ADHD in children: What you should know about diagnosis & overdiagnosis

© 2022 Gwen Dewar, Ph.D., all rights reserved

The difficulty of identifying ADHD in children

Diagnosing ADHD, or attention deficit hyperactivity disorder, is intrinsically problematic.

The symptoms—distractibility, impulsivity, and hyperactivity—are consistent with the normal behavior of young children.

So when young children are diagnosed, the implication is that they aremore distractible, impulsive, or hyperactive than theyshould be for their age.

But where do we draw the line between developmentally-normal behavior and medical disorder?

That's a crucial question because diagnosis rates among very young children are on the rise, and many kids are beingness medicated.

According to historical health information collected in the U.s., the pct of 2-to-five-year-olds diagnosed with ADHD increased past 50% between 2008 and 2022 (Danielson et al 2017).

And a report by the U.S. Middle for Affliction Control indicates that children diagnosed in this age group are more than likely to receive prescription medication (Visser et al 2016).

Should we be concerned virtually these trends? I recall so, and public wellness experts agree.

In a recent review of published studies, Luis Kazda and her colleagues (2021) written report evidence that ADHD is being over-diagnosed and over-treated.

In addition, they note that medication comes with side effects. And beingness stuck with a label of ADHD? That can sometimes take negative psychological consequences.

So for kids who are wrongly diagnosed — or who suffer from just mild or borderline ADHD symptoms — diagnosis and treatment might exercise more harm that good (Kazda et al 2021).

Here I review current ideas nigh ADHD in children, including reasons for doubt and caution.

It's non a comprehensive account of ADHD, and information technology's not meant to deny that some kids endure from important attention or hyperactivity problems. If yous call up your child might accept ADHD, you should discuss your concerns with a physician.

But the post-obit account provides an overview of the reasons why parents should practise a healthy skepticism when information technology comes to diagnosing and medicating immature children for ADHD.

i. Defining ADHD in children

Attention arrears disorder, or ADHD, has been defined every bit "the co-existence of attentional problems and hyperactivity."

According to the American University of Child Adolescent Psychiatry (AACAP), this means a kid who

• seems to be in constant movement—squirming and fidgeting and moving effectually the room;
• behaves impulsively, blurting out comments without thinking them through first;
• presents unrestrained displays of emotion; and
• tends to get bored chop-chop, unless it'southward an activity the child peculiarly enjoys.

The ADHD child opens in a new window"may oftentimes be easily distracted, make devil-may-care mistakes, forget things, have trouble following instructions, or skip from one action to another without finishing anything."

In add-on, the child must be symptomatic for at least half dozen months, and the symptoms must interfere with the kid's ability to function in at to the lowest degree two areas of life:

• at home,
• in the classroom,
• on the playground, and
• in other social settings.

In an article online, the American University of Kid Adolescent Psychiatry also specifies that the symptoms should emerge earlier the historic period of 7 years.

2. Is it possible to diagnose a young child with ADHD?

It's possible, but information technology's problematic. Why? Because young children are naturally squirmy, impulsive, and prone to emotional outbursts. They accept shorter attending spans. They find it hard to follow directions and stay on task.

In other words, information technology'due south normal for young children to behave in means that mimic ADHD. These are age-typical behaviors. If nosotros're patient, we may detect that young children will grow out of their ADHD "symptoms."

To run across what I mean, consider the results of a written report conducted in Sweden. Researchers screened 422 first graders for signs of ADHD by request parents and teachers to answer a standard, x-indicate questionnaire (the "Conners x-detail scale").

Iii years afterwards, they checked on the children's progress.

Did the early screening predict which kids would receive a formal diagnosis of ADHD in the fourth grade?

It did, but with a big margin of error. The verybest predictor–which was a combination of high scores from both parents and teachers–had a positive predictive value of l%, meaning that only half the children who screened positive for ADHD in the first grade ended up with a formal diagnosis in the quaternary grade (Holmberg et al 2013).

3. How early on are children existence tested for ADHD?

Western organizations, similar the American Academy of Pediatrics, have suggested that children can exist diagnosed as early as four.

Just it appears that some kids are getting tested and diagnosed at even younger ages. Based on a recent survey of more than 45,000 kids in the U.s., approximately 2.4% of children between the ages of two and 5 have been diagnosed with ADHD (Danielson et al 2018).

