Is it true that ADHD is overdiagnosed? Did it used to be? It seems to be an item of faith that it is, but what is the Straight Dope?
Thanks for your help,
Rob
No, it’s probably that it was underdiagnosed before. Either that, or it’s happening more now due to reasons we haven’t figured out, like peanut allergies.
The question, if considered in its pure form as a GQ question, is difficult if not impossible to answer. In order to know what percentage of the people diagnosed ADHD were misdiagnosed and do not in fact have ADHD (that number would constitute the “overdiagnosis” index, yes?), we’d have to know what percentage of the people diagnosed ADHD do, in fact, have ADHD. The process of making that latter evaluation is generally called, uh, “diagnosis”.
Presumably, you see the problem. If we had a way to make the latter diagnosis to a virtually iron-clad solid degree of accuracy, we’d be using that method to make the initial diagnosis. (And, as is the case with all of the ailments & conditions that full under the rubric of “mental illness”, you can’t take 30 cc’s of blood and stick it in a centrifuge and get the parts per billion of ADHD-polymerase or something. All such diagnoses are made on the basis of observable and reported behavior)
The useful version of what you’re asking for is called “inter-rater reliability”. You take a group of people diagnosed as ADHD by psychiatrist #1, and a control group of equal size and comparable values on other human variables like age and sex and socio-economic status and grade-point average and hair color and so on; and you have psychiatrist #2 evaluate the whole group, without being made privy to which people were diagnosed ADHD by psychiatrist #1 (the kids don’t get to know yet either). The idea being that if there’s a sloppiness-in-diagnosis problem, the inter-rater reliability quotient is going to be pretty lousy. (It can be anywhere from perfect concurrence to no more concurrence than sheer happenstance would have created).
I don’t know the inter-rater reliability for ADHD (or ADD) and I don’t know for sure that such a test has been performed and reported.
Even inter-rater reliability won’t tell you if the threshold is simply set too low — a high concurrence of shrinks that 85% of nervous kids who don’t sit still have ADHD could give you good inter-rater reliability and still be “wrong” in some meaningful sense of the word. (At some point it becomes necessary to ask whether Condition X is a “disease” even if every shrink in the world is in agreement about which kids exhibit Condition X. But now you’re dealing with questions that are not matters of fact, but of opinion, perspective, judgment calls, and priorities)
In order for you to decide whether it is over or under diagnosed, you will first have to decide how you would ‘know’ that someone ‘had’ ADHD.
This is a bit strong. There are some pretty good leads as to what ADHD looks like in the brain. Brain scans aren’t going to become a common diagnosis any time soon, though, simply because of their high cost, but if needed they are available.
I did a quick Google and came back with this report on an ADHD test. I don’t know what constitutes a good inter-rater reliability.
The Psychiatrist’s Bible is DSM IV.
http://www.cdc.gov/ncbddd/adhd/symptom.htm
This defines ADHD as:
*DSM-IV Criteria for ADHD
I. Either A or B:
-
Six or more of the following symptoms of inattention have been present for at least 6 months to a point that is disruptive and inappropriate for developmental level:
Inattention
-
Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities. -
Often has trouble keeping attention on tasks or play activities. -
Often does not seem to listen when spoken to directly. -
Often does not follow instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions). -
Often has trouble organizing activities. -
Often avoids, dislikes, or doesn't want to do things that take a lot of mental effort for a long period of time (such as schoolwork or homework). -
Often loses things needed for tasks and activities (e.g. toys, school assignments, pencils, books, or tools). -
Is often easily distracted. -
Is often forgetful in daily activities.
Six or more of the following symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for developmental level:
Hyperactivity
-
Often fidgets with hands or feet or squirms in seat. -
Often gets up from seat when remaining in seat is expected. -
Often runs about or climbs when and where it is not appropriate (adolescents or adults may feel very restless). -
Often has trouble playing or enjoying leisure activities quietly. -
Is often "on the go" or often acts as if "driven by a motor". -
Often talks excessively.
