adhd overdiagnosed essay

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Breaking Barriers: My Battle with ADHD

In a prize-winning essay about overcoming obstacles, a child with attention deficit disorder explains the effects of adhd on his life. from enlisting the help of family members to keeping a journal, this is how jack prey manages his diagnosis..

Have you ever been working on something important, when a song pops into your head? Then that leads you to think of something in the song about flying, which leads you to play with your remote control glider? Next thing you know, it’s dinnertime, and you haven’t finished the homework you started two hours before.

That’s what it’s like to have Attention Deficit Disorder. I know because I’ve had ADHD for as long as I can remember. For me, ADHD means that I can’t focus whenever I really need to. It’s something I will live with for the rest of my life. And it’s no fun!

When I was younger, people told me I was really smart. But I never got good grades to show it. When I was at school, I would get bored really quickly. Then I would look for something more interesting to do. Sometimes I would try to help other kids with their work. The problem was, I didn’t finish my work, and that would lead to trouble. There were lots of days I even felt like quitting school.

My parents were confused. They knew I was smart, but I wasn’t showing it. My doctor suggested that I see a specialist. He gave me a bunch of tests. When it was all done, he told my parents that I had ADD . Now it’s called ADHD. The H stands for “hyper.” He said I didn’t really have the H , so I guess that was some good news.

To help me focus, the doctor gave me some tips to follow. One of them is to keep a special journal with me all the time to write down things, like what homework I have and when things are due. I try to keep the notebook with me wherever I go. It really helps.

[ Get This Free Download: 5 Powerful Brain Hacks for Focus & Productivity ]

I came up with another tip myself. When I have a test or a quiz, I challenge myself to get it done by a certain time. That keeps me focused on the test and not on the pretty girl sitting in front of me or the lizard in the aquarium. Ah, lizards. I really like lizards. Where was I again?

Oh yeah, my focus techniques. With the help of my parents and my older brother, I started doing some other things that help, like going to bed a little earlier so I can get a good night’s sleep.

My brother and I share a bedroom, and he has agreed to go to bed earlier to help me out. Another thing our whole family has started doing is eating a healthy diet. I used to eat a lot of junk food, but now I only eat a little bit. Ah, junk food. Oops, I’ll try not to do that again.

I’ve been working hard, using these focus techniques for the last year and guess what? My grades have started to go up! In fact, on my last report card I got five As and one B. That’s the best I’ve ever done!

[ Your Free Download: What Every Teacher Should Know About ADHD: A Poster for School ]

My teacher, Miss Ryan, suggested I write this essay. I’m not sure if I knew who Jackie Robinson was before this, but I did some checking. Turns out, he was a great man who had to overcome one of the worst things there is: racism. He did it using the values of courage, determination, teamwork, persistence, integrity, citizenship, justice, commitment, and excellence.

I have used some of these same values to help me overcome ADHD. For instance, I am committed to using my focus techniques, and I am determined to do better in school. Plus, my family has helped me, and that is being a team. Go, team! Also, when I focus, I am a good citizen and don’t bother my classmates as much. Last but not least, using these values has helped me to get almost all As on my report card, which is an example of excellence. Thanks for being such a good example, Jackie!

[ Read This Next: How I Came to Rock My ADHD ]

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ADHD Is Overdiagnosed, Here's Proof

Let's stop turning immaturity into a mental disorder.

Posted May 23, 2016

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There are three possible explanations for the explosion of the ADHD diagnosis during the past 20 years—with rates that have skyrocketed from only 3-5 percent of kids to 15 percent.

1) Diagnostic enthusiasts celebrate the jump as indication of increased awareness of ADHD and better case finding. 2) Diagnostic alarmists worry that we are making our kids sicker via environmental toxins, computers, an over-stimulating world, maternal drug use, or some combination. 3) Diagnostic skeptics attribute the change to the raters, not the rated—it's not that the kids are sicker, it's that the diagnosis is being made too loosely.

There is no gold standard or biological test to prove precisely which view is correct and what would be the ideal rate of ADHD to best balance the risks and benefits of being diagnosed.

I am strongly in the skeptic school. Long experience has taught me how great is the impact on diagnostic rates of even small changes in how any disorder is defined or appraised. And this is greatly amplified when drug companies aggressively sell the disorder to doctors, parents, and teachers.

Fortunately, there is one ingenious and compelling indirect way to determine whether rates of ADHD are inflated. Five large studies in four different countries have compared rates of reported ADHD in the youngest vs. the oldest kids in classrooms. The studies converge on the inescapable finding that we are turning immaturity into disease.

I invited Joan Lipuscek, M.S., LMFTA, a child and teen therapist, to summarize the results of these studies.

Taiwan (2016) : The sample was 378,881 Taiwanese school children, ages 4-17, who were in school from 1997 to 2011. Kids born just one month prior to the grade cut-off date were 61 percent more likely to be diagnosed with ADHD compared with their oldest classmates. These youngest children were also 75 percent more likely to be medicated. According to the authors, these findings “emphasize the importance of considering the age of a child within a grade when diagnosing ADHD and prescribing medication for treating ADHD.”

Canada (2012) : The sample was 937,943 children in British Columbia ranging between 6 and 12 years of age and used data from between 1997 through 2008. The study found that male children born one month prior to the grade cut-off date were 30 percent more likely to be diagnosed with ADHD and 41 percent more likely to be medicated compared with the oldest male children in the same grade. Female children born one month prior to the grade cut-off date were 69 percent more likely to be diagnosed with ADHD and 73 percent more likely to be medicated compared with the oldest female children in the same grade. The study concluded that, "The potential harms of over-diagnosis and over-prescribing and the lack of an objective test for ADHD strongly suggest caution be taken in assessing children for this disorder and providing treatment."

Iceland (2012) : The sample was 11,785 Icelandic children, ages 9 and 12. Male children born 1-4 months prior to the grade cut-off date were 52 percent more likely to be medicated for ADHD compared with the oldest male children in the same grade. Female children born 1-4 months prior to the grade cutoff date were 73 percent more likely to be medicated for ADHD compared with the oldest female children in the same grade. The study concludes that, “Relative age among classmates affects children’s…risk of being prescribed stimulants for ADHD.”

