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September 24, 2013

ADHD Diagnosis in Childhood

by Angel Pumila

ADHD DIAGNOSIS IN CHILDHOOD:

INCREASING DIAGNOSIS RATES OR OVERLY DIAGNOSED

Abstract

     The diagnosis of attention deficit hyperactivity disorder (ADHD) and prescription of psychostimulant drugs has multiplied by 700% in the last century.  These numbers are especially high within the area of child diagnosis.  The roots of behavior problems that these children are exhibiting are not being addressed.  They are simply being medicated to mask the underlying problem(s).  Here, we will examine research to find the problems with diagnosis of childhood attention deficit hyperactivity disorder.  The questions that will be answered include diagnostic rates for ADHD in school aged children, criteria that psychologists and medical doctors are using to diagnose ADHD, alternative methods to the use of psychostimulant drugs, and success rate of behavioral therapy in eliminating ADHD symptoms. Results show that adherence to ADHD diagnostic criteria is not followed in all cases.  It is suggested that future research be performed on alternative treatment methods for behavioral disorders including behavioral, cognitive, and family therapy.

Keywords: attention deficit hyperactivity disorder, over diagnosis of ADHD in children

Tables

Table 1:  Percentage of attentiondeficit/hyperactivity disorder (ADHD) diagnoses for the eight different case vignettes (Bruchmuller, Basel, Margraf, & Schneider, 2012). GAD = generalized anxiety disorder.

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Introduction

     According to the Diagnostic and Statistical Manual for Mental Disorders (DSM-IV-TR), the criteria for diagnosis of attention deficit hyperactivity disorder contains six or more of the following symptoms that are present for a minimum period of six months.

“Inattention:

  1. Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities.
  2. Often has trouble keeping attention on tasks or play activities.
  3. Often does not seem to listen when spoken to directly.
  4. Often does not follow instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instruction).
  5. Often has trouble organizing activities.
  6. Often avoids, dislikes, or doesn’t want to do things that take a lot of mental effort for a long period of time (such as schoolwork or homework).
  7. Often loses things needed for tasks and activities (e.g. toys, school assignments, pencils, books, or tools).
  8. Is often easily distracted.
  9. Is often forgetful in daily activities.

Six or more of the following symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for developmental level:

Hyperactivity:

  1. Often fidgets with hands or feet or squirms in seat.
  2. Often gets up from seat when remaining in seat is expected.
  3. Often runs about or climbs when and where it is not appropriate (adolescents or adults may feel very restless).
  4. Often has trouble playing or enjoying leisure activities quietly.
  5. Is often “on the go” or often acts as if “driven by a motor”
  6. Often talks excessively.

Impulsivity:

  1. Often blurts out answers before questions have been finished.
  2. Often has trouble waiting one’s turn.
  3. Often interrupts or intrudes on others (e.g., butts into conversations or games” (American Psychiatric Association, 2000).

Research

     There is a biological basis for these symptoms that can be found in PET scans of the brain.  Research has found that “where the chemical norepinephrine and dopamine are not produced in the proper amount, the receptor sites in the brain, there’s fewer receptor sites, there is, if you look at some of the PET scans, the area which are affected, the blood vessels are narrower in those areas, and it’s a medical disorder” (Firmin & Phillips, 2009).  Yet, because of costs or other factors, tests like these are not preformed when confirming a diagnosis for attention-deficit hyperactivity disorder in children or adults.

     Even with these criteria available for psychologists and medical doctors, ADHD is often diagnosed without sufficient cause. According to a study published in the Journal of Consulting Psychology, ADHD is not always diagnosed properly.  Researchers performed a study to see if therapists were diagnosing correctly by using case vignettes sent out to 1,000  “psychologists, psychiatrists, and social workers” (Bruchmuller, Basel, Margraf, & Schneider, 2012).  These professionals were asked to offer a diagnosis based upon the criteria presented in each vignette.  Vignette 1 fully met 10 of the criteria of ADHD as stated in the DSM-IV-TR.  Vignette 2-4 offered a few symptoms of ADHD, but did not qualify for diagnosis. The results show that 16% of professionals diagnosed ADHD to the case vignettes that did not qualify (see table 1).  In addition, it was found that the vignettes that represented boys were two times more likely to be diagnosed than the vignettes that represented girls.

Misdiagnosis

     This misdiagnosis can be seen in the increasing rates of psychostimulant use since the 1990s.  The evidence can be found in the study by LeFever and Arona from the Center for Pediatric Research at Eastern Virginia Medical School and Children’s Hospital of the King’s Daughters.  They found that there has been a 700% increase in the drugs being prescribed for ADHD.    That amounts to approximately six million children in the United States being diagnosed on an annual basis (Dilleer, 1998; Sinha, 2001).  “The high rate of prescription for Ritalin and expensive brand-name drugs such as Adderall, Concerta, and Metadate reflect a more general reliance on phsychotropic drugs in American healthcare practices.  In 1998, doctors mentioned psychotropic drug treatment and estimated 85.8 million times during 36.7 million office visits (Health Care Financing Administration, 2001) averaging 2.3 documented references to psychotropic drug treatment per physician visit” (LeFever & Arcona, 2003).

