Attention Deficit Hyperactivity Disorder Misdiagnosis

Introduction

ADHD misdiagnosis in children literally means there are mistakes in the diagnostic process conducted by the medical practitioner or other stakeholders involved, such as the teacher or the care provider. The literature states that the process of diagnosis should be conducted in at least two settings (i.e. at home and school) and that multiple people should be involved, including the parents or primary care provider, the teacher, and the medical practitioner. These major stakeholders should coordinate with each other and help in identifying the symptoms, but not to the extent of overdiagnosing or underdiagnosing.

The articles on ADHD misdiagnosis were taken from peer-reviewed journals, which were searched from online databases (EBSCOHOST, Academic Search Premier, ProQuest, and so forth). The inclusion criteria should only include articles focusing on ADHD diagnosis/ misdiagnosis, with empirical studies using variables for the study of ADHD. Most of these sources were recent articles, except the articles by Barkley (1990), Weinberg and Emslie’s (1991) study, and the article by Nicholas and Baird (2000). These early studies were included because of the relevant information they provided about ADHD diagnosis. The studies, including the sample, methods, and analyses used are summarized in table 1.

The different appropriate steps involved in ADHD diagnosis are not known. The diagnostic process should include examining the brain and its functions, after a child is referred by the teacher (Weinberg & Emslie, 1991). Therefore, ADHD diagnosis is not a one-step process.

Researchers view ADHD as a psychiatric problem that is commonly associated with growing children. Common ADHD symptoms that are also prevalent in other disorders include “inattentiveness, hyperactivity, and impulsivity” (APA as cited in Barton, 2001). According to the American Psychiatric Association (APA), ADHD is present among 3 to 7 percent of all school-aged children in the United States (APA as cited in Sciutto & Eisenberg, 2007).

Article/Authors sample methods Analysis
Asherson et al., 2010 Four studies: Swensen et al., 2004; Birnbaum et al., 2005; Secnik, Swensen, & Lage, 2005; Kessler et al., 2009 Review of the Literature Qualitative/Quantitative
Barton, 2001 17 articles on ADHD and BPD Review of the literature and comparison of ADHD and Bipolar Disorder (PBD) Qualitative analysis; comparison of ADHD and BPD symptoms
Cuffe, Moore, & McKeown, 2009 41,000 households with 107,000 persons sampled Review of the literature (clinical data) from the Centers for Disease Control and Prevention Qualitative analysis, diagnosing Strengths and Difficulties Questionnaire (SDQ) and ADHD
Dang et al., 2007 Unidentified number of students referred to the Student Study Team or Student Success Team ADHD Identification and Management in Schools (AIMS) framework Qualitative analysis
Lee & Olenchak,2015 41 articles about ADHD and giftedness were reviewed Review of the Literature Qualitative and quantitative analysis
Manuzza et al., 2011 207 6- to 12-year-old White boys; a comparison group of 178 non-ADHD White males Participants were referred because of behaviour; Conners Teacher Rating Scale (CTRS) was the method used to assess the boys Qualitative analysis and follow-up, using reliability and validity of the impairment/distress ratings
Morley, 2010 35 African-American & Latino children Strengths & Difficulties Questionnaires Qualitative
Nelson, Rinn, & Hartnett, 2006 21 articles reviewed Review of the Literature; critique on Mika’s (2006) article Qualitative analysis; critique of the articles
Nicholas & Baird, 2000 3 ADHD teenaged boys and an 11-old-girl were used as case studies Case study and review of the literature Qualitative; analysis of the DSM-IV diagnostic criteria
Safer, 2015 6 parents, 12 ADHD outpatients 26 sets of standard ratings Qualitative and quantitative analysis
Sciutto & Eisenberg, 2007 14 studies on prevalence of ADHD in U.S. Review of the Literature; evaluation of prevalence studies Qualitative analysis
Serrano, Ezpeleta, & Castro-Fornieles, 2011 100 children with ADHD Interviews and questionnaires Qualitative analysis
Silverstein et al., 2016 156 children Face-to-face interviews; Adult ADHD Self-Report Scale; caregiver health literacy using the Brief Test of Functional Health Literacy Statistical analysis
Vance & Luk, 2000 31 articles reviewed Review of the Literature Qualitative analysis
Williamson, Koro-Ljungberg, & Bussing, 2009 8 teenagers, mothers, and teachers Interviews and treatment Qualitative analysis

Table 1. Studies of ADHD diagnoses and methods used.