U.S. (2010) : Of all the studies reviewed, this one showed the highest increase in risk of diagnosis and medication of ADHD for the youngest children in a class. The study gathered data from 11,784 children in the Early Childhood Longitudinal Study-Kindergarten longitudinal survey tracked them for 9 years starting in 1998. Children born 1 month prior to the September 1st class grade cut-off date were 122 percent more likely to be diagnosed with ADHD and 137 percent more likely to be medicated for ADHD. The study concludes by noting that, "Whether relatively young children are overdiagnosed, relatively old children are underdiagnosed, or both, current efforts to define and diagnose ADHD evidently fall short of an objective standard."

U.S. (2010) : This study used a sample of 35,343, children from the National Health Interview Survey and 18,559 children from the Medical Expenditures Panel Survey. Children born 1-3 months prior to the grade cut-off date were found to be 27 percent more likely to be diagnosed for ADHD and 24 percent more likely to be medicated for ADHD compared with children born 10-12 months prior to the grade cut-off date. The study does a nice job of relating its findings to the "real world" scale of the problem when it states, "To put our estimates into perspective, an excess of two percentage points implies that approximately 1.1 million children received an inappropriate diagnosis and over 800,000 received stimulant medication due only to relative maturity."

For additional data on these studies see: joanlipuscek.com

Thanks so much, Joan. The results could not possibly be more consistent or convincing. Being the youngest kid in the class clearly puts you at great risk to be tagged with an inappropriate ADHD diagnosis and to be inappropriately treated with stimulant medication that is both unneeded and potentially harmful.

We should let kids outgrow immaturity the old fashioned way: by getting older, not by treating it with a pill.

If you are concerned about the overdiagnosis and over-treatment of ADHD, you will also be interested in several recent blogs done with Keith Conners, the world's expert on the diagnosis.

On his regrets about how the diagnosis is misused: keith-connors-father-adhd-regrets-its-current-misuse

How parents can protect kids from over-treatment. how-parents-can-protect-kids-the-adhd-epidemic

On the risks of diagnosing ADHD in adults. stopping-the-false-epidemic-adult-adhd

Allen Frances, M.D. , was the chair of the DSM-IV Task Force and is currently a professor emeritus at Duke.

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• Volume 9, Issue 11
• Evidence of potential overdiagnosis and overtreatment of attention deficit hyperactivity disorder (ADHD) in children and adolescents: protocol for a scoping review
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• http://orcid.org/0000-0003-4105-0402 Luise Kazda 1 ,
• http://orcid.org/0000-0002-0137-3218 Katy Bell 1 ,
• http://orcid.org/0000-0002-2165-5917 Rae Thomas 2 ,
• Kevin McGeechan 1 ,
• Alexandra Barratt 1
• 1 Sydney School of Public Health , The University of Sydney , Sydney , New South Wales , Australia
• 2 Institute of Evidence-Based Healthcare , Bond University , Gold Coast , Queensland , Australia
• Correspondence to Luise Kazda; luise.kazda{at}sydney.edu.au

Introduction Worldwide, attention deficit hyperactivity disorder (ADHD) diagnosis rates in children and adolescents have been increasing consistently over the past decades, fuelling a debate about the underlying reasons for this trend. While many hypothesise that a substantial number of these additional cases are overdiagnosed, to date there has been no comprehensive evaluation of evidence for or against this hypothesis. Thus, with this scoping review we aim to synthesise published evidence on the topic in order to investigate whether existing literature is consistent with the occurrence of overdiagnosis and/or overtreatment of ADHD in children and adolescents.

Methods and analysis The proposed scoping review will be conducted in the context of a framework of five questions, developed specifically to identify areas in medicine with the potential for overdiagnosis and overtreatment. The review will adhere to the Joanna Briggs Methodology for Scoping Reviews. We will search Medline, Embase, PsycINFO and the Cochrane Library electronic databases for primary studies published in English from 1979 onwards. We will also conduct forward and backward citation searches of included articles. Data from studies that meet our predefined exclusion and inclusion criteria will be charted into a standardised extraction template with results mapped to our predetermined five-question framework in the form of a table and summarised in narrative form.

Ethics and dissemination The proposed study is a scoping review of the existing literature and as such does not require ethics approval. We intend to disseminate the results from the scoping review through publication in a peer-reviewed journal and through conference presentations. Further, we will use the findings from our scoping review to inform future research to fill key evidence gaps identified by this review.

• epidemiology
• mental health
• paediatrics
• child & adolescent psychiatry
• public health

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See:  https://creativecommons.org/licenses/by/4.0/ .

https://doi.org/10.1136/bmjopen-2019-032327

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Strengths and limitations of this study

This is the first comprehensive synthesis of evidence on the potential for overdiagnosis and overtreatment of attention deficit hyperactivity disorder in children and adolescents.

Broad and systematic search strategy is used to retrieve all relevant studies published since 1979.

The review compares evidence against established criteria for potential overdiagnosis and overtreatment.

The review includes a critical appraisal of included studies but no formal risk of bias assessment.

Underdiagnosis and undertreatment may also occur, but are outside the scope of this review.

Introduction

Review questions.

Our primary study question for this scoping review is: ‘Does the published literature indicate a potential for overdiagnosis and/or overtreatment of Attention Deficit Hyperactivity Disorder (ADHD) in children and adolescents?’ Besides this question, we will consider two further, secondary questions in our review: ‘When mapped against an existing framework for identifying potential overdiagnosis, 1 are there any gaps in the current evidence?’ and ‘How does the framework 1 perform in terms of applicability and usability for identifying potential overdiagnosis of a mental health condition?’