One cause for this drastic increase can be seen in research conducted nationally has shown that primary care doctors seldom adhere to DSM-IV-TR standards for diagnosis (Kellerher & Larson, 1998). They seem to be diagnosing the onset of behavioral problems and using medications to control school aged children, instead of addressing the behavior directly.  Not only is this a problem with ADHD, but other childhood psychiatric conditions as well.  According to a study examining outpatient child and adolescent psychiatry prescribing practices, “the use of selective serotonin reuptake inhibitors and methylphenidate in children has become widespread” (Aras, Tas, & Unlu, 2007).  This suggests that reform needs to be considered in the treatment services offered to minors.  LeFever and Arona suggest that, along with stricter implementation of diagnostic criteria, community-based intervention programs are warranted on a nationwide level in the United States.

Symptom Longevity

     The transition from childhood to adolescence includes many changes physically, emotionally, and cognitively.  In some, these changes can be in their previous ADHD diagnosis as well.  In a study published in the Journal of Consulting and Clinical Psychology, some of those that were previously diagnosed in childhood no longer met the full criteria once they entered into adolescence.

Increased family adaptation is helpful in managing symptoms of ADHD as well.  Qualitative case studies concerning the families of children diagnosed with attention-deficit hyperactivity disorder report that parents are more attuned to needs of the children and make “adaptations and interventions when needed to accomplish family objectives” (Firmin, 2009).  It is argued that clinical treatment without changing family contexts can reduce the success of ADHD interventions (Corrin, 2004) (Fabiano, 2007) (Labauve, 2003).

Attention-deficit hyperactivity disorder is not always present throughout the lifespan.  According to findings reported in the Journal of Consulting and Clinical Psychology, symptoms found in childhood ADHD have been shown to dissipate in adolescence and early adulthood in some patients (Sibley, Pelham, Molina, Gnagy, Waschbusch, Garefino, & Karch, 2012). This could be a result of a combination of misdiagnosis, as well as simply outgrowing the symptoms associated with the disorder.

Criteria used to diagnose ADHD were evaluated by Purpura, Wilson, & Lonigan to find if the current diagnostic criteria as outlined in the DSM-IV-TR were related as a whole to the disorder itself.  Out of the eighteen items that were measured using polytomous and dichotomous scoring, they found that all eighteen criteria were in line with proper diagnosis.  So, the problem with the increasing numbers of those diagnosed in the United States has been ruled out, according to this study, as being associated with the individual metrics of diagnosis.

Conclusion

     In conclusion, it has been shown that there are a significant amount of cases that involve diagnosis that does not fully adhere to professional standards.  In these cases, many have been medicated with psychotropic drugs when other methods of behavior treatment have been available and not fully considered.  Alternatives to medications can be found in the forms of behavioral and cognitive therapy to treat these symptoms.  Further research should be performed to find out if the results of over diagnosis or a changing cultural acceptance to drug therapy and what particular causes attribute to diagnosis of ADHD changing throughout lifespan development.

Annotated Bibliography

LeFever, G & Arcona, A. (2003) ADHD Among American Schoolchildren. The Scientific Review of Mental Health Practice. Volume 2 (1). Retrieved from www.srmhp.org

LeFever & Arcona find a substantial increase in the diagnosis of Attention-deficit/hyperactivity disorder (ADHD) and the subsequent use of psychostimulants used to treat behavioral problems in children.  The authors review the history of the disorder and diagnostic criteria as compared to today’s statistical data.  Researchers examine the rates of administered medication in two school districts in Virginia during the 1995-1996 school year to examine criteria as described in the DSM-IV, along with gender and ethnicity factors to determine if a significant rate of diagnosis exists.  This article will contribute to support or reject the question of over diagnosis of ADHD in children and offers a variation in gender and race diagnosis for future research on biases.

Bruchmüller, Katrin; Margraf, Jürgen; Schneider, Silvia. Is ADHD Diagnosed in Accord with Diagnostic Criteria? Over-diagnosis and Influence of Client Gender on Diagnosis. Journal of Consulting and Clinical Psychology, Dec 26, 2011.

Authors look into the unequal male-female ratio of ADHD diagnosis as compared to the criteria in the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV) and the International Classification of Diseases (10th rev.; ICD-10.  It is suggested that ADHD diagnosis is children is based upon a concept of the disorder instead of the diagnostic criteria.  A case vignette is sent to 1,000 child psychologists and social workers for potential diagnosis. Result statistics are then compared to formal criteria to examine diagnostic biases.

Firmin, M. & Phillips, A. (2009). A Qualitative Study of Families and Children Possessing Diagnoses of ADHD.  Journal of Family Issues (September, 2009) vol 30, pp. 1155-1174, doi:10.1177/0192513X09333709

Firmin & Philips conduct a qualitative study of 17 families to find the challenges that parents encounter with raising a child diagnosed with ADHD.  They notice three themes found with most families observed.  1) Parents are more observant of the needs of their children and the adaptations needed within the family.  2) Mornings and afternoons are more difficult than evenings with their participants with the exception of homework time.  3) Families exhibit structural routines when going about daily life with their ADHD children.

