ADHD – Exploring Possibilities for Misdiagnosis Among School Age Children

The Diagnostic Statistical Manual, Edition Five (DSM IV) defines ADHD as a neurological issue with characteristics of inattention, impulsivity, and hyperactivity. Treatment for ADHD includes medication, behavioral therapy and/or community care plans. The CDC reports that 6.4 million children between the ages of 4-17 were diagnosed with ADHD. In 2011 67.3% of kids with ADHD received medication treatment. From 2003 to 2011 ADHD diagnosis increased about an average of 5% per year! Was it underdiagnosed before 2003 or over diagnosed after 2003? There are multiple factors contributing to this controversy and it is important to explore the possibilities for what may drive misdiagnosis. The ADHD diagnostic criteria require six inattentive symptoms and/or six impulsive/hyperactive symptoms that have been present for at least six months that is not normal for the developmental age. Symptoms starting before age 12 and occur in two or more environments such as school, home, and other settings such as place of religious gatherings if applicable. Symptoms negatively interfere with the quality of academic, social or occupational function. One of the most important criteria is to make sure symptoms are not explained better by a different diagnosis. Multiple studies have proved that sometimes other conditions are not being considered.

Research by Conner (2011) points out that the ADHD diagnosis and stimulant treatment boom started in the 1990s. Congress made Medicaid available to a lot more children which included coverage for psychotropic medications, including stimulants. The 1997 FDA modernization Act encouraged pharmaceutical drug development for children and randomized controlled trials for ADHD stimulants and other types of medication. This helped create scientific rationale leading to a 9.5% increase of stimulant prescription for ADHD between 2000 and 2005.

The No Child Left Behind Act (NCLB) of 2001 may have contributed to the alarming increase of students evaluated, diagnosed, and/or medicated for ADHD. Teachers are at the frontline of suggesting ADHD diagnosis followed by other school personnel and then parents. Then very often ADHD diagnosis is not made with a mental health specialist but rather a pediatrician or family physician (Evans et al., 2010). The new pressure of creating plans to improve performance of mandated standardized testing in grades three to eight and at least twice in high schools called for more attention and less hyperactivity in school or for more students. Bokhari & Schneider (2011) discusses intended and unintended consequences by pointing out more controversy: On one hand, some schools may be gaming the system by inappropriately labeling marginal students as ADHD to provide them with accommodations as well as to reshape the testing pool. On the other hand, stricter accountability leads to more ADHD students receiving the appropriate diagnosis, academic accommodations and efficacious medical treatment that improves their academic performance, as well as of their peers. This study further explored this issue by analyzing state level data of ADHD diagnosis and the consumption of medication by ADHD school aged children also looking closely at the years 1999-2003. Variations between state laws in the US for being held accountable to NCLBA were also considered. This was compared to private schools whom were not subjected to the accountability laws pressure but still consider the same risk factors in recommending ADHD evaluations. Their research determined that while NCLB did have a large influence on the increases of ADHD diagnosis, hence for children consuming psychostimulants there it was well justified as the students with medication therapy performed better suggesting that the accountability laws did not cause children to be misdiagnosed with ADHD.

Other literature suggests that there may be a correlation of misdiagnosis in ADHD with the age the students entered school. Elder (2010) states that over 8% of children are born in the month prior to kindergarten cutoff date are diagnosed with ADHD when in fact they may just in fact be developmentally more immature than their peers who are born after the cutoff date. U.S. schools' kids must first turn five years old to enter kindergarten. Elder compares this to the approximate 5% of other students diagnosed born in the month right after. These children are also twice as likely to be medicated. He referred to the work of the Evans et al. (2010) that states that kids who just turned five compared to kids who are almost six years old can be more than a 20% difference. Younger children tend to exhibit more behavioral and educational issues and less academic readiness. This may imply that over 500,000 taking stimulant medication for not being mature enough. Most of the children diagnosed with ADHD are boys. It is very well known that girls mature faster than males. Sax (2001) explored this issue by citing studies that show developmental neurological differences in the development between males and females. It was found that that on average the female brain is more mature than from about age 6 to 29. Cytological analysis determined female adults have about an 11% greater density of neocortical neurons which helped the function of sensory perception, cognition, generation of motor commands, spatial reasoning and language. On average, women also have better hearing as they tend to hear more sounds at lower amplitudes. The was reinforced by a study that female babies 12 -14 weeks responded to more auditory stimuli. Girls also tend to articulate verbally earlier with more proficiency. The overrepresentation of boys in learning disabilities and other related conditions such as ADHD may be collected to the slower maturation rate.

