ADHD
Attention-deficit/hyperactivity disorder (ADHD) is common mental health disorder characterized by developmentally inappropriate levels of inattention and hyperactivity-impulsivity that result in chronic functional impairment across settings (American Psychiatric Association, 2000). These symptoms have the tendency to persist into adulthood and can cause individuals to experience several impairments in social, academic and occupational functioning (Gapin et al., 2011). According to the Centers for Disease Control and Prevention (CDC), ADHD is a central nervous system (CNS) neurobiological disorder prevalent in children and adolescents and it is the most common mental disorder diagnosed in children. Research indicates that the number of individuals using ADHD medications rose by 35.5% from 2008 to 2012 thus, increasing the number of individuals on these medications to > 4.8 million in 2012. CDC also reports that an estimated 6.1 million (9.4%) of US children were diagnosed in 2012 with ADHD. Out of this number, 388 000 were children aged 2-5 years, 4 million were children aged 6-11years and 3 million were children aged 12-17 years and the rate of ADHD in boys was 12.9% compared to 5.6% in girls. Between 2015-2017, the percent of children diagnosed ADHD increased to 10.8% with boys having 14.8% while girls diagnosed with ADHD were rated 6.7% (CDC, 2017). Again, CDC reports that despite a steady increase ADHD prevalence in that last three decades there have been conflicting opinions and public debate over the diagnosis and treatment of ADHD. The steady increase in the prevalence of ADHD and increased stimulant medications can be associated with the innovation of the Diagnostic and Statistical Manual of Mental Disorders (DSM), a guidebook especially DSM-5, the latest edition produced by the American Psychiatric Association. A comprehensive diagnosis of ADHD is invaluable in addressing concerns of ADHD diagnosis and treatment and because sometime diagnoses are based on the subjective views, clinical observations and phenomenology of symptoms of the conditions that lead to the disorder, common errors are bound to be made in diagnosing ADHD. As stated by (Licthblau 2011), this is a false positive meaning an individual has been diagnosed with ADHD when he or she does not. And the reverse of false negative when and individual has ADHD and is diagnosed not to have it. In this regard, some individuals argue that the increase rate in ADHD is as result of false positives.
Those argue overdiagnosis of ADHD in children advance that practitioners are the cause of overdiagnosis as both research and observations show that most cases of ADHD are done with limited assessments and lack of information from multiple sources or settings as required by the DSM-5 for the symptoms to present in more than 2 environments. The American Academy of pediatricians also demands physicians to find out about child’s behavior from their care takers (parents, teachers, etc) in different settings such in school, with peers and at home as other conditions might be the cause of the behaviors. This therefore implies that the teacher’s observation alone within the classroom setting is not enough to suggest a child has ADHD. These individuals also say that ADHD is also overdiagnosed in children stating that gender and ethnic biases exist during the diagnostic process leading to the diagnosis being influenced. Boys are more likely to be diagnosed with ADHD and children from certain ethnic minority are suspectable to high ADHD diagnoses Morgan, et al., (2013). Another point put forth by those for ADHD being overdiagnosed in children is the conflict of interests between medical/psychiatric diagnosticians and pharmaceutical companies. These companies are well-resources and determined lobbyists and persuade the marketing and use of stimulants such as Ritalin and Adderall. This facilitated by the fact that medical approach to treat clients is gaining grounds especially ADHD. The FDA Modernization Act passed in Congress in 1997 has also been a motivating factor for ADHD overdiagnosis. The Act encourages pharmaceutical companies to develop and test drugs for children by extending patent exclusivity Visser, Lesesne & Perou, (2007). They stipulate that, this Act caused an increased in random controlled trials in children with stimulant compounds for ADHD and this venture is supported by an evidence-based rational for drug intervention in ADHD. Because of this, the prescription of stimulants for children has quadrupled between 1987-1996, 9.5% increase between 2000 and 2005 and it is presently more than 4% for children and adolescent using ADHD medication in the U.S. Visser, Lesesne & Perou, (2007). Furthermore, the first half of the 1990s witnessed an expansion of ADHD diagnosis and treatment as a result of amalgamation of events and forces that came together such the political strengths of children’s welfare advocacy groups and mental health associations that create awareness, educate and reduce stigma association with the disorder. Although the DSM-5 is vital tool in diagnosing mental disorders, it can not perfectly distinguish behaviors that need diagnosis and those that reflect commonplace developmental behavior in children like those suffering from ADHD disorder thus, the criteria in DSM-5 are pathologically biased. Previous editions of DSM have the term ‘clinically significant’ has been revised into other descriptions like behavior that ‘interferes with or reduces the quality of social, academic, or occupational functioning’ and such changes lead to increase in diagnosis among individuals who display ADHD