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Is ADHD overdiagnosed? Findings from a new study in Germany

Is ADHD over­diag­nosed? Despite wide­spread con­cerns that this occurs, a study that specif­i­cal­ly address­es this issue has not been con­duct­ed in the US. Thus, although it is well estab­lished that many chil­dren with ADHD are nev­er iden­ti­fied or treat­ed, the extent to which chil­dren are incor­rect­ly diag­nosed with ADHD is not known.

There are sev­er­al rea­sons to be con­cerned about over­diag­no­sis. First, it may lead chil­dren to be inap­pro­pri­ate­ly treat­ed with stim­u­lant med­ica­tion when they do not need it. Sec­ond, it may con­tribute to chil­dren not receiv­ing treat­ment that would bet­ter address anoth­er con­di­tion they actu­al­ly have. Third, it could con­tribute to increased health care costs for soci­ety as a whole. Issues relat­ed to pos­si­ble stig­ma are also impor­tant.

The DSM-IV-TR sets out clear diag­nos­tic cri­te­ria for ADHD. In addi­tion to a min­i­mum num­ber of inat­ten­tive and/or hyper­ac­tive-impul­sive symp­toms, chil­dren must show impair­ment from these symp­toms in at least two set­tings, the symp­toms must cause clin­i­cal­ly sig­nif­i­cant impair­ment in social or aca­d­e­m­ic func­tion­ing, they must have been asso­ci­at­ed with some impair­ment before age 7, and they must not be bet­ter explained by anoth­er men­tal dis­or­der such as a mood or anx­i­ety dis­or­der. For a more com­plete pre­sen­ta­tion of the diag­nos­tic cri­te­ria, go to www.helpforadd.com/criteria-for-add/

Unfor­tu­nate­ly, some clin­i­cians who diag­nose ADHD in chil­dren may not care­ful­ly fol­low the diag­nos­tic guide­lines. Instead, clin­i­cians’ may focus on the pres­ence of par­tic­u­lar symp­toms that they believe are cen­tral to the dis­or­der, and, when these are present, fail to con­sid­er whether all the nec­es­sary addi­tion­al cri­te­ria are met.

It is pos­si­ble that this par­tial­ly explains why many more boys are treat­ed for ADHD than girls. Specif­i­cal­ly, boys with ADHD are more like­ly than girls with ADHD to dis­play dis­rup­tive behav­ior. If clin­i­cians regard dis­rup­tive, impul­sive, and hyper­ac­tive behav­ior as to the dis­or­der it could con­tribute to boys being over­diag­nosed and girls being under­diag­nosed. That is because when such behav­ior is present, clin­i­cians may be less atten­tive to nec­es­sary diag­nos­tic cri­te­ria that are not met. And, when it is not evi­dent, clin­i­cians may dis­re­gard or at least under­em­pha­size the pres­ence of oth­er ADHD symp­toms when mak­ing their diag­nos­tic deci­sion.

A study pub­lished recent­ly in the Jour­nal of Con­sult­ing and Clin­i­cal Psy­chol­o­gy presents a very inter­est­ing look at this issue [Bruch­muller et. al., (2011). Is ADHD over­diag­nosed in accord with diag­nos­tic cri­te­ria? Over­diag­no­sis and influ­ence of client gen­der on diag­no­sis. Jour­nal of Con­sult­ing and Clin­i­cal Psy­chol­o­gy, 80, 128–138. The study was con­duct­ed in Ger­many and involved over 470 psy­chi­a­trists, psy­chol­o­gists, and social work­ers who were licensed to prac­tice child and youth psy­chother­a­py. These clin­i­cians were rep­re­sen­ta­tive of all such men­tal health pro­fes­sion­als licensed to work with chil­dren in Ger­many.