4. Why are nosotros testing children and so immature?

Are we imposing unrealistic demands on them, and then diagnosing them with ADHD when they fail to see those demands?

I'm non a psychiatrist, and I'm not saying we should dismiss all early diagnoses every bit erroneous. Only I think we demand to consider the possibility thatcultural factors are playing an of import role in the diagnosis of ADHD.

In places like the United States — where ADHD diagnoses are on the ascension — young children may face special challenges.

They attend daycare or preschools where adults are continually telling them where to become and how to deport.

They attend kindergarten classes that are more enervating, more than academic than classes were in previous generations.

In consequence, information technology seems to me that many young children are being asked to comport similar niggling office-workers.Sit at your desk. Pay attention to my instructions. Stay on task. Don't talk out of turn.

Some kids might thrive in these environments. They are more developmentally-avant-garde than their peers, and they discover it relatively easy to comply.

Merely other kids may struggle. Not because they have ADHD, but considering they are developmentally-normal individuals who aren't yet equipped for the mature demands adults are placing on them.

We're just asking too much. Kids neglect to encounter our standards, and we perceive that the children endure from behavior problems — and, possibly — ADHD.

What makes me think this is going on? One line of evidence isanthropological.

To put the "niggling office-worker" demands into perspective, consider how children are treated in other cultures.

Around the world, people living in traditional societies evidence remarkable agreement.They don't expect kids to evidence much cocky-discipline until they are vi or 7 years sometime.

For instance, in a famous study, psychologist Barbara Rogoff and her colleagues reviewed attitudes about children in 50 different traditional cultures — including societies where people make a living by foraging, herding, and farming (Rogoff et al 1975).

The researchers asked all sorts of questions. At what age do people think kids are capable of making rational decisions and showing common sense? When should adults expect kids to follow rules? At what historic period should adults brand an earnest attempt to teach kids manners and etiquette?

The answers were pretty consistent.

In near places, people didn't expect children to playrule-based games until they were at to the lowest degree 6 years quondam.

They didn't expect kids to bear witness common sense or rationality until they were at to the lowest degree 6.

They didn't make a special effort to teach children social etiquette until kids were around 7 years old.

And so we see a different set of expectations here, relative to the "picayune office-worker" expectations that some preschoolers may encounter in places like the United States.

A 4- or 5-twelvemonth-erstwhile who struggles in a U.s.a. preschool classroom might have no difficulty meeting the standards of a traditional, pre-industrial society.

In the United States, people wonder if the kid has ADHD. In a traditional, pre-industrial culture, people don't perceive anything anomalous or pathological. They view the child's behavior as developmentally-normal.

The difference is cultural.

What else?

5. Western statistical studies suggest that young children are being misdiagnosed for exhibiting age-appropriate beliefs.

The first look at a troubling pattern

Todd Elder of Michigan State University wanted to know if children are beingness misdiagnosed with ADHD because they show normal levels of distraction and hyperactivity for their age.

Then he trawled through some old information: a large, longitudinal study of kindergartners conducted by the U.S. National Heart for Education Statistics (Elder 2010). And he took a look at two groups of kindergartners:

• the youngest kids, who were born in the month prior to their state's cutoff date for kindergarten, and
• the oldest kids, who were born in the month immediately after the cutoff.

Elder'due south reasoning went similar this. If kindergartners are getting diagnosed with ADHD because they take a real psychological disorder—and not because they show developmentally-normal signs of immaturity—then there should exist no correlation between a child's age and his or her diagnosis.

In other words, the youngest kindergartners should exist no more than likely than the oldest kindergartners to get diagnosed with ADHD.

But that's non what he found. On the reverse,  the youngest kindergartners were 60% more likely to be diagnosed with ADHD than were the oldest kindergartners.

And being labeled with ADHD seemed to take lasting consequences. When Elder examined older kids, he institute that the youngest students in the fifth and 8th grades were twice as probable to be medicated for ADHD.

Based on his analysis, Elder estimates that as many equally 20% of the 4.5 1000000 American kids identified with ADHD have been misdiagnosed (Elder 2010).

