giving ADHD medication to children who do not have ADHD can be disastrous. Hinshaw finds that there is about a 0.01 chance that a child with ADHD who takes medication will become addicted to stimulants. A child who takes medication without actually having the condition has about a 10 percent chance of becoming addicted. “Kids who don’t have ADHD but are taking stimulants are a thousand times more likely to fall into addiction,” Hinshaw said.

Hinshaw and a growing number of child health experts argue that overdiagnosis of ADHD can be avoided by proper assessment. Sleep disorders, learning disabilities, abuse and anxiety have symptoms similar to ADHD, according to Dr. Elizabeth Roberts, child psychiatrist in Murrieta, Calif. Only thorough assessment can differentiate these conditions.

The trouble is that there is no uniformly adhered to standard for diagnosing ADHD. According to Hinshaw, a diagnosis usually looks very similar to what Amy Barr experienced: A teacher suggests that a child with “behavioral issues” has the condition and could benefit from medication. The concerned parent takes the child to a doctor who, after a 10-minute evaluation, hands down a diagnosis and prescribes some pills. “You can’t do this in 10 minutes,” Hinshaw said. “There are so many factors that need to be considered before you can say it is ADHD.”

Robin Richeson isn't sure what to make of Hinshaw and Sheffler's research. She wonders if they lived in another state, would her son have received the diagnosis? It's a thought that weighs heavily on her. She doesn't want to compromise her child's health, and yet "since he got the diagnosis (and went on medication), he's being doing better at school and is more manageable at home," she said.