With steadily increasing prevalence rates of ADHD throughout the developed world, 2–6 there is growing debate about whether this trend is due to an actual increase in prevalence, better detection and diagnosis, misdiagnosis, or overdiagnosis. 7–10 While the evidence for overdiagnosis in many other conditions (especially in screen-detected cancers) is increasingly recognised, 1 11 12 the evidence for overdiagnosis of ADHD, a non-cancer condition where overdiagnosis is widely thought to occur, has not yet been comprehensively evaluated. 13 Quantifying the potential for overdiagnosis is only just emerging as a field of interest in both paediatric and mental health research. 7 14

The potential overdiagnosis of ADHD could be caused by three main drivers. First, it can arise due to the problem of overdefinition, 15 that is, lowering the threshold for a disease, by expanding the disease definition to include people with ambiguous or very mild symptoms without evidence that doing so improves patients’ health overall and in the longer term. 16 17 Second, overdiagnosis may also be caused by overdetection 4 18 (eg, screening children at young ages for behaviour problems), and third by the medicalisation of some behaviour patterns (eg, those typical of relatively younger school children). 19 Other factors may also have played a part. These include formal changes to the diagnostic threshold (Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 vs DSM-IV), pharmaceutical industry influence, 13 and health and social service drivers (eg, access to resources linked to a diagnosis). 10

Although the prevalence rates of ADHD seem to have risen substantially in the past few years, most cases continue to be reported as mild to moderate forms (87% in 2007, 84% in 2011 and 86% in 2016 of all reported cases in a large USA-based survey), 2 20 and it has been argued that many of those cases may represent overdiagnosis. Should this be the case, these children may not experience a net benefit from an ADHD diagnosis and subsequent treatments, but may be harmed. 13

While correctly diagnosing and treating ADHD have many potential benefits, 21 the harms from overdiagnosing and overtreating ADHD are significant and costly on multiple levels. Not only may the individual child experience negative physical and psychosocial effects, their families may also experience psychosocial and financial burdens. Overdiagnosis and overtreatment also result in financial and opportunity costs to the health system, and to society at large. 7 It has also been pointed out that the resulting potential overuse of healthcare resources contributes to the simultaneous underuse of said resources, 22 for example, by depriving underdiagnosed and undertreated groups of children who would largely benefit from ADHD treatment and timely access to diagnostic and treatment services. 23 While also addressing the twin issues of underdiagnosis and undertreatment is beyond the scope of this proposed review, we see our work as a starting point for a broader discussion around the principles of ‘right care’, where resources need to be reallocated to where they are most needed and effective. 22

In summary, while there are increasing concerns about the potential for overdiagnosis of ADHD in children and adolescents, there is scant evidence quantifying the problem. Consequently, a systematic review of the literature to quantify ADHD overdiagnosis is not possible due to the current lack of synthesisable evidence in this field. The rationale for this broader scoping review then is to use a recently developed framework of questions 1 to systematically determine if the existing literature indicates a potential for overdiagnosis and overtreatment in ADHD. We hypothesise that ADHD fulfils these predetermined criteria for potential overdiagnosis. A secondary aim is to further examine and highlight any gaps in the current evidence that may prevent us from determining whether or not ADHD is overdiagnosed and overtreated. This aim will be especially helpful in guiding subsequent research in this area. A further secondary aim of the study is to rigorously test the existing five-question framework 1 for its applicability and usability in another area, namely paediatric mental health.

Preliminary searches of the literature were conducted in March and April 2019 to determine if any previous scoping or systematic reviews had been conducted or protocols submitted which aimed to summarise existing evidence on overdiagnosis and overtreatment in ADHD. Databases searched were the Cochrane Database of Systematic Reviews, PROSPERO, Medline, Scopus and the JBI (Joanna Briggs Institute) Database of Systematic Reviews and Implementation Reports. Two scoping reviews on overdiagnosis in healthcare were found, but neither review was focused on overdiagnosis and overtreatment of ADHD. One review covered the drivers of overdiagnosis and potential solutions, 22 while the other addressed overdiagnosis across different medical disciplines. 24 25 While a number of systematic reviews have been conducted on ADHD, these have been restricted to prevalence 26–28 or treatment options. 29 30 We also identified one systematic review on overprescribing or underprescribing of ADHD medication that is currently under way with a published protocol. 31 Literary reviews and commentaries on overdiagnosis in mental health, including ADHD, have been published. 13 21 32 However, we found no reviews that have been conducted or are in preparation that systematically gather and analyse all available evidence to allow a comprehensive assessment on the potential for overdiagnosis of ADHD.

Methods and analysis

The proposed review will follow the Joanna Briggs Methodology for Scoping Reviews, 33 which is based on and extends the work of Arksey and O’Malley 34 as well as that of Levac and colleagues. 35 The scoping review will also adhere to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) 36 ( online supplement I ). This approach was chosen to document the review process as clearly and rigorously as possible. The timeframe for undertaking of the review is from 13 June 2019 (date that the final search strategy was run in all included databases) until 31 December (anticipated completion date of the review).

Supplemental material

Inclusion criteria, participants.

The scoping review will include studies whose main focus is on children and adolescents under the age of 18 who have been either clinically diagnosed or identified by the parent, teacher or self-report as having behavioural symptoms of ADHD. Articles that have a clear emphasis on adult ADHD will be excluded unless they are longitudinal follow-up studies where participants were determined to have ADHD in childhood and were then followed through into adulthood. Moreover, studies with other health issues or disabilities as the primary focus will also be excluded. However, studies considering any other comorbidities as a secondary diagnosis will be eligible for inclusion if the focus of the study is clearly on ADHD (outcomes on any other disorders will not be reported or included in the analysis).

The two core concepts to be examined by this scoping review are ‘overdiagnosis of ADHD’ and ‘overtreatment of ADHD’. Debate over the definition of overdiagnosis is ongoing, 1 16 17 37 38 especially in non-cancer contexts. We define overdiagnosis as occurring where a person is correctly diagnosed (according to contemporary professional standards) with a condition but the net effect of the diagnosis for the individual concerned is unfavourable (ie, when consideration is given to the balance of potential harms and benefits). 1 39 The resulting overtreatment can then be defined as receiving treatment following an overdiagnosis (or among overdiagnosed individuals). 16 40 It is important to note that overtreatment can occur as a result of overdiagnosis but also without it, due to other drivers. 16 In this scoping review we will only consider pharmaceutical treatment options for ADHD in terms of overtreatment.

