Skip to main content

Main menu

  • Home
  • Content
    • Current
    • Archive
    • Podcast: NC Health Policy Forum
    • Upcoming Scientific Articles
  • Info for
    • Authors
    • Reviewers
    • Advertisers
    • Subscribers
  • About Us
    • About the North Carolina Medical Journal
    • Editorial Board
  • More
    • Alerts
    • Feedback
    • Help
    • RSS
  • Other Publications
    • North Carolina Medical Journal

User menu

  • My alerts
  • Log in

Search

  • Advanced search
North Carolina Medical Journal
  • Other Publications
    • North Carolina Medical Journal
  • My alerts
  • Log in
North Carolina Medical Journal

Advanced Search

  • Home
  • Content
    • Current
    • Archive
    • Podcast: NC Health Policy Forum
    • Upcoming Scientific Articles
  • Info for
    • Authors
    • Reviewers
    • Advertisers
    • Subscribers
  • About Us
    • About the North Carolina Medical Journal
    • Editorial Board
  • More
    • Alerts
    • Feedback
    • Help
    • RSS
  • Follow ncmj on Twitter
  • Visit ncmj on Facebook
Research ArticlePolicy Forum

ADHD in North Carolina

Prevalence, Treatment, and Looking to the Future

Will Canu
North Carolina Medical Journal March 2020, 81 (2) 122-125; DOI: https://doi.org/10.18043/ncm.81.2.122
Will Canu
professor, Department of Psychology, Appalachian State University, Boone, North Carolina
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • For correspondence: canuwh@appstate.edu
  • Article
  • References
  • Info & Metrics
  • PDF
Loading

Abstract

At present, data suggests that attention-deficit/hyperactivity disorder may be more prevalent in North Carolina than other states, but whether we are properly identifying and treating cases, in childhood and adulthood, is murky. Much innovative work to this end is being done in North Carolina, but more is needed.

Attention-deficit/hyperactivity disorder (ADHD) exists in North Carolina as it does elsewhere: it emerges in childhood, but tends to persist across adolescence and into adulthood, as documented in a recent long-term follow-up study of hundreds of children diagnosed with ADHD suggesting that 60% have clinically significant symptoms persisting at least to their mid-20s [1]. It impairs functioning in many domains, including school achievement, work, physical health and safety, relational satisfaction, and other outcomes [2]. There are many facets of this disorder that could be focused on, but herein I have organized my commentary to focus on a) the apparent scope of the “ADHD problem” in our state, b) how we appear to be coping with that in assessment and intervention efforts, and c) related thoughts that also highlight innovative research and intervention directions.

Scope of the Problem: Relative Prevalence

Various studies can inform our understanding of ADHD prevalence in North Carolina. The National Survey of Children's Health (NSCH) periodically documents the physical and emotional health of children in the United States, is one of the Centers for Disease Control and Prevention's (CDC) primary benchmarks, and provides data at both the national and state level [3, 4]. Data from the NSCH indicates that by parent report of both a child's lifetime and current diagnosis by a health care provider the children of North Carolina have had elevated rates of ADHD across the past two decades [3, 4]. Using 2011 data as a reference, North Carolina ranked seventh in the nation on both of these metrics, with 14.4% of children reported by parents as having a lifetime diagnosis and 11.6% a current diagnosis.a Mirroring the national trend, these percentages climbed in North Carolina across the three most recent published reports (2003, 2007, and 2011), from the low of 9.6% lifetime diagnosis in 2003 [3].b A recent population study in 17 elementary schools in Johnston County utilizing data from teachers and parents estimated that 15.5% of students met criteria for current ADHD [6], providing additional evidence that this is a relatively common problem for children in North Carolina and exceeding the prevalence estimates of the Diagnostic and Statistical Manual of Mental Disorders (5th ed., DSM-5) [7]. All published data sources suggest that ADHD is more prevalent in boys than girls [2].

