Potential downsides of ADHD overdiagnosis

Over the past few decades, U.S. children have become increasingly likely to receive a diagnosis of attention-deficit/hyperactivity disorder (ADHD), according to multiple national surveys. This unexplained rise in prevalence may be partly due to overdiagnosis, suggested a Lown Right Care article by Dr. Elizabeth Wolf and colleagues in the March issue of American Family Physician. They noted that the characteristic traits of ADHD – hyperactivity, inattentiveness, and impulsiveness – “exist on a continuum with normal behavior,” and that disease cutoffs have been gradually lowered, culminating in the DSM-5 diagnostic criteria which “lowered the percentage of criteria needed for diagnosing ADHD in older adolescents and increased the age by which behaviors must have first appeared (from seven to 12 years).” Evidence of situational ADHD overdiagnosis includes wide variations in stimulant prescriptions across states, higher rates in children who are young for their school grade, and comorbid learning and psychiatric disorders that may be mistaken for ADHD.

Although children diagnosed with ADHD can qualify for individualized education plans, and those with moderate to severe symptoms who take stimulant medications show improvements in math and reading performance, the benefit of diagnosing a child with mild symptoms is less clear. Harms of an ADHD diagnosis include labeling, disempowerment, lowered school expectations, the opportunity costs of medical visits (e.g., missed work for parents), and medication adverse effects, including insomnia. In an accompanying patient perspective, Helen Haskell and John James expressed concern that “medicating children to change their behavior may help them sit quietly at school, but viewing medication as a first-line solution may mask problems with the school or home environment and inhibit the development of important life skills.”

A recent episode of the Pharmanipulation podcast, featuring interviews with a licensed clinical psychologist and an investigative journalist, further explored the subjectivity involved in ADHD diagnoses and educational and societal pressures that may be driving these diagnoses in borderline cases. For example, the Vanderbilt Assessment Scales that are completed by a child’s parents and teachers to assist with diagnosing ADHD “[take] a subjective impression and quantify it so that it makes it seem objective.” If the parent or teacher already thinks that the child has ADHD, they will be more likely to complete the questionnaire in a way that leads to the diagnosis. Having ADHD makes a child likely to receive pharmacologic treatment, even though psychosocial interventions such as parent training in behavioral management and classroom behavior interventions can also be effective, particularly in younger children.

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This post first appeared on the AFP Community Blog.