Depending on whom you ask, attention-deficit hyperactivity disorder (ADHD) is either over- or underdiagnosed. A new European study weighs in on the question suggesting gender, both of the clinician and of the client, plays a significant role in the diagnosis.

German researchers from Ruhr-Universität Bochum (RUB) and University of Basel believe the study shows that child and adolescent psychotherapists and psychiatrists tend to give a diagnosis based on heuristics or rules of thumb, rather than adhering to recognized diagnostic criteria. This suggests that ADHD is over-diagnosed.

Clinical psychologists Drs. Silvia Schneider and Jürgen Margraf (both from RUB) and Dr. Katrin Bruchmüller (University of Basel) believe that boys in particular are substantially more often misdiagnosed compared to girls.

In the study, researchers presented one of four available case vignettes to 473 child and adolescent psychotherapists and psychiatrists across Germany. The practitioners were asked to give a diagnosis and a recommendation for therapy.

In three out of the four case vignettes, the described symptoms and circumstances did not fulfill ADHD criteria. Only one of the cases fulfilled ADHD criteria based strictly on the valid diagnostic criteria. In addition, the gender of the child was included as a variable resulting in eight different case vignettes.

As the result, when comparing two identical cases with a different gender, the difference was clear: Sam has ADHD, Sarah doesn’t.

The researchers believe that many child and adolescent psychotherapists and psychiatrists seem to proceed heuristically and base their decisions on prototypical symptoms. The prototype is male and shows symptoms such as motoric restlessness, lack of concentration and impulsiveness.

In connection with the gender of the patient, these symptoms lead to different diagnoses. A boy with such symptoms, even he does not fulfill the complete set of diagnostic criteria, will receive a diagnosis for ADHD, whereas a girl will not.

Also the therapist’s gender plays a role in the diagnostic: Male therapists give substantially more diagnoses for ADHD than their female counterparts.

In Europe, as in the U.S., diagnoses for ADHD have exploded over the past two decades. Between 1989 and 2001, the number of diagnoses in German clinical practice increased by 381 percent.

The costs for ADHD medication, such as for the performance-enhancing psychostimulant methylphenidate (Ritalin), have grown nine times between 1993 and 2003. In Germany, the government health insurance company, Techniker, reports an increase of 30 percent in methylphenidate prescriptions for its clients between the ages of 6 and 18. Similarly, the daily dosage has increased by 10 percent on average.

Researchers say that despite these statistics, there is a remarkable lack of research on the diagnostics of ADHD. In spite of strong public interest, very few empirical studies have addressed the issue, Schneider and Bruchmüller noted.

Nevertheless, the current study shows that in order to avoid a misdiagnosis of ADHD and premature treatment, it is crucial for therapists not to rely on intuition but strictly adhere to well-defined, established diagnostic criteria.

The researchers recommend that standardized diagnostic instruments, such as diagnostic interviews be used to determine a definitive diagnosis.

Their research is published in the Journal of Consulting and Clinical Psychology.

Source: Ruhr-University Bochum