While prevalence statistics are easy to obtain for children, data regarding adults in the United States, and in North Carolina specifically, are relatively sparse. The National Comorbidity Survey Replication (NCS-R), completed in the early 2000s, is still the most robust source, producing a national estimate of 4.4% [8]. As in childhood, ADHD occurs more frequently in adult men than adult women, but the disparity is less dramatic [8]. Kessler and colleagues' estimate contrasts the statistics in children, but notes that other research indicates that it is still likely a majority of affected children continue to experience significant symptoms and impairment as adults [1, 9] and, indeed, that even sub-threshold cases may be associated with clinically significant impairment [10]. While specific statistics regarding North Carolina are not currently published, it seems likely to me that, as in children, our adult population either mirrors or exceeds these ADHD prevalence benchmarks.

ADHD Assessment and Intervention in North Carolina

While a full authoritative review is impossible, I think it is important to reference here some important assessment and intervention standards for ADHD. Current American Academy of Pediatrics (AAP) guidelines for child and adolescent patients generally emphasize using multiple sources of data (eg, self [for adolescents], parent[s], teacher[s], and/or direct behavioral observation), standardized instruments, documentation of impairment in multiple domains of functioning, and rule-outs of other conditions or circumstances that could be driving symptoms [11]. They clearly signal that age of patient is relevant to treatment planning, and note that strong evidence exists for the benefits of well-titrated and managed psychostimulants as well as behaviorally oriented therapies that involve parents and/or schools. These current AAP recommendations generally concur with the broad literature regarding empirically supported assessment [12-14] and intervention [15, 16].

Unfortunately, there is very little concrete, published information that either supports or disputes that medical or mental health professionals in our state, specifically, are following these sorts of standards, or even how “well” we are doing at identifying who has ADHD and attempting any sort of intervention at all. Rowland and colleagues note in their Johnston County sample that 42% of the children identified as having ADHD had no prior diagnosis, and that 27% of those with an existing ADHD diagnosis were not currently taking medication to address it, possibly suggesting some significant shortcomings [5]. Further, data from a pilot study by the same team suggests that while Black and White children were diagnosed with ADHD at roughly comparable rates, the former were significantly less likely to be taking medication [17]. Extrapolating from other data seems dicey. For instance, publicly available data suggests that the percentage of students in public K-12 schools in North Carolina who receive special education services under the Other Health Impaired designation (where ADHD fits, per the Individuals with Disabilities Education Act) likely falls far short of the prevalence statistics (in 2017: 35,133 of 1,533,180 students, = 2.3%c) [18]. This might initially be seen as evidence of poor screening and assessment. However, there is no telling how many received less formal intervention, had adequately managed ADHD via medical or psychosocial therapies, or had ADHD but still managed to cope well enough in school to not draw concern.

General Commentary

Anecdotally, given my experience as a licensed psychologist specializing in ADHD and practicing in Boone, a researcher focusing on young adults with ADHD, and a professor who has conferred with numerous students with related experiences, I suspect we are falling somewhat short in assessment and intervention. There are some aspects of this that probably have very logical roots. For instance, while it is common knowledge among health professionals that ADHD is not a disorder that always presents with prominent hyperactivity-impulsivity, it is my impression that some children—particularly girls—who have clinically relevant inattention without hyperactivity are fairly often not identified until late in the game (ie, high school or later), and this can have negative and long-lasting consequences. However, in an era in which teachers are increasingly expected to do more with less, where physicians face economic and other work-place realities that may push efficiency over lengthy consultation, where many parents have little flexibility in terms of time or attention due to myriad demands, highly elevated inattention alone may not rise to the level of concern that motivates allocating precious resources for assessment and follow-up, particularly if impairment is relatively mild.

