Are We Overdiagnosing ADHD?

ADHD-widely recognized by many as the most common neurodevelopmental disorder of childhood-is a chronic condition that can last a lifetime. Approximately half of children with ADHD experience debilitating symptoms into adulthood. Notable hyperactivity and impulsivity may abate, but inattention and executive functioning deficits often persist. Prevalance of ADHD seems to be growing in the US for a variety of reasons. But overdiagnosis and overtreatment are major concerns. Accurate diagnosis is critical, but challenging. Here’s help. 

. More likely to be diagnosed in boys
. It negatively affects academic and social achievement
. It often co-occurs with other symptoms and disorders, including tics, anxiety, mood dysregulation, disruptive behavior, and/or learning disabilities
. Adults with ADHD have markedly higher rates of divorce, unemployment, traffic violations, substance use, and arrest

.Overdiagnosis may cause medicalization of normal variants and lead to unnecessary treatments with little or no benefit and with unacceptable risks.
.There is no established diagnostic gold-standard or neuroimaging test, nor well-established biomarkers.
.Diagnosis depends on phenomenology, subjective reports, and clinical observations of symptoms.

The Table summarizes DSM and ICD diagnostic criteria. For a mobile-friendly view, click here.

. Prevalence seems to be increasing in the US. Factors? Possibly, better public education and awareness, and increasing recognition of the inattentive subtype. . Pollution, prematurity, and food additives have been explored as pathophysiologic contributors. No clear relationships have been established.. The trend may be also be artificial and reflect poor diagnostic practices.

. Best Dx practices are well established. Rating scales are sensitive, but lack specificity. Must be paired with a comprehensive assessment of patients and/or their parents.. Information about symptoms in multiple environments from multiple sources is critical. . Meticulous assessment for ADHD reduces misidentification when symptoms are a manifestation of another disorder.

. In a 2016 practice advisory in Neurology, the authors evaluated evidence for EEG theta/beta power ratio for diagnosing, or helping to diagnose, ADHD.
. The combo of EEG frontal beta power and theta/beta power ratio had relatively high sensitivity and specificity but was insufficiently accurate. It should not be used to confirm an ADHD diagnosis or to support further testing after a clinical evaluation. See: http://www.neurology.org/content/87/22/2375.full

For more on this topic, see Are We Overdiagnosing and Overtreating ADHD?, on which this slideshow is based.

Dr. Jummani is Clinical Assistant Professor, Director of Residency Education and Training, and Medical Director, Department of Child and Adolescent Psychiatry, Long Island Campus, Child Study Center at Hassenfeld Children’s Hospital of New York at New York University Langone Medical Center. Ms. Hirsch is Graduate Trainee and Doctoral Candidate, Clinical Psychology, Fordham University, New York. Dr. Hirsch is Associate Professor, Vice Chair for Clinical Affairs, Department of Child and Adolescent Psychiatry, and Medical Director, Child Study Center at Hassenfeld Children’s Hospital of New York at New York University Langone Medical Center, New York. The authors report no conflicts of interest concerning the subject matter of this article.