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Is ADHD Overdiagnosed or Underdiagnosed? Looking at Evidence.

Most evidence these days point to the fact that ADHD is overdiagnosed – especially among children and teenage boys. What many people fail to realize is that many children experience attention deficits and engage in hyperactive, impulsive behavior naturally. It is pretty normal for kids to engage in this type of behavior. My guess is that most kids meet criteria for attention-deficit/hyperactivity disorder and the problem is that instead of trying alternative treatment options to stimulants, most people settle for a stimulant and assume that they have ADHD.

According to the literature that I’ve reviewed, it appears as though ADHD is an overdiagnosed disorder. The University of Basel demonstrated that child and adolescent psychotherapists as well as psychiatrists tend to make diagnoses for ADHD based on unclear evidence rather than sticking to the specific diagnostic criteria as laid out by the DSM-5. For this reason, we have professionals loosely interpreting the diagnostic criteria in order to diagnose someone with a disorder.

ADHD is overdiagnosed: German study shows the results

One study took a look at 1,000 child and adolescent psychiatrists and psychotherapists across Germany. They participated in a survey and a total of 473 responded. They received one of 4 scripted cases from a patient and were asked to make a diagnosis based on symptoms. It was found that in 3/4 cases, individuals did not meet DSM-5 criteria for ADHD. In other words, only one of the four potential cases could be legitimately diagnosed as ADHD. Gender of the patient was included as a variable – which ended up resulting in a total of 8 different cases; 4 per gender.

Boys more ADHD than girls: One of the findings from this study was that ADHD was diagnosed significantly more among boys than girls. They are misdiagnosed significantly more than girls. This shows that more psychiatrists and professionals are judging the condition based on gender – which should not be a factor. Similarly a male with restless symptoms is more likely to be diagnosed with ADHD than a girl who actually meets full criteria for the condition.

300% increases in diagnoses: The number of people that have been diagnosed with ADHD has risen by over three-hundred percent from 1990 to 2000. Obviously the population is growing and there are more people on the planet that could be diagnosed, but the staggering increases indicates a different problem – more people believe that they need stimulants to cope with the condition and/or similar symptoms to ADHD. Both costs and dosage of medications have increased throughout the years. Daily dosage has increased by 10% over the past couple decades – this is pretty substantial.

Financial interests: It was found that over 75% of the medical experts who created the DSM-5 guidelines for ADHD had financial conflicts of interests through ties to the pharmaceutical companies (his is according to a BMJ paper). We are not sure whether this has affected diagnoses of ADHD, but some would hypothesize that it has. It has been suggested that up to $500 million has been spent annually in the United States just for individuals that are misdiagnosed with ADHD.

Is ADHD ever underdiagnosed?

Some would suggest that although ADHD is overdiagnosed in boys and in general, there are certain individuals who believe that it may be underdiagnosed in women. This is in part due to the fact that studies have shown gender biases when making ADHD diagnoses. Girls who exhibit early symptoms of ADHD may go unrecognized as having the condition and instead labeled as “drama queens” or instead having mood issues.

Usually among girls, they first notice their ADHD during adolescent years when they begin dealing with increased demands from school, socialization, and work. Most young girls with ADHD experience social deficits at a younger age, but these finally become apparent once they reach adolescence. It is also not uncommon for women to experience anxiety and/or depression as a result of their ADHD.

Keep in mind that the underdiagnosis of ADHD tends to be only with girls. It is more over-diagnosed in both boys than girls than it is underdiagnosed.

ADHD Misdiagnosis: Other similar conditions

  1. Common excuse: Many people that are officially diagnosed with ADHD are misdiagnosed. It almost seems “trendy” or cool to be diagnosed with this disorder these days. Many people get diagnosed with ADHD to use it as an “excuse” for doing well in school or trying hard to be productive. The majority of individuals that have symptoms can be cured or effectively treated with Adderall alternatives.
  2. Getting pills: Then we also have the other people that attempt to get diagnosed just for the amphetamine medication. In college students it is not uncommon for people to fake ADHD symptoms or describe to their doctor that they have the symptoms just so they can get a stimulant medication like Adderall or Vyvanse. Instead of properly using the medication, they may use it to cram for a test, write a paper, and/or as a party drug.
  3. Similar disorders: There are many similar disorders that lead to inability to pay attention or hyperactivity. Certain conditions such as anxiety disorder, depression, or other health conditions may result in similar symptoms. It is important to rule out other psychiatric disorders before an ADHD diagnosis is made. Unfortunately, many general practitioners assume ADHD before considering other options. This can result in misdiagnosis.

