Is ADHD underdiagnosed or overdiagnosed? One doctor emphatically says the former.
Margaret Sibley, PhD, in her session “Adult ADHD: Are We Missing It in Practice?” at the 2022 APSARD Virtual Conference, spoke about adult ADHD and specific diagnostic issues that might help clinicians make more precise diagnoses in clinical practice.
“A lot of people ask this question: Are we overdiagnosing ADHD or are we underdiagnosing ADHD?” said Sibley. “I think the answer to this question is that we're actually often misdiagnosing ADHD. There's both false positive and false negative diagnoses.”
The reasons, Sibley believes, behind the controversy over ADHD diagnoses are numerous and potentially include:
-Symptoms are subjective. No 2 people have the exact same symptoms.
-Symptoms are internally experienced.
-Symptoms overlap with other mental or physical health diagnoses.
Sibley shared that there are often 2 classes of people who are underdiagnosed: 1) individuals who are overlooked, meaning they come to clinical attention but do not receive an ADHD diagnosis, and 2) individuals who are not referred. Individuals in the second group may include those who were diagnosed with ADHD as children, but are no longer identified as someone with ADHD. This is supported by data from the Pittsburgh ADHD Longitudinal Study, Sibley explained, which demonstrated that when children with ADHD grew up, they expressed they were no longer experiencing ADHD symptoms even though their parents stated they were still observing ADHD symptoms in their children.1
“One of the things that this translates into in real life is possibly people underutilizing treatment because they don’t acknowledge that their symptoms are still happening,” said Sibley.
According to longitudinal literature on ADHD, when children with ADHD grow up, they tend to struggle to complete higher education, have unstable employment histories and difficulties performing at work, struggle with substance abuse, have legal and financial problems, and have adulthood difficulties with self-esteem, shared Sibley.
Sibley encourages all clinicians to review the Canadian ADHD Resource Alliance (CADDRA) guidelines2 for treating ADHD and comorbid psychiatric disorders. “This is a really nice sort of framework for thinking about not only do I have the right diagnosis, but when I do have the diagnosis sorted out, what do I do first? What do I treat first? What can I treat at the same time? What modalities of treatment should I use?”
Sibley also views motivational interviewing as a really important tool in the initial treatment arsenal. “It's important for us to frame the symptoms of ADHD during clinical assessment in the proper developmental context for the person that we're sitting across from. The appropriate environmental context considering what their life demands are, and the cultural context that the person lives in. We should feel equipped to be able to recognize ADHD in these contexts.”
1. Molina BSG, Sibley MH, Pedersen SL, Pelham WE. The Pittsburgh ADHD Longitudinal Study (PALS). In: Hechtman L, ed. Attention Deficit Hyperactivity Disorder: Adult Outcome and Its Predictors. Oxford University Press; 2017:105-155.
2. Canadian ADHD Practice Guidelines, 4.1 Edition. ADHD Institute; 2020. Accessed January 14, 2022. https://www.caddra.ca/canadian-adhd-practice-guidelines/