It has also been suggested that symptoms of trauma can be confused for or lead to ADHD diagnosis. Szymanski et al. 2011 explores the association between trauma and ADHD and refers to a couple studies that explores this matter. Some given examples of traumatic events are homelessness, foster care placement, and incarceration of parents/caregivers. Traumatic events may put children and adolescents at high risk for exhibiting inattention, hyperactivity, impulsivity and other ADHD like behaviors. One of the studies cited worked with a group of severely deprived Romanian orphans who were adopted before they were before the age of four portrayed ADHD symptoms but were actually who trying to cope with post-traumatic stress. Coping mechanisms of PTSD can mirror the ADHD diagnostic criteria. While it is very possible for PTSD can be comorbid with ADHD, Trauma screening is very important before jumping to conclusions. Another possible reason for ADHD misdiagnosis could be undetected and untreated sleep issues. Wiggs et al. (2005) 71 one kids diagnosed with ADHD ranging in ages 3-15 years old. Using the DSM IV criteria, they were given assessments to confirm which ADHD the appropriate subtype weather just inattentive, just hyperactive, or combined. assessments to divide kids into appropriate subtypes. It was found 63 had some type of sleep abnormality. The alarming part of this study was that 21 kids failed to meet the ADHD diagnostic criteria despite being previously diagnosed by their clinicians. Hamed et al. (2015) speaks about some research attempting to make ADHD diagnosing more objective focusing on genetic and environmental factors affecting the human biology.

One study did EEG and brain imaging on ten children which should that medicated ADHD children have less theta/Alpha but more beta activity than child who are not medicated. Unfortunately, this radiological imaging does not have enough credibility or information to be used in diagnosis yet. Another study looked at iron deficiency because iron is critical in the development of the central nervous system. Other studies have been looking deep into diet and suggest that artificial food coloring and some preservatives may be linked to ADHD. Again, while all of this is a start it doesn't have enough information to contribute to a more concrete process of ADHD diagnosing. Hamed et al. (2015) also examined factors and key people involved in ADHD diagnosis and talks about why this is a complex issue with much risk for error. The process is influenced by subjective perceptions of different members of the child's community. Ideally parents should be the first to recognize early behavioral issues. They may or may not perceive as serious enough to seek medical attention. As mentioned earlier it's usually teachers who suggest evaluation first. That is why it's also very important for teachers to have training in this area since there is a heavy reliance of their behavioral ratings report. Seeking specialist help may also be a financial burden that families avoid. Then of course there are differences in cultures where mental health help of any form is seen as unfavorable or nonsense. This is why trust, communication, and education is very important school personnel and parents. The health care providers role is really to get as intimate as possible with assessment and evaluations.

