The diagnosis of ADHD is typically made when a person has marked inattention, or distractibility, along with “executive dysfunction”, or disorganization. “Hyperactivity” is not, in our view, a scientifically valid central part of this diagnosis. In children, an inability to sit still in a classroom occurs secondary to the main problem of inattention. There is no “increased energy” and “decreased need for sleep” which would reflect a primary problem with having excessive energy compared to the general population; that increased energy and decreased need for sleep has been shown in two centuries of psychiatric research to happen only in one pathological state: mania.
Inattention in children can lead to poor function at school; teachers are thus common observers of behaviors that lead to the diagnosis of childhood ADHD. According a to a national epidemiological study by the Centers for Disease Control (CDC), about 5-10% of all US children meet ADHD criteria (boys more than girls). In that study, the state-by-state distribution of childhood ADHD prevalence varied greatly, being twice as high in poor deep South states (like Louisiana or Mississippi) than in well-to-do Western states (like Colorado and California). Thus, the claim that ADHD is more or less a purely biological disease flounders on the fact that the risk can be reduced two-fold by moving from Louisiana to Colorado. Further discussion of social factors related to ADHD can be found here.
In our view, a notable proportion of ADHD in children is not a separate illness. Using the concept of a diagnostic hierarchy, as explained here, inattention can be caused by many other illnesses – most notably anxiety conditions, depression, mania, and psychosis. Many children do not have ADHD, but rather other anxiety or mood illnesses that are impairing their concentration. They should not be treated with amphetamines, but rather with medications for anxiety, depression, or bipolar illness. This is especially the case in older children and adolescents, where the diagnosis of ADHD is being increasingly made.
Another group of children are diagnosable with ADHD without any diagnosable mood or anxiety condition. Our view is that this subgroup reflects a normal developmental delay in cortical areas that subsume executive function (frontal and parietal regions), as shown in the available limited prospective data. In that research, children followed from age 7 with ADHD had normalization of brain abnormalities by age 10, compared to normal controls. This is why – when no other mood or anxiety disease is present – ADHD should go away on its own in the majority of children; older studies found that 90% of children did not meet ADHD criteria by age 18. (The controversy surrounding adult ADHD is discussed here).
In the children with “true” ADHD, not caused by another disease, we recommend, if needed, short-term amphetamine treatment, but at the lowest doses possible and for the shortest amount of time necessary, not beyond age 10 based on the current research. The treatment of ADHD with amphetamines is further discussed in detail here, providing our rationale based on the best randomized studies of these agents that they are not necessary in the majority of children diagnosed with ADHD.