School Testing and the Rising Rate of ADHD

A new book finds a startling connection

Read the Interview:

Is the increased demand for performance behind the increased diagnoses of ADHD? Two University of California professors have released a book this month titled, “The ADHD Explosion.” They call it a “reality check” for parents, providers, educators and politicians.

The Berkeley professors, Dr. Stephen Hinshaw and Dr. Richard Scheffler, are noted researchers on ADHD. Their research tells them that federal policy issues may be behind the recent explosion in cases of ADHD.

“When you look at that [national testing policy], you get the
closest thing there is to a smoking gun,” says Dr.Scheffler.

The Journal of the American Medical Association (JAMA) Pediatrics, found that rates of ADHD in California have jumped by 24% since 2001. Additionally, the Center for Disease Control (CDC) reports increases from 7.8 percent in 2003 to
9.5 percent in 2007 and to 11 percent in 2011— a rate of 5 percent a year.

It looks for all the world like a growing epidemic. But ADHD wasn’t even something people noticed until recently,” says Hinshaw.

“It started about the same time in history that we made kids go to school,” Hinshaw told NBC News in an interview.

Then come the 1990s, and a crisis of falling test scores. “What happened is that a number of states began to pass accountability laws,” Hinshaw said.

Hinshaw and Scheffler examined the correlation between diagnoses of ADHD and maps of states that had passed accountability laws.

According to NBC News, by the turn of the century, 30 states had passed accountability laws. They tended to be Republican-leaning states in the South, such as North Carolina. In 2007, 15.6 percent of all children in North Carolina had been diagnosed with ADHD at some point, including nearly one in three teenage boys.

Two things happening together don’t prove a correlation. Is it coincidence? Hinshaw and Scheffler were persuaded to look further.

AN NBC News article reports that the professors then examined date related to the No Child Left Behind federal policy enacted in 2002. It was one of the first official acts of President George W. Bush after he took office.NCLB required standardized testing to show if schools were, in fact, educating students. A truly salient aspect of NCLB was that it held teachers and principals directly responsible for the results and removed federal and state bureaucrats who mandate curriculum and educational policy.

According to the NBC News article:

“Now what happens is a natural experiment,” says Hinshaw. The other states raced to write accountability laws, requiring schools to show they are actually educating children.

“When you incentivize test scores above all else, there is probably pressure to get kids diagnosed with ADHD.”

Hinshaw and Scheffler compared ADHD rates in the 30 states that had been requiring testing with the 20 states that had to play catchup.

Rates of ADHD diagnoses soared.

“Children ages 8 to 13, living in low-income homes and in states without previous consequential accountability laws, went from a 10 percent to a 15.3 percent rate of ADHD diagnoses once No Child Left Behind started,” they wrote. That’s a 53 percent increase over four years.

California’s current rate, post-testing? It’s 7.3 percent. North
Carolina’s rate actually fell slightly, to 14.4 percent in 2011.

“When you incentivize test scores above all else, there is probably pressure to get kids diagnosed with ADHD,” Hinshaw said. “We know from our own research that medication not only makes you less fidgety but also can bump up your test scores.”

That would be the benign interpretation, that testing has
encouraged parents to get their kids in to see specialists for
much-needed medical care. But there’s also a more sinister
possibility and one that Hinshaw and Scheffler say is at work in
some states.

“If you can identify the children with ADHD, you can take them out of the pool that measures how schools are doing,” says Scheffler.

He says some districts — he won’t say where — do seem to have been doing so. State school officials and the federal Department of Education did not respond when contacted by NBC News.

No Child Left Behind ties federal funding to test scores, Scheffler points out.“You can see the incentive for schools to get kids diagnosed with ADHD,” he says.

Either way, Scheffler and Hinshaw say the increase in ADHD cases is real, and it’s not just affecting kids. Recent studies show adult diagnoses are on the rise, too.

“Although often ridiculed, ADHD represents a genuine medical
condition that robs people of major life chances,” they write in the book.

“You can see the incentive for schools to get kids diagnosed with ADHD.”

Scheffler doesn’t see the increase in adult ADHD diagnoses as
surprising. “This has nothing to do with the schools. This has to do with global competition and performance,” he says. People are under pressure to perform better at work.

And news about adult ADHD in turn sends more people to their doctors, and diagnoses spike even more, Hinshaw adds. “Here are we are in 2014 with evidence that medications can benefit. Adult ADHD clinics spring up,” he says.

“That’s not necessarily a bad thing,” says Hinshaw.

