ADHD Overdiagnosis? I don’t think so…
ByThe news has been buzzing with the results of a new study which suggests that over 1 million American kids are misdiagnosed with ADHD, when they don’t in fact have it.
When I saw these news reports, I got a copy of the article to review it, and I was also interviewed for a TV news show to discuss this issue.
What Does This Research Study show?
This study was published in the Journal of Health Economics. The author, Todd Elder, reviewed statistical information from insurance databases, and prescriptions records to look at the rates of the diagnosis and treatment of ADHD as it relates to birth month.
Each school system has a ‘cut off date’ for kids entering kindergarten. In my local school system, it is January 1st. So, if a child is born on January 1, 2005, he can be in the same kindergarten class as a child born on December 31st, 2005. Of course, these kids are a year apart in chronological age, even though they are in the same year. So there are some kids who are younger than their peers in the same grade, related to their birthday.
This study showed that there was a higher rate of diagnosis and treatment of ADHD in the kids who were younger for their grade compared to kids who were older for their grade. The study also showed that these younger kids were more likely to be taking stimulant medicines in grade 5 and grade 8 related to the higher rate of ADHD diagnosis.
It is important to note that this is not the first study to show this – I found two other studies – one by the same author, and one by William Evans et al who found similar findings. It’s important to note that these other studies were also statistical analyses of databases and not clinical studies. In other words, the researchers did not interview and assess children, or even doctor’s clinical charts to assess the rates of ADHD diagnosis, and the relationship to birth month as it relates to the school entry cut 0ff.
What do I see in my office?
In my clinical office, I see a lot of children and teens with ADD/ADHD who clearly meet criteria for diagnosis. Are there more of them who are younger for their grade? I don’t honestly know – I’ve never been aware to even consider that as a factor.
I have had many kids with ADHD whose parents may have held them back a year in kindergarten because they were younger for their grade, and the parent was concerned about the child’s maturity level and functioning. Did this eliminate lower the risk of ADHD diagnosis? In my opinion, not at all. Kids who met criteria for ADHD who became the oldest in their class (because they were held back a year, so that their November or December birthday made them older than all of the kids who started the year with a birthday after January 1st) still met criteria for ADHD. They may have functioned better… but I can only say that this was an individual response, and I can’t say what it was like for each person.
Who Assesses ADHD As A Factor:
The study suggests that most ADHD diagnoses are done by Pediatricians, and even Family Doctors, and only a small percentage of patients see Psychiatrists, or other mental health professionals. This is mentioned as a criticism, and suggests that more errors are made in diagnosis because of this.
I believe that there are excellent pediatricians and even family doctors who do a very thorough job in assessing and treating ADD/ADHD. Should you refuse to accept a diagnosis unless it comes from a child psychiatrist? Absolutely not. There is such a shortage of child psychiatrists that it would just interfere with diagnosis and treatment if that were to happen.
Does Birth Month Matter?
In his book on success Outliers, author Malcolm Gladwell discusses the factors which help people to succeed. One such factor he discusses is birth month – using the example of Canadian Elite Hockey players. He contends that players who are born early in the year (i.e. January birthdays) are older, bigger, and have more skill than the players with later birthdays (i.e. November, December birthdays). He describes that these players get noticed more readily, and then they get the opportunity to develop their skills more readily. The suggestion is that the ‘advantage’ of an early birthday may provide a slight margin, and then that margin improves chances of developing opportunities through the years, which can widen the gap.
It is possible that a similar process is occurring with ADD/ADHD.
What You Should Do With This Information:
I know that there will be many parents who will read this and say, “My son was born in November or December – does this mean he doesn’t have ADD/ADHD? Does this mean we should stop the medication?’ Here are my suggestions on how to proceed with this information:
- Remember – ADHD is real. This study doesn’t suggest that ADHD is a farce, that it is not a true medical condition, or that it doesn’t need treatment.
- Make sure you had a thorough assessment and diagnosis: You will want to make sure that your child has a proper assessment for ADD/ADHD, and that you are confident with the assessment done. Hold your doctor to a high standard, particularly if you are concerned that your child is born late in the year.
- Do not stop prescribed medication just because you heard about this news story. Talk to your doctor before any treatment decisions are made.
Probably the most important suggestion is #2 – ensure you had a thorough and proper assessment. Realize that I suggest that to everyone, not just people who are concerned that their kids are young for their grade.
What do you think about this issue? Did this news story raise concerns for you? Please share your opinions below in the comments.
Best,
Dr. Kenny
The real problem I see with this study is that by only studying insurance databases, they have automatically skewed the data. the reality is that ADHD is severely under diagnosed in the US because so many families are uninsured, and even among families who are insured, mental health is rarely if ever insured, usually with severe limitations.