International studies report a similar trend

Elder's results have been replicated past researchers in other countries.

For instance, in Taiwan, investigators found that boys and girls born in August (the last calendar month before the official school cutoff) had 63% higher odds of being diagnosed than kids born in September. Their odds of being medicated were 76% higher (Chen et al 2016).

In Sweden, six-twelvemonth-old kids built-in in the two month interval earlier the cutoff had 80% higher odds of existence prescribed ADHD medication compared with kids built-in in the two month interval after (Halldner et al 2014).

The relative age upshot has too been documented in Canada (Morrow et al 2012) and Israel (Hoshen et al 2016).

And — overall — in that location's reason to think that some kids are being wrongly diagnosed.

In a recent review of the scientific literature, Luise Kazda and colleagues analyzed 334 published studies of ADHD in children and adolescents. The researchers ended that there is convincing show that ADHD is overdiagnosed (Kazda et al 2021).

half dozen. If kids are being over-diagnosed because of inappropriate expectations, what can nosotros do about it?

In that Swedish study I just mentioned, the researchers noticed an interesting pattern: The youngest kids in the classroomdidn't seem to take more troubleat home. Parental reports of ADHD-like symptoms were unrelated to a child's relative age.

So force per unit area to diagnose kids with ADHD was mostly coming fromschoolhouse. What tin we practice to alleviate that pressure?

One approach is to filibuster school entry for kids who aren't ready. Equally the Swedish researchers note:

"…[F]lexibility regarding age at schoolhouse start according to private maturity could reduce developmentally inappropriate demands on children and meliorate the precision of ADHD diagnostic practice and pharmacological treatment."

This approach is common in Kingdom of denmark, which may explain why researchers in that country have found near no relative historic period effect on medication use Pottegård et al 2014).

Only another culling is to adjust our expectations about what kids tin can do.

Can we redesign school in ways that acknowledge individual differences in maturity level? Or is would this be too costly and difficult to manage? These are important questions to research and debate.

vii. What near the genetics and brain chemistry of ADHD?

Doesn't biology prove that distractible, hyperactive kids have a medical problem? Isn't that enough to demonstrate that a child needs medication? Not exactly. What biological science supports is that there is a spectrum.

Granted, information technology's true that ADHD is highly heritable.

We know this from twin studies that compare identical twins (who share almost 100% of their genetic polymorphisms) with fraternal twins (who share, on average, just fifty% of their genetic polymorphisms).

Identical twins are much more probable than fraternal twins to share a diagnosis of ADHD (Faraone and Mick 2010).

Presumably, that'due south considering there are genes that play a role in the development of ADHD. These genes may lawmaking for traits that modify levels of neurotransmitters in the brain.

Researchers take developed medications that target specific neurotransmitters, and some of these medications have high success rates in helping ADHD patients control their symptoms, at least in the short-term (Stuhec et al 2015).

But that doesn't prove that every individual diagnosed with ADHD has a disorder. And it doesn't mean that everybody benefits from medication.

The observation that kids with ADHD share certain genes—or even sure neurotransmitter profiles—is interesting, but not unusual. We tin can say the same thing well-nigh kids who are shy, or perennially cheerful, or more ambitious than average (DiLalla 2002).

People are dissimilar, in part, considering they deport different genes and develop different encephalon chemistries. That doesn't imply that all differences are pathological. Nor does information technology peculiarly affairwhy private differences evolved—not when nosotros're trying to decide if Marcus or Sylvia needs to exist medicated.

Some researchers speculate that development has favored certain "ADHD genotypes." For example, one theory posits that ancient social groups would have benefited by having a few ADHD-types as members. The more hyperactive, distractible people would accept been the trailblazers—the people who sometimes discovered new survival tactics (Williams and Taylor 2006).

Information technology's an interesting theory. Simply information technology doesn't—by itself—tell u.s. whether a specific individual'south beliefs is consistent with an ADHD diagnosis. And even if we make the sentence that a kid has ADHD, we must weigh the costs of specific treatments (like the risks of side-furnishings for taking a detail medication) against the credible benefits.

For example, we might judge that a child has indisposition, only that diagnosis doesn't imply that medication is the all-time response. Subsequently examining the best available prove, we may determine that the costs of medication (the issues and risks posed past side effects) outweigh any apparent benefits.