On the intervention side, one basic aspect on which I believe we fall short is psychoeducation. This is part of effective treatments for older adolescents and adults with ADHD, such as manualized cognitive behavioral therapy (CBT) [19, 20]. An informed client is an empowered client, one likely to have more realistic beliefs and attributions and make better behavioral choices. However, in my experience with college students with ADHD this is often sorely missing. They lack an understanding of ADHD and how it is likely to affect their lives, and what seems to follow is failing to procure accommodations or other educational or psychotherapeutic assistance, discontinuing prescription medication, diversion of the same to unaffected peers, and other mal-adaptive behaviors. Again, this may in practice be difficult to counter. ADHD is most commonly diagnosed in childhood, in primary care, and there is limited time to educate parents about the nature of the disorder, much less to provide developmentally appropriate information to children. Parents and other adults who support these kids as they grow into teens and young adults (eg, physicians and counselors, teachers, and others in schools) also have many fires to tend to, and providing education about ADHD's effects and how they may play out over time can, logically, fall through the cracks.

Obstacles and Future Opportunities

While it may seem to the reader at this point that I have a pessimistic view of how well we are coping with ADHD in North Carolina, I want to counter by writing about the opportunities for the future and the important work that has been and continues to be done in our state.

First, one of the obstacles to adequate care for those with ADHD is a dearth of well-trained behavioral health specialists (ie, psychologists, clinical social workers, counselors) who can implement the empirically supported parent- and school-based behavioral interventions that are indicated. This is a lamentation that I often hear in Boone, and I imagine it is particularly problematic in other rural areas of the state, too. Two fruitful directions that I see for growth here lie in integrated medical and school-based models of mental health care. In rural and urban areas alike, between the physician's office and public schools we can draw a network that provides services to the vast majority of youth. Family doctors and pediatricians could actively recruit child-clinical behavioral specialists (ie, those with expertise in assessment and parent-school interventions) to participate in office-based care and assessment of patients with concerns related to ADHD. Such specialists could be more keenly attuned to gender differences (eg, sensitive to predominantly inattentive cases in girls) and local patterns of ethnic disparities, as well (eg, over- or under-identification of black versus white children), and may help primary care professionals in particular, as sounding boards for borderline cases and decisions regarding initial and continuing treatment (eg, medication versus psychosocial). Parent training classes could be offered during the evenings, and with dedicated space, telehealth consultation and follow-up with families and schools could become a reality. Medical practices could make such desires known to master's and doctoral-level programs in their vicinity, which might then prioritize training options that would benefit their trainees and the community alike.

As for school-based interventions, multiple directions are being pursued that have potential to improve outcomes for those with ADHD. Psychologists at Appalachian State University, along with professionals in other allied disciplines, have established Assessment, Support, and Counseling (ASC) Centers in local high schools [21]. ASCs address issues ranging from problems of life to severe mental illness and suicidality, taking intervention to the patient; for adolescents with ADHD, such a venue might provide psychoeducation and cognitive behavioral intervention that would facilitate better adjustment in their transition to adulthood. Schultz, a professor at East Carolina University, has been involved in the upward extension of the middle-school-focused Challenging Horizons after-school program for children with ADHD [22], with promising initial results that suggest application in North Carolina high schools may be indicated [23]. At the University of North Carolina at Greensboro, Anastopoulos and colleagues run a community-based ADHD specialty clinic and also have implemented the Accessing Campus Connections and Empowering Student Success (ACCESS) program, which employs empirically supported psychotherapy and skills training to bolster the success of college students with ADHD [24]. Duke University Medical Center, one of the core data collection sites of the groundbreaking Multimodal Treatment for ADHD (MTA) that was conducted in the late ‘90s (see [25], among many others), operates another exceptional specialty clinic that also facilitates novel treatment outcomes research (eg, [26]).

To conclude, something that I think transcends my own biased and imperfect perspective into truth is this: we have work yet to do to identify, understand, and treat ADHD. There are many who are progressing with that work, but we could use reinforcements. Are you in?