Misdiagnosis entails errors in the process of diagnosing, meaning that children who do not have ADHD are incorrectly diagnosed with the disorder. Studies have shown that there is a definable percentage of children who should fall within the diagnostic level. If physicians and others involved diagnose ADHD at a rate that exceeds this level, there is overdiagnosis, meaning that more children are diagnosed as having ADHD than actually have the disorder (Sciutto & Eisenberg, 2007).

Morley (2010) has noted that there are discrepancies in the assessment, diagnosis, and treatment of ADHD and that disparities exist between racial and socioeconomic groups. Trends in ADHD diagnosis and treatment do not coincide with the direction of diagnosing who are seen to meet the criteria. ADHD diagnosis involves not only psychiatric doctors but also the child’s teacher or the primary care provider (Morley, 2010). The two-settings principle (commonly the home and school) provides reliable information significant to the diagnostic process (Silverstein et al., 2016). In addition to information from teachers and care providers, clinical data are also considered reliable in predicting accurate ADHD diagnosis (Silverstein et al., 2016).

Background

Clinicians must have a strategy to accurately diagnose children and adolescents with apparent symptoms of ADHD. Doctors have to examine beyond what they see and perceive as a mental disorder because common ADHD symptoms may actually be the result of another underlying illness or disorder. The clinician should know that ADHD can lead to a health problem as fever also is a symptom of infection or inflammation and their causes. This circumstance actually leads to misdiagnosis.

The symptoms common to ADHD have been perceived very differently throughout history. In the 1930s, the symptoms of impulsivity and hyperactivity were associated with brain-damaged children. Further, in the 1940s and the 1950s, children with the cited symptoms were considered to have Strauss syndrome. Then in the 1960s, this same group of children was thought to have brain dysfunction and was classified as having hyperkinetic-impulse disorder, also known as Hyperactive Child Syndrome (Weinberg & Emslie, 1991).

In recent years, they are simply called children or adolescents with ADHD. Though the symptoms of hyperactivity may seem simple to identify, the literature recommends that ADHD diagnosis be a long, careful process of examining the child involving clinicians, teachers, and parents. In some cases, gifted children are mistakenly diagnosed as having ADHD. A lack of proper training in diagnosing and dealing with gifted children may lead psychologists to misinterpret the behaviors of gifted children (Amend & Beljan, 2009).

Children with ADHD are diagnosed from the time they show symptoms of hyperactivity, impulsivity, inattention, or a combination thereof, up through teenage years and even into adult life. The symptoms are maladaptive and not consistent with normal development. These symptoms should be demonstrated by the child in at least two settings, most likely at home and at school. Some or all of the symptoms may decline as the child grows, though some people continue to display ADHD symptoms throughout their lifetimes (Williamson, Koro-Ljungberg, & Bussing, 2009). The context of the two settings demonstrates the disorder’s pervasiveness, which is the “key diagnostic criterion” for ADHD (Vance & Luk, 2000, p. 719).

Asherson et al. (2012) have argued that one of the reasons for the perceived underdiagnosis of adult ADHD can be attributed to cultural factors. Asherson et al. (2012) conducted a review of the literature covering a period of 10 years, and they found that much of the existing research has focused on the difficulty in diagnosing adult ADHD. However, the articles provided the information that cultural factors influenced ADHD diagnosis.

In diagnosing ADHD, medical professionals should follow the guidelines set forth by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV as cited in Manuzza et al., 2011). This standard system of nomenclature classifies mental disorder symptoms according to their severity, which includes factors such as the intensity, frequency, and duration of the symptoms. To avoid underdiagnosis and overdiagnosis, psychologists should determine whether the exhibited symptoms cause significant impairment in the contexts of “social, academic, or occupational functioning” of the child (APA as cited in Manuzza et al., 2011).

Another reason for the misdiagnosis of ADHD is the confusion brought about by the disorder’s frequent comorbidity of other conditions, including BPD, a disorder that is “characterized by repeated cycles of disturbance in [a] patient’s mood and level of activity” (Nicholas & Baird, 2000, p. 596). Moreover, the definition of BPD almost exactly coincides with the ADHD definition, which may cause confusion in the diagnostic process.