The design of the study was both clever and straight­for­ward. The authors cre­at­ed 2 series of 4 dif­fer­ent case vignettes — one series depict­ing a school-aged boy and an iden­ti­cal series describ­ing a girl. In one vignette for both gen­ders, the infor­ma­tion pro­vid­ed was ful­ly con­sis­tent with ADHD, Com­bined Type. That is, not only were a suf­fi­cient num­ber of spe­cif­ic symp­toms described, but oth­er infor­ma­tion in the vignette made it clear that the symp­toms were impair­ing the child in at least 2 set­tings, were cre­at­ing impair­ment judged to be clin­i­cal­ly sig­nif­i­cant, had emerged pri­or to age 7, and that alter­na­tive expla­na­tions for the child’s symp­toms could be ruled out.

In the oth­er 3 vignettes, the required diag­nos­tic cri­te­ria were not present. In one of the vignettes, symp­toms were described as present only in one set­ting (school) and as hav­ing only appeared when the child was 9. In anoth­er vignette, not only were only 3 total symp­toms described, but these were report­ed to be present in only one set­ting and not to have appeared before age 9. In the final vignette, the behav­iors described ful­filled the diag­nos­tic cri­te­ria for Gen­er­al­ized Anx­i­ety Dis­or­der, which includes symp­toms of rest­less­ness, ner­vous­ness, and con­cen­tra­tion dif­fi­cul­ties that can be mis­tak­en for ADHD. Thus, the chil­dren described in these vignettes should nev­er have been diag­nosed with ADHD accord­ing to cur­rent diag­nos­tic cri­te­ria.

These vignettes were pretest­ed using 14 expert diag­nos­ti­cians instruct­ed to care­ful­ly apply com­plete diag­nos­tic cri­te­ria to deter­mine whether the child qual­i­fied for an ADHD diag­no­sis. All clin­i­cians diag­nosed ADHD for the vignette where full cri­te­ria were met and none diag­nosed ADHD to any of the remain­ing vignettes.

One vignette was select­ed at ran­dom to be mailed to each of 1000 men­tal health pro­fes­sion­als across the coun­ty. They were instruct­ed to read the vignette care­ful­ly and to deter­mine what, if any diag­no­sis, should be assigned to the child described. Of the thou­sand par­tic­i­pants invit­ed to par­tic­i­pate, respons­es were pro­vid­ed by over 470. These respons­es were cat­e­go­rized as ADHD diag­no­sis or no ADHD diag­no­sis. The lat­ter cat­e­go­ry includ­ed any diag­no­sis oth­er than ADHD, state­ments indi­cat­ing that insuf­fi­cient infor­ma­tion was avail­able to make any diag­no­sis, no diag­no­sis, and sus­pect­ed ADHD.

Results

For Vignette 1, where the child described met full diag­nos­tic cri­te­ria for ADHD, approx­i­mate­ly 79% of the ther­a­pists diag­nosed ADHD. Near­ly 10% stat­ed they did not have enough infor­ma­tion and just over 4% indi­cat­ed ‘sus­pect­ed ADHD’. The remain­ing 7% of clin­i­cians assigned a diag­no­sis oth­er than ADHD, most often an adjust­ment dis­or­der. These cas­es rep­re­sent false neg­a­tives, i.e., assign­ing a diag­no­sis oth­er than ADHD when ADHD should have been diag­nosed.

For the vignettes where cri­te­ria for ADHD were not met, near­ly 17% diag­nosed ADHD. This rep­re­sents the false pos­i­tive rate, i.e., assign­ing a diag­no­sis of ADHD when it did not apply. Clin­i­cians were thus more than twice as like­ly to diag­nose ADHD when they should not have than to assign a dif­fer­ent diag­no­sis when they should have assigned ADHD, i.e., a false pos­i­tive rate of 17% com­pared to a false neg­a­tive rate of 7%. And, when an ADHD diag­no­sis was assigned, clin­i­cians were far more like­ly to indi­cate that they would rec­om­mend med­ica­tion treat­ment. Anoth­er 6% indi­cat­ed ‘sus­pect­ed ADHD’. Fifty-sev­en per­cent made anoth­er diag­no­sis and just over 10% indi­cat­ed they would make no diag­no­sis at all.