symptoms but who only manifest minor functional impairment Bruchmüller, Margraf, & Schneider, (2012). Other factors such as ADHD organizations, general and social networking, media turn to produce and favor unethical consumer demands that promote overdiagnosis of ADHD in children. Because we are living in the technological era, individuals visit websites that encourage initial diagnosis from homes for related symptoms and questions thus permitting pharmaceutical companies view it as a sort of promotion for ADHD that fuel and promote overdiagnosis and overused of stimulant medications Zuvekas, Vitiello & Norquist, (2006). As mentioned above that diagnosis requires more than two environmental settings, the increase in ADHD overdiagnosis can equally be caused by inadequate evaluation and societal pressure for treatment and the high demands made on children, families and schools. This is because, ADHD diagnosis is contextual. This implies that, a child having the same neurodevelopmental traits may be view as having ADHD or not based on the child’s unique social and educational environments. As stipulated by (Morrow, al., 2012) accurate diagnosis of ADHD needs time as it requires that other conditions with ADHD-like symptoms like anxiety, posttraumatic stress disorder (PTSD) and learning disabilities are eliminated. Thus, is relevant to have knowledge of the child and his entire social environment before make conclusion on the diagnosis. Often, teachers, parents, practicing pediatricians, and other care giver rushed into diagnosis leading to overdiagnosis. Another reason for overdiagnosis is teachers’ expectancy of the children. For instance, a study carried out in Journal of Health Economics in 2010, 10 % of children in kindergarten born in August ( the youngest in the class) were diagnosed with ADHD compared with 4.5% of those born in September(the oldest in the class) and those born in August were more likely to be treated with stimulants than their counterparts been September. As stated by (Hinshaw & Scheffler, 2014), cultural attitudes about special education labels learning disabilities (LD) and ADHD, and school accountability policies and pressures have been identified to influence overdiagnoses in children in the U.S. They also assert that for school districts to meet accountability standards through test scores, they seek and exclude underachieving children, diagnose and treat them for ADHD. To back this assertion, they reported a correlation between an increased accountability demands and increases in ADHD diagnosis over the years. Those who see ADHD as being overdiagnosed also cognitive biasing is a contributing factor of an increase in the prevalence of ADHD. Cognitive biases lead to observers to misattribute the of problem and overestimate prevalence (Nickerson, 1998). He emphasized on two types of biases; confirmation and attribution biases. Confirmation bias has the tendency to influence an individual to attach to an unconfirmed hypothesis and then only attend to and seek information that support the hypothesis and ignore and abate counterevidence. On the other hand, attribution bias has the tendency to influence someone to attribute a problem behavior to a stable and internal cause. These are the main reasons why there unequal overdiagnoses of adolescents, some minority racial groups and males.
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is compounded by related increases in use of medications to treat ADHD
http://smhp.psych.ucla.edu/pdfdocs/overdiag.pdf
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Bruchmüller, K., Margraf, J., & Schneider, S. (2012). Is ADHD diagnosed in accord with diagnostic criteria? Overdiagnosis and influence of client gender on diagnosis. Journal of Consulting and Clinical Psychology, 80, 128.
Danielson ML, Bitsko RH, Ghandour RM, Holbrook JR, Kogan MD, Blumberg SJ. Prevalence of parent-reported ADHD diagnosis and associated treatment among U.S. children and adolescents, 2016. Journal of Clinical Child and Adolescent Psychology. 2018, 47:2, 199-212.
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Hinshaw, S. P., & Scheffler, R. M. (2014). The ADHD explosion: Myths, medication, money, and today's push for performance. Oxford University Press.
Lichtblau, L. (2011). Psychopharmacology demystified. Clifton Park, NY: Delmar, Cengage
Morgan, P. L., Staff, J., Hillemeier, M. M., Farkas, G., & Maczuga, S. (2013). Racial and ethnic disparities in ADHD diagnosis from kindergarten to eighth grade. Pediatrics, 132, 85-93.
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Nickerson, R. S. (1998). Confirmation bias: A ubiquitous phenomenon in many guises. Review of General Psychology, 2, 175-220.
Visser, SN Danielson ML, Wolraich ML, Fox M, Grosse SD, Valle LA, Holbrook JR, Claussen AH, Peacock, P. Vital signs: National and state-specific patterns of attention deficit/hyperactivity disorder treatment among insured children aged 2–5 years — United States, 2008–2014. Morbidity and Mortality Weekly Report (MMWR); 2016,65, 443–450.
Zuvekas, S., Vitiello, B., & Norquist, G. (2006). Recent trends in stimulant medication use among US children. American Journal of Psychiatry, 163, 579-585.
Visser SN, Lesesne CA, Perou R. National estimates and factors associated with medication treatment for childhood attention-deficit/hyperactivity disorder. Pediatrics. 2007;119(suppl 1):S99-S106.
Zuvekas, S., Vitiello, B., & Norquist, G. (2006). Recent trends in stimulant medication use among US children. American Journal of Psychiatry, 163, 579-585.
https://www.nimh.nih.gov/health/topics/attention-deficit-hyperactivity-disorder-adhd/index.shtml