Lee and Olenchak (2015) have similarly focused on the misdiagnosis of gifted children; because the term “gifted” has a vague definition along with ADHD, the two may be confused, resulting in a misdiagnosis. The occurrence of misdiagnosis between ADHD and giftedness is more than a myth, according to Nelson, Rinn, and Hartnett (2006). Goerss et al. (2006) have argued that there is a problem of misdiagnosis of giftedness for ADHD fostered by Mika (2006 as cited in Goerss et al., 2006).

The National Health Interview Survey (NHIS) helps identify symptoms of ADHD and thus prevent overdiagnosis or underdiagnosis of the disorder. To determine the possibility of ADHD, the NHIS offers the Strength and Difficulties Questionnaire (SDQ), which focuses on medical problems and other health symptoms of children (Cuffe, Moore, & McKeown, 2009).

Article Authors Subject Summary of findings
Asherson et al., 2010 Cultural influences Cultural factors influence of misdiagnosis
Barton, 2001 Definition/misdiagnosis Misdiagnosis can occur in both ADHD and BPD
Cuffe, Moore, & McKeown, 2009 Diagnostic process Strengths and Difficulties Questionnaire (SDQ) determined ADHD
Dang et al., 2007 School-based approach ADHD was determined using school based and home approaches
Lee & Olenchak,2015 Misdiagnosis of giftedness and ADHD ADHD and giftedness must be properly understood/diagnosed
Morley, 2010 Discrepancies in assessment, diagnosis, and treatment Appropriate diagnosis & assessment by physicians
Manuzza et al., 2011 Impairment criterion Study of White & middle class ADHD boys were determined but cannot be generalized.
Nelson, Rinn, & Hartnett, 2006 Misdiagnosis between giftedness and ADHD a myth Giftedness and ADHD have to be differentiated.
Nicholas & Baird, 2000 Diagnostic confusion Early onset ADHD can be determined and may continue until adulthood.
Safer, 2015 Prevalence ADHD is increasing in youth.
Sciutto & Eisenberg, 2007 Overdiagnosis/Underdiagnosis There is evidence of overdiagnosis and underdiagnosis in children and youth
Serrano, Ezpeleta, & Castro-Fornieles, 2011 Comorbidity Comorbidity in different disorders result in misdiagnosis
Silverstein et al., 2016 Insufficient assessment process Studies to support clinical data in ADHD diagnosis
Vance & Luk, 2000 Two settings as criterion The home and school-based approach provide more accurate diagnosis
Williamson, Koro-Ljungberg, & Bussing, 2009 Illness transitions ADHD in children will continue up to adulthood.

Table 2 Articles significant to ADHD diagnosis.

Table 1 shows the articles that discuss the various aspects of ADHD misdiagnosis, specifying the concepts or factors that contribute to misdiagnosis. The factors include overdiagnosis and underdiagnosis; the definition of ADHD; discrepancies in assessment diagnosis and treatment; insufficient assessment process; school-based approach; illness transition; two settings as criterion, impairment criterion; cultural influences; diagnostic process; misdiagnosis of giftedness and ADHD; and diagnostic confusion.

Definitions

ADHD has become so popular among clinicians and school administrators that it has been termed the “diagnosis of the decade” (Lee & Olenchak, 2015, p. 185). ADHD has often been diagnosed among school-aged children in the United States (Pilling, 2000). Furman (as cited in Pilling, 2000) has indicated that ADHD has become an epidemic in the United States, with as many as 3 million children receiving stimulant medication in early 2000. This figure does not even take into account those children who were diagnosed with the disorder but were not taking medication for it (Pilling, 2000).

Researchers have argued that the increased prevalence of ADHD in the United States could be due to errors in diagnosis. Some of the possible causes for misdiagnosis include the lack of education by referring individuals (e.g., parents and teachers) and changes in the guidelines in the diagnostic criteria. Wolraich et al. (as cited in Manuzza et al., 2011) argued that a large increase in ADHD diagnoses resulted in the shift from DSM-III-R to DSM-IV criteria, a change that was also noted by some clinicians and teachers.

In some studies, teachers completed questionnaires in which they rated all their students based on both DMS-III-R and DSM-IV criteria for disruptive behavior disorders, including ADHD. DSM-IV allowed for a 57% higher rate for ADHD diagnoses than did the DMS-III-R (Manuzza et al., 2011).

An analysis of the literature reveals that one of the causes for misdiagnosis is a faulty definition of ADHD; there is no agreed-upon definition for ADHD, but most authors and clinicians follow the definition given by the DSM-IV (DSM-IV as cited in Manuzza et al., 2011).