The study will be conducted in the context of a previously published and tested framework of five questions that identify characteristics consistent with the occurrence of overdiagnosis and overtreatment. 1 It is not limited to any geographical areas or settings. The five questions were developed by experts in the field of overdiagnosis as a guide to identifying areas in medicine where overdiagnosis and overtreatment may be occurring. Additionally, an overarching primer question will be included to avoid missing evidence. Hence, the questions by which the search will be guided and to which the evidence will be mapped are the following:

Is ADHD overdiagnosed in children and adolescents?

Is there potential for increased diagnosis?

Is diagnosis actually increased?

Are additional cases subclinical or low risk?

Are additional cases treated?

Might harms outweigh benefits?

For treatment.

For diagnosis.

Types of evidence

For questions 0–4 any existing, peer-reviewed primary studies as well as systematic reviews will be considered. As our preliminary searches came up with very large amounts of evidence from primary studies that could be deemed suitable to answer question 5, we will limit the types of evidence included to answer this question as follows: the search for question 5 part A will be limited to systematic reviews (of randomised controlled trials or observational studies) and cohort studies investigating short-term and long-term outcomes from ADHD pharmaceutical treatment. The search for question 5 part B will be wider and include any primary studies investigating outcomes after an ADHD diagnosis.

Search strategy

Initially, various basic, restricted searches in Medline and Scopus were performed on each of the five predetermined questions (1–5) to uncover some articles relevant to the topic. This initial search was followed by an analysis of key concepts in titles and abstracts as well as index/medical subject heading terms from key papers. Moreover, we reviewed published search strategies from reviews on similar topics to identify keywords related to our study aims. 24 25 A second full and complex search strategy with the identified keywords and index terms was then developed with the assistance of a research information specialist. This search will be conducted in Medline, Embase, PsycINFO and the Cochrane Library to locate articles relevant to all five aspects of the framework and the additional primer question (0). For practical reasons this search will be restricted to English-language articles only. Databases will be searched from 1979 onwards. Publications from before 1979 will be excluded as their findings would reflect a historical definition of ADHD (hyperkinetic reaction of childhood) in line with DSM-II. 41 These are unlikely to be relevant to our study question. The complete search strategy for Medline can be found in online supplement II . Finally, the search will be supplemented by forward and backward citation searches of all included papers.

Study selection

After an initial pilot phase to ensure appropriate training for high-level decision making and to test our inclusion/exclusion criteria, all titles and abstracts identified by the database and hand searches will be screened and reviewed for relevance by two researchers independently. Abstrackr ( http://abstrackr.cebm.brown.edu ), a text mining tool, will be used to help with this initial screening. 42 43 Full-text reviews of all potentially suitable papers will be independently conducted by two researchers, according to the predefined inclusion/exclusion criteria. All studies excluded at the full-text screening stage will be reported with reasons for exclusion provided. At both stages of the screening process (abstract and full-text screening), any discrepancies will be resolved through discussion with the team.

Data extraction

Data from the final articles to be included in the review will be charted independently into a standardised and piloted template by two researchers. Any uncertainties will be again discussed and resolved by the entire study team. Data will be extracted on the source, eligibility, methods, population characteristics, intervention/exposure, outcomes, results and other areas of interest. A template for data extraction is attached ( online supplement III ) and may be further refined and updated during the review stage. As part of the data extraction process, all included studies will undergo a basic critical appraisal using the Joanna Briggs Institute Critical Appraisal Tools for the relevant study type ( https://joannabriggs.org/critical_appraisal_tools ).

Presentation of results

All information regarding the selection of sources will be presented in a flow diagram according to PRISMA-ScR. 36

Results from all included studies will be mapped to our predetermined five-question framework in the form of a table as well as in descriptive, narrative form. This results table will include summary information from the conducted critical appraisals. Estimates from quantitative studies will be included in a summary table but will not be meta-analysed as we expect results to be too heterogeneous to allow for meaningful synthesis. Further, evidence will be categorised by type of article and study type in order to highlight where additional research may be needed to fill current evidence gaps.

Patient and public involvement

Neither the protocol nor the proposed scoping review will involve patients or members of the general public.

Ethics and dissemination

Due to the proposed study being a scoping review, there are no ethical or safety considerations to be made. It is planned to disseminate the results from the scoping review through publication in a peer-reviewed journal and through conference presentations.

Acknowledgments

The authors acknowledge the contributions towards the search strategy development and other useful recommendations with regard to literature searching made by Justin Clark, Senior Research Information Specialist at the Institute for Evidence-Based Healthcare, Bond University.

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Twitter @@LuiseKazda, @KatyJLBell, @rthomasEBP

Contributors LK, KB, RT and AB contributed to the conception and design of the protocol. LK, KB, RT, KM and AB contributed to the establishment of searches. LK drafted the protocol, KB, RT, KM and AB made contributions to the drafting and revising of the article. All authors approved the final version of the protocol for publication and its accuracy and integrity.

Funding This work is supported by Wiser Healthcare, which is funded by the National Health and Medical Research Council (NHMRC) Program Grant 1113532 and CRE Grant 1104136. The funding source has no role in study design, data collection, data analysis, data interpretation or writing of the report.

Competing interests None declared.

Patient consent for publication Not required.

Provenance and peer review Not commissioned; externally peer reviewed.

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You might have heard ADHD risks being over-diagnosed . Here’s why that’s not the case

Research Fellow in Biomedical Ethics, The University of Melbourne

Financial Markets Foundation Chair of Developmental Mental Health, The University of Melbourne

Principal research fellow, Murdoch Children's Research Institute

Disclosure statement

Christopher Gyngell via his affiliation with the Murdoch Children's Research Institute received funding from the Victorian State Government via the Operational Infrastructure Support Program. He also receives funding from the Medical Research Future Fund

David Coghill receives funding from The National Health & Medical Research Council and the Medical Research Future Fund. He consults to Takeda, Medice, Novartis & Servier. He is a board member and director of the Australian ADHD Professionals Association.

Jonathan Payne does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.

