By Austin Ulrich, PharmD, BCACP

Clinical Pharmacist Practitioner, UpStream Pharmaceutical Care, Greensboro, NC

SYNOPSIS: A growing concern about overdiagnosis of attention-deficit/hyperactivity disorder in adolescents and children demonstrates a need for a decisive answer to this concern.

SOURCE: Kazda L, Bell K, Thomas R, et al. Overdiagnosis of attention deficit/hyperactivity disorder in children and adolescents: A systematic scoping review. JAMA Netw Open 2021;4:e215335.

In recent years, rates of ADHD diagnosis have risen, along with a growing concern about overdiagnosis.1,2 Suggested reasons for increased ADHD diagnosis range from improved detection, true increases in frequency, and diagnostic inflation caused by misdiagnosis or overdiagnosis, but there is no clear consensus.

To investigate the role of diagnostic inflation, Kazda et al designed a series of definitions and questions about overdiagnosis, applied to a systematic review and meta-analysis. Studies published between Jan. 1, 1979, and Aug. 21, 2020, were included. Investigators considered only research that clearly identified diagnoses and outcomes in patients younger than age 18 years.

The authors mapped all data to five questions: Is there potential for increased diagnosis? Has the diagnosis rate actually risen? Are additional cases subclinical or low risk? Have some additional cases been treated? Might harms outweigh benefits of diagnosis and treatment? Kazda et al derived these questions from a previously identified framework for establishing overdiagnosis. The authors evaluated 334 studies, 61 of which were primary research studies. Kazda et al reported the following information in terms of each research question: 104 studies provided evidence for a reservoir of ADHD, 45 studies indicated diagnosis of ADHD has increased, 25 studies showed the additional diagnoses of ADHD were on the mild end of the spectrum, 83 studies demonstrated pharmacological treatment of ADHD is increasing, and 151 studies reported on outcomes of diagnosis and pharmacological treatment.

The authors concluded there is convincing evidence to suggest increased overdiagnosis and overtreatment of ADHD in children and adolescents in recent years. They also identified a need for high-quality research on the long-term risks and benefits of ADHD diagnosis and treatment in youths with milder symptoms.

COMMENTARY

Overdiagnosis is a significant concern in healthcare because it frequently triggers a cascade of overtreatment, higher costs, and potential harm that can persist over years. Patients who receive pharmacologic treatment for ADHD often experience an improvement in symptoms, but many also might experience adverse effects of ADHD therapies. Notably, up to 30% of adults discontinue stimulants because of intolerable adverse effects or lack of symptomatic relief.3 If a patient has only mild or borderline ADHD symptoms, the improvement in symptoms (if any) may be so minimal that treatment could result in a lack of net benefit. While the ADHD overdiagnosis observed by Kazda et al was in children and adolescents, adults can be affected, too. Two of the key criteria for diagnosis of adult ADHD is establishing a childhood history of ADHD and a family history of ADHD.3 Thus, increases in youth ADHD diagnoses are likely to lead to more adult ADHD diagnoses and subsequent treatment. Clinicians should be aware of the potential for overdiagnosis of ADHD in youth and how this can influence ADHD diagnosis in adults.

Overall, there is a need for more research aimed at determining the harms and benefits of diagnosing and treating youth with mild or borderline ADHD symptoms. Further elucidating ADHD diagnosis patterns and implementing practice patterns to avoid harmful overdiagnosis will help optimize the treatment of ADHD in children, adolescents, and adults. 

REFERENCES

  1. Xu G, Strathearn L, Liu B, et al. Twenty-year trends in diagnosed attention-deficit/hyperactivity disorder among US children and adolescents, 1997-2016. JAMA Netw Open 2018;1:e181471.
  2. Conrad P, Bergey MR. The impending globalization of ADHD: Notes on the expansion and growth of a medicalized disorder. Soc Sci Med 2014;122:31-43.
  3. Post RE, Kurlansik SL. Diagnosis and management of adult attention-deficit/hyperactivity disorder. Am Fam Physician 2012;85:890-896.