Social & Cultural Factors influencing ADHD Over- or Misdiagnosis

This post is part of a series of guest posts on GPS by the graduate students in my Psychopathology course. As part of their work for the course, each student had to demonstrate mastery of the skill of “Educating the Public about Mental Health.” To that end, each student has to prepare three 1,000ish word posts on a particular class of mental disorders, with one of those focusing on changes made from the DSM-IV to the DSM-5.

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Social & Cultural Factors influencing ADHD Over- or Misdiagnosis by Kristopher Thompson

More than likely, you know someone that has been diagnosed with Attention Deficit Hyperactivity Disorder (ADHD) or someone whose child has received this diagnosis. Of course, this is assuming that you haven’t been diagnosed with ADHD yourself. ADHD is prevalent in the United States, to say the least, with as many as 8.4% of children between the ages of 3 and 17 having received a diagnosis of this disorder at some point. Between 2003 and 2007 alone, parent-reported ADHD in the United States grew by 22%. In recent decades, ADHD has received extensive media coverage regarding increases in diagnoses and concern for the health of those prescribed amphetamines as treatment. It is the most frequently diagnosed pediatric neurobehavioral disorder, as well as the most widely studied, yet there is still a great deal of uncertainty regarding the extent of its over- or misdiagnosis.

Associated with this uncertainty are differing definitions of ADHD, which have resulted in enormous differences in prevalence rates in children. These have ranged from 0.5% to 26% across different epidemiological studies. Because of differences in interpretations of the diagnostic criteria, and consequent differences in findings, questions regarding the extent to which interpretations of ADHD are culturally based abound. In other words, we need to ask to what degree is this disorder based on differing cultural conditions. On the one hand, it is argued that ADHD may be best understood as culturally constructed. The way that immaturity is interpreted in Western culture, for instance, can be argued to play a substantial role in ADHD diagnoses. Further, it can be argued that such cultural emphases in the West on competiveness and individuality, coupled with profit-incentives of the pharmaceutical industry, create the ideal preconditions for ADHD to emerge as a construct. In opposition to this culturally-constructed view, though, there are areas of the brain specifically associated with hyperactivity, and there is evidence of a strong heritability component, meaning that first and second-degree relatives of individuals with ADHD have an increased likelihood of receiving this diagnosis. This points dramatically to a biological, not just socially-constructed, basis for the disorder.

Importantly, rates of ADHD diagnoses can vary drastically from one Western country to the next (not just between the West and East), which are thought to indicate cultural differences in diagnostic practices. Children in the United Kingdom, for example, are diagnosed with ADHD at a substantially lower rate than children in the United States. It is important to address such differences, because if children are under-diagnosed many may not receive appropriate health services. A diagnosis can provide a child with a sense of relief, giving meaning to their experiences of impairment. It can also spur the opportunity for children to receive treatment, as well as possible reimbursement for the expenses of treatment. However, if children are wrongly diagnosed with ADHD, they may receive inappropriate treatment (for example, treating obsessive-compulsive disorder with stimulant medication rather than exposure and response prevention therapy). Further, a diagnosis can potentially create negative expectations for a child’s behavior on behalf of parents and teachers. Children may also apply stereotypes associated with their diagnosis to themselves, possibly harming their self-esteem and confidence.

Debates regarding rates of over- and misdiagnosis are often particularly focused on differences between sexes. Males are about three times more likely to receive a diagnosis of ADHD than females. Whether this is representative of real differences in prevalence between males and females or is simply the result of males better fitting clinicians’ stereotypes associated with ADHD (or even for ADHD being a biased diagnostic construct) is not entirely clear. There is strong evidence that clinicians do not firmly keep to diagnostic criteria for ADHD, often allowing stereotypes to influence their clinical judgment. In a recent study assessing the bias to diagnose young males with ADHD more readily than young females, it was found that even if the only difference between descriptions of ADHD symptoms was the associated name of the patient (male or female name), males are more likely than females to receive a false positive diagnosis. In other words, even if identical behaviors between a young male and female were described, the young male was more likely to be perceived as having ADHD by the clinician. Further, about 1/6 of the involved clinicians diagnosed ADHD when criteria for the disorder were not fulfilled in the provided descriptions, supporting the idea that ADHD is over-diagnosed. Turning to treatments in response to these diagnoses, clinicians who diagnosed ADHD when criteria were not met for this diagnosis recommended medicinal treatment more often than clinicians who did not diagnose ADHD in these circumstances.

Results from this study (and similar others) poses a serious problem, demonstrating that over- or misdiagnosis has the consequence of increased recommendations for treatment with medication. Another critical factor associated with this issue of over- or misdiagnosis is the relative age of children in comparison to their classmates. Children that are young for their grade level are far more likely to be diagnosed with ADHD than their older classmates, meaning that the closer their birth dates are to the cutoff dates for their grade level, the greater their probability of receiving an ADHD diagnosis. In a study using data from across the United States, collected over a period of multiple years, researchers determined that the prevalence of ADHD diagnoses was about 60% greater for children born directly before the cutoff date for entry to Kindergarten in their state than children born directly after the cutoff date. These younger children were also found to be considerably more likely to be prescribed to stimulant medication in 5th and 8th grade. The effect of relative age on stimulant prescriptions holds especially true for Ritalin, considering that children born directly before their states’ cutoff dates had twice the likelihood of being prescribed this specific medicine.

It should be mentioned that similar trends have been found in Canada, showing that the effect of relative age on ADHD diagnosis and treatment is not isolated to the United States. In comparison to male children born in the month after the cutoff date, those born in the month prior to the cutoff date for school entry in British Columbia had a 30% greater likelihood of receiving an ADHD diagnosis. Further, female children born in the month prior to the cutoff date had a 70% greater likelihood than those born in the month after. These findings highlight the importance of considering relative age when interpreting the actions of children with possible. Also, the drastic difference between male and female likelihoods again demonstrates a disparity between genders.

Gender and age are inherently associated in terms of ADHD diagnosis. In effect, expectancies stemming from the interaction of a child’s gender and age are central in shaping whether the child is perceived as having of ADHD or not. In child populations, males are at the greatest risk of over- or misdiagnosis, especially if they are young for their grade level. In light of this, parents and teachers should be cautious of misinterpreting children’s behaviors in relation to their peers. Additionally, before any steadfast opinions are made, each child’s behaviors should be thoroughly compared to criteria required for a diagnosis. While there may be biological components underlying symptoms of ADHD, the importance of realizing the roles of expectancies for young males and females cannot be overstated, as they are vital to understanding the over- or misdiagnosis of this disorder.