Impulsivity
-
Often blurts out answers before questions have been finished. -
Often has trouble waiting one's turn. -
Often interrupts or intrudes on others (e.g., butts into conversations or games). -
Some symptoms that cause impairment were present before age 7 years. -
Some impairment from the symptoms is present in two or more settings (e.g. at school/work and at home). -
There must be clear evidence of significant impairment in social, school, or work functioning. -
The symptoms do not happen only during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder. The symptoms are not better accounted for by another mental disorder (e.g. Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).
Based on these criteria, three types of ADHD are identified:
-
ADHD, Combined Type: if both criteria 1A and 1B are met for the past 6 months -
ADHD, Predominantly Inattentive Type: if criterion 1A is met but criterion 1B is not met for the past six months -
ADHD, Predominantly Hyperactive-Impulsive Type: if Criterion 1B is met but Criterion 1A is not met for the past six months. *
Getting any reasonable inter-rater reliability on the above incredibly subjective value judgements is going to be virtually impossible. Even single rater reliability from one interview to another is likely to be poor.
The internal consistency number looks good. The parent-teacher agreement rate looks pretty awful.
It’s an odd way to report it, I’m confused by this. Did they have parents and teachers separately evaluate kids using the instrument, on a double-blind basis? (If not, why the heck is it being reported under inter-rater reliability?) The numbers for “internal consistency” are more in the range of what you like to see for inter-rater reliability, but the way they wrote it out it looks like “internal consistency” is intended to be a category separate from and parallel to inter-rater.
Of course this describes 90% of preadolecents in the US
This has been discussed in Great Debates a few times, but no definite consensus was reached. The criteria of diagnosis are rather subjective and cynics say that it’s just a way for parents and/or teachers to get difficult kids out of their hair.
[Personal Anecdote]
I don’t know what conditions I may or may not have, but I tend to get bored a lot, but I can also get overwhelmed if I don’t feel in control of a hectic situation.
(In public school, I was eventually bumped up to the Gifted/Advanced/whatever courses because I found the usual taskwork entirely unchallenging - my fellow classmates were STILL eciting the multiplication table in the third freaking grade, and I’d already not only memorized the whole thing but started working out the table beyond 12 x 12!)
My coworkers have jokingly asked if I have ADD because I do have a tendancy to doodle if I have a piece of paper and pen in front of me.
Any time I’m not actively engaged in something = stare off into space and daydream time. Unfortunately, I haven’t yet found a job that pays me to do that, so I try to keep it to a minimum.
Agree totally.
“Of course this describes 90% of preadolecents in the US”
You missed the bit where it says “and inappropriate for developmental level”. And when they say ‘inappropriate’, it generally means ‘really really inappropriate’.
One of the main problems with the DSM is that it doesnt give a good idea of what a clinical level of dysfunction generally really involves, you need case examples for that really. Its very easy to overdiagnose as a result when you just read a given diagnosis description literally.
Otara
Well, you see, it depends which diagnostic criteria you use, and how you interpret them.
In the USA where the diagnostic standard is the *DSM IV * and the condition is known as ADHD, the prevalance is between 3% and 7%. DSM-IV allows diagnosis of ADD, ADHD and pure hyperactivity.
In Europe, where the WHO’s ICD-10 manual is the diagnostic standard, the condition is known as Hyperkinetic Disorder and the prevalance in the UK is about 1%. In order to fill the criteria for the ICD-10, both attention problems and hyperactivity must be present, which obviously mean that some American kids diagnosed as ADD or ADHD wouldn’t be considered to have Hyperkinetic Disorder.
ICD 10 criteria for Hyperkinetic Disorder (F90).
The most important thing to realise is that the child must show the behaviours in all circumstances- when they’re at home, at school, at play, happy, sad, angry- everywhere, all the time. ADHD or Hyperkinetic Disorder is not an appropriate diagnosis for a child who “acts out” only in certain circumstances and it is not an appropriate diagnosis for a child who is merely noisy and active.
It is also not an appropriate diagnosis if the child suffers primarily from anxiety or depression (which can affect attention and behaviour), or if the child’s behaviours are appropiate for their IQ (a child with a learning disability should not be expected to have the same attention levels as other kids their age).