What is bad is if ADHD is not being diagnosed with the proper care, Hinshaw says. A 10-minute pediatrician visit is not adequate for an ADHD diagnosis and certainly not as the basis for writing a prescription for a powerful stimulant, such as Ritalin or Adderall, to treat it.

“Many pediatricians are not trained in the emotional disorders of childhood, or not reimbursed for the time it takes,” Hinshaw said.

“It is easy to pull out prescription pad at the end of a visit.”

He calls the book a “reality check” and says parents, providers, educators and politicians should take note, and make sure the right kids are being diagnosed, and helped, properly.


The Global Market For ADHD Medications

The Global Market For ADHD Medications

The University of California, Berkeley reports that ADHD has more than tripled worldwide since 1993. Researchers at UC, Berkeley found that the United States, Canada, and Australia “presented higher-than-expected rates of ADHD medication use between 1993 and 2003 – based on predictions from per-capita GDP indicators – a country-by-country analysis showed increases in ADHD drug consumption in countries ranging from France and Sweden, to Korea and Japan.” The US still leads the world in dollars spent on ADHD medication at $2.7 billion in 2006.

The University of California at Berkeley study was published in the journal, Health Affairs.  Researchers reviewed data on ADHD medication use among 5-19 year-olds in countries belonging to the Organization for Economic Cooperation and Development (OECD), whose members are largely economically fit North American, European and Northeast Asian nations.

The researchers stated that one in twenty-five children is taking medication for ADHD in the US. However, their research also suggests that the diagnosis of ADHD and subsequent use of medications to control it is now spreading worldwide.

Dr. Richard Scheffler, a UC Berkeley distinguished professor of health economics and public policy Overall thinks the study reflects global trends. “Given the global diffusion of ADHD medications, as well as the prevalence of this condition, ADHD could become the leading childhood disorder treated with medications across the globe,” Scheffler said. “We can expect that the already burgeoning global costs for medication treatment for ADHD will rise even more sharply over the next decade.”

The Berkeley researchers also cite that “Growth trends indicate that other countries are following in its tracks. For example, global spending on ADHD medications increased nine-fold among OECD countries during the time period studied. This increase is largely due to the advent and availability of more costly and long-acting medications such as Concerta™, Strattera™ and Adderral XR™”.

The use of medications outside of the US is still primarily short acting amphetamines. However, the pharmaceutical industry is well aware that they cannot reach the estimated $3.4bn by 2015, unless it is led by the launch of drugs with novel delivery mechanisms such as improved durations of action and anti-abuse profiles as media are raising the abuse flag significantly. These custom drugs will help differentiate these pipeline drugs from the current established ADHD therapies and increase market share.

It is important to note that although ADHD drugs have demonstrated efficacy in improving the three main symptoms of ADHD – inattention, hyperactivity and impulsivity – none have shown efficacy in treating the cognitive deficits of ADHD.

Drug makers are likely to increase the costs of these novelty release (e.g. long acting) drugs globally as they become more prevalent outside the U.S. in order to reach the estimated $3.4bn target in 2015.

Back to Berkeley, using the IMS Health MIDAS™, an international pharmaceutical database, researchers looked at data and found that between 1993 and 2003, “the number of countries using ADHD medications rose from 31 to 55, with the U.S. share of global market decreasing from 86.8 percent to 83.1 percent. Meanwhile, countries with traditionally low and moderate consumption of ADHD drugs were showing steady upswings.”

Stephen Hinshaw, who is frequently approached by the media to comment on ADHD, is chair of UC Berkeley’s Department of Psychology was a co-author of the study. Commenting on this study, Hinshaw states, “The results temper some key criticisms of ADHD. A common misconception is that ADHD only exists in the U.S. and that the pharmaceutical firms are getting bigger sales because of the ‘creation’ of the disorder in the U.S. Yet cross-cultural research has shown that ADHD exists in nearly any culture that has compulsory education. Clearly, ADHD–which has a substantial genetic liability–is not just a figment of American doctors’ imaginations.”

In a nutshell, here’s Hinshaw’s argument: The use of stimulant
medication in wealthy member nations of the OECD outside of the U.S. is
growing, therefore, “ADHD is not just a figment of American doctors’
imaginations.” I’m not arguing that ADHD is real or not real. I am
simply citing that pharmaceutical marketing dollars greatly contribute
to the rise in use of stimulant medications in these nations. For
example, when adult ADHD medication was marketed heavily in the U.S.,
sales of the drug skyrocketed. Did the number of diagnosed cases
increase? Yes. Did that mean more people had the disorder? No. If this
poor logic and poor research is the best Berkeley and Hinshaw can
produce, then the students that are graduated from Berkeley are doomed!
But, wait, that’s also a non causa pro causa!

