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Are We Overdiagnosing and Overtreating ADHD?

Are We Overdiagnosing and Overtreating ADHD?

SIGNIFICANCE FOR THE PRACTICING PSYCHIATRISTSIGNIFICANCE FOR THE PRACTICING PSYCHIATRIST
Comparison of DSM-5 and ICD-10 diagnostic criteria for ADHDTABLE. Comparison of DSM-5 and ICD-10 diagnostic criteria for ADHD

While the existence of ADHD continues to be debated in some circles, descriptions of the syndrome date back to the 18th century and its treatment to a report by Charles Bradley in 1935.1 It has since come to be widely recognized by many as the most common neurodevelopmental disorder of childhood. It is more likely to be diagnosed in boys and negatively affects academic and social achievement. Untreated, the condition takes a toll on a child’s self-esteem and self- confidence.

Comorbidity is the rule as ADHD often co-occurs with other symptoms and disorders, including tics, anxiety, mood dysregulation, disruptive behavior, and/or learning disabilities. Moreover, persons who have ADHD are at increased risk for a substance use disorder.

ADHD is a chronic condition that can last a lifetime. Approximately 50% of children with the disorder continue to experience debilitating symptoms into adulthood. While notable hyperactivity and impulsivity may abate, inattention and executive functioning deficits often persist. Adults with ADHD have markedly higher rates of divorce, unemployment, traffic violations, substance use, and arrest than their unaffected peers.

While ADHD clearly places a significant burden on the individual, family, and society at large, there has been debate regarding its diagnosis and treatment. Overdiagnosis is a concern as it may cause the medicalization of normal variants in the population and lead to unnecessary treatment interventions that may have little or no benefit and that pose unacceptable risks of adverse effects. Overtreatment not only burdens patients with adverse effects but misappropriates and overwhelms limited medical and other resources essential to the management of those with actual disease.

To address diagnostic and treatment concerns, it is critical to understand how ADHD is diagnosed. As with most, if not all, neuropsychiatric disorders, there is no established gold-standard or neuroimaging test to confirm the diagnosis of ADHD; nor are there well-established biomarkers—diagnosis and treatment are symptomatically rather than etiologically driven. Diagnosis therefore depends on phenomenology, subjective reports, and clinical observations of symptoms of the condition that lead to dysfunction.

Diagnosis

The contemporary diagnosis of ADHD based on DSM-5 criteria requires the presence of 6 or more inattentive symptoms and/or 6 or more symptoms of impulsivity and hyperactivity in children. The criteria for ADHD are slightly different for adults: those aged 17 years and older need only demonstrate 5 symptoms to meet the criteria. DSM-5 further stipulates that symptoms must be present in 2 or more environments, begin prior to age 12, cause notable dysfunction, and not occur primarily in the context of a psychotic illness or be better accounted for by another mental disorder or medical condition.

DSM-5 is not the only diagnostic nosology. While it is commonly used in the US, much of the world uses ICD-10. ICD-10 refers to ADHD as hyperkinetic disorder (HD), and the diagnosis requires the presence of symptoms of both overactivity and inattention, present before age 6. Given inconsistencies in diagnostic criteria for the condition worldwide and over time, one may expect discrepant estimates of its prevalence from one region to another and over the years.

The Table summarizes DSM and ICD diagnostic criteria.

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