Things that cause similar symptoms to ADHD

  • Bad parenting: Poor parenting may contribute to symptoms of a child acting out, not paying attention, etc. This does not mean that the child has ADHD. This simply means that they are not getting parental support and thus may have a million thoughts going through their head about their parents. They may have an abusive relationship, the parent may be neglectful, and/or have a drug or alcohol addiction.
  • Lack of exercise: People who don’t exercise may wonder why they have a ton of extra energy. It’s simply because they eat food and do not move around. Many people are sedentary and eat, go to work, sit all day with minimal exercise. Then they don’t “burn up” the extra energy that they have and it results in fidgety behavior or hyperactivity. Many people with even severe “ADHD” can successfully manage the condition with a structured workout protocol.
  • Mood disorders: It is important to make sure that a mood disorder isn’t what is causing ADHD symptoms. People with depression often appear spacey and have a difficult time paying attention. This is not a result of ADHD, although the person may experience psychomotor slowing just like that of attention-deficit disorder. For this reason, some people actually find that Adderall works for depression.
  • Normal childhood behavior: Certain parents don’t know how to deal with normal childhood behavior these days. Many parents assume that when a kid is acting crazy that it must be ADHD. Many people forget how wild and crazy kids can act – even if they do not have any indication of ADHD. I would go as far as to say that most children display some signs of attention deficits and hyperactivity. Their brains are not fully developed and they may have a more difficult time
  • Poor diets: Individuals that are not getting enough vitamins, omega-3 fatty acids, nutrients, and protein in their diets may struggle with inability to focus. If your child or a person you know with ADHD is eating a poor diet, it may be that the diet is the cause of their symptoms. This is something that many people do not even consider, yet diet can significantly contribute to symptoms of many mental illnesses.
  • Trauma: People that have to deal with traumatic experiences such as PTSD may exhibit similar symptoms. This is due to the fact that trauma can significantly slow brain activity and impact similar regions to ADHD. This can make symptoms seem very similar even though this is an entirely different problem.

People with legitimate ADHD need to be diagnosed

The problem with misdiagnosis is that it undermines the legitimate condition that is ADHD. Some people that are severely affected by this condition may be overlooked and/or not properly treated. Some would argue that the most successful individuals with ADHD tend to be those who find ways to cope with and manage the symptoms on their own.

Although there are drawbacks associated with ADHD, some people are able to channel their hyperactivity towards being productive. Keep in mind that there are many different types of ADHD that a person could be dealing with. According to the DSM-5 there are 3 types, but according to others there are 7 types. Therefore individuals that don’t know much about this subject may be prone to making a misdiagnosis.

In order to get an official diagnosis for ADHD, it is recommended to get evaluated by a psychiatrist and/or psychologist. Family doctors do have experience with this type of condition, but they are not as good as a psychiatrist at evaluating symptoms. In order to make sure you are accurately assessed and diagnosed in accordance with DSM-5 criteria, consult a mental health professional.

To avoid a misdiagnosis, it is important to make sure that professionals strictly adhere to DSM-5 criteria instead of going with their personal intuition.

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{ 1 comment… add one }
  • Shannon D September 9, 2016, 3:44 pm

    Interesting article but I think it still relies on outdated and stereotypic ideas about what ADHD is. It has to be one of the most misunderstood and stigmatizing diagnoses I am aware of. Here are my objections: the Basel study was flawed b/c it directed the participants to make a diagnosis, thereby prejudicing their actions in advance by implying there was a diagnosis to make. You also failed to mention that many of the participants failed to diagnose the true ADHD patient.

    I respectfully ask that you be very careful about perpetuating the already strong public perception that ADHD is not “real.” That these kids just need better parenting, food and exercise. ADHD is a medical disorder that can be seen in PET scans and MRI imaging. The ADHD brain functions very differently in how it processes glucose and what parts of the brain are activated during various cognitive and social tasks as compared to the non-ADHD brain.

    I’d ask you not to imply that the stimulant meds used for ADHD are somehow an “easy out” for tired, overworked parents. Most parents agonize over that decision – yet these meds have an 80℅ success rate. Imagine if tomorrow’s headlines announced a new breast cancer drug with an 80℅ success rate at saving women’s lives.

    Would we not celebrate that? Why can’t we do the same for a drug that makes it possible for a child to succeed, learn, fit in and be confident? As a friend of mine said (after 5 years of unsuccessful attempts with alternative therapies, behavior modification plans and diets), “I didn’t realize how much my daughter wanted to be successful until she had the means to do so.”

    Finally, please consider taking a balanced approach to this issue by writing about the horrible toll that undiagnosed and untreated ADHD has on kids, families and society. ADHD kids who never get treated are at *much* higher risk for life-changing injuries, suicide, depression, dropping out of school, working at jobs below their abilities and having severe difficulty maintaining meaningful friendships and marriages. They live just a shadowy version of the life they really want and are capable of having.

    Which kind of raises the question – at least for me – which is worse: over diagnosing ADHD… or under diagnosing? Thanks for your time.

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