Hinshaw has essentially committed a non causa pro causa (false cause). He’s co-authored a study of data from a pharmaceutical database and citing that the number of persons outside the U.S. in the Organization for Economic Cooperation and Development (OECD), whose members are largely economically fit North American, European and Northeast Asian nations. The pharmaceutical industry has spent many millions of dollars over the past few years to increase their profit in these nations in an effort to obtain their estimated goal of $3.4bn by 2015.

What can be clearly gleaned is that the Berkeley study is meaningless. It might have some teeth if the researchers actually correlated the marketing dollars spent by the pharmaceutical manufacturers to the numbers of persons using their medications in the OECD. It would be interesting to see the data on usage in third world countries who cannot afford it. I’d wager that they have far fewer cases of ADHD and use far less medication.

9/8/2005 New Video Game Shows Promise In Treatment of Attention Deficit Disorder (ADHD)

As many as three million children in the United States are being treated for Attention Deficit Disorder. And they’re not the only ones. 4.4 percent of the adult population have A.D.D. or a related disorder, making it the second most common psychological problem in adults after depression. VOA’s Paige Kollock reports on a new ‘game’ that might be able to help them.

New Video Game Shows Promise In Treatment of Attention Deficit Disorder

By Paige Kollock
Washington, DC
29 August 2005

Medical studies have shown that television and video games may contribute to the rise in Attention Deficit Disorder, especially in children.

Doctor Stephen Hinshaw of the University of California researches children with attention deficit hyperactivity disorder. He says, “Very fast paced media are in some ways overwhelming the young brains.”

Now a company called Unique Logic and Technology has created a video game that helps re-train those young brains. It’s called “Play Attention,” and the company claims it can teach your brain how to pay attention. It works by using a helmet that has sensors.

The sensors can tell whether or not the user is paying attention. In conjunction with computer software, the sensors teach the user what it feels like to pay attention and reward them for paying attention for longer periods. Over time, the user acquires the skill of concentration.

Former Principal Pat Faulkner says the $1,795 program is worth the money. “I think Play Attention was worth every penny they ever spent on it, and all the time that was spent on it, because it has the power to change a child’s life. When a child can learn to participate in class, then he can learn, and that’s a life changing experience.”

Adults are using Play Attention too. While the U.S. Women’s Olympic bobsled team may not have A.D.D, using Play Attention helps them increase their focus, which gives them a competitive edge.

Educators say the game takes between eight and 12 months to become permanently effective. From that point on, they say, users can fall back on the skill for the rest of their lives.

Can custom-made video games help children with attention deficit disorder?

From the  Berkeley Medical Journal:

y Attention!

Can custom-made video games help kids with attention deficit disorder?

By Gordon Kwan

For children with Attention Deficit Hyperactivity Disorder (ADHD), life can feel like a never-ending video game. They are wired–restless, impulsive, and easily distracted. Their minds are constantly bombarded with different elements of reality that compete for their attention.

So far, the most popular treatment for ADHD has been Ritalin, a rapid-acting stimulant for adults that has the opposite effect in children, calming the jitters associated with the disorder. According to the National Institute of Mental Health, about three percent of American school children take stimulants like Ritalin regularly. However current research suggests a surprising new strategy for treating this disorder: video games linked to brain-wave biofeedback that can help kids with ADHD train their minds to tune in and settle down.

It is difficult for a child with ADHD to learn how to self-regulate and know what it feels like to concentrate. Biofeedback teaches patients to control normally involuntary body functions such as heart rate by providing real-time monitoring of such responses. More than 15 years of studies show that with the aid of a computer display and an EEG sensor attached to the scalp, ADHD patients can learn to modulate brain waves associated with focusing. Increasing the strength of high-frequency beta waves and decreasing the strength of low-frequency theta waves, for example, creates a more attentive state of mind. With enough training, changes become automatic and lead to improvements in grades, sociability, and organizational skills.

Despite its proven success, the technique has not become a mainstream treatment for several good reasons. First, unlike drug therapy, which can have immediate results, a typical course of biofeedback treatment takes a series of about 40 one-hour sessions over a span of several months before benefits become apparent. Second, it is more expensive than drugs. Costs range from $3,000 to $4,000 for these treatments, so insurance companies tend to pick the less expensive option. Finally, biofeedback training requires the very kind of prolonged concentration that patients with ADHD struggle to attain.