University of Melbourne provides funding as a founding partner of The Conversation AU.

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At the same time as it has attracted support and understanding, attention deficit hyperactivity disorder (ADHD) has invoked passionate debate in recent years. One hot topic is whether ADHD is being over-diagnosed.

This concern dovetails with calls from GPs to be able to help provide wider access to diagnosis and for the condition to be added to the National Disability Insurance Scheme (NDIS).

Public hearings for the Australian Senate’s inquiry into “consistent, timely and best practice assessment” of ADHD and support services begin today.

Reflecting on the unique features of ADHD, as well as how the idea of overdiagnosis came about, shows this misplaced concern should not distract us from helping people impacted by the condition.

Read more: Wondering about ADHD, autism and your child’s development? What to know about getting a neurodevelopmental assessment

What is ADHD?

ADHD is a neurodevelopmental condition that involves a person’s ability to regulate their behaviour, attention, and/or activity levels. Worldwide, around 5% of children and 2.5% of adults meet the full diagnostic criteria for ADHD.

Importantly, just having hyperactive, impulsive and inattentive symptoms is not sufficient to qualify for a diagnosis of ADHD. To meet current diagnostic criteria , these symptoms must have a negative effect on a person’s “social, school, or work functioning”.

This makes ADHD (and other mental health conditions) different from most physical health problems like cancer, diabetes, or heart disease. You can have cancer without it affecting your family, work, or social life. Some people might have cancer but not show any symptoms and still be doing well.

But by definition, you can’t have ADHD without both showing its symptoms and feeling their impact.

Read more: 29,000 cancers overdiagnosed in Australia in a single year

Overdiagnosis or misdiagnosis?

Overdiagnosis is a concept first developed in cancer screening to highlight situations where “the diagnosis of disease that would never cause symptoms or death during a given patient’s lifetime”. This definition has since been employed in many other areas of medicine, as well as analyses of health systems.

When defined in this way, overdiagnosis is distinct from the concept of misdiagnosis, which is where an incorrect diagnosis has been made. Misdiagnosis is when someone is diagnosed with a condition when they do not meet diagnostic criteria.

Overdiagnosis is something we should avoid. If a condition is not going to cause a person harm, we should not waste medical resources identifying it, or use invasive procedures to treat it. But when we reflect on the fact it’s impossible to have ADHD and not experience negative effects, we can see ADHD is not a condition that can be over-diagnosed in the way a disease such as cancer can.

Read more: Is it anxiety or ADHD, or both? How to tell the difference and why it matters

Different definitions

Of course, there are other ways we could define overdiagnosis, so that it could apply to ADHD.

One 2021 article on ADHD and overdiagnosis defined it as occurring when the “net effect of the diagnosis is unfavourable”. But the implications of this definition of overdiagnosis are difficult to unpack.

There are many reasons an ADHD diagnosis may be “unfavourable”, for some individuals. It could be a misdiagnosis. A person might not have access to any needed treatments and/or social supports. Some people experience negative side effects from ADHD treatments, or experience stigma as a result of ADHD diagnosis.

One finding sometimes quoted as evidence for overdiagnosis of ADHD is that children who are youngest in their class are the ones most likely to be diagnosed.

But when you think about ADHD as not just having certain symptoms, but as having harmful outcomes, this might be expected. Trouble staying focused during class is more likely to be harmful if you are already behind your classmates – so harms are compounded.

In contrast to over-diagnosed physical diseases, it will still be important to identify such children, to reduce the negative impact of their inattentiveness. This need not involve medications but could involve environmental interventions – including perhaps repeating a year of school.

Read more: What is ADHD coaching and do I really need it?

Not a medical condition

Some concerns about ADHD overdiagnosis appear to be based on a belief ADHD should not be considered as a medical condition. From this perspective, the concerns would again be more accurately and transparently phrased in terms of misdiagnosis.

It is true some children who currently have an ADHD diagnosis might in fact be hyperactive, impulsive, or inattentive, but these traits may have neutral or positive effects on their lives. Again, this would not be an overdiagnosis, but an incorrect diagnosis.

Even in the United States where rates of ADHD diagnosis exceed 5% , they still fall short of the estimated epidemiological prevalence . That means even though there have been significant increases in the rates of diagnosis of ADHD over recent years, there are still many more children, adolescents and adults who likely meet the diagnostic criteria for ADHD. They may never have had these problems recognised, do not have a diagnosis and do not get any support.

Where to from here?

So GPs and others – like Mental Health Nurse Practitioners – may well play an important role in assessing and managing ADHD.

There would clearly need to be extensive training and support and also changes in the way assessments are funded. A good assessment takes time and at the moment funding preferences shorter appointments.

As things stand, we are a long way from “overdiagnosis”. In fact, we are still a long way from adequately supporting those who need it.

• Overdiagnosis
• Australian Senate inquiry
• ADHD diagnosis
• Disability coverage

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Problems of Overdiagnosis and Overprescribing in ADHD

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The Myth of ADHD Overdiagnosis

 Attention Magazine August 2021

 Download PDF

Misdiagnosis means that in some people ADHD is incorrectly diagnosed, while in others, ADHD is missed. Many people with ADHD struggle for years before they finally receive a diagnosis. Doctors often miss ADHD in women and girls, older adults, people from minority backgrounds, and people who are successful, smart, or likable. To prevent missed diagnoses, professionals must get to know the full spectrum of ADHD presentations and make sure they follow rules for making ADHD diagnoses. Untreated ADHD can lead to self-doubt and low self-esteem. Without the correct diagnosis and treatment, people with ADHD can be held back from becoming their best selves.

So why does it look like ADHD has skyrocketed over the last thirty years? Mistakes by doctors and faking by college students do not explain this increase. The biggest factor has been increased public awareness of ADHD. In 1991, the US government wrote a memo that said that students with ADHD could receive special education services under the Individuals with Disabilities Education Act (IDEA). This law provided greater opportunities for students with ADHD to receive special support at school. Now teachers had a bigger reason to talk to parents about a student’s ADHD symptoms. Meanwhile, big marketing campaigns for new ADHD medications in the early 2000s increased awareness of ADHD by patients, families, pediatricians, and other doctors. ADHD treatments were becoming easier for families to find. When treatments are more available, more diagnoses are made. This is because insurance companies require a diagnosis before they will pay for treatment.

