With increased diagnoses has come widespread concern about the degree of overdiagnosis. This concern is compounded by related increases in use of medications to treat ADHD. Errors are common when diagnoses of ADHD are made. These include indicating a person has ADHD when they do not (designated as a false positive), indicating a person doesn't have ADHD when they do (designated as a false negative), or misclassifying the person's problem. In this respect, some argue that rising ADHD prevalence rates reflect many false positives; others argue the increases reflect a reduction in false negatives.

Variations within and across nations suggest the role of cultural and societal factors in determining rates of diagnosis. For example, in the U.S., cultural attitudes about special education labels such as ADHD and LD, and school accountability policies and pressures have been identified as playing a role in overdiagnoses. For example, in order to meet accountability standards and avoid being designated as low performing schools, districts try to exclude or at least ensure special accommodations for special education students in order to report higher test score averages.

Those arguing that overdiagnosis is a significant problem suggest that: Practitioners' Overdiagnose. Both empirical and observational studies are cited as revealing that practitioners often diagnose ADHD despite limited assessment. For example, in a study of 1,000 clinicians assessing ADHD, only 15% reported regularly using information from multiple sources and settings; other studies have demonstrated false negatives resulting from gender and ethnic bias in the diagnosis process. Conflicting Interests. The relationship between medical/psychiatric diagnosticians and pharmaceutical companies is pointed to as the type of conflict of interest that contributes to ADHD overdiagnosis. Criteria are Pathologically Biased. Diagnostic criteria in the DSM have been described as blurring the line between behaviors that warrant diagnosis and behaviors that reflect a commonplace developmental trajectory. For instance, DSM 5 is seen as further widening the definition of ADHD with the inclusion of more behavioral descriptions and delays the maximum onset age to include late onset diagnosis. The term "clinically significant" in previous editions is seen as having been revised into more lenient descriptions (e.g., behavior that "interferes with or reduces the quality of social, academic, or occupational functioning"). The concern is that changes in DSM may further increase ADHD diagnosis among individuals who display ADHD symptoms but who only manifest minor functional impairment. Forces are at Work that Produce Uncritical Consumer Demand. General and social networking media and ADHD organizations are seen as contributing to increasing demand, overdiagnosis, and overprescription. For example, a variety of websites promote initial home diagnosis based on a small set of symptom related questions. Relatedly, direct to consumer pharmaceutical advertising is seen as the type of mass promotion of ADHD that fuels demand for and overdiagnosis of ADHD along with overprescription of medication (e.g., a particular focus is on parents of students doing poorly at school). Cognitive Biasing Factors. Research emphasizes various cognitive biases that can lead observers to misattribute the source of problems and overestimate prevalence. For example, availability bias suggests there is a tendency to inflate the likelihood of an event based on a few salient examples. Confirmation bias suggests the tendency for one to become attached to an unconfirmed hypothesis and subsequently only attend to and seek information that support the hypothesis while disregarding and minimizing counter evidence. Attribution bias suggests the tendency for observers to attribute an actor's (e.g., a student's) problem behavior to a stable, internal cause. Such biasing factors are seen as playing a role in disparate overdiagnosis of males, adolescents, and some racial groups.

Examples of efforts to counter such arguments suggest that in discussing overdiagnosis: Underlying bias against ADHD diagnosis. The claim is that biasing factors have reified the view that diagnostic rates are excessive. Such bias is seen as perpetuated by media through sensational portrayals of ADHD false positives that mislead people to believe that overdiagnosis is more prominent than it really is. Widely presented anecdotal accounts of children receiving unwarranted ADHD diagnosis along with aggressive pharmacological treatment are cited as misleading the public into overestimating the prevalence of false positives in ADHD. Moreover, the bias against ADHD diagnoses is seen as colluding with the tendency to overemphasize false positives, while deemphasizing estimates of false negatives. Furthermore, cognitive biases (e.g., information availability and confirmation) leading to judgments of overdiagnosis are viewed as reinforced by reports that overstate the case for overdiagnosis. In particular, mass promotion of the idea that ADHD overdiagnosed is seen as contributing to the tendency for people to become attached to an unconfirmed. Improved diagnostic practices. It is widely stressed that changes in DSM 5 are intended to reduce clinician subjectivity in the diagnostic process and increase diagnostic reliability by providing additional behavioral descriptions that include developmentally appropriate examples. It is also emphasized that just because many of the behaviors viewed as ADHD symptoms are commonplace is not a sound reason to question the validity of ADHD diagnoses. Data about Racial Bias. Claims of overdiagnosis due to racial bias are seen as ignoring findings that report racial minority children were less likely than their white peers to receive ADHD diagnosis across early to middle childhood. Related to this, data are referenced indicating racial differences in parental reports about ADHD symptoms in their children, with parents of racial minorities less likely to report such symptoms compared to parents of non Latino whites.

*From: Arguments About Whether Overdiagnosis of ADHD is a Significant Problem – an information resource developed at the national Center for Mental Health in Schools at UCLA based on material culled from the literature and drafted by Joyce Chen as part of her work with the Center. Online at: http://smhp.psych.ucla.edu/pdfdocs/overdiag.pdf

For more on this, see


• Center for Mental Health in Schools (2013). Schools and the challenge of LD and ADHD misdiagnoses. Los Angeles: Author at UCLA. http://smhp.psych.ucla.edu/pdfdocs/ldmisdiagnoses.pdf
  
  
• Hinshaw, S. P., & Scheffler, R. M. (2014). The ADHD explosion: Myths, medication, money, and today's push for performance. Oxford University Press.

WHAT’S YOUR TAKE ON ALL THIS? Send comments for sharing to Ltaylor@ucla.edu

You can also post a response on our Facebook page.

In addition, see the list of Emerging Issues identified over the years by the Center and used as a stimulus for discussion on our Net Exchange - http://smhp.psych.ucla.edu/newnetexchange.htm

Previously highlighted hot issues

• Moving Beyond the Concept of Integrated Student Supports

• Special Education Disputes Continue to Reflect the Many Issues that Permeate the Field

• Maintaining Momentum for Sound Systemic Changes When the Superintendency Changes

• And Yet Another Discrete Initiative!

• Enabling Learning: It's a Bigger Policy Problem than Most Education Reformers Appreciate

• Reporting on Teacher Effectiveness: The Discussion Heats Up

• Reauthorizing the No Child Left Behind Act and Addressing Barriers to Learning

• Grade Retention: What's the Prevailing Policy and What Needs to be Done?
• Suicide Prevention in Schools
• Should Policy Specify a Formal Role for Schools Related to Mental Health?
• Screening Mental Health Problems in Schools

  ---

  Table of Contents

  Home Page

  Search

  Send Us Email

  WebMaster: Perry Nelson mailto:smhp@ucla.edu