The aforementioned is true of an ADHD diagnosis. The most frequently prescribed drugs for ADHD have been linked with slumber problems, poor appetite, and abdominal pain (Storebo et al 2015; Punja et al 2016). For some people, such risks may make drug apply undesirable.

Moreover, information technology's of import to understand that these stimulants are classified as schedule Ii drugs by the FDA, indicating that they have a high potential for corruption and severe dependence. When driveling or taken in loftier doses, the drugs may cause psychosis (Lakhan and Kirchgessner 2012).

Finally, nosotros should be concerned about what we don't know. As the authors of leading meta-analyses have noted, virtually all of our noesis of side furnishings is based on "very depression quality evidence" (Storebo et al 2015; Punja et al 2016). Studies are poorly-controlled, and typically track children simply for short intervals.

This conclusion nigh the state of inquiry on ADHD-prescribed amphetamines summarizes the nature of the trouble (Punja et al 2016):

"Well-nigh of the included studies were at high hazard of bias and the overall quality of the bear witness ranged from depression to very depression on most outcomes. Although amphetamines seem efficacious at reducing the core symptoms of ADHD in the brusque term, they were associated with a number of agin events…Future trials should be longer in duration (i.east., more than 12 months), include more psychosocial outcomes (e.chiliad. quality of life and parent stress), and exist transparently reported."

8. How else tin can we explicate symptoms of ADHD in children?

Are some kids just "overtired?"

Immature children aren't the only people who have problem property withal and controlling their impulses.

Experimental studies show that unproblematic school kids become more than moody when they get less sleep (El Sheikh and Buckhalt 2005). Even adults become more than distracted and emotional when they are sleep-deprived (Yu et al 2007). Are some kids diagnosed with ADHD really only suffering from sleeplessness?

It's plausible. Studies confirm that ADHD-diagnosed kids are more than likely to suffer from slumber disorders (Shur-Fen Gau S 2006; Chiang et al 2010; Hansen et al 2013; Moreau et al 2013). And in ane study, kids who were treated for specific sleep problems, like obstructive sleep apnea, experienced improvements in their ADHD symptoms (Huang et al 2007). Could your kid's troubles stalk from poor sleep? It's worth investigating.

Other conditions that tin mimic symptoms of ADHD in children include

• thyroid bug
• clinical anxiety or depression
• emotional traumas and sudden life changes
• lead poisoning
• undetected seizures

It's also possible that some cases of ADHD in children are caused by poor working memory.

9. Denying that ADHD exists at all

You may have heard the claim that ADHD doesn't be. That it's a "lie" being perpetrated by special interests, like drug companies. Is this a valid point of view?

As with near claims, it depends on your specific pregnant. It'due south not a prevarication that some people are more distracted, impulsive, or hyperactive than others. Information technology's not a lie that some of these people endure substantial impairments in their daily lives. And information technology'due south clear that attention deficits and hyperactivity — like other traits — are related to differences in brain chemical science.

So in that location's no question that millions of people fit the medical definition, and many of these folks accept serious bug. What's less clear is causation. Exercise people diagnosed with ADHD stand for a group affected by the same underlying causal mechanisms? Or is the population of ADHD patients a mixed bag? A drove of people who experience like behavior problems for a variety of different reasons?

If your definition of ADHD depends on identifying a single, underlying crusade that explains the symptoms of anybody who gets diagnosed, and then there is reason to dubiousness the existence of ADHD. The science isn't there, at least not yet.

But that'southward a very restrictive definition. If nosotros took the same line confronting, say, indisposition, then we'd take to incertitude the being of insomnia.

If you take a less restrictive definition, the label captures a real phenomenon: Individuals struggling with behavioral tendencies that put them at a serious disadvantage in their everyday world.

More reading

For more reading on related topics related to ADHD in children, bank check out these inquiry-based tips for helping children develop self-control and my manufactures about the psychological benefits of play and working retentivity in children.

In addition, for more than cross-cultural insights about child beliefs problems, check out my article, "Why kids rebel (and what we can practise to encourage cooperation)."

---

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Content of "ADHD in children" concluding modified four/21

Portions of this text are derived from an earlier version of this article.

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