Editor’s Note: We received so many questions during our September show on ADHD that we invited one of our guests back to answer some of the most common ones. Alan Schwarz is an investigative journalist who spent four years researching his book, “A.D.H.D. Nation: Children, Doctors, Big Pharma, and the Making of an American Epidemic.” Here he shares some of what he learned from hundreds of interviews with doctors, parents, researchers and children.  

What goes into making a proper diagnosis of ADHD?

Unfortunately, a proper diagnosis cannot be done in a 20- or 40-minute visit with a pediatrician or psychiatrist. It takes much more investigation to get to the root of a child’s problems–it might be ADHD, and it might not be.

To qualify for the American Psychiatric Association’s definition of the disorder–which really is the official guideline–a child’s symptoms of hyperactivity, impulsivity and/or inattention must interfere with both their school and home/social life. (The definition used to require that the child be “impaired” by the symptoms, but the definition was loosened in 2013 to accommodate more diagnoses).

There are a few conditions:

• They symptoms must be persistent for at least six months and, for adolescents, have been apparent before the age of 12. (It used to be 7, but once again the definition was loosened to let more kids qualify).
• The symptoms also can’t be attributable to anything else – such as trauma, anxiety, improper sleep, poor diet, the parents’ breakup or remarriage, things like that. Not all that coughs is bronchitis, and not all that is hyperactive or inattentive is ADHD. Some is, some isn’t.

To conduct the proper appraisal with the best chance at pinpointing the child’s underlying issues, the medical provider must take a full health and behavioral history of the child, talk with parents and teachers (even from several years back) and rule out all of the other possibilities. You can’t do it in one or even two sessions. Sadly, the process is rushed way too many times, which runs the serious risk of missing what the child’s true problems are—and then prescribing treatments that won’t help, or even make things worse.

No parent should accept any diagnosis made in one session. Some doctors consider anything more than one session a waste of your time or theirs, in part because most insurance companies will not pay them for anything more than a brief assessment.

One doctor who botched a case horribly told me: “I hate to say this, but when you put in five hours and get paid for only one, it’s hard to make a living.”

You wouldn’t tolerate a mechanic telling you, “Well, I skipped some steps on your brakes because Ford doesn’t reimburse me.” If it’s not good enough for your car, it’s not good enough for your child.

What are the benefits and risks of medication?

Few would dispute that both classes of ADHD medication–amphetamine (such as Adderall and Vyvanse) and methylphenidate (Ritalin, Concerta)–are likely to improve any person’s wakefulness, focus and tendency to stay on task. They do to varying degrees in different people, and do not boost intelligence or improve memory. But in general, most people become more focused and attentive. These effects are perhaps more significant and therapeutic in people with ADHD, because there is more room and need for improvement. But the medications work that way in just about anyone. Some doctors will say, “Maybe Tommy has ADHD; let’s try some Adderall and see if it helps.” That’s the rough equivalent of saying, “Give him some platform shoes, see if he gets taller.”

As for the side effects and risks, the most common are insomnia and loss of appetite; these are sometimes assuaged by adjusting the amount or timing of the dose. Far more rarely, but still often enough to watch for, a person can hallucinate–feel as if bugs are crawling under their skin, see or hear things that aren’t there, etc. Of course then the drug should be immediately stopped.

But most important, amphetamine and methylphenidate have been long known to be addictive substances, particularly when an adolescent or adult really likes the buzz and starts abusing them. There’s a reason the drugs are Schedule 2 Controlled Substances, along with opioid painkillers like oxycodone. The cycle can be extremely hard to break, the side effects then can be quite severe and the person then runs the risk of abusing other substances (Xanax/Valium, alcohol) to rejigger and modulate their moods. I’m not saying a parent of a 7-year-old should worry about their child becoming a speed junkie. That’s absurd. What is undeniable, however, is that abuse is a real risk when adolescents and adults handle the medication—whether prescribed or given to them by others—themselves.

What are your thoughts on concerns about over-diagnosis?

I never use the word “over-diagnosis.” I say “misdiagnosis.” Over-diagnosis frames children as a somewhat abstract, epidemiological population, which I understand, but I think it clouds the issue in this case. I prefer looking at each child as an individual—which, after all, is the point of psychiatry itself – and ask, “Did this child get the right diagnosis and treatment?” Sometimes they do, sometimes they don’t. We want to maximize the number of correct diagnoses and minimize the incorrect ones.

Now, discussions of how the system is functioning must first start with numbers. The American Psychiatric Association, which writes and distributes the official definition and diagnosis guidelines for ADHD, ends its section on the disorder with the following statement: “Population surveys suggest that ADHD occurs in most cultures in about 5 percent of children. ” OK, fine. That is the level that the field’s top experts, after great, consensus-building deliberations, have decided is a fair approximation of how many children truly have the serious, life-altering psychiatric condition. Now, let’s be fair. Most people could live with 7 or 8 percent, because there isn’t a telltale blood test or magic X-ray to make the diagnosis—it’s made through the subjective, presumably good-faith impressions of doctors, parents and teachers, and there are lots of reasons why this system will never function perfectly. The question then becomes: What is actually happening in actual doctors’ offices?

Well, 11 percent of children aged 6 to 17 have already been diagnosed with ADHD, according to long-validated surveys conducted by the Centers for Disease Control. The difference between 8 and 11 percent might sound like no big deal, but that’s more than 1.5 million kids being told they have a brain disorder when they probably don’t. They have problems—and we have to care and pursue solutions—but ADHD isn’t one of htem.

Yet it gets worse, far worse. Many kids living today are not old enough to have received the diagnosis they will ultimately get. (Clearly, many current 7-year-olds won’t receive a diagnosis for several years.) When you consider, again, children as individuals, the data show that 15 percent of all American kids–and 20 percent of boys, a staggering 1 in 5, get diagnosed with ADHD by the time they leave high school. The numbers have long careened past what is at all defensible or healthy. Many kids are getting diagnosed properly, and that’s wonderful (seriously), but just as many, or more, are getting misdiagnosed and receiving inappropriate treatments. I would contend that there is no other serious condition in American medicine for which doctors accept an inaccurate diagnosis rate of more than 50 percent.

It’s time we acknowledge and deal with this. Because whether it’s just one child or today’s six million, if we’re going to tell a kid that he has a permanent, potentially devastating brain disorder, we’d better damn well be right.

For more: Listen to our September show: The Story Behind The Rise Of ADHD In The United States.