View Full Version : ADHD Overdiagnoses in young children


LynneC
08-17-10, 09:21 PM
http://www4.ncsu.edu/~msmorril/EvansMorrill_ADHD.pdf

Above is the link to one of the studies cited in the news article below.

http://www.npr.org/blogs/health/2010/08/17/129255572/a-second-thought-on-the-accuracy-of-adhd-diagnosis-in-kids

meridian
08-17-10, 09:32 PM
It's interesting that the cut off date for a school year is now Sept 1.

When I was in elementary school, that cutoff date was Dec 31.

My younger brother and I are both in-between those 2 dates and were among the youngest students in our classes.

My Mom was clearly aware that my brother (Nov 29) was particularly younger than his classmates and wondered if he should have been held back a year for maturity issues alone.

I often wondered that about myself.

We are both dyslexic BTW.

Thanks for the links!

BTW, KMiller started a similar thread with different links.

http://www.addforums.com/forums/showthread.php?t=87979

. . . an excess of 2 percentage points implies that approximately 1.1 million children received an inappropriate diagnosis and over 800,000 received stimulant medication due only to relative maturity.

One would think that a misdiagnosed child given a stimulant medication would not experience the desired effect of the medication and would become more hyper rather than less. In that case, misdiagnosed children should be readily identifiable.

Imnapl
08-18-10, 12:34 AM
Meridian, the cut-off date varies with each ministry of education. In my province, December 31 is the cut-off date for school enrollment.

LynneC
08-18-10, 09:55 AM
One would think that a misdiagnosed child given a stimulant medication would not experience the desired effect of the medication and would become more hyper rather than less. In that case, misdiagnosed children should be readily identifiable.
I was thinking that, too, but I wonder if stims have that effect on everyone.(making an NT kid worse)
In low doses, ie morning cup of caffeine, stims do help with focus, so why wouldn't they help with focus for an NT kid if the dose was small enough?

If that is the case, then it would be very difficult to weed out social immaturity based on age, vs ADHD. (The meds are working, so my child must have ADHD.) And it seems as though younger kids are being diagnosed and treated with stims (5 year olds) more frequently. At least, I have observed this from posts here...

P.S. I am not knocking meds; after being educated on this board as to what parents are going through with their ADHD kids, I can see that meds are crucial to maintaining a normal life for the child and the family, in many cases.

Dizfriz
08-18-10, 02:28 PM
Originally Posted by meridian One would think that a misdiagnosed child given a stimulant medication would not experience the desired effect of the medication and would become more hyper rather than less. In that case, misdiagnosed children should be readily identifiable.Response by LynnC I was thinking that, too, but I wonder if stims have that effect on everyone.(making an NT kid worse) In low doses, ie morning cup of caffeine, stims do help with focus, so why wouldn't they help with focus for an NT kid if the dose was small enough? [Good questions and points.


As I understand it from my readings, the stimulants will help most people to be more focused. Think of college students taking Amphetamines to help them study before a test. The old deal of give them Ritalin and if it works, they are ADHD is no longer considered valid and should not be used for diagnostic purposes.

Another issue meridian brought up is the stimulants making any child more hyper is an area of concern when seen. This is called a paradoxical reaction and paradoxical reactions to stimulants is one of the screening tools for alerting to the possibility of bipolar disorder.

If that is the case, then it would be very difficult to weed out social immaturity based on age, vs ADHD. (The meds are working, so my child must have ADHD.) And it seems as though younger kids are being diagnosed and treated with stims (5 year olds) more frequently. At least, I have observed this from posts here... The age of six is considered a proper age to make a fairly definitive diagnosis of ADHD. For younger kids, it needs more severe symptoms to justify the diagnosis but it is often done. I have seen kids diagnosed as young as three but these were *very* severe and the possibility of other diagnosis coming to the fore as they mature was not ruled out.

P.S. I am not knocking meds; after being educated on this board as to what parents are going through with their ADHD kids, I can see that meds are crucial to maintaining a normal life for the child and the family, in many cases.As it is so often said on the forum, the consequences of not medicating can be much worse that the consequences of medicating.

Good comments and questions.


