In the United States, there is concern that attention deficit hyperactivity disorder in children is overdiagnosed.

The American Psychiatric Association estimates that 5 percent of children have ADHD, yet the United States Center for Disease Control estimates that up to 11 percent are diagnosed with this condition. Just over 6 percent of children between the ages of 4-17 take medication for the condition.

In fact, there has been a dramatic increase in the rate of diagnosis and treatment over the last several years.

There is considerable speculation about this increase in diagnosis. Unfortunately, ADHD is a diagnosis of exclusion — other conditions that can contribute to attention problems have to be ruled out. It also requires parent and teacher observation of the child in a wide variety of situations to determine if there is an attention deficit. There are no tests that alone can be used to diagnosis this condition.

Is there a difference in diagnosis around the globe? While 11 percent of children are diagnosed with ADHD in the U.S., less than 1 percent are diagnosed with ADHD in France. Cultural differences could be at play — expectations of children in France are quite different, and French parenting emphasizes good behavior.

A new study published in the New England Journal of Medicine found that children whose birthdays are in August are more likely to be diagnosed with ADHD than children born in September. Why? The cutoff for kindergarten is often Sept.1, so children born in September start kindergarten a year later. It’s possible that by starting school at a later age, children are more mature when they are required to pay attention and sit still in class.

A large number of children with ADHD are diagnosed in second or third grade where the demands for sitting still and sustained attention significantly increases from earlier grades. Children who are unable to pay attention, keep their hands to themselves and are disruptive in class are more likely to be identified as having problems needing treatment.

The higher rate of diagnosis in the United States may also have to do with our culture’s comfort with using medication to solve psychological problems. If a pill can help a child fit in better in the classroom, be more attentive and less disruptive, parents and teachers may gravitate toward a diagnosis that supports taking medication. Needless to say, pharmaceutical industry advertising reinforces this trend.

ADHD — unless it is an extreme case — is most often identified by problems in school rather than at home. Family life is better able to accommodate to a wide range of behavior. Classroom size and teacher-student ratio, impacted by changes in the economy and birth rate, have been increasing in recent years. It makes it more difficult for teachers to accommodate children whose learning styles are different.

As a child psychologist with 40 years of clinical experience, I think that ADHD is both over- and underdiagnosed. Children with attention problems that don’t include disruptive behavior are often underdiagnosed. Kids with behavior problems and poor school performance may be overdiagnosed. Many teens are diagnosed with ADHD when their attention problems may be more closely related to lack of sleep.

So what should parents do if you or your teacher suspects that your child has ADHD?

Make sure your child receives a thorough evaluation by a qualified provider. An evaluation should include a full physical exam by a pediatric primary care provider, an evaluation by a child provider that has experience and training in the diagnosis and treatment of ADHD (this could include a pediatric or family primary care provider, child psychologist, child psychiatrist or child psychiatric nurse practitioner), an interview with the parents and child, use of rating scales completed by teachers and parents, and careful evaluation of other problems that may be contributing factors.

Behavior therapy should be the first line treatment for younger children. According to the CDC, behavior therapy should be used first for children who are diagnosed between the ages of 4 and 5. For kids 6-11, ideally both behavior therapy and medication can be used in combination.