We have been exploring the theme of ADHD diagnosis this month on ADHD Central. We began with a heated discussion of Why Some People Do Not Believe in ADHD. You gave your opinion and we listened. Next I followed up with an Interview with Michael Laskoff, a writer for the Huffington Post who has been diagnosed with Adult ADHD. Michael's interview points out that ADHD is not just a disorder of childhood and that adults can have it too. There are some experts who say that Adult ADHD is underdiagnosed.
Last week I reported on the news that there will be some major changes made to the Diagnostic and Statistical Manual of Mental Disorders with the new edition of the DSM-5. It seems there may be some big changes for how ADHD, Autism Spectrum Disorders and Pediatric Bipolar Disorder will be diagnosed. They are still in the process of revising the manual and nothing is set in stone as of yet.
Today I wish to continue this theme on diagnosis by discussing the problems which have historically plagued the process of diagnosing ADHD. One of the reasons I feel that some people question the validity of ADHD as a formal diagnosis is due to the overdiagnosing or underdiagnosing of this disorder. Then to add further confusion are the lengthy lists of co-morbid and coexisting conditions which may accompany a diagnosis of ADHD. Not to mention, many of the symptoms of ADHD overlap with other conditions and disorders. What is sometimes diagnosed as ADHD may in fact be something else. One hope is that the streamlining of the diagnostic criteria for ADHD in the newly revised DSM-5 will clear up this confusion and make the process more credible.
In 1998, The Journal of the American Medical Association Council on Scientific Affairs had this to say about the validity of ADHD diagnostic criteria:
"ADHD is a childhood neuropsychiatric syndrome that has been studied thoroughly over the past 40 years. Available diagnostic criteria for ADHD are based on extensive empirical research and, if applied appropriately, lead to the diagnosis of a syndrome with high interrater reliability, good face validity, and high predictability of course and medication responsiveness. ADHD is one of the best-researched disorders in medicine, and the overall data on its validity are far more compelling than for most mental disorders and even for many medical conditions."
This statement was made over ten years ago. Does it hold true today?
The following information is from our ADHD Diagnosis section entitled, Difficulties in Identifying Children with ADHD: "There are currently no laboratory or imaging tests to reliably diagnose ADHD. A diagnosis relies only on behavioral symptoms and ruling out other disorders." So basically we are relying predominantly upon a behavioral checklist. My question about ADHD has always been: how does one reliably rule out other disorders? Why can't a child have both autism and ADHD, for example? Again, there are hopes that the newly revised DSM-5 will address these issues.
Here is but one study reported in our diagnosis information section of ADHD Central indicating that ADHD may be overdiagnosed: "In one center, after careful testing, ADHD was the actual diagnosis in only 11% of children referred for ADHD, and 18% had no disability. Others were simply poorer learners or had no problems at all."
Then there seems to also be evidence to show that ADHD may be underdiagnosed for some populations including females, minorities and adults.
Clearly there seems to be a problem with the current diagnostic process if there are many people who are being given this diagnostic label when they should not be. Likewise there is a problem if there are many people who need treatment for their ADHD but are not getting it because they are not properly identified.
Let's add more confusion to this topic by pointing out the many overlapping, coexisting, or co-morbid conditions of ADHD:
- Our Eileen Bailey discusses Ten Medical Conditions that Share Symptoms with ADD/ADHD including things like Hypothyroidism, lead toxicity and sleep disorders to name a few.
- If you want to see how related conditions to ADHD are diagnosed, please see this informative article by Eileen Bailey, Co-Existing Condtions which cites specific symptoms of each condition or disorder.
- In my post, ADHD and Multiple Diagnoses members chimed in by sharing their experience with having a child who has been diagnosed with ADHD as well as other diagnoses such as OCD, Tourette's Syndrome, and CAPD (Central Auditory Processing Disorder).
Lastly I am going to leave you with a link to A February 10th PBS NewsHour transcript of their show entitled, Psychiatrists Propose Revisions to Diagnosis Manual. The PBS host gets to talk to Dr. Alan Schatzberg, President of the American Psychiatric Association and Dr. Allen Frances, former Chief of Psychiatry at the Duke University Medical Center.
Dr. Frances was involved in revising the last diagnostic manual. It may or may not shock or surprise you to hear some of the things Dr. Frances confesses such as: "But, inadvertently, I think we helped to trigger three false epidemics, one for autistic disorder that you mentioned, another for the childhood diagnosis of bipolar disorder, and the third for the wild overdiagnosis of attention deficit disorder."
In this PBS transcript Dr. Frances goes on to explain the end result of the overdiagnosis of ADHD has been an explosion of prescriptions for stimulants and a secondary illegal market for these drugs. He then cites a statistic that 30 percent of college students use stimulants to do better at school. Some of you have discussed here on ADHD Central that you feel it is becoming more difficult to get the ADHD medications you need because of this misuse of these drugs from people who don't need them. It is a problem which has no easy answers unfortunately.
ADHD does exist. There is much research to prove that this is a neurological condition which requires treatment. But what about the diagnostic process itself? Is it working? Are there different "types" of ADHD? Can ADHD be a symptom of another condition? Why is this disorder being overdiagnosed to the point where it is called a "false epidemic"? As much as this disorder has been researched and discussed, there remain many unanswered questions. Time will tell if new changes to the diagnostic process will help to decrease the current problems inherent in diagnosing ADHD.
Thoughts? We want to hear them
Goldman, L.S., Genel, M.,Bezman, R.J., Slanetz, P.J. (1998) Diagnosis and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. For the Council on Scientific Affairs. American Medical Association (JAMA)279: 1100-1107.
Transcript: Psychiatrists Propose Revisions to Diagnosis Manual. (February 10, 2010 air date) Retrieved from PBS NewsHour.