Alan Pope, a behavioral scientist at NASA Langley Research Center in Hampton, Virginia, came up with a more engaging approach through work with NASA flight simulators. He was determining the degree of interaction with cockpit controls necessary to help pilots stay attentive during routine flights. In an experiment, he linked the level of automation in the cockpit to the pilots’ brain-wave signals, so that some controls switched from autopilot to manual when the pilot started to lose focus. He found that with practice the pilots could begin to adjust the controls to the level of automation that felt most comfortable by regulating their own brain waves.

Pope applied his findings to help ADHD patients stay focused by rewarding an attentive state of mind. He realized, however, that the simple displays that were already part of biofeedback treatment may not be enough to hold the interest of restless youngsters. He then chose several common video games and linked the biofeedback signal from the player’s brain waves to the handheld controller that guides the games’ actions. “In one auto-racing game, a car’s maximum speed increases if the player’s ratio of beta to theta waves improves. The same sort of feedback also controls the steering,” Pope says.

In the test, six Sony PlayStation games were used with 22 boys and girls between the ages of nine and thirteen who had ADHD. Half the group received traditional biofeedback training; the other half played the modified video games. After 40 one-hour sessions, both groups showed substantial improvements in everyday brain-wave patterns as well as in tests of measuring attention span, impulsiveness, and hyperactivity. Parents in both groups also reported that their children were doing better in school.

The difference between the two groups was motivation. “In the video-game group, there were fewer no-shows and no dropouts,” according to Pope. The parents were more satisfied with the results of the training, and the kids seemed to have more fun.

Since children are more motivated toward video-game biofeedback and may already be familiar with video games, they will not need one-on-one coaching to master the technique. As a result, the cost of the treatment should be reduced and maybe even permit “do-it-yourself” biofeedback. One North Carolina company markets their Play Attention system as a fun bike helmet and game-like video exercises that work on almost any computer. The helmet is lined with sensors that monitor the child’s brain waves, and the child actually controls the computer video exercises by mind alone. Parents should not expect regular video games to help their children. The wrong kinds of video games might actually hurt children with attention disorders.

Parents, however, may be hesitant to switch from traditional treatment programs. One parent whose child currently takes drugs to control ADHD says, “Our son is using drugs to control his attention problems and although we don’t like giving him the pills, he is no longer causing problems at school. We try to keep our son away from things that might make him hyperactive. Unless our doctor tells us to do this brain wave training in a hospital, we are not going to buy a machine to do our own treatment at home.”

Brain-wave biofeedback alone may not be a substitute for drug therapy. Professor Stephen Hinshaw, an expert in the field of child clinical psychology at UC Berkeley, gives a reserved opinion about biofeedback treatment. “Biofeedback is a promising potential alternative, but unfortunately the kinds of really well-controlled studies that might support its clinical benefits have yet to be performed.” The two treatments have complementary aspects that make them effective as adjuncts. A single dose of Ritalin, for example, acts quickly but only for a few hours, and most patients take it only on school days. Brain-wave regulation takes a long time to learn but has the potential for longer-lasting effects.

Researchers and clinicians are realizing that ADHD is not easily outgrown. Most doctors support an approach that combines good nutrition, sleep, exercise, and learning strategies as well as biofeedback and drug therapy. The possibilities for brain-wave biofeedback are very promising since its benefits could last a lifetime. Video game biofeedback therapy may provide a more tolerable and long-lasting form of treatment for children through a medium they are more likely to enjoy.

Stephen Hinshaw

I just wanted to take a moment to further comment on The November 13, 2004 Boston Globe article, Playing their Way to Improved Concentration, referring to Play Attention, a feedback based learning system I created for persons with attention problems. It uses a video game format to teach cognitive skills typically deficit in children and adults with diffused attention.

In order to balance out the article, Globe reporter Hiawatha Bray sought out the expert opinion of Dr. Stephen Hinshaw.

Dr. Stephen Hinshaw chairman of the psychology department at the University of California at Berkeley and an expert on hyperactivity disorders, said techniques that teach concentration may work in a doctor’s office, but often stop working when the child reenters his home or classroom. “I’m not a cynic, but I’m a skeptic until things are proven pretty thoroughly,” Hinshaw said.

I admire Hinshaw’s candor. Frequently experts are requested to remark on technology or teaching methods they have never seen or used. They must produce off the cuff remarks. Hinshaw should be respected as he utilizes multi-modal approaches to treating AD/HD and has a book worth reading.

While I was not allowed to comment about Dr. Hinshaw’s remarks in the article, I would like to comment that Play Attention is the preferred educational learning system for students struggling with attention problems in over 450 school systems in the US. We’ve recently received a 91% satisfaction rating from our users because of our great support and teaching method utilizing feedback technology.