Overdiagnosing & Overprescribing Children with ADHD
Today, it is very common that kids today are being diagnosed with ADHD; it has become the most extensively studied pediatric mental health disorder, with constant controversy and debate occurring (Goldman). Hyperactivity in children was first clinically described in 1902, and the first use of stimulants to treat the hyperactivity was in 1937 (Bradley).
The DSM-5 criteria emphasize several factors:
· The symptoms specified in the criteria must be present for at least 6 months, ensuring that persistent rather than transient symptoms will be included.
· The symptoms must be “maladaptive and inconsistent with developmental level.” This ensures that the symptoms are of sufficient severity to cause problems and that the child’s age and neurodevelopment are considered in evaluating symptoms.
· The symptoms must be present across 2 or more settings, ie, school problems alone do not meet criteria for the diagnosis.
· The symptoms are not better explained by another disorder, such as mood disorder, psychosis, or pervasive developmental disorder (autism).
With all these points in mind, one can conclude that this criterion requires an illness with a long-term pattern that has led to impairment. Courtesy of the ADHD Institute, below is a complete overview of the DSM-5 medical classification system for ADHD:
To assess a child, the clinician must understand normal child development, gather information from multiple sources to evaluate the child’s consistent behavior across different settings, and establish an appropriate diagnosis for what has been presented. The criteria used displays high interrater reliability of individual items and of overall diagnosis (Goldman). Are children really being appropriately assessed and treated to ensure the criteria is being used accurately (i.e. is there under or overdiagnosis, or even misdiagnosis)?
Evaluating whether or not a patient has ADHD should take time and use multiple methods. With many financial restraints as well as clinical time restraints, many physicians are quick to diagnose ADHD through cross-sectional symptom evaluation, which may result in overdiagnosing ADHD or even underdiagnosing it due to extreme cases of children who do not meet the full diagnostic criteria. There are lots of other rating scales and psychological testing instruments used in the assessment of ADHD, but none that should be used in isolation to the rest. Some of the scales used in the assessment are: SNAP-IV, the Conners, and Disruptive Behavior Disorder Scale, which all assess the responses patients have to treatments. There are also tests like the Wisconsin Card-Sorting Test, the Continuous Performance Task, the Matching Familiar Figures Test, the Wechsler Intelligence Scale for Children-Revised, and the Test of Variables of Attention; all of these neurological tests focus on the attention. To make a proper diagnosis, there will be multiple approaches such as: an interview with the child’s adult caregivers, mental status examination of the child, medical evaluation for general health, a cognitive assessment of ability and achievement, the use of ADHD-focused parent and teacher rating scales, and school reports/ other further evaluations if needed.
In regards to overprescribing, research has suggested that, in fact, overprescribing may not be a major issue. The prevelance of ADHD among kids ages 4–17 is 7.8% with stimulant prescription rates between 4.3–4.4%, which does not suggest a culture of stimulant overprescribing (Visser). In a recent National health and Nutrition Examination Survey, children ages 8–15 indicated a prevalence rate of 7.8% but only 48% of them had received mental health care over the past 12 months (Merikangas).
Although there is still a debate as to whether or not ADHD is being overdiagnosed and medication to treat it is being overprescribed, it is important to assess the diagnostic criteria and the methods of evaluation as to how these medical conclusions are being made. It is important that doctors and health professionals take the time to assess each patient and ensure that they meet the proper amount of criteria before jumping to a conclusion.
Sources:
Bradley C. The behavior of children receiving Benzedrine. Am J Psychiatry. 1937;94:577–588.
Gregory, R. (2016). Psychological Testing: History, Principles, and Applications. United States of America: Pearson Education, Inc.
Merikangas KR, He JP, Brody D, et al. Prevalence and treatment of mental disorders among US children in the 2001–2004 NHANES. Pediatrics. 2010;125:75–81. — See more at: http://www.psychiatrictimes.com/adhd/problems-overdiagnosis-and-overprescribing-adhd/page/0/4#sthash.GUe1OgfW.dpuf
Visser SN, Lesesne CA, Perou R. National estimates and factors associated with medication treatment for childhood attention-deficit/hyperactivity disorder. Pediatrics. 2007;119, S99-S106.
