Why so many children in America have ADHD

为什么美国有这么多儿童患有多动症

Not for the reasons espoused by Robert F. Kennedy junior

并非小罗伯特·F·肯尼迪所宣扬的那些原因

Few things agitate Robert F. Kennedy junior, America’s new health secretary, more than the rate of attention-deficit hyperactivity disorder (ADHD) among American children. And for good reason: one in nine children aged 3-17 years has been diagnosed with ADHD, two to three times the rate in other Western countries. 

在美国新任卫生部长小罗伯特·F·肯尼迪眼中，没有什么比美国儿童注意力缺陷多动症（ADHD）发病率更令他不安。这确实情有可原：美国3至17岁儿童中，每九人就有一人被诊断患有多动症，是其他西方国家发病率的两到三倍。

On February 13th, Mr Kennedy’s first day in office, President Donald Trump put him in charge of a special commission tasked with working out, in the next 100 days, why so many American children have ADHD and other chronic conditions.

2月13日，肯尼迪上任首日，总统唐纳德·特朗普便委任他牵头一个特别委员会，责成其在未来100天内查明美国儿童多动症及其他慢性病高发的根源。

There are reasons to worry that the commission will miss the mark. Its terms of reference mirror Mr Kennedy’s beliefs. He blames ADHD on the rampant use of chemicals by America’s food industry. While there is scientific evidence that artificial food colours can worsen some ADHD symptoms in children, their role is marginal. The actual reason why America is an outlier is widespread over-diagnosis.

然而，人们有理由担忧这个委员会可能偏离重点。其职权范围完全反映了肯尼迪的个人观点。他将多动症归咎于美国食品工业对化学品的滥用。尽管有科学证据表明人工食用色素可能加剧部分儿童的多动症症状，但其影响微乎其微。美国多动症发病率偏高的真实原因在于普遍存在的过度诊断现象。

A typical ADHD diagnosis in America is done by a paediatrician or a family doctor in an office visit as brief as 15 minutes. The norm in Europe is an hours-long assessment by a psychiatrist. The difference has to do with America’s scant health-insurance coverage for mental health care and lax rules about who can diagnose ADHD. 

美国典型的多动症诊断流程，是由儿科医生或家庭医生在短短15分钟的门诊中完成的。而在欧洲，标准做法是精神科医生耗时数小时进行评估。这种差异源于美国医保对心理健康的覆盖不足，以及对多动症诊断资质的宽松规定。

Lots of corners are cut in those 15 minutes. A full ADHD assessment that follows psychiatric guidelines entails cognitive tests of the child, detailed interviews of parents and teachers and even observing the child in the classroom. This helps to rule out other causes for ADHD-like behaviour. Often, it is a child’s normal reaction to a chaotic home or classroom.

15分钟的仓促问诊难免偷工减料。遵循精神病学指南的完整多动症评估应包括儿童认知测试、对家长和教师的深度访谈，甚至课堂行为观察。这有助于排除其他可能导致类似多动症行为的因素——很多时候，这些行为只是儿童对混乱家庭或课堂环境的正常反应。

Fresh evidence of specious diagnoses landed in December, in a study published by the National Bureau of Economic Research. It found that ADHD diagnoses in America spike by 14% on Halloween compared to the ten weekdays before or after that. It is easy to guess why—the children were examined on the one very exciting day when you get to wear a fun costume and collect bucketloads of candy. 

关于草率诊断的最新证据出现在去年12月国家经济研究局发布的一项研究中。研究发现，美国万圣节当天的多动症诊断量比节前节后十个工作日高出14%。原因显而易见——孩子们是在这个穿奇装异服、收获满桶糖果的兴奋日子接受检查的。

Joel Nigg, a psychiatrist at Oregon Health and Science University, says that in his clinical practice he sees many cases that look like ADHD on the surface but, once fully evaluated, turn out to be something else (anxiety or a learning disability, for example).

俄勒冈健康与科学大学精神科医生乔尔·尼格指出，临床实践中常遇到表面看似多动症、经全面评估后实为其他问题（如焦虑或学习障碍）的案例。

Doctors are not alone in over-diagnosing ADHD. In a study in 2020, 10% of Americans rated their children high on a scale of ADHD symptoms, compared with 3-4% of Swedish and Norwegian parents. Cognitive tests showed that the American parents over-reported ADHD symptoms by a wide margin; the Swedish and Norwegian parents were generally accurate.