The reality is that is not a standardized method for determining whether ADHD is a proper diagnosis which leave room for biases. It is very important for clinicians to get as much detail about family history including prenatal details. The more that is know the better process of elimination of other conditions can be incorporated before diagnosing. Dona Ford, professor of special education and human development is also passionate about this controversy and writes about this in multiple articles including some in The New York Times. In the article 2016 article titled: Don't Rush to Saddle Children With the A.D.H.D. Label, Ford puts an emphasis on the fact that some medicated students use this as almost a crutch to justify certain behaviors: Even when drugs are truly required, students still need strategies to help them pay attention and adjust their behavior when they have lots of energy. It's unnerving to hear your student say, I need my medication to pay attention, or I can't sit still until I have my medication. I have heard this more times than I want to remember, even from elementary-aged students She also states that a A checklist of behaviors should not be the only or primary source of an evaluation and then goes on to give examples of other settings in which children to be observed for multiple periods of time such as when watching television, in places of worship, when traveling, in routine/ non-routine out of school settings etc. Ford also talks about how too many of the male children labeled with ADHD are Black. ...boys tend to be more active than girls, and African-Americans are known for being movement-oriented, tactile and kinesthetic.

This is considered normal and healthy in the African-American community but not necessarily so in schools. In another 2011 New York Times article titled: Racism and Sexism in Diagnosing ADHD Ford poses this question: When we have white female teachers who don't understand their black male students, who is the 'problem'? As I reflect on this information I think that teachers and mental health counselors need to collaborate more on this topic. Professional development and educational supplemental information if needed on both ends to prevent misidentification and prescription of unnecessary ADHD medication. ADHD is real disorder and is not treated it can lead to some serious consequences such as substance/alcohol abuse, increased risk for incarceration, lack of positive relationships, lack of academic achievement, financial instability, and/or other factors (Taper & Cooper, 2016). However, advocating for children is very important to finish the opinion and biases in assessment and evaluation. Therefore, it is imperative to make sure that it's not something else before giving the ADHD label.

Works Cited

Bokhari, F. A. S., & Schneider, H. (2011). School accountability laws and the consumption of psychostimulants. Journal of Health Economics, 30(2), 355-372. doi:10.1016/j.jhealeco.2011.01.007 DSM-5. Attention-Deficit/Hyperactivity Disorder. Alfred University Canvas PDF. Retrieved 1 May 2017, from https://file:///C:/Users/clogrono/Downloads/ADHD.DSM%205%20(2).pdf

Elder, T. E. (2010). The importance of relative standards in ADHD diagnoses: Evidence based on exact birth dates. Journal of Health Economics, 29(5), 641-656. doi:10.1016/j.jhealeco.2010.06.003

Evans, W. N., Morrill, M. S., & Parente, S. T. (2010). Measuring inappropriate medical diagnosis and treatment in survey data: The case of ADHD among school-age children. Journal of Health Economics, 29(5), 657-673. doi:10.1016/j.jhealeco.2010.07.005 Ford, D. (2016, February 1). Don't Rush to Saddle Children With the A.D.H.D. The New York Times. Retrieved from https://www.nytimes.com/roomfordebate/2016/02/01/is-the-adhd

Ford, D. (2011, October 13). Racism and Sexism in Diagnosing A.D.H.D. The New York Times. Retrieved from https://www.nytimes.com/roomfordebate/2016/02/01/is-the-adhd

Hamed, A. M., Kauer, A. J., & Stevens, H. E. (2015). Why the Diagnosis of Attention Deficit Hyperactivity Disorder Matters. Frontiers in Psychiatry. Retrieved from https://go.galegroup.com/ps/i.do?p=AONE&sw=w&u=suny_ceramics&v=2.1&it=r&id=G

Sax, L. (2001). Reclaiming kindergarten: Making kindergarten less harmful to boys. Psychology of Men & Masculinity, 2(1), 3-12. doi:10.1037/1524-9220.2.1.3 Thapar, A., & Cooper, M. (2016). Attention deficit hyperactivity disorder. The Lancet, 387(10024), 1240-1250. doi: https://ezproxy.alfred.edu:2134/10.1016/S0140

Wiggs, L., Montgomery, P., & Stores, G. (2005). Actigraphic and parent reports of sleep patterns and sleep disorders in children with subtypes of attention-deficit hyperactivity disorder. Sleep, 28(11), 1437. doi:10.1093/sleep/28.11.1437

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