Are We Over Diagnosing ADHD?

These days ADHD seems like a household term. It seems that every person with a "difficult" child fears ADHD might be to blame, and these fears can only be spurned on by television commercials, psychiatrists and psychologists quick to jump to conclusions, and ADHD drug companies that push their medication like candy. The CDC (2010) noted that the instances of ADHD diagnosis has gone up 22% from 2003 to 2007, and that from 1997 to 2006, ADHD diagnosis saw an increase, on average, of 3% per year. This is an alarming rate and begs the question of whether children are really experiencing higher rates of ADHD, or whether over diagnosis and ADHD paranoia are to blame. As of 2007, it was reported that "9.5% or 5.4 million children 4-17 years of age have ever been diagnosed with ADHD" (CDC, 2010). Are we diagnosing children with legitimate issues, or are we pushing the ADHD label onto them when other issues may be at fault? Are we overmedicating children that may truly be exhibiting typical childhood behaviors? And just as seriously, are we over diagnosing ADHD to the point where children with other mental issues are falling through the cracks of the ADHD machine, instead of being properly evaluated, diagnosed, and treated? What effect is the ADHD diagnosis having on our children? Could ADHD diagnosis, especially faulty diagnosis, be doing damage to our kid's mental states and peer relationships?

Before we can properly delve into any of these questions, it is important to understand exactly what ADHD is. ADHD stands for attention deficit/hyper-activity disorder. This particular disorder generally surfaces in children before they are of school-attending age, with around 90% of those diagnosed being male (Comer, 2005). The American Psychiatric Association lists ADHD in the DSM-IV, a diagnostic manual detailing signs and symptoms, for which the "requirements" for ADHD diagnosis is rather vast and sometimes vague in terms of typical childhood behavior versus an ADHD child. However, in general, children diagnosed with ADHD exhibit over activity, impulsivity, excessive talking, frequent failure to listen, frequent failure to pay attention to instruction or detail, difficulty in organizing or following through with tasks, and difficulty remaining still and quiet, among other things (American Psychiatric Association, 2000). It is important to note that the American Psychiatric Association (APA) uses a number of these behaviors, and other similar, to actually diagnose a child with ADHD. This means that just because a child exhibits one or two of these behaviors, doesn't mean they had ADHD. This is one of the most vital things for parents to remember. Just because your child has difficulty concentrating, or talks your ear off, doesn't mean they have ADHD. Remember that many of these behaviors are typical of childhood, or can be attributed to other environmental or family factors. Take, for example, a child who may only see their mother several hours a day when she returns from work. An excited and eager child might run around the house, talk excessively, and have trouble finishing dinner. They are simply excited and eager to spend time with their parent. If these behaviors are getting out of control or causing trouble at school, it is sometimes helpful to consult a school psychologist or peer to discuss techniques for dealing with the behaviors, both at home and at school, with the help of a teacher. It is only when a number of factors, and a proper history is taken and evaluated, that these typical, albeit it sometimes troublesome, behaviors can be diagnosed as ADHD.

If a child is indeed diagnosed with ADHD, it becomes important to realize what the causes may be, since medication is not always necessary to treat the disorder. Comer (2005) notes that children with parents who were diagnosed with ADHD are more likely to also be diagnosed with the disorder. However, he also goes on to state that most modern clinicians associate the onset of the disorder to a number of reasons. Biologically, abnormalities in certain regions in the brain may be to blame; separately, or in conjunction with excessive stress and/or dysfunction within the family (Comer, 2005).

Over diagnosis as a Factor in Heightening ADHD Rates

As mentioned earlier, it becomes important to evaluate the possibility of over diagnosis as a factor in the 3% rise discussed by the CDC (2010). Mota-Castillo (2007) documented a specific case in which a young girl was diagnosed with ADHD when in reality she was experiencing symptoms of another, but much more serious disorder. The result? An instance of self-harm, brought on by auditory hallucinations, and damage done that will be extremely hard to repair and treat, if her severe psychosis can at all be reversed. This is a scary realization, and Mota-Castillo (2007) states that this case is a clear illustration of the "trend toward over diagnosing ADHD."

A 1999 study by pediatric psychologist Gretchen LeFever and Andrea Arcona found that while ADHD "is not universally over diagnosed; however for some U.S. communities there is evidence of substantial ADHD over diagnosis, adverse educational outcomes among children treated for the disorder, and suboptimal management of childhood behavioral problems."

Clearly these instances and concerns are not over-rated, and doctors, parents, and teachers need to take a more practical approach to differentiating between ADHD behaviors and average childhood behaviors. Furthermore, clinicians need to be more thorough in gathering a patient history, and parents need to make sure they are participating in this history; citing examples of behaviors, consulting school teachers and counselors, and most of all finding a reputable clinician who is willing to take the time to properly evaluate their child and their child's medical and family history before diagnosing the child. In a 2001 PBS special, William Dodson, a Colorado psychiatrist, spoke on the diagnosis of ADHD saying that ADHD is not the kind of disorder than can be diagnosed in 15 minutes, and that "in order to do a good, adequate, evaluation, you need several hours: to do the evaluation, to rule out all the things that might mimic ADHD; to thoroughly evaluation all the things that can co-exist within ADHD; to educate the parents about the use of medication, and about the ancillary treatments that are going to be necessary; to do a quick screening for learning disabilities."

