Earlier this year, the CDC released data that showed that diagnoses of attention deficit hyperactivity disorder (ADHD) went up over the past few years. But the CDC data also showed that diagnoses went up across the board for multiple mental disorders.
Some media outlets at the time, however, only focused on the increase in the diagnosis of ADHD. This two-part article (part 1 is here) examines whether there really is an “over”-diagnosis of ADHD — or whether it’s more complicated than answering with a simple “yes” or “no.”
The Recent BMJ Study
This past month, the prestigious BMJ entered the fray with this study (Thomas et al., 2013) — which sadly only clouds things further. The researchers note the rise of ADHD diagnoses… but not by physicians, but by parental self-report:
In US population surveys the prevalence of parent reported diagnosis of ADHD rose from 6.9% in 1997 to 9.5% in 2007.
Which is all good and fine, but the researchers trust that parents are self-reporting their children’s diagnosis accurately (as opposed to the data-neutral method of collecting actual diagnostic data from medical records themselves).
And while the BMJ authors note the rise of the diagnosis of ADHD around the world — citing the changes in the DSM criteria (which were last changed about 20 years ago) — most countries don’t actually use the DSM for diagnosing of mental disorders. Australia and the UK both use the ICD-10 more so than the DSM. So changes to the DSM aren’t really reflected in most clinical practice in these countries.
While the BMJ cites three reasons for this “over-diagnosis” of ADHD, their data don’t really help their arguments. For instance, one reason they cite for the changes in prevalence in ADHD is “shifting definitions.” But the last major change to the definition of ADHD was, as I mentioned, nearly 20 years ago. How does that explain the rise they noted above from 1997 to 2007?12
Unmet criteria is another reason they cite — and this one is actually more likely to account for the changes as much as anything else. But this is a nice way to say that the professionals themselves are really falling down in the proper and rigorous application of the diagnostic criteria.
Last, they cite commercial influence:
Advertising on the internet through “mental health information websites” is also an effective tool to promote discussion about mental healthcare.
Yes, that’s right — helping to educate consumers is apparently a bad thing in the eyes of some. Because if a person has more information about a health or mental health concern they may, god forbid, actually talk to a health care professional or doctor about their concerns! Scary!!3
They also make an association that has no apparent connection to their current data:
Among the work group advisers of DSM-5 for ADHD and disruptive behaviour disorders, 78% disclosed links to drug companies as a potential financial conflict of interest. [Ed. note – This is up from 61.9% in the DSM-IV.]
While that may be true, none of the data the researchers previously discussed had anything to do with the DSM-5. The DSM-5 is too new to have impacted ADHD diagnoses one way or another. Just throwing that information out there and suggesting the changes in the DSM-5 will again increase diagnoses of ADHD in children is pure speculation, without research backing of actual data.
The researchers also miss a few more big reasons ADHD is possibly overdiagnosed in America — secondary gains and access to stimulant drugs. Once well-meaning psychologists and educators started tying the diagnosis to changes in the academic environment (e.g., more time to turn in a paper or take a test), some students (or their parents) saw an opportunity that could benefit them academically.
And since ADHD’s primary treatment is with stimulant medications — wildly popular on school and college campuses everywhere — why wouldn’t you try and gain access to these drugs? Even if you don’t have ADHD, students report taking them helps with their ability to study, take exams, and complete papers.
When you attach these kinds of secondary gains to a diagnosis, it’s no wonder you see a rise in the diagnosis.
So is there an actual, real overdiagnosis of ADHD, or is this a figment of the media’s imagination?
The answer is probably somewhere in between. Yes, more teens and children are probably receiving a diagnosis of attention deficit disorder that isn’t warranted. It doesn’t help when the media pays undue attention to this one diagnosis, without putting the rise in diagnosis rates in context with other disorders (which, in some cases, have experienced similar increases).
But in my opinion, the problem lies — as it ultimately always does — at the feet of the professionals making the diagnosis. They are the gatekeepers to the treatment system, and if they’re falling down in doing their job — in effect, being lazy diagnosticians — that’s nobody’s fault but their own.
A book can’t change that. The diagnostic criteria themselves can’t change that. And all of the pharmaceutical advertising in the world can’t change that.
The only way this problem will get better is if primary care physicians and mental health professionals work harder to apply the diagnostic criteria stringently and rigorously in every patient encounter. Until that happens, I suspect we will continue to see a rise in ADHD diagnoses.
This is part two of a two-part article. Read Part 1 here: Is ADHD Overdiagnosed? Yes & No
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, 128-138.
Child and Adolescent Health Measurement Initiative. (2012). National Survey of Children’s Health.
Egede, L.E. (2007). Failure to Recognize Depression in Primary Care: Issues and Challenges. J Gen Intern Med., 22, 701–703. doi: 10.1007/s11606-007-0170-z
Phelps J. & Ghaemi S.N. (2012). The mistaken claim of bipolar ‘overdiagnosis’: solving the false positives problem for DSM-5/ICD-11. Acta Psychiatr Scand. 2012 Dec;126(6):395-401. doi: 10.1111/j.1600-0447.2012.01912.x.
Sciutto, M. J., & Eisenberg, M. (2007). Evaluating the evidence for and against the overdiagnosis of ADHD. Journal of Attention Disorders, 11, 106–113. doi:10.1177/1087054707300094
Thomas, R., Mitchell, GK., & Batstra, L. (2013). Attention-deficit/hyperactivity disorder: are we helping or harming?
BMJ 2013; 347 doi: http://dx.doi.org/10.1136/bmj.f6172 (Published 5 November 2013)
Vöhringer P.A., et al. (2013). Detecting Mood Disorder in Resource-Limited Primary Care Settings: Comparison of a self-administered screening tool to general practitioner assessment. J Med Screen. 2013 Sep 30
- It also begs the question — is a change in the diagnostic criteria that only happens once every two decades is an example of “shifting definitions,” would the researchers prefer new diagnostic criteria not reflect updated research and thinking around diagnoses? E.g., would they prefer criteria to be set in stone forever, regardless of what dozens or hundreds of new research studies may show over two decades’ worth of time?? [↩]
- Notice, too, that the researchers used the carefully-chosen word, “shifting,” here. Shifting connotes something that is constantly changing positions — e.g., a shifter in a car. They could’ve used more neutral language, such as “updated definitions,” but chose not to. [↩]
- The logical alternative is that the BMJ researchers would prefer consumers be kept in the dark about mental health disorders, and not seek out mental health information online or talk to their doctor about their concerns. [↩]