In the 1990s, researchers discovered that most children with ADHD do not grow out of their symptoms. Professionals learned how to detect ADHD in teenagers and adults. ADHD diagnoses increased in these age groups.

There is no test for ADHD, so doctors must act like a detective when they make diagnoses. They should count a patient’s ADHD symptoms, look at how a person is doing in their daily life, think about all other possible diagnoses, and gather a history of the patient’s life over time. They should gather information from schools, parents, teachers, family members, and the patient. Providers who are not following these rules risk making incorrect diagnoses.

ADHD is actually on a spectrum. Some people have very strong attention to detail, organization skills, memory, and self-control. Other people really struggle in these areas. Most of us are somewhere in between. A diagnosis of ADHD should only be given when symptoms cause major problems for the person. If a person with ADHD symptoms has good social relationships, is successful at work and school, and stays on top of their responsibilities, a diagnosis of ADHD would not be given. This “impairment” rule prevents ADHD from being overdiagnosed.

A person’s ADHD symptoms also can change over time. A lot of people have ADHD during some years of their life but not others. At any given point in time, 5% of people may currently have ADHD. However, a larger number of people (10% to 15%) may have had ADHD at some point in their life (past or present). Sometimes when people read these higher statistics they get confused about what they mean. They think that ADHD is being overdiagnosed.

Some people do not like the idea of ADHD and complain that it is overdiagnosed without doing their research first. They may not know that chemical imbalances cause ADHD symptoms. They may think that people with ADHD are just lazy or not trying hard enough. Some people who are against ADHD may have struggled with ADHD symptoms themselves. They might think that because they did not get diagnosed, no one else should either. Other people may have different reasons for not liking ADHD. In some cultures, the behaviors we call ADHD are thought about in a different way.

Overall, ADHD is not overdiagnosed. Incorrect diagnoses may be made sometimes. A bigger problem is that many people with ADHD are missed. The biggest source of ADHD misdiagnosis is probably when doctors do not notice uncommon forms of ADHD. If doctors carefully follow the rules of making an ADHD diagnosis, they will usually make a correct diagnosis. If you believe that you or someone you know has been misdiagnosed, seek a second opinion from a doctor who specializes in ADHD.

Margaret H. Sibley, PhD , is an associate professor of psychiatry and behavioral sciences at the University of Washington School of Medicine and a clinical psychologist at Seattle Children’s Hospital. She is a licensed clinical psychologist in Florida and Washington and a member of the Motivational Interviewing Network of Trainers. She has authored over ninety scholarly publications on ADHD in adolescence and adulthood, including a comprehensive therapist’s guide to treating ADHD in teens. Dr. Sibley’s research is funded by the National Institute of Mental Health and the Institute of Education Sciences. She is a member of CHADD’s professional advisory board and serves on the editorial advisory board for CHADD’s Attention magazine.

Overdiagnosis of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents: A Systematic Scoping Review

Affiliations.

• 1 Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.
• 2 Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Queensland, Australia.
• PMID: 33843998
• PMCID: PMC8042533
• DOI: 10.1001/jamanetworkopen.2021.5335

Importance: Reported increases in attention-deficit/hyperactivity disorder (ADHD) diagnoses are accompanied by growing debate about the underlying factors. Although overdiagnosis is often suggested, no comprehensive evaluation of evidence for or against overdiagnosis has ever been undertaken and is urgently needed to enable evidence-based, patient-centered diagnosis and treatment of ADHD in contemporary health services.

Objective: To systematically identify, appraise, and synthesize the evidence on overdiagnosis of ADHD in children and adolescents using a published 5-question framework for detecting overdiagnosis in noncancer conditions.

Evidence review: This systematic scoping review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) Extension for Scoping Reviews and Joanna Briggs Methodology, including the PRISMA-ScR Checklist. MEDLINE, Embase, PsychINFO, and the Cochrane Library databases were searched for studies published in English between January 1, 1979, and August 21, 2020. Studies of children and adolescents (aged ≤18 years) with ADHD that focused on overdiagnosis plus studies that could be mapped to 1 or more framework question were included. Two researchers independently reviewed all abstracts and full-text articles, and all included studies were assessed for quality.

Findings: Of the 12 267 potentially relevant studies retrieved, 334 (2.7%) were included. Of the 334 studies, 61 (18.3%) were secondary and 273 (81.7%) were primary research articles. Substantial evidence of a reservoir of ADHD was found in 104 studies, providing a potential for diagnoses to increase (question 1). Evidence that actual ADHD diagnosis had increased was found in 45 studies (question 2). Twenty-five studies showed that these additional cases may be on the milder end of the ADHD spectrum (question 3), and 83 studies showed that pharmacological treatment of ADHD was increasing (question 4). A total of 151 studies reported on outcomes of diagnosis and pharmacological treatment (question 5). However, only 5 studies evaluated the critical issue of benefits and harms among the additional, milder cases. These studies supported a hypothesis of diminishing returns in which the harms may outweigh the benefits for youths with milder symptoms.

Conclusions and relevance: This review found evidence of ADHD overdiagnosis and overtreatment in children and adolescents. Evidence gaps remain and future research is needed, in particular research on the long-term benefits and harms of diagnosing and treating ADHD in youths with milder symptoms; therefore, practitioners should be mindful of these knowledge gaps, especially when identifying these individuals and to ensure safe and equitable practice and policy.

Publication types

• Research Support, Non-U.S. Gov't
• Systematic Review
• Attention Deficit Disorder with Hyperactivity / diagnosis*
• Attention Deficit Disorder with Hyperactivity / drug therapy
• Attention Deficit Disorder with Hyperactivity / epidemiology
• Medical Overuse / statistics & numerical data*
• Practice Patterns, Physicians' / statistics & numerical data
• Severity of Illness Index

How to Tackle an Essay (an ADHD-friendly Guide)

6 steps and tips.