Gen­der dif­fer­ences

Diag­nos­tic accu­ra­cy rates in rela­tion to gen­der yield­ed very inter­est­ing find­ings. For the vignette where ADHD cri­te­ria were met, clin­i­cians were equal­ly like­ly to diag­nose ADHD regard­less of whether the vignette described a boy or a girl.

How­ev­er, for the remain­ing 3 vignettes, clin­i­cians were sig­nif­i­cant­ly more like­ly to diag­nose ADHD when the child described was a boy. In fact, when aver­aged across the 3 vignettes, they were over twice as like­ly to incor­rect­ly diag­nose ADHD in boys than in girls, i.e., 23% vs. 11%.

What’s more, these dif­fer­ences depend­ed on the gen­der of the clin­i­cians. Female clin­i­cians did not dif­fer in the rate of false pos­i­tive and false neg­a­tive diag­noses accord­ing to whether the child described was a boy or girl. For male clin­i­cians, how­ev­er, the false pos­i­tive rate clear­ly depend­ed on the child’s gen­der, and was incor­rect­ly assigned by 39% of the clin­i­cians diag­nos­ing boys vs. only 13% of clin­i­cians diag­nos­ing girls. Thus, male clin­i­cians diag­nosed ADHD near­ly 40% of the time in boys who did not meet diag­nos­tic cri­te­ria. This is strik­ing­ly high.

The authors also exam­ined fac­tors oth­er than gen­der of the clin­i­cian that were asso­ci­at­ed with the over­diag­no­sis of ADHD, includ­ing years of expe­ri­ence, report­ed famil­iar­i­ty with the DSM diag­nos­tic cri­te­ria, the­o­ret­i­cal ori­en­ta­tion (e.g., cog­ni­tive behav­ioral vs. psy­cho­dy­nam­ic), and pro­fes­sion­al occu­pa­tion (i.e., psy­chi­a­trist, psy­chol­o­gist, or social work­er). None of these fac­tors were found to be sig­nif­i­cant pre­dic­tors of the diag­noses that clin­i­cians assigned.

Sum­ma­ry and Impli­ca­tions

Results from this study sug­gest that ADHD may be over iden­ti­fied by clin­i­cians in that rough­ly 17% diag­nosed ADHD for a child where full diag­nos­tic cri­te­ria were not met. In con­trast, when all ADHD diag­nos­tic cri­te­ria were present, a diag­no­sis oth­er than ADHD was assigned only 7% of the time. The mis­di­ag­no­sis of ADHD is like­ly to lead some chil­dren to be placed on med­ica­tion inap­pro­pri­ate­ly, as med­ica­tion was far more like­ly to be a rec­om­mend­ed treat­ment when the diag­no­sis of ADHD was assigned.

Also impor­tant was the find­ing that boys were more like­ly to receive an ADHD diag­no­sis than girls even when the symp­toms described were iden­ti­cal. And, male clin­i­cians were far more like­ly than female clin­i­cians to mis­di­ag­nose ADHD in boys. In fact, near­ly 40% male clin­i­cians incor­rect­ly assigned a diag­no­sis of ADHD when the male child described did not meet diag­nos­tic cri­te­ria.

Anoth­er inter­est­ing result was find­ings per­tain­ing to the diag­no­sis of boys and girls when ADHD diag­nos­tic cri­te­ria were met. Recall that for this vignette, clin­i­cians were equal­ly like­ly to diag­nose ADHD regard­less of whether the child described was male or female. In con­junc­tion with the above, these sug­gest that the poten­tial over­diag­no­sis of males may be a greater prob­lem then the under­diag­no­sis of females.

This study does not specif­i­cal­ly exam­ine why many clin­i­cians diag­nosed ADHD incor­rect­ly. The authors sug­gest that since each vignette described some ADHD symp­toms, clin­i­cians may have been bas­ing their deci­sion on the pres­ence of sev­er­al promi­nent symp­toms rather than care­ful­ly deter­min­ing whether all nec­es­sary diag­nos­tic cri­te­ria were present. This does not nec­es­sar­i­ly indi­cate a prob­lem with the diag­nos­tic cri­te­ria per se, but rather in how even expe­ri­enced clin­i­cians apply them.

