ADHD is defined as a problem with inattentiveness, over-activity, impulsivity, or a combination. For these problems to be diagnosed as ADHD, they must be out of the normal range for a child's age and development. ADHD affects about 3 - 5% of school aged children, and is diagnosed much more often in boys than in girls. Depression, lack of sleep, learning disabilities, tic disorders, and behavior problems may be confused with, or appear with, ADHD. Some children with ADHD primarily have the inattentive type. Others may have a combination of types. Those with the inattentive type are less disruptive and are more likely to not be diagnosed with ADHD. Too often, difficult children are incorrectly labeled with ADHD. On the other hand, many children who do have ADHD remain undiagnosed. In either case, related learning disabilities or mood problems are often missed. The American Academy of Pediatrics (AAP) has issued guidelines to bring more clarity to this issue.
What experts and the public have already long suspected is now supported by representative data collected by researchers at Ruhr-Universitat Bochum (RUB) and University of Basel: ADHD, attention deficit hyperactivity disorder, is over-diagnosed. The study showed that child and adolescent psychotherapists and psychiatrists tend to give a diagnosis based on heuristics, unclear rules of thumb, rather than adhering to recognized diagnostic criteria. Boys in particular are substantially more often misdiagnosed compared to girls. These are the most important results of a study conducted by Prof. Dr. Silvia Schneider and Prof. Dr. Jurgen Margraf (both from RUB) and Dr. Katrin Bruchmuller (University of Basel) as reported in the American periodical "Journal of Consulting and Clinical Psychology".
Leon has ADHD, Lea doesn't
The researchers surveyed altogether 1,000 child and adolescent psychotherapists and psychiatrists across Germany. 473 participated in the study. They received one of four available case vignettes, and were asked to give a diagnoses and a recommendation for therapy. In three out of the four case vignettes, the described symptoms and circumstances did not fulfill ADHD criteria. Only one of the cases fulfilled ADHD criteria based strictly on the valid diagnostic criteria. In addition, the gender of the child was included as a variable resulting in eight different case vignettes. As the result, when comparing two identical cases with a different gender, the difference was clear: Leon has ADHD, Lea doesn't.
Male and conspicuous: the "prototype" makes the difference
Many child and adolescent psychotherapists and psychiatrists seem to proceed heuristically and base their decisions on prototypical symptoms. The prototype is male and shows symptoms such as motor restlessness, lack of concentration and impulsiveness. In connection with the gender of the patient, these symptoms lead to different diagnoses. A boy with such symptoms, even he does not fulfill the complete set of diagnostic criteria, will receive a diagnosis for ADHD, whereas a girl will not. Also the therapist's gender plays a role in the diagnostic: male therapists give substantially more frequently a diagnosis for ADHD than their female counterparts.
Diagnostic inflation, more medication, higher daily doses
In the past decades the diagnoses ADHD have become almost inflationary. Between 1989 and 2001, the number of diagnoses in German clinical practice increased by 381 percent. The costs for ADHD medication, such as for the performance-enhancer Methylphenidate, have grown 9 times between 1993 and 2003. The German health insurance company, Techniker, reports an increase of 30 percent in Methylphenidate prescriptions for its clients between the ages of 6 and 18. Similarly, the daily dosage has increased by 10 percent on average.
Remarkable lack of research
Considering these statistics, there is a remarkable lack of research in the diagnostic of ADHD. "In spite of the strong public interest, only very few empirical studies have addressed this issue", Prof. Schneider and Dr. Bruchmuller point out. While in the 70s and 80s a "certain upswing" of studies on the frequency and reasons for misdiagnoses could be observed, current research hardly examines the phenomena. The current study shows that in order to avoid a misdiagnosis of ADHD and premature treatment, it is crucial for therapists not to rely on their intuition, instead to strictly adhere to defined, established diagnostic criteria. This is best possible with the help of standardized diagnostic instruments, such as diagnostic interviews.
Psychotherapeut 2012, DOI: 10.1007/s00278-011-0883-7
K. Bruchmuller, J. Margraf, S. Schneider: Is ADHD Diagnosed in Accord With Diagnostic Criteria? Over-diagnosis and Influence of Client Gender on Diagnosis. Journal of Consulting and Clinical Psychology 2012, DOI: 10.1037/a0026582
Prof. Dr. Silvia Schneider, Clinical Child and Adolescent Psychology, Ruhr-Universitat Bochum, Tel. +49 234 32 23168, email@example.com
Editorial: Jens Wylkop