There are several definitions for ADHD that come into conflict with other psychiatric illnesses that display maladaptive behavior and other similar symptoms. ADHD is a childhood and adolescent disorder but is also found in adults. Dang et al. (2007) consider it a chronic condition, characterized by “comorbid mental health disorders such as anxiety, depression, and oppositional defiant disorder” (National Institute of Mental Health as cited in Dang et al., 2007).

Comorbidity with other disorders

Misdiagnosis of other disorders is a major problem. When the clinician finds more than one condition, such as depression or a learning disorder, he or she must determine which one is the primary cause of the patient’s exhibited symptoms. The clinician should ask, “Which condition is the major problem at home and at school?” Some children only present ADHD symptoms when they are feeling depressed or immediately before the onset of depression (Weinberg & Emslie, 1991).

Comorbidity also leads to confusion and misdiagnosis. ADHD has always been associated with BPD in children and youth. In their study on ADHD and BPD, Serrano, Ezpeleta, and Castro-Fornieles (2011) found an 8 percent association between ADHD and BPD-DSM and a 6 percent association between ADHD and BPD-NOS (not otherwise specified). Even more challenging is the fact that ADHD and BPD have similar symptoms, which may give clinicians and teachers difficulty in determining whether the child has ADHD, BPD, or both. For example, hyperactivity and inattentiveness are also common symptoms in BPD.

Most clinicians define ADHD according to its symptoms; for example, a clinician might note that the child displays a pattern of inattention accompanied by hyperactivity and impulsivity, which are mostly noticeable at display symptoms of other disorders such as learning disabilities and Tourette’s Syndrome (National Institute of Mental Health as cited in Barton, 2001).

When parents or teachers recognize the onset of ADHD, they should first attempt to identify the child’s corresponding difficulties in learning and communication. The required method of clinical evaluation for developmental disorders should be administered. But the teacher or clinician should be able to determine first left-brain dysfunctions of verbal and written language skills. The right brain shows functions of prosody, order, humor, and so forth (Weinberg & Emslie, 1991).

Underdiagnosis/Overdiagnosis

The conception that ADHD is overdiagnosed is not new (Bogas as cited in Sciutto & Eisenberg, 2007). This idea has also been voiced by politicians such as Hillary Clinton, who has said that politicians may have triggered the overdiagnosis problem when children are just demonstrating normal characteristics and behavior (Vatz & Weinberg as cited in Sciutto & Eisenberg, 2007). The general public is also concerned and has regarded the higher incidence of ADHD diagnosis as overdiagnosis (Sciutto & Eisenberg, 2007).

The theory of overdiagnosis implicitly states that there is a predetermined number of children who should be diagnosed with ADHD. If the number of children diagnosed exceeds 3 to 7 percent of the total population of children, then there is overdiagnosis. According to Sciutto and Eisenberg (2007), ADHD overdiagnosis could be tested in a nationally representative study using “standardized, multi-method assessments” that can be compared to actual rates of diagnosis (p. 107).

However, as the authors note, such research has not been undertaken yet. According to Safer (2015), the prevalence of psychiatric disorders in general has significantly increased over the last decade or two. The increase in prevalence is particularly evident in autism spectrum disorder (ASD) and pediatric bipolar disorder, the latter of which has increased 40-fold (Moreno et al. as cited in Safer, 2015).

Ethnicity/Cultural Factors

ADHD diagnosis and treatment are also influenced by race or ethnicity and cultural factors. For example, some studies have found that treatment and medications are provided more often to white than black children (LeFever et al. as cited in Cuffe et al., 2009). Because of underdiagnosis, approximately 75% of children with mental disorders do not receive the necessary health care services, and children of lower socioeconomic classes have the highest unmet needs (Cuffe et al., 2009). Underdiagnosis can result in undertreatment. The studies of Rowland and Umbach et al. (as cited in Cuffe et al., 2009) have found that Hispanic children are the least likely to be treated with ADHD medications compared to white children.

A study by LeFever et al. (1999 as cited in Cuffe et al., 2009) focused on the opposite issue, overdiagnosis of ADHD. The researchers found that between 8 and 10 percent of children in Grades 2 through 5 were treated for ADHD. This case demonstrates diagnosis rates exceeding the standard prevalence of 3 to 7 percent (American Psychiatric Association as cited in Cuffe et al., 2009). In this study, ADHD treatment rose along with grade level. Other studies, such as those by Zito et al. (1999 as cited in Cuffe et al., 2009), discovered a 90 percent increase in the number of children’s visits to physicians for ADHD treatment for the period from 1989 to 1996.