All stud­ies have lim­i­ta­tions and the authors are care­ful to acknowl­edge lim­i­ta­tions of their study. First, they note that results obtained with clin­i­cians in Ger­many may not gen­er­al­ize to oth­er coun­tries like the US. Although I am not aware of any rea­son to believe find­ings with US clin­i­cians would be sub­stan­tial­ly dif­fer­ent, it would be impor­tant to con­duct a sim­i­lar study here.

One could also ques­tion the valid­i­ty of diag­nos­tic deci­sions that are based on writ­ten case vignettes com­pared with real-world clin­i­cal set­tings. In par­tic­u­lar, the vignette method­ol­o­gy does not enable clin­i­cians to gath­er addi­tion­al infor­ma­tion to con­firm or dis­con­firm his or her deci­sion. How­ev­er, even when diag­nos­ing based on case vignettes, clin­i­cians should still have applied the diag­nos­tic cri­te­ria. And, con­duct­ing a study of this issue in real clin­i­cal set­tings would have its own set of chal­lenges.

One oth­er lim­i­ta­tion worth not­ing is that the vignette depict­ing a child who met ADHD diag­nos­tic cri­te­ria was lim­it­ed to the com­bined type of the dis­or­der, i.e., both inat­ten­tive and hyper­ac­tive-impul­sive symp­toms were present. And, in the vignettes where ADHD should not have been diag­nosed, some inat­ten­tive and hyper­ac­tive-impul­sive behav­iors were described. To com­ple­ment the inter­est­ing results obtained, future work should exam­ine how the find­ings may or may not change when chil­dren with the inat­ten­tive and hyper­ac­tive-impul­sive sub­types are described. It would be inter­est­ing to learn whether the ten­den­cy towards over­diag­no­sis of ADHD varies by sub­type and whether this varies by gen­der for the dif­fer­ent sub­types.

It is also impor­tant to empha­size that the find­ings report­ed here do not negate the fact that many chil­dren who would qual­i­fy for an ADHD diag­no­sis, and could cer­tain­ly ben­e­fit from treat­ment and school-based ser­vices, are nev­er iden­ti­fied or treat­ed. Thus, results from this study not with­stand­ing, the under­diag­no­sis of ADHD remains a seri­ous prob­lem and it is impor­tant not to lose sight of that.

In sum­ma­ry, this inter­est­ing study demon­strates that not all clin­i­cians fol­low DSM-IV cri­te­ria “…require­ments to base their diag­no­sis on a thor­ough eval­u­a­tion of rel­e­vant diag­nos­tic cri­te­ria.” Pre­lim­i­nary evi­dence sug­gests this may espe­cial­ly be true for male clin­i­cians eval­u­at­ing male chil­dren. Diag­nos­ing chil­dren incor­rect­ly can poten­tial­ly lead to a num­ber of adverse con­se­quences and this research will hope­ful­ly con­tribute to rais­ing aware­ness of this impor­tant issue.
Rabiner_David– Dr. David Rabin­er is a child clin­i­cal psy­chol­o­gist and Direc­tor of Under­grad­u­ate Stud­ies in the Depart­ment of Psy­chol­ogy and Neu­ro­science at Duke Uni­ver­sity. He pub­lishes Atten­tion Research Update, an online newslet­ter that helps par­ents, pro­fes­sion­als, and edu­ca­tors keep up with the lat­est research on ADHD, and teach­es the online course  How to Nav­i­gate Con­ven­tion­al and Com­ple­men­tary ADHD Treat­ments for Healthy Brain Devel­op­ment.

Pre­vi­ous arti­cles by Dr. Rabin­er:

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  1. Luke says:

    I think ADHD being mis­di­ag­no­sis is at its biggest in col­leges where healthy stu­dents are tak­ing Adder­all just to com­pete. I start­ed tak­ing Dox­iderol and I feel a men­tal edge with­out the need for pre­scrip­tion drugs.

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