Acknowledgments

The author would like to warmly thank and acknowledge all of his colleagues—physicians, psychologists, counselors, social workers, teachers, and others—who are on the “front lines” supporting and advocating for people with ADHD in North Carolina.

Potential conflicts of interest. W.C. has no relevant conflicts of interest.

Footnotes

  • ↵a For reference, the national averages for these statistics were 11.0% (lifetime) and 8.8% (current); Kentucky had the highest prevalence (18.7% and 14.8%, respectively), and Nevada had the lowest (5.6%, 4.2%; [3]).

  • ↵b Note that an online query of 2017-2018 NSCH data indexing the rate of current, parent-reported ADHD in the United States indicated a decline in North Carolina (10.3%) and general stability nationally (8.7%) [5].

  • ↵c Per reports of students aged 6-21 in “By LEA (6-21)” and “6-21 by LRE, Disability, Race and Sex” documents for 2017 indexed at https://ec.ncpublicschools.gov/reports-data/child-count/reports/december-1

  • ©2020 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.

References

  1. ↵
    1. Sibley MH,
    2. Swanson JM,
    3. Arnold LE, et al.
    Defining ADHD symptom persistence in adulthood: Optimizing sensitivity and specificity. J Child Psychol Psychiatry. 2017;58(6):655-662. doi:10.1111/jcpp.12620.
    OpenUrl
  2. ↵
    1. Barkley RA
    , ed. Attention-Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment. New York, NY: The Guilford Press; 2015.
  3. ↵
    1. Centers for Disease Control and Prevention
    State-based Prevalence Data of Parent Reported ADHD Diagnosis by a Health Care Provider. CDC website. https://www.cdc.gov/ncbddd/adhd/prevalence.html. Updated August 27, 2019. Accessed January 7, 2020.
  4. ↵
    1. Visser SN,
    2. Danielson ML,
    3. Bitsko RH, et al.
    Trends in the parent-report of health care provider-diagnosed and medicated ADHD: United States, 2003-2011. J Am Acad Child Adolesc Psychiatry. 2014;53(1):34-46.e2. doi: 10.1016/j.jaac.2013.09.001.
    OpenUrlCrossRefPubMed
  5. ↵
    1. Data Resource Center for Child & Adolescent Health
    NSCH Interactive Data Query (2016-2018). Data Resource Center for Child & Adolescent Health website. https://www.childhealthdata.org/browse/survey/results?q=6932&r=1&r2=35. Accessed January 2, 2020.
  6. ↵
    1. Rowland AS,
    2. Skipper BJ,
    3. Umbach DM, et al.
    The prevalence of ADHD in a population-based sample. J Atten Disord. 2015;19(9):741-754. doi: 10.1177/1087054713513799.
    OpenUrlCrossRefPubMed
  7. ↵
    1. American Psychiatric Association
    Diagnostic and Statistical Manual of Mental Disorders. 5th ed. New York, NY: American Psychiatric Publishing; 2013.
  8. ↵
    1. Kessler RC,
    2. Adler L,
    3. Barkley R, et al.
    The prevalence and correlates of adult ADHD in the United States: Results from the National Comorbidity Survey Replication. Am J Psychiatry. 2006;163(4):716-723. doi: 10.1176/ajp.2006.163.4.716.
    OpenUrlCrossRefPubMed
  9. ↵
    1. Faraone SV,
    2. Biederman J,
    3. Mick E
    The age-dependent decline of ADHD: A meta-analysis of follow-up studies. Psychol Med. 2006;36(2):159-165. doi: 10.1017/S003329170500471X.
    OpenUrlCrossRefPubMed
  10. ↵
    1. Hartung CM,
    2. Lefler EK,
    3. Canu WH, et al.
    DSM-5 and other symptom thresholds for ADHD: Which is the best predictor of impairment in college students? J Atten Disord. 2019;23:1637-1646. doi: 10.1177/1087054716629216.
    OpenUrl
  11. ↵
    1. Wolraich ML,
    2. Hagan JF Jr.,
    3. Allan C, et al.
    Clinical practice guideline for the diagnosis, evaluation, and treatment of Attention-Deficit/Hyperactivity Disorder in children and adolescents. Pediatrics. 2019;144(4):e20192528. doi: https://doi.org/10.1542/peds.2019-2528.
    OpenUrlAbstract/FREE Full Text
  12. ↵
    1. Evans SW,
    2. Youngstrom E
