3 Situations Where a Child May Be Overdiagnosed with ADHD

A frustrated, upset child, or child with learning difficulties.

The number of children diagnosed with ADHD has skyrocketed over the last 30 years. But do more kids have ADHD, or are other factors in play?

The number of children diagnosed with ADHD has skyrocketed since the early 2000s, and with it, so have prescriptions for powerful stimulant medications — with a long list of side effects — that many doctors are too often eager to dole out.

So, what’s going on here? Why are so many more children being exposed to medications like Adderall and Ritalin, with side effects including poor appetite, stomach aches, irritability, sleep problems, and slowed growth. There are even some indications that ADHD meds are linked to hallucinations and psychosis.

Have so many of our children always had ADHD and we just missed it? Has some cataclysmic genetic or epigenetic shift taken place, causing ADHD to be the most prevalent childhood disease second only to obesity? I don’t think so.

I believe the increase is due to 2 factors: Overdiagnosis due to poor evaluation and pressure by society for treatment, and increasing pressure being put on children and families.

With this in mind, what’s a parent to do? As a pediatrician who has studied ADHD for decades, there may be situations where your child might be misdiagnosed with ADHD. Here are 3 such examples to look out for to make sure your child isn’t needlessly given medication and other possible issues are not overlooked.

1. If you do not see symptoms of ADHD both at home and at school

Your daughter, Sarah, is in the middle of 3rd grade and the teacher says that she is not able to focus on academic tasks and tends to be disruptive in class. You are puzzled because Sarah is quite well behaved at home and does not seem to have trouble focusing, getting work done, or have any other of the symptoms of ADHD that you have read about.

But you see your pediatrician, who speaks to you for a few minutes and then gives you ADHD questionnaires for yourself and her teacher. Two weeks later, you see the pediatrician again, and he says the teacher’s questionnaire is positive for ADHD and yours is not. The pediatrician suggests a trial of a stimulant medication like Ritalin, to see if Sarah really has ADHD. You wonder if perhaps you should give the medication a try.

This is a situation in which the possibility of overdiagnosis is very high. First, the accepted definition of ADHD is that the symptoms “have an impact in 2 areas of life.” In children, this is home and school. Clearly this is not the case. When the problem is only in one of these areas, one must look very carefully to see if there is some other issue that is causing problems that may be interpreted as ADHD.

Second, just using questionnaires is an inaccurate way to make the diagnosis. In one study, children had a complete ADHD evaluation and this was compared to the results of just using the questionnaires. Two-thirds of the children diagnosed as having ADHD only using the questionnaires were misdiagnosed; that is, they did not have ADHD based on a more complete evaluation. These questionnaires were never meant to be a “stand-alone” diagnostic tool. They are highly subjective, with scoring easily influenced by the intentions and prejudices of those filling them out.

Finally, a trial of a stimulant drug is not a good way to confirm a diagnosis of ADHD. Most kids will focus better with these medications whether they have ADHD or not, much like most adults focus better if they drink coffee. Therefore, this method should never be used to determine if a child or adult has ADHD.

So what would constitute a good ADHD evaluation and who would do it? There are a number of types of professionals who would be qualified to make the diagnosis of ADHD. These would include pediatric psychiatrists, pediatric neurologists and developmental pediatricians. Some general pediatricians and family doctors or nurse practitioners would be qualified if they had the time and expertise to devote to the evaluation, which is not true for most generalists. Child psychologists can make the diagnosis,  but a medically trained provider should be included in that case.

The evaluation should consist of interviews with both the parents and the child, separately when the child is old enough. Teacher feedback is crucial, at least with the questionnaires but ideally with telephone interviews or email feedback. Information from counselors, tutors or others directly involved with the child can be very helpful. In many cases, psychoeducational or neuropsychological testing to rule out learning disabilities, anxiety disorder, or other issues is very important, although not required for all children.

School observation can also be very helpful. In my opinion, blood tests for levels of iron and zinc are necessary, although this is not an opinion shared by most mainstream providers. Overall, if the initial evaluation and treatment plan are scheduled for less than 2 hours, I do not believe there will be time for an adequate evaluation.

2. When a child is having attention problems with only one subject area

Johnny is in 2nd grade. During any reading or writing assignment, he has trouble staying focused and finishing his work. He is falling behind academically. He may even be disruptive; talking to other students, getting out of his seat, becoming uncharacteristically defiant. At home, the reading and writing homework takes forever. Johnny does not want to sit down and do it. He needs frequent breaks, and anger and tears are common. As was the case with Sarah, ADHD questionnaires are positive, this time with both parents and teachers, and medication is recommended.

However, more in-depth questioning reveals that the opposite is true of math or any other assignment that that does not involve reading. He breezes through math homework both at home and at school. He has no trouble focusing on art projects, and is a well-organized boy who rarely loses things or forgets his assignments. Mom remembers that even early reading was very difficult for Johnny.

In this situation, dyslexia, or a reading disability, is a very strong possibility. Children with reading disabilities have a difficult time picking up the basics of learning. It can become frustrating and aversive to them. They may begin to act out or stop paying attention when any reading or writing work is required. This may also result in behavioral problems. The crucial issue here is the dyslexia, though, not the ability to pay attention.

The major clue here is the ability to focus and complete math assignments so easily. This would not be true if the only issue was ADHD. Johnny needs psychoeducational testing to evaluate for learning disabilities. This problem can be tricky because many children have both learning disabilities and ADHD. This is where a team approach, including testing by a psychologist, is crucial.

3. A child with emotional problems

These could include anxiety, depression, or PTSD. Children with these issues may find it very difficult to concentrate on academic subjects. Anxiety, especially, is often confused with ADHD. It is well known that a mild level of anxiety, as most of us feel when taking a test or meeting a deadline, can improve performance. However, higher levels of anxiety can severely impair performance. This can result in a destructive feedback cycle, as these children begin to do poorly and then become understandably more anxious about their poor performance. A similar pattern may occur with depression or PTSD.

As with learning disabilities, this can be difficult to sort out, as a child can have both emotional issues like anxiety or depression and ADHD. Again, this requires careful evaluation, often with the help of a mental health professional.

One thing to watch for especially is when a child who previously had no symptoms suggestive of ADHD suddenly develops these symptoms. This may indicate that some event has caused symptoms of anxiety, depression, or PTSD. Careful history may uncover a source of these feelings, including bullying, family issues, or even sexual or physical abuse.

These are just a few of many situations where ADHD may be overdiagnosed. I hope it is clear that the solution to these and other diagnostic problems rests with a careful and complete evaluation by a provider who is knowledgeable, skilled, and willing to take the time to do it properly.

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