Pharmacies are dispensing more Ritalin and other ADHD medication every year and more suspected cases are being referred for a diagnosis. Is the condition actually on the rise? OLIVER LEWIS reports.
The problems became obvious at school. About two years ago Jane* noticed her then 6-year-old son was struggling. He wasn’t hyperactive, but he was forgetting things and playing up.
“He was just doing stuff he should have grown out of really, like hitting someone during play. Not having good social skills and making bad, impulsive decisions,” she said.
She sought help, and last year he was diagnosed with ADHD. The diagnosis came as a relief – it provided a reason for his behaviour, and it meant teachers and others treated him with more understanding.
“It doesn’t stop it from being frustrating, but having an explanation does mean that you change your expectations,” Jane said, adding her son still got told off much more than his classmates.
Attention deficit hyperactivity disorder (ADHD) is the most common diagnosis given to children in youth mental health services, according to Ministry of Health assessment guidelines, last updated in 2001.
Persistent overactivity, impulsiveness and inattention are all symptoms, although not all have to be present. Having a Ferrari brain with bicycle brakes is how Jane described it to her son.
Micronutrients are having a positive impact on a Christchurch teen’s ADHD. (Video first published in October 2017)
Increased awareness of the condition means cases that might once have been missed are now being picked up, according to clinicians and ADHD advocates.
“Across the world there is a sharp rise in ADHD diagnoses, and that is a trend that has continued for about 20 years, and New Zealand is part of the trend,” ADHD New Zealand chairman Darrin Bull said.
The flipside is that parents might mistakenly attribute behaviours to ADHD. Both factors have resulted in increased referrals and pressure on youth mental health services.
Bull said wait times varied drastically around the country, but were often better in the main centres. He believed public services were trying their hardest, but it was still challenging for families.
“You don’t suddenly have ADHD. Often you start to realise you need to see a specialist when you’re in crisis mode.”
In Canterbury, young people suspected of having the condition make up more than half the overall waitlist for youth mental health services. At the end of January, there were 144 patients waiting with suspected ADHD.
Figures provided by the Canterbury District Health Board (CDHB) show the average wait time from referral to a face-to-face appointment with a specialist was 90 days.
CDHB chief of psychiatry Dr Peri Renison said referrals for suspected cases of ADHD had increased over recent years, putting pressure on the service to the point it was now implementing a new ADHD-specific pathway.
“It doesn’t mean there’s more ADHD in society,” she said. “It simply means that what is there is being picked up, but a large number of referrals don’t result in a diagnosis of ADHD.
“While it’s good that people have more awareness and want it checked out, we need to be careful of not putting labels on things that are pretty normal.”
The 90-day wait was a massive reduction, Renison said. Some young people had previously waited up to a year for an assessment before changes were made to the referral process.
“We have identified a group of clinicians to work in this area and now aim to gather all the relevant information prior to the child or youth being seen by a doctor.
“This will not only enable the best use of resources but fast-track their access to treatment.”
The new process had been piloted in one area, and would be fully rolled out across the service later this year.
It involved sending questionnaires to the parents and teacher of a child suspected of having ADHD, followed by a phone consultation and then an appointment with a specialist to clarify the diagnosis and agree on a treatment plan.
Medication such as Ritalin, a stimulant drug for the treatment of ADHD, could be prescribed at the appointment or at a later date. A case manager was assigned to the family to monitor progress and arrange future appointments.
Renison said ADHD made up the largest share of all confirmed diagnoses for the Child, Adolescent & Family service, ahead of anxiety. The condition made up 28 per cent of confirmed mental health diagnoses in 2014, rising to 37 per cent last year.
However, while the proportion had increased, the numbers of confirmed cases had not. There was 300 cases with a confirmed diagnosis of ADHD in 2014, rising to a high of 374 in 2016 before falling to 265 last year.
“So while we’re doing more assessments it doesn’t necessarily result in more diagnoses,” Renison said.
Across the CAF service in 2018 there was a total of 2379 cases closed covering all types of suspected conditions, not just ADHD. Of these, only 709 had a confirmed diagnosis entered.
Jane, a Canterbury woman, said it was important young people with the condition were diagnosed as soon as possible. If it was missed, there could be life-long consequences, she said.
“There’s a huge cost: kids dropping out of school, disrupted classrooms for years and years, stressed teachers. There’s massive advantages to identifying these kids early.”
Treatment options included medication and talking therapies. Ministry figures for ADHD treatments showed, across all age groups, the total number of pharmacy dispensings rose from 120,000 in 2008 to more than 300,000 in 2018.
Estimates for the prevalence of the condition vary. New Zealand Health Survey data from 2016-17 suggested 2.4 per cent of children aged 2 to 14 had ADHD. ADHD New Zealand puts the figure at between 2 to 5 per cent of children.
Renison said a fear the condition was being overdiagnosed was a valid concern and one clinicians were aware of, and took care to avoid. They used numerous sources of information to make a diagnosis, she said.
Ritalin was a stimulant drug that had the opposite effect on people with ADHD due to their brain chemistry, Renison said. If someone was misdiagnosed and prescribed the drug it should quickly be apparent it was not working.
Renison agreed it was important ADHD was picked up early. Treatment tended to be harder for people who were diagnosed as adults, she said.
“The problem as it goes into adulthood is the person really struggles to stay on task, to stay with jobs. It affects relationships and all sorts of things, so it’s important to address,” she said.
What is ADHD?
Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder (a problem with the way the brain is wired and functions). Children with ADHD often have other neurodevelopmental problems as well, such as learning difficulties and autism. They are also at increased risk of developing mental health problems, such as anxiety or depression.
What are the symptoms?
Difficulty concentrating, impulsive behaviour and, in some children, very hyperactive behaviour – not being able to sit still, fidgeting, running around. Renison said the symptoms could become apparent at a very early age, but were most often picked up when a child was at school.
How is it diagnosed?
A diagnosis of ADHD should be made by a specialist, a child psychiatrist or developmental paediatrician, after a detailed assessment including the child’s behaviour, development, medical problems, educational progress, emotional wellbeing and psychosocial information.
* Name changed to protect the identity of the woman and her son.