Most of the college students I work with have one major assignment type that gets them stuck like no other: the dreaded essay. It has become associated with late nights, requesting extensions (and extensions on extensions), feelings of failure, and lots of time lost staring at a screen. This becomes immensely more stressful when there is a thesis or capstone project that stands between you and graduation.

The good news?

An essay doesn’t have to be the brick wall of doom that it once was. Here are some strategies to break down that wall and construct an essay you feel good about submitting.

Step 1:  Remember you’re beginning an essay, not finishing one.

Without realizing it, you might be putting pressure on yourself to have polished ideas flow from your brain onto the paper. There’s a reason schools typically bring up having an outline and a rough draft! Thoughts are rarely organized immediately (even with your neurotypical peers, despite what they may say). Expecting yourself to deliver a publishing-worthy award winner on your first go isn’t realistic. It’s allowed to look messy and unorganized in the beginning! There can be unfinished thoughts, and maybe even arguments you aren’t sure if you want to include. When in doubt, write it down.

Step 2: Review the rubric

Make sure you have a clear understanding of what the assignment is asking you to include and to focus on. If you don’t have an understanding of it, it’s better to find out in advance rather than the night before the assignment is due. The rubric is your anchor and serves as a good guide to know “when you can be done.” If you hit all the marks on the rubric, you’re looking at a good grade.

I highly recommend coming back to the rubric multiple times during the creative process, as it can help you get back on track if you’ve veered off in your writing to something unrelated to the prompt. It can serve as a reminder that it’s time to move onto a different topic - if you’ve hit the full marks for one area, it’s better to go work on another section and return to polish the first section up later. Challenge the perfectionism!

Step 3: Divide and conquer

Writing an essay is not just writing an essay. It typically involves reading through materials, finding sources, creating an argument, editing your work, creating citations, etc. These are all separate tasks that ask our brain to do different things. Instead of switching back and forth (which can be exhausting) try clumping similar tasks together.

For example:

Prepping: Picking a topic, finding resources related to topic, creating an outline

Gathering: reading through materials, placing information into the outline

Assembling: expanding on ideas in the outline, creating an introduction and conclusion

Finishing: Make final edits, review for spelling errors and grammar, create a title page and reference page, if needed.

Step 4: Chunk it up

Now we’re going to divide the work EVEN MORE because it’s also not realistic to expect yourself to assemble the paper all in one sitting. (Well, maybe it is realistic if you’re approaching the deadline, but we want to avoid the feelings of panic if we can.) If you haven’t heard of chunking before, it’s breaking down projects into smaller, more approachable tasks.

This serves multiple functions, but the main two we are focusing on here is:

• it can make it easier to start the task;
• it helps you create a timeline for how long it will take you to finish.

If you chunk it into groups and realize you don’t have enough time if you go at that pace, you’ll know how quickly you’ll need to work to accomplish it in time.

Here are some examples of how the above categories could be chunked up for a standard essay. Make sure you customize chunking to your own preferences and assignment criteria!

Days 1 - 3 : Prep work

• ‍ Day 1: Pick a topic & find two resources related to it
• Day 2: Find three more resources related to the topic
• Day 3: Create an outline

Days 4 & 5 : Gather

• ‍ Day 4: Read through Resource 1 & 2 and put information into the outline
• Day 5: Read through Resource 3 & 4 and put information into the outline

Days 6 - 8 : Assemble

• ‍ Day 6: Create full sentences and expand on Idea 1 and 2
• Day 7: Create full sentences and expand on Idea 3 and write an introduction
• Day 8: Read through all ideas and expand further or make sentence transitions smoother if need be. Write the conclusion

Day 9: Finish

• ‍ Day 9: Review work for errors and create a citation page

Hey, we just created an outline about how to make an outline - how meta!

Feel like even that is too overwhelming? Break it down until it feels like you can get started. Of course, you might not have that many days to complete an assignment, but you can do steps or chunks of the day instead (this morning I’ll do x, this afternoon I’ll do y) to accommodate the tighter timeline. For example:

Day 1: Pick a topic

Day 2: Find one resource related to it

Day 3: Find a second resource related to it

Step 5: Efficiently use your resources

There’s nothing worse than stockpiling 30 resources and having 100 pages of notes that can go into an essay. How can you possibly synthesize all of that information with the time given for this class essay? (You can’t.)

Rather than reading “Article A” and pulling all the information you want to use into an “Article A Information Page,” try to be intentional with the information as you go. If you find information that’s relevant to Topic 1 in your paper, put the information there on your outline with (article a) next to it. It doesn’t have to be a full citation, you can do that later, but we don’t want to forget where this information came from; otherwise, that becomes a whole mess.

By putting the information into the outline as you go, you save yourself the step of re-reading all the information you collected and trying to organize it later on.

*Note: If you don’t have topics or arguments created yet, group together similar ideas and you can later sort out which groups you want to move forward with.

Step 6: Do Some Self-Checks

It can be useful to use the Pomodoro method when writing to make sure you’re taking an adequate number of breaks. If you feel like the 25 min work / 5 min break routine breaks you out of your flow, try switching it up to 45 min work / 15 min break. During the breaks, it can be useful to go through some questions to make sure you stay productive:

• How long have I been writing/reading this paragraph?
• Does what I just wrote stay on topic?
• Have I continued the "write now, edit later" mentality to avoid getting stuck while writing the first draft?
• Am I starting to get frustrated or stuck somewhere? Would it benefit me to step away from the paper and give myself time to think rather than forcing it?
• Do I need to pick my energy back up? Should I use this time to get a snack, get some water, stretch it out, or listen to music?