The ICD-10 also insists that the condition be present early, i.e. before the child goes to school. A child cannot develop Hyperkinetic Disorder if they have been previously normal.
Such is the joy of psychiatry, when ther is no diagnostic test, you’re left to make up lists of criteria, which are open to interpretation, and which may not be universally agreed on, nor applied. This applies not just to ADHD/Hyperkinetic Disorder, but to almost every mental health problem you can think of. ICD-10 and DSM IV have similar (but not identical) criteria for everything from Dementia to OCD.
No I didn’t. As a special ed teacher I deal with this all the time with advocates claiming that anyone above 5 years old can focus on classwork, therefore since they can’t focus, it is ADD and is therefore a disability. I can’t say that I disagree, kids are able to focus, but a kid who doesn’t pay attention when you talk to them automatically meets 5 or 6 of the criteria.
Before anyone says anything - I know ADD is not considered a learning disability under IDEA, but it can be considered as OHI and parents can always find a psychologist willing to sign off on an ADD diagnosis.
It doesn’t really. Parents and teachers almost ALWAYS evaluate children differently. Parents are parents they almost always evaluate their children as “normal” (a horrible word and one I don’t usually use). Teachers have a greater level of comparision.
Currently I am dealing with two children who are VERY obviously far from the norm (not ADHD…more serious), my purely (very current) anecdotal evidence tells me that 3 out of 4 parents believe their child is on a par with their cohorts when ALL evidence shows they are not.
Parents WANT to and SHOULD believe that their child is wonderful and can achieve anything. Teachers can afford to be more objective.
IMO It’s a conspiracy by the big drug companies to sell more product…just like the chemical imbalance thing. Make people believe that there is something wrong with them and that they cannot survive without drugs. Better living through chemistry. There’s a line about it in a song by Zager and Evans, I think. We are conditioned to believe that there is a pill for every condition. My wife believed that and she is dead because of it. I watch my friends make their children take drugs for ADHD so that they will be normal. When they turn fifteen or sixteen will they believe the “Just say no to drugs” speech? Please forgive my ranting.
Yeah, and that’s an ignorant slap in the face to every parent who has seen their child unable to focus on basic tasks and see marked improvement when medication is used. ADHD does exist and medications do work for a lot of kids and if you could be arsed to read something about it you’d maybe get a fucking clue as to what you’re talking about.
Sorry about being so harsh; I always regret it immediately when I do that…
Anyway, I do agree that there’s a tendency in the medical establishment to go “OK, we have a pill that’s somewhat effective (but has side effects, etc.), our work’s done here” and not revisit the problem to see if they can come up with something better. Case in point: I recently had my thyroid nuked…they kill the thyroid with radiation when it goes hyper. They’ve been doing this for something like 50 years, and haven’t seemed to even try to come up with a less invasive solution, because it’s easy for them to just go with what they already have.
Interestingly, just yesterday js_africanus provided a link in An Arky’s thread to an article by Michael Fumento discussing ADD/ADHD under the title Trick Question: A Liberal Hoax Turns Out to Be True that provides a fair amount of information on this topic.
I didn’t say that ADHD doesn’t exist, but rather stating an opinion that it is overdiagnosed. My stance is also probably offensive to parents that would rather put their child/children on drugs than learn actual parenting skills. I have observed this. Also, a diagnosis has often been an automatic Social Security check in the past. I have observed this, too.
When the children grow up, the diagnosis is often switched to Bipolar Disorder, the diagnosis de jour for grown ups.
I’ll repeat, “Better living through chemistry.”
I’d be curious to know how often you think that this occurred. I rather doubt that SSI has been authorized for anyone solely on a basis of an ADD or ADHD diagnosis. I’ve been through the SSI qualifying process for my daughter who has multiple issues and it was not a matter of simply sending in a doctor’s note. The local (county) board of mental retardation qualified her (and disqualified my ADHD son) with far less evidence than was demanded by the Social Security Administration.
You also might want to read the Fumento article to which I linked.