过度诊断多动症的责任并非全在医生。2020年一项研究显示，10%的美国父母认为自己的孩子表现出严重多动症症状，而瑞典和挪威父母的比例仅为3%-4%。认知测试表明，美国父母对症状的夸大程度显著；瑞典和挪威父母的判断则基本准确。

America’s ethos of “school achievement above all else” is part of the problem, says Stephen Hinshaw of the University of California at Berkeley. It does not help that Americans are bombarded with advertisements for ADHD drugs. Only America and New Zealand allow direct prescription-drug advertising to consumers.

加州大学伯克利分校的斯蒂芬·欣肖认为，美国"学业成就至上"的风气是问题的一部分。此外，铺天盖地的多动症药物广告也在推波助澜——全球仅美国和新西兰允许药企直接向消费者投放处方药广告。

All too often, however, the push for ADHD diagnoses comes from schools. Accountability rules can incentivise them to get ADHD diagnoses for poor-performing students: they can place children with ADHD into special-education classes and exclude their test results from reporting. 

但更多时候，推动多动症诊断的力量来自学校。问责制度可能激励校方为成绩不佳的学生诊断为多动症：这些孩子可被纳入特殊教育班级，其考试成绩无需计入学校统计。

Dr Hinshaw and others have found that ADHD rates are higher in states with more stringent accountability rules, especially for poor children. In Louisiana and Mississippi, poor states and early adopters of school accountability, one in six children has been diagnosed with ADHD.

欣肖等人的研究发现，在问责制度更严格的州（尤其是针对贫困儿童），多动症发病率更高。路易斯安那和密西西比等贫困州率先推行学校问责制，当地六分之一儿童被诊断患有多动症。

At the same time, rich American parents and the competitive schools where they enroll their children have been tempted to exploit school accommodations for ADHD, such as extra time on exams. 

与此同时，富裕家庭及其子女就读的精英学校也倾向于利用针对多动症学生的考试便利（如延长作答时间）。

This shows up in the data for the so-called “504 designation”, a disability category for students who are expected to learn as much as other students, with certain accommodations (their test scores are included in the school average). An analysis by The Economist found that 8.6% of secondary-school students in the most affluent areas have a 504 designation, compared to 1.4% of students in the poorest areas.

这体现在所谓"504条款"的数据中——该残疾类别允许学生在获得特殊关照的前提下达到与其他学生相同的学习要求（其考试成绩计入学校平均分）。《经济学人》分析发现，最富裕地区8.6%的中学生拥有504条款资格，而最贫困地区仅1.4%。

What would the ADHD rate in America be if children were diagnosed properly? According to a study of 12,000 American children published in 2022 by Dr Nigg and his colleagues, 9% of children would be categorised as having ADHD based solely on parents’ answers about symptoms. 

如果采用规范诊断流程，美国多动症发病率会是多少？尼格博士及其同事2022年对1.2万名美国儿童的研究显示：仅依据家长描述的症状，9%儿童会被归为多动症。

If both parents’ and teachers’ ratings were required, only about 5% of the children would have ADHD. When the researchers went further, taking into account standardised scales that show how far behaviour is from that typical for a child’s age, the ADHD rate dropped to 3.5%—falling in line with that in other Western countries.

若同时参考教师评估，该比例降至约5%；当研究人员进一步采用标准化量表衡量行为与年龄常态的偏离程度时，发病率降至3.5%——与其他西方国家持平。

（红色标注词为重难点词汇）

重难点词汇：

espouse [ɪˈspaʊz] v. 支持；拥护 

agitate [ˈædʒɪteɪt] v. 鼓动；煽动；使不安 

rampant [ˈræmpənt] adj. 猖獗的；蔓延的 

scant [skænt] adj. 不足的；缺乏的 

specious [ˈspiːʃəs] adj. 似是而非的；华而不实的 

stringent [ˈstrɪndʒənt] adj. 严格的；严厉的