    Evidence-based assessment of attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. 2006;45(9):1132-1137. doi: https://doi.org/10.1097/01.chi.0000228355.23606.14.
    OpenUrlCrossRefPubMed
    1. Frazier TW,
    2. Youngstrom EA
    Evidence-based assessment of attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. 2006;45(5):614-620. doi: 10.1097/01.chi.0000196597.09103.25.
    OpenUrlCrossRefPubMed
  13. ↵
    1. Pelham WE Jr.,
    2. Fabiano GA,
    3. Massetti GM
    Evidence-based assessment of attention deficit hyperactivity disorder in children and adolescents. J Clin Child Adol Psychol. 2005;34(3):449-476. doi: 10.1207/s15374424jccp3403_5.
    OpenUrl
  14. ↵
    1. Evans SW,
    2. Owens JS,
    3. Wymbs BT,
    4. Ray AR
    Evidence-based psychosocial treatments for children and adolescents with attention-deficit/hyperactivity disorder. J Clin Child Adol Psychol. 2018;47(2):157-198. doi: https://doi.org/10.1080/15374416.2017.1390757.
    OpenUrl
  15. ↵
    1. Pelham WE Jr.,
    2. Fabiano GA
    Evidence-based psychosocial treatments for attention-deficit/hyperactivity disorder. J Clin Child Adol Psychol. 2008;37(1):184-214. doi: 10.1080/15374410701818681.
    OpenUrl
  16. ↵
    1. Rowland AS,
    2. Umbach DM,
    3. Stallone L,
    4. Naftel AJ,
    5. Bohlig EM,
    6. Sandler DP
    Prevalence of medication treatment for attention-deficit hyperactivity disorder among elementary school children in Johnston County, North Carolina. Am J Public Health. 2002;92(2):231-234. doi: 10.2105/ajph.92.2.231.
    OpenUrlCrossRefPubMed
  17. ↵
    1. Public Schools of North Carolina
    Exceptional Children Reports and Data Child Count Reports December 1 2018 By LEA (3-21). State Board of Education Department of Public Instruction website. https://ec.ncpublicschools.gov/reports-data/child-count/reports/december-1. Accessed January 9, 2020.
  18. ↵
    1. Safren SA,
    2. Sprich SE,
    3. Perlman CA,
    4. Otto MW
    Mastering Your Adult ADHD: A Cognitive Behavioral Treatment Program: Therapist Guide. New York, NY: Oxford University Press; 2005.
  19. ↵
    1. Solanto MV
    Cognitive-Behavioral Therapy for Adult ADHD: Targeting Executive Dysfunction. Reprint ed. New York, NY: The Guilford Press; 2013.
  20. ↵
    1. Albright A,
    2. Michael K,
    3. Massey C,
    4. Sale R,
    5. Kirk A,
    6. Egan T
    An evaluation of an interdisciplinary rural school mental health programme in Appalachia. Adv Sch Ment Health Promot. 2013;6(3):189-202. doi: 10.1080/1754730X.2013.808890.
    OpenUrl
  21. ↵
    1. Evans SW,
    2. Langberg JM,
    3. Schultz BK, et al.
    Evaluation of a school-based treatment program for young adolescents with ADHD. J Consult Clin Psychol. 2016;84(1):15-30. doi: http://dx.doi.org/10.1037/ccp0000057.
    OpenUrlPubMed
  22. ↵
    1. Evans SW,
    2. Schultz BK,
    3. DeMars CE
    High school-based treatment for adolescents with attention-deficit/hyperactivity disorder: Results from a pilot study examining outcomes and dosages. School Psychology Review. 2014;43(2):185-202.
    OpenUrl
  23. ↵
    1. Anastopoulos AD,
    2. King KA
    A cognitive-behavior therapy and mentoring program for college students with ADHD. Cogn Behav Pract. 2015;22(2):141-151. doi: 10.1016/j.cbpra.2014.01.002.
    OpenUrlCrossRef
  24. ↵
    1. Molina BSG,
    2. Hinshaw SP,
    3. Swanson JM, et al.
    The MTA at 8 years: Prospective follow-up of children treated for combined type ADHD in a multisite study. J Am Acad Child Adolesc Psychiatry. 2009;48(5):484-500. doi: 10.1097/CHI.0b013e31819c23d0.
    OpenUrlCrossRefPubMed
  25. ↵
    1. Mitchell JT,
    2. McIntyre EM,
    3. English JS,
    4. Dennis MF,
    5. Beckham JC,
    6. Kollins SH
    A pilot trial of mindfulness meditation training for ADHD in adulthood: Impact on core symptoms, executive functioning, and emotion dysregulation. J Atten Disord. 2017;21(13):1105-1120. doi: 10.1177/1087054713513328.
    OpenUrl
PreviousNext
Back to top