Furthermore, parents need to be wary of television and magazine advertisements for ADHD. Drug companies don't often have an individual's best interest in mind, and care only for the profits they can make. While many top psychiatrists and psychologists interviewed to PBS Frontline's special "The Business of ADHD" report that they agree that the use of medication is valid, and that they trust the FDA in regulating what is being advertised and it's benefits, they fail to address the impact that incessant ADHD advertising might have on children and parents alike. It cannot be argued that the medical profession and the pharmaceutical companies work hand-in-hand, but it can be argued that medical professionals need to do more to education individuals on proper use, and when to worry, and when to back off. Furthermore, individuals across American need to be aware of what constitutes as ADHD, which obviously cannot be diagnosed by a simple commercial claiming that inattentive school-time behavior and failing grades indicate an ADHD diagnosis. This is especially true since the CDC (2010) reported that "the highest rates of parent-reported ADHD diagnosis were noted among children covered by Medicaid and multiracial children" which raises concern that clinicians may be passing off the educational and attention needs of these children as ADHD, instead of addressing the issues at hand. It is no unknown fact that the increase in multiracial children in American schools demands changes in education to reach out to all learning types and children, all socioeconomic classes, and children from homes where English is not their first language.

Furthermore, the CDC (2010) reported that in 2007 66.3% of children diagnosed with ADHD were on medication as a treatment for the condition. This is over half of the ADHD population, and since over diagnosis seems to be an issue, this means that children without the condition may also be on medication unnecessarily. Furthermore, behavioral therapies are available for both ADHD and children with typical childhood behaviors that may prove disruptive at home and in the classroom, begging the question "why are we using medication in over half of the ADHD children instead of turning to alternative methods of correction?" Are we raising a generation of medicated children that will go on to use the medication as adults? More importantly, are we encouraging the use of ADHD medication to enhance school performance?

Jennifer Setlik, a doctor from Cincinnati working for the Children's Hospital Medical Center in Ohio is quoted as saying "we need to be aware of the increasing abuse of ADHD medications and [their] misuse...[teens] using their prescriptions, or their friends' prescriptions to, for example, pull an all-nigher studying for a test" (Brauser, 2009). That being said, the same article goes on to state that most children with ADHD use their medication appropriately, but the fact that there are even reports off abuse by those with and without ADHD is alarming. More alarming is the reports that this practice is on the rise. Drug company advertisements and doctors fast to dismiss behavior as ADHD related only fuel this reliance on medication, and the education our children are getting to take the medication as a solution for any and all concentration and organizational troubles.

ADHD Label and Our Children's Performance

The last issue to be addressed is the very real, and sometimes dangerous issue of labeling. Placing a label on a child can not only affect the way a child sees themselves, but how their peers view them. In a previous finding by LeFever and Arcona (2003) it was noted that the diagnosis had adverse educational behaviors and outcomes. Furthermore, the CDC (2010) notes that children diagnosed with ADHD have nearly three times as many peer problems as those without ADHD, and that "children with a history of ADHD are almost 10 times as likely to have difficulties that interfere with friendships." While one may argue that this is discussing children with the disorder, we have already discussed over diagnosis as an issue, and the labeling of these individuals can be a self-fulfilling prophecy. Children labeled as having the disorder may feel low-self esteem, may act or, or may feel they have an excuse to behave in a certain manner. Psychology students are warned in college about the dangers of labeling even adults, as a label adds not only an idea about oneself, but a social stigma. If this is true of adults, it is certainly true of children as well. Grohol (2007) noted that a study revealed that few children were able to readily identify how ADHD affected an individual, and this lack of education and understanding on the issue created social stigmas, and left ADHD children open for rejection, teasing, and other peer trouble.

In Conclusion...

As this article clearly illustrates, there are issues with ADHD diagnosis, the influence of television advertisements, the improper use of medication, and the high rate of medication use that needs to be addressed in America today. Proper time and care needs to be taken in diagnosing a child with ADHD, as the over diagnosis or improper diagnosis dilemma must stop now. We are only doing a disservice to American kids by jumping to conclusions, by medicating healthy children, and in doing so are only fueling the ADHD paranoia. Remember that children are going to be children, and that not all disruptive or troublesome behaviors are due to ADHD.

Furthermore, credible education on the issue needs to be provided to eliminate, or at least lessen, the social stigmas attached to individuals with the disorder as a means of relieving some of the stress that is associated with these stigmas.

References:

1) American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR. Washington: American Psychiatric Association, 2000.

2) Brauser, D. (2009). Prescription ADHD Medication Abuse by Adolescents on the Rise. Medsape Medical News.

3) Centers for Disease Control and Prevention. (2010). Attention-Deficit/Hyperactivity Disorder (ADHD).

4) Grohol, J.M. (2007). Social Stigma Awaits Kids with ADHD. PsychCentral.

5) LeFever, G. & Arcona, A. (2003). ADHD among American Schoolchildren. The Scientific Review of Mental Health Practice, 2(1).

6) Mota-Castillo, M. (2007). The Crisis of Overdiagnosed ADHD in Children. Psychiatric Times, 24(6).

7) PBS. (2001). The Business of ADHD. Frontline.