Some health practitioners diagnose ADHD through checklists that they provide to parents and teachers. Other assessments include the Test of Everyday Attention (TEA) or the Test of Variables of Attention (TOVA) (Lee & Olenchak, 2015). Mostly, the child is hyperactive but that is not enough.

The prescribed process for diagnosing ADHD includes the following: an analysis of the situation; an explanation of the problem, which defines the situation surrounding the problem; a motivational analysis of the situation; a growth analysis, in which the different biological changes are identified; an analysis of the subject’s self-control; an analysis of the subject’s social interactions; and an analysis of the socio-cultural factors surrounding the subject under study (Barkley, 2005).

Prevalence

For any given population, the ADHD prevalence ranges from 1 to 39.2 percent of the population, but it is more prevalent in boys at a ratio of 9:1 (Dang et al., 2007). The large range may be caused by the problem of diagnosis. Other symptoms of ADHD include academic underachievement, low self-esteem, mood instability, low tolerance for frustration, and temper outbursts. Teacher ratings are key to the identification of students who can be studied for ADHD research purposes. In ADHD studies, factor analytic studies of teacher ratings were instrumental in providing the empirical basis for the development of the DSM-IV criteria for ADHD. So the actual criteria upon which professionals judge a child to have ADHD were developed based on teacher ratings (Dang et al., 2007).

Teacher ratings have also been instrumental to identifying subjects for a wide range of studies examining ADHD including genetic studies and studies to determine the validity of the DSM diagnostic criteria (Sherman et al. as cited in Dang et al., 2007). Some research designs also look at teacher ratings to obtain a diagnosis for the subjects in the study. In their study, Guab and Carlson (as cited in Pilling, 2000) used teacher ratings exclusively, obtaining results from 2744 children and validating the ADHD subtypes without incorporating collateral information on this population of children.

Conclusion

The label ADHD has been given to children and adolescents who show symptoms of affective illness, developmental disorder, and specific learning disorder. The clinician should be able to determine depression and mania using the criteria provided by the DSM-IV and should examine other aspects of the child, including his or her feelings and intelligence, communication skills, and ability to stay alert and awake in specific school or academic settings.

Depression, the primary order of vigilance, and the child’s speech or intonation are dysfunctions of the right-hemisphere and are considered ADHD symptoms. The left hemisphere includes mania. Weinberg and Emslie’s (1991) study consider these ADHD symptoms. The clinician can avoid a misdiagnosis by focusing on these symptoms, but appropriate diagnosis should always involve a collaboration of the parents, the teacher, and the clinician.

According to Weinberg and Emslie (1991), when presented with a child or adolescent exhibiting ADHD or bipolar disorder (BPD) symptoms, doctors must examine the brain and its functions, instead of judging right away that the child or adolescent has ADHD. The stakeholders involved in the diagnosis should also know that diagnosis is a long process that starts with the teachers and parents and ends with the doctors closely examining the child or adolescent.

References

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Asherson, P., Akehurst, R., Kooij, J.J., Huss, M., Beusterien, K., Sasane, R.,…Gholizadeh, S. (2010). Under diagnosis of adult ADHD: Cultural influences and societal burden. Journal of Attention Disorders, 16(5), 20S-38S. Web.

Barkley, R. (1990). Attention deficit hyperactivity disorder: A handbook for diagnosis and treatment. New York: The Guilford Press.

Barton, L. (2001). Attention deficit hyperactivity disorder (ADHD) and bipolar disorder in children and their coexisting comorbidity: A challenge for family counsellors. The Family Journal: Counseling and Therapy for Couples and Families, 9(4), 424-430.

Cuffe, S., Moore, C., & McKeown, R. (2009). ADHD and health services utilization in the national health interview survey. Journal of Attention Disorders, 12(4), 330-340. Web.

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Manuzza, S., Castellanos, F., Roizen, E., Hutchison, J., Lashua, E., & Klein, R. (2011). Impact of the impairment criterion in the diagnosis of adult ADHD: 33-year follow-up study of boys with ADHD. Journal of Attention Disorders, 15(2), 122-129. Web.

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Silverstein, M., Hironaka, K., Feinberg, E., Sandler, J., Pellicer, M., Chen, N. (2016). Using clinical data to predict accurate ADHD among urban children. Clinical Pediatrics, 55(4), 326-332. Web.

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