Judith Warner’s new book analyzed this, amazing footnotes and research, turns out the rate of pediatric diagnosis is wildly skewed depending on the state and economic status of families. here in Canada, I have friends who can’t get diagnosis or meds for many many mental health problems due to a reluctance of GPs to handle it and a shortage of psychiatrists. but also cutbacks in school boards for assessments.
worst of all is the skewing of kids in care of CAS. boys are automatically assumed to have ADD, and put on stimulants, and girls are automatically put on antidepressants, regardless of actual needs. Ombudsman on Ontario has some scandalous reports detailing it, and the US stories are worse.
It is just as likely that kids who are the oldest in class are under diagnosed, but the researchers knew that wouldn’t sell papers, so. Sigh
And the final possibility, maybe correlation isn’t causation and this whole thing is just a coincidence, like dinner and music. Or cold weather and viruses.
Aurelia – excellent comment. Thank you for sharing the information that you did. It’s very helpful!
I agree that many children are misdiagnosed with ADHD. My 12yr old son was diagnosed as ADHD when he had trouble finishing his work in school. He has always been able to pick up school workvery fast and has always tested well abouve his grade level. We spent thousands of dollars and realized that he was board and felt like he wasn’t being challenged. We found that exercise and a controlled diet did wonders for him. He doesn’t like sports so it was hard to find exercise that he would do. We bought a kidsercise kit from fit your world. it was the first exercise that he actually liked to do. That and adjusting his diet made a huge difference. I am a huge believer in the benefits of exercise!
I think one of the biggest problems for parents is lack of education. Most parents tackle the issue when they are in crisis mode instead of intervention. I have two children and several nieces and nephews with ADHD and its co-exiting conditions. I have looked for a long time to find some source of information that brought together educators, doctors, parents, clinicians, law enforcement etc to proivde information about ADHD and conditions with over-lapping symptoms. I finally found a website that provides this: http://www.questforwhatsbest.info/Quest_for_Whats_Best/Welcome.html. To be able to look at the symptoms of ADHD vs ODD vs Bi-polar disorder can be very helpful to parents so that they feel empowered as they talk to doctors and teachers. These conditions are very real. The more we know, the better we as parents, schools, communities etc can help individual deal with the many struggles that come from having ADHD or any of its co-existing conditions.
I would like to note – Although this comes months late, that the study also doesn’t account for the number of kids who get diagnosed much later in adolescence. I mean, just as an example, I WAS one of the older kids who was “much more likely to get undiagnosed”, so I coasted through School and High School on relatively mediocre grades for what I felt was a higher capacity/potential for learning.
After going through bouts of treatments with sleep medication, antidepressants, it was at Dr. Handelmans office I was finally diagnosed with ADHD – Inattentive type.
Since then, things have improved dramatically, especially in regards to attention, grades, driving, etc. I have much more ambitious goals that I’m striving for now, compared to before. I always enjoyed learning about the brain and psychology, but never had the ability to do well in broader spectrum classes like Biology or Physics. However, in addition to my normal courses (English, Political Science) I have since been able to get the pre-requisites and been enrolled in some of my favorite classes, such as Behavioural Neuroscience, Quantification in Psychology, etc etc.
Whether it’s under-diagnosed or over-diagnosed really is a side issue in my mind. I’m so concerned about every aspect of this disorder. I’m the mother of an adhd son & I’m a teacher. What I see is misunderstood kids, longing to fit in, be acknowledged & accepted. Because of their track record they’re scapegoats for every naughty kid around them who can fly low under the radar but blame them. Of course the teacher/parent will believe it – they’re “always” naughty. We have to not only study this neurological disorder but also the ways we can build self-esteem and strengthen their own awareness of their needs. They need adult advocates as well as an ability to begin to advocate for themselves as early as possible. I really think books are wonderful tools but we need a bigger power and in this country that would be media. We desperately need more media focus on the needs of these struggling and often-times failing young people. We as parents need to know others are out there and understand which is exactly why I recently started a blog to deal with this issue. Charlotte (charlottesadhdweb.blogspot.com)
I’m personally very tired of participating in this debate of whether ADHD is overdiagnosed. It may be a concern for medical professionals but it is also a hot issue- even among people who don’t have and don’t know people with ADHD! They have strong opinions about it, for sure, as well as appallingly little knowledge of it and sometimes a personal preoccupation with people like me cheating by pretending to have ADHD. I always have people tell me I can’t possibly have ADHD. They wonder about my grades and I tell the the truth: I’m nearly a straight A student. Then they look at me as if I’m joking: how can I still say you have ADHD? My son gets Bs and Cs! Surely HE is more likely to have it? “You don’t seem hyper!” precisely. I’m inattentive. And my grades, I gave everything, my health, social life and mental well being for because I wasnt diagnosed until the summer before college. I get tired of explaining to interested but unsympathetic laymen, and tired of feeling my life’s work invalidated because they think it’s an excuse and that because they think it’s overdiagnosed and I have a good SAT score, I must not have it.
Great points, Crystal. Thanks for taking the time to share them.