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.

American Psychological Association’s reference for diagnostic criteria of metal disorders.

Semrud-Clikeman, M., Pliszka, S., & Liotti, M. (2008). Executive functioning in children with attention-deficit/hyperactivity disorder: Combined type with and without a stimulant medication history. Neuropsychology, 22(3), 329-340. doi:10.1037/0894-4105.22.3.329

Researchers compare the behavioral and neuropsychological functioning in children diagnosed with ADHD that receive medication to children with no history of medication treatment.  Measures were taken on achievement, executive functioning, verbal working memory, and behavior.  The goal of the authors is to find out if medically treated children perform better or worse than those that have chosen not to take prescription medication for the disorder.

Sibley, M.H., Pelham, W.R., Molina, B.G., Gnagy, E.M., Waschbusch, D.A., Garefino,          A.C., & Karch, K.M. (2012). Diagnosing ADHD in adolescence.  Journal Of Consulting And Clinical Psychology, 80(1), 139-150. doi:10.1037/a0026577

This study examines adolescents that were diagnosed with ADHD as children.  The objective of researchers is to find out if there is a difference in symptom reduction at the time of adolescence compared to their original diagnosis in childhood.  The goal of the study is to prove a decrease in symptoms in order to suggest a change in diagnostic criteria for adolescents in the DSM-IV.

Purpura, D.J., Wilson, S.B., & Lonigan, C.J. (2010). Attention-deficit/hyperactivity disorder symptoms in preschool children: Examining psychometric properties using item response theory.  Psychological Assessment, 22(3), 546-558 doi:10.1037/a0019581

Purpura, Wilson & Lonigan assess the eighteen items used for diagnosis of ADHD for relevance to the disorder.  In this study, 268 preschool children were examined using an item response theory analysis.  Psychometric properties of ADHD symptoms were calculated via dichotomous and polytomous scoring.  It was found that current symptoms do relate and are helpful in diagnosing ADHD in children.  Some symptoms were indicated as needing further research.

References

LeFever, G & Arcona, A. (2003) ADHD Among American Schoolchildren. The Scientific      Review of Mental Health Practice. Volume 2 (1). Retrieved from http://www.srmhp.org

Bruchmüller, Katrin; Margraf, Jürgen; Schneider, Silvia. Is ADHD Diagnosed in Accord with Diagnostic Criteria? Over-diagnosis and Influence of Client Gender on Diagnosis. Journal of Consulting and Clinical Psychology, Dec 26, 2011.

Firmin, M. & Phillips, A. (2009). A Qualitative Study of Families and Children Possessing Diagnoses of ADHD.  Journal of Family Issues (September, 2009) vol 30, pp. 1155-1174, doi:10.1177/0192513X09333709

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.

Sibley, M.H., Pelham, W.R., Molina, B.G., Gnagy, E.M., Waschbusch, D.A., Garefino,          A.C., & Karch, K.M. (2012). Diagnosing ADHD in adolescence.  Journal Of Consulting And Clinical Psychology, 80(1), 139-150. doi:10.1037/a0026577

Purpura, D.J., Wilson, S.B., & Lonigan, C.J. (2010). Attention-deficit/hyperactivity disorder symptoms in preschool children: Examining psychometric properties using item response theory.  Psychological Assessment, 22(3), 546-558 doi:10.1037/a0019581

Kellerher, K., & Larson, D. (1998).  Prescription of psychotropics to children in office-based practice.  American Journal of Disabled Children, 143, 855-859.

Van Lier, P.C., Muthen, B. O., van der Sar, R. M., & Crijenen, A.M. (2004). Preventing

Disruptive Behavior in Elementary Schoolchildren: Impact of a Universal Classroom-Based Intervention. Journal of Counsulting And Clinical Psychology, 72(2), 467-478. Doi:10.1037/0022-006X.72.3.467

Diller., L. (1998). Running on Ritalin: A physician reflects on children, society, and performance in a pill.  New York: Bantam Books.

Sinha, G. (2001). New evidence about Ritalin: What every parent should know.  Popular Science, 48-52.

Health Care Financing Administration. (2001). National health expenditures projections: 2000-2010.  Retrieved from http://www.hcfa.gov/stats/NHSProj/proj2000/default.html.

Aras, S. S., Tas, F., & Unlu, G. G. (2007). Medication prescribing practices in a child and adolescent psychiatry outpatient clinic.  Child: Care, Health And Development, 33(4), 487-490.  Doi:10.1111/j.1365-2214.2006.00703.x

Corrin, E.G. (2004). Child group training versus parent and child group training for young children with ADHD.  Dissertation Abstracts International, 64, 7B.

Fabiano, G.A. (2007). Father participation in behavioral parent training for ADHD.  Journal of Family Psychology, 21, 683-693.

Labauve, B.J. (2003). Systemic treatment of attention deficit hyperactivity disorder.  Journal of Systemic therapies, 22, 44-45.

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