General Tips:

• If you are having a difficult time trying to narrow down a topic, utilize office hours or reach out to your TA/professor to get clarification. Rather than pulling your hair out over what to write about, they might be able to give you some guidance that speeds up the process.
• You can also use (and SHOULD use) office hours for check-ins related to the paper, tell your teacher in advance you’re bringing your rough draft to office hours on Thursday to encourage accountability to get each step done. Not only can you give yourself extra pressure - your teacher can make sure you’re on the right track for the assignment itself.
• For help with citations, there are websites like Easybib.com that can help! Always double check the citation before including it in your paper to make sure the formatting and information is correct.
• If you’re getting stuck at the “actually writing it” phase, using speech-to-text tools can help you start by transcribing your spoken words to paper.
• Many universities have tutoring centers and/or writing centers. If you’re struggling, schedule a time to meet with a tutor. Even if writing itself isn’t tough, having a few tutoring sessions scheduled can help with accountability - knowing you need to have worked on it before the tutoring session is like having mini deadlines. Yay, accountability!

Of course, if writing just isn’t your jam, you may also struggle with motivation . Whatever the challenge is, this semester can be different. Reach out early if you need help - to your professor, a tutor, an ADHD coach , or even a friend or study group. You have a whole team in your corner. You’ve got this, champ!

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A bit on neurodiversity.

Advocacy for Atypical Thinkers

I wrote this short essay for an assignment in a social policy class back in 2012 or 2013 I think. It was during the first few years after my diagnosis when I was beginning to understand the paradigm of ableist culture.

Neurodiversity is a term coined by sociologist Judy Singer to describe conditions like autism, dyslexia and ADHD.  Her hope was to begin to set a new tone in the everyday discourse about atypical ways of thinking that didn’t focus on the negative deficits and impairments of such disorders.  Singer’s term was adopted quickly by the large and growing autism rights movement.  Today the neurodiversity movement, though rooted in the autism rights movement, is a global movement that encompasses all of the following neurological differences: autism spectrum disorder (ASD) which also includes Aspergers’ Syndrome, dyspraxia, dyscalculia, dyslexia, tourettes and AD(H)D ( neurodiversitysymposium ).

Growing up I was an early victim of the assembly line public school system, immediately being labeled inattentive and disruptive by some teachers, while others reported they found me a delight in class and a model student.  Despite the few positive words, the negative reports are what gained momentum in the chit-chatty teacher circles and before I even finished second grade, unbeknownst to me the next ten years of my academic life had now been pre-determined.

I had applied to community college after high school wanting to start in a general science curriculum, but upon examining my grades and test scores the admissions advisor told me I wasn’t smart enough for science and should consider something like broadcasting because I have a great personality.  Needless to say, I barely survived two semesters of community college before completely dropping out.

I was diagnosed with ADD combined type at age 28, began taking medication and going to therapy to help undo the past 28 years of being told I was stupid or lazy along with learning how to move forward with a fresh outlook.  I know from first hand experience how horrible an experience the world can be when you can’t perform within the established constraints set forth by today’s society.

The neurodiversity movement is an extension of the disability rights movement into the cognitive, affective and perceptual differences realm and is collectively represented by individuals, families, allies, advocates and organizations of the various disorders that fall under its umbrella.  To explore the movement in more detail, I will focus on the ADHD sub-movement as a result of my personal involvement.

The primary return on advocating for neurodiversity is to ensure equal opportunity and rights for atypical thinkers and help to increase awareness and acceptance that will lead to larger scale changes where society can benefit from the many unique talents found within the atypical thinkers group.  Ultimately our goal is to encourage society to appreciate and celebrate cognitive differences while asking for reasonable accommodations in areas like education and the work environment. Given the 10,154 articles on ADHD in the past year, one might be surprised to find that ADHD awareness and understanding are still very limited outside of the institutions, organizations, families and individuals who are directly affected by it.  There are various organizations that exist to provide advocacy and support for the ADHD community including  CHADD  (Children and Adults with Attention-Deficit/Hyper-Activity Disorder),  ADHDAware ,  ADDA  (Attention Deficit Disorder Association) and  help4adhd . These non-profit organizations are funded by donations from individual members and groups in return for providing information, resources and advertising space.  CHADD provides resources and facilities throughout the nation where individuals can obtain support via volunteering professionals and support groups along with local advocacy resources.

The most recurring topic among the three websites mentioned in the previous section is that of dispelling ADHD myths, specifically that of what ADHD really is.  For example:

Public perceptions of attention-deficit hyperactivity disorder (ADHD) are replete with myths, misconceptions and misinformation about the nature, course and treatment of the disorder. Popular misconceptions assert that ADHD is not a disorder or at minimum, is a benign one that is over- diagnosed. Critics often claim that children are needlessly medicated by parents who have not properly managed their unruly, unmotivated or underachieving children, or who are looking for an academic advantage(e.g., testing or classroom accommodations) in competitive, high-stakes educational environments.

The above quote comes from the  help4adhd  website and summarizes the most prevalent myth and awareness issue for ADHD and those who suffer from it.  The site then builds their argument citing various research studies.  Studies over the past 100 years demonstrate that ADHD is a chronic disorder that has a negative impact on virtually every aspect of daily social, emotional, academic and work functioning (Barkley, 1998).  Dr. Russell Barkley  is a research psychiatrist with the State University of New York (SUNY) Upstate Medical University who has devoted the past 40 years of his career to understanding ADHD. On their Myths and Misunderstandings page, help4adhd.org cites 26 different research papers to provide a varied background of information to support their answers and conclusions.

Despite the large number of references to scientific articles, research in the psychological, psychiatric and neurological fields is very challenging for many reasons which are beyond the scope of this paper.  Keeping this in mind, there is always room to question with some inquisitive skepticism as to validity of all the claims made by the researchers.  I know from reading Dr. Barkley’s papers, he clearly states the uncertainties in his studies that he is aware of, how they may skew the data and invites others to replicate his work as to help strengthen or dismiss some of this findings.  

Autism, Aspergers, ADHD, Dyslexia, Dyspraxia, Tourette’s are neurological conditions that can’t be cured or corrected.  Those of us who are born with these neurological differences are quite capable of contributing to society in a many great ways, but unfortunately many of us are lost and tossed aside because of the current rigid structure of society today that is highly unfriendly and unwelcoming to the non-neurotypical types.  

For more on human centered design, accessibility and neurodiversity check out my Medium page .

References: Barkley, R. A., (1998). Attention-deficit hyperactivity disorder: A handbook for diagnosis and treatment. New York: Guildford Press.

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