According to the DSM-V, attention-deficit and hyperactivity disorder (ADHD) is defined as a neurobiological disorder characterized by either attention deficit or hyperactivity and impulsivity, or (and most often), two jointly. In general, the Diagnostic and Statistical Manual of Mental Disorders (5th edition) sets out the various criteria for this disorder: persistent pattern of inattention or hyperactivity (or both) interfering in at least two (or more) contexts, present before the age of 12 and which cannot be explained by another disorder (depression, anxiety, trauma). Numerous public debates and controversies concerning the relevance of the diagnosis, emerging in parallel with the increase in diagnosis rates, raise many questions : real increase, better detection or inflation of diagnostics ? (Kazda et al., 2021).
Over the years, an increasing prevalence …
The prevalence of ADHD diagnosis varies widely depending on the country and the diagnostic criteria used. Before 1970, the diagnosis of this disorder was rare in children (about 1%) and almost non-existent in adolescents and adults.The increase in ADHD diagnoses is observed in many countries (France, Belgium, etc.) but is the most significant in the United States where the prevalence of ADHD increased 42% from 2003 to 2011 (Milanowski et al., 2018). Currently in the United States, more than one in ten children meet the diagnostic criteria.
How to explain this overdiagnosis ?
Multiple battery explanations have been proposed to explain this overdiagnosis of ADHD. Among these explanations, we find a very low levels interrater reliability due to unclear diagnostic criteria and to the fact that only one in 4 pediatricians refers to the diagnostic criteria proposed by the DSM. Thus, in the absence of clear guidance, specialists often refer to stereotypical patterns to diagnose a child with ADHD. For example, it seems that evaluators “overrate male externalizing behavior” and that childs born close to school cut-off dates are 30 to 60 percent more likely to be diagnosed with ADHD. Diagnostic criteria seems to be not reliable enough (low validity) because trained clinicians interpret the same symptoms differently. In new editions of the DSM, diagnostic restrictions have been relaxed. ADHD is now a global diagnostic with a lot of confounding factors : epileptic crisis, traumatism, HPI, sleeping trouble, immaturity, psychosis, autism, dyslexia, anxiety and obsessional symptoms, schizophrenia, mood disorders.. ADHD is no longer considered as a behavioral disorder but is now included among the neurodevelopmental disorders with perceived biomedical explanations, determinants and remedies. But behind this medical mask hides many psychological, social and educational difficulties.
What consequences ?
One of the risks of ADHD overdiagnosis is overprescribing a psychostimulant called “Ritalin”. This inappropriate diagnostic would affect around 1.1 million children in the U.S and over 800 000 of them would receive treatment in the absence of a real disorder. The researchers alerts on intentional overdiagnosis due to health policy constraints. In the U.S for example, you must be diagnosed with ADHD to qualify for drug treatment. Patrick Landman, a french psychiatrist said that ADHD was a “bespoke disorder” which means that ADHD is a disorder modeled to fit pre-existing chemical substances such as ritalin (methylphenidate). In fact, the nosography related to ADHD is modified by pharmacology. It warns about the risk of methylphenidate becoming à kind of academic doping substance and a sort of “opium for school people” (Lane, 2017).
How to avoid this overdiagnosis and overtreatment ?
Behavioral therapy makes it possible to reduce medication dosages. Landman proposes to demedicalize the difficulties of paying attention at school with pedagogical innovations. For example reducing screen time, increasing rec time at school to do some extra work, to have recess or to relax. A healthy diet is also strongly recommended (less sugar and caffeine).
CONCLUSION
ADHD is a neurodevelopmental disorder that experiences a wave of overdiagnosis. This overdiagnosis is explained by different reasons: unclear diagnostic criteria with low validity leading to very low inter-rater reliability and leading professionals to refer to stereotypical patterns. Additionally, ADHD is now a global diagnosis with several confounding factors (eg. epileptic crisis, traumatism, HPI, sleeping trouble, etc.). On the other hand, this overdiagnosis is not without consequences. Among the most important consequences, we find the fact that many children are prescribed psychostimulant treatments (eg. ritalin), or that they do not suffer from this disorder. Several solutions are proposed to avoid this overdiagnosis and this overtreatment such as behavioral therapy, demedicalizing or not over-pathologizing attention difficulties in young children, proposal for educational innovations, healthy eating.
Bibliographical references :
Kazda, L. M. (2021, 12 avril). Overdiagnosis of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents : A Systematic Scoping. JAMAnetwork. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2778451
Milanowski, A. (2018, 21 février). ADHD : Overdiagnosed and Overtreated, or Misdiagnosed and Mistreated? Consult QD. https://consultqd.clevelandclinic.org/adhd-overdiagnosed-and-overtreated-or-misdiagnosed-and-mistreated/
Lane, C. (2017, 20 octobre). ADHD Is Now Widely Overdiagnosed and for Multiple Reasons. Psychology Today. https://www.psychologytoday.com/us/blog/side-effects/201710/adhd-is-now-widely-overdiagnosed-and-multiple-reasons