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See Inside Scientific American Mind Volume 24, Issue 2

Are Doctors Diagnosing Too Many Kids with ADHD?

Some boys may be labeled incorrectly with the condition, but undertreatment may be the bigger problem
ADHD, attention deficit hyperactivity disorder, boy making faces



JAN FELDT

A German children's book from 1845 by Heinrich Hoffman featured “Fidgety Philip,” a boy who was so restless he would writhe and tilt wildly in his chair at the dinner table. Once, using the tablecloth as an anchor, he dragged all the dishes onto the floor. Yet it was not until 1902 that a British pediatrician, George Frederic Still, described what we now recognize as attention-deficit hyperactivity disorder (ADHD). Since Still's day, the disorder has gone by a host of names, including organic drivenness, hyperkinetic syndrome, attention-deficit disorder and now ADHD.

Despite this lengthy history, the diagnosis and treatment of ADHD in today's children could hardly be more controversial. On his television show in 2004, Phil McGraw (“Dr. Phil”) opined that ADHD is “so overdiagnosed,” and a survey in 2005 by psychologists Jill Norvilitis of the University at Buffalo, S.U.N.Y., and Ping Fang of Capitol Normal University in Beijing revealed that in the U.S., 82 percent of teachers and 68 percent of undergraduates agreed that “ADHD is overdiagnosed today.” According to many critics, such overdiagnosis raises the specter of medicalizing largely normal behavior and relying too heavily on pills rather than skills—such as teaching children better ways of coping with stress.

Yet although data point to at least some overdiagnosis, at least in boys, the extent of this problem is unclear. In fact, the evidence, with notable exceptions, appears to be stronger for the undertreatment than overtreatment of ADHD.

Medicalizing Normality

The American Psychiatric Association's diagnostic manual of the past 19 years, the DSM-IV, outlines three sets of indicators for ADHD: inattention (a child is easily distracted), hyperactivity (he or she may fidget a lot, for example), and impulsivity (the child may blurt out answers too quickly). A child must display at least six of the nine listed symptoms for at least half a year across these categories. In addition, at least some problems must be present before the age of seven and produce impairment in at least two different settings, such as school or home. Studies suggest that about 5 percent of school-age children have ADHD; the disorder is diagnosed in about three times as many boys as girls.

Many scholars have alleged that ADHD is massively overdiagnosed, reflecting a “medicalization” of largely normative childhood difficulties, such as jitteriness, boredom and impatience. Nevertheless, it makes little sense to refer to the overdiagnosis of ADHD unless there is an objective cutoff score for its presence. Data suggest, however, that a bright dividing line does not exist. In a study published in 2011 psychologists David Marcus, now at Washington State University, and Tammy Barry of the University of Southern Mississippi measured ADHD symptoms in a large sample of third graders. Their analyses demonstrated that ADHD differs in degree, not in kind, from normality.

Yet many well-recognized medical conditions, such as hypertension and type 2 diabetes, are also extremes on a continuum that stretches across the population. Hence, the more relevant question is whether doctors are routinely diagnosing kids with ADHD who do not meet the levels of symptoms specified by the DSM-IV.

Some studies hint that such misdiagnosis does occur, although its magnitude is unclear. In 1993 Albert Cotugno, a practicing psychologist in Massachusetts, reported that only 22 percent of 92 children referred to an ADHD clinic actually met criteria for ADHD following an evaluation, indicating that many children referred for treatment do not have the disorder as formally defined. Nevertheless, these results are not conclusive, because it is unknown how many of the youth received an official diagnosis, and the sample came from only one clinic.

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