In this issue

North Carolina Medical Journal: 81 (2)
North Carolina Medical Journal
Vol. 81, Issue 2
March-April 2020
  • Table of Contents
  • Index by author
Print
Download PDF
Email Article

Thank you for your interest in spreading the word on North Carolina Medical Journal.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
ADHD in North Carolina
(Your Name) has sent you a message from North Carolina Medical Journal
(Your Name) thought you would like to see the North Carolina Medical Journal web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
17 + 1 =
Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.
Citation Tools
ADHD in North Carolina
Will Canu
North Carolina Medical Journal Mar 2020, 81 (2) 122-125; DOI: 10.18043/ncm.81.2.122

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Share
ADHD in North Carolina
Will Canu
North Carolina Medical Journal Mar 2020, 81 (2) 122-125; DOI: 10.18043/ncm.81.2.122
del.icio.us logo Digg logo Reddit logo Twitter logo Facebook logo Google logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One

Jump to section

  • Article
    • Abstract
    • Scope of the Problem: Relative Prevalence
    • ADHD Assessment and Intervention in North Carolina
    • General Commentary
    • Obstacles and Future Opportunities
    • Acknowledgments
    • Footnotes
    • References
  • Info & Metrics
  • References
  • PDF

Related Articles

  • No related articles found.
  • PubMed
  • Google Scholar

Cited By...

  • Youth Mental Health in North Carolina: Creative Innovations in Challenging Times
  • Google Scholar

More in this TOC Section

Policy Forum

  • Breaking the Cycle
  • Breaking the Cycle
  • From Here to There—With a Spring in Our Steps
Show more Policy Forum

INVITED COMMENTARIES AND SIDEBARS

  • Sidebar: Community-driven Approaches to Preventing Overdoses Among American Indians
  • Sidebar: History Shaping the Future: How History Influences Health in North Carolina Native American Communities
  • Sidebar: Impact of Racial Misclassification of Health Data on American Indians in North Carolina
Show more INVITED COMMENTARIES AND SIDEBARS

Similar Articles

About & Contact

  • About the NCMJ
  • Editorial Board
  • Feedback

Info for

  • Advertisers
  • Authors
  • Reviewers
  • Subscribers

Articles & Alerts

  • Archive
  • Current Issue
  • Get Alerts
  • Upcoming Articles

Additional Content

  • Current NCIOM Task Forces
  • NC Health Data & Resources
  • NCIOM Blog
North Carolina Medical Journal

ISSN: 0029-2559

© 2022 North Carolina Medical Journal

Powered by HighWire