Now to the article:

This was a fairly good article focusing on some of the difficulties of diagnosing ADHD. Most of these are issues that a good clinician should be aware of and take steps to account for. All to often, however, some of those doing the diagnosing are not all that well trained in this and will have problems correctly identifying an immature child young for the grade. The article is a good heads up on the problem.

As I discuss often ADHD is a difficult diagnosis to make correctly primarily because there so many issues that can mimic the symptoms. While here have disagreed, I stand by my statement and the article is a good discussion backing up my view. Thanks for posting it.


Dizfriz

Dizfriz
08-19-10, 12:59 PM
Returning here from the Notre Dame ADHD Research thread.

I read the news article cited by NotreDameDAD. It disturbed me in that it said that Today 5 to 10 percent of all U.S. children between the ages of 6 and 18 have been diagnosed with ADHD. That goes against most of what I have seen in the past. I decided to give the Evans paper a closer reading (I had just skimmed it earlier). I checked the Evans paper and it did indeed give these figures.

Evans states In the United States about 5 to 10 percent of children aged 6 to 18 have been diagnosed with ADHD and some estimates suggest this number increased by 500 percent between the late 1980’s and early 2000’s (Zuvekas et al., 2006). The Zuvenkas paper was on trends in medication for ADHD with children. In that paper it was stated that The point prevalence of ADHD is generally estimated around 4%–5% of the child population, although higher rates have been recently reported.Note: Point prevalence is a measure of the proportion of people in a population who have a disease or condition at a particular time. It is not a measure of diagnostic rate.

This figure does not seem to support Evans figure of 5-10% of kids being diagnosed with ADHD. Perhaps someone a little more time and a detail orientated bent bent will read it carefully and verify if Evans' 5-10% diagnostic rate was or was not supported in the article. I find my ability and desire to read word for word has diminished greatly since I was in grad school so I can miss things especially when limited in time.

Also Evans stated According to our estimates, approximately 9 percent of all children are diagnosed with ADHD and approximately 4 to 6 percent of children current take a prescription stimulant to treat ADHD. Again this is not what I have seen in other studies. The Zuvenkas study Evans cited stated that the prevalence use of stimulants among subjects under 19 years of age was 2.7% in 1997 and 2.9% in 2002, with no statistically significant change during these 6 years. This goes along with what I have read elsewhere.

Of interest but not a criticism, Evans is reported to be an economist rather than someone in the medical/social work/psych field. I do not thank that this should make any difference but it struck me as a bit unusual and was of interest to me.

From Evans' paper:

Conclusions The evidence presented above indicates that for some children, a diagnosis of ADHD is not solely based upon underlying biological conditions. Rather, being born just before versus just after the kindergarten eligibility cutoff date in one’s state is a significant factor in the probability of receiving an ADHD diagnosis. This is likely a result of relative maturity and is therefore not a surprise given the difficulty of diagnosing ADHD and the explicit consideration that health care providers are advised to give to whether the behaviors in question “happen more often in this child compared with the child’s peers? 27 As Elder and Lubotsky (2009) demonstrate, younger children in classes are more likely to have educational and behavioral problems compared to their peers, and therefore, some children who are relatively young compared to their classroom peers are more likely to be diagnosed with ADHD. These results suggest that the comparison sample for diagnosis should not be other children in class but rather, other children of a similar age within a class.All of the ADHD specific home/school surveys (as recommended in the ADHD diagnostic protocols) are normed by age not by class and some are also normed by gender/age as well.

It is not unusual for there to be a two year range in a first grade class and a three year range is not unheard of (no redneck jokes on father and son in the same class) and Evans reports a much wider range. The problems with comparing with classmates is or should be well known by clinicians and is why class comparisons are never recommended for diagnostic purposes, only age ones.

This is really nothing new here that I can see but it is a good thing as a caution and too perhaps get the attention of those doing ADHD diagnosis especially pediatricians.

I am however concerned about the diagnostic and medication rates he reports as well as some other of his statistics. If the stats do not hold then this paper could be seen possibly as an alarmist paper with concerns about its validity and its purpose. Right now I would have to recommend taking this paper with a grain of salt and waiting to see how it is received.

Just my thoughts. Others may vary.

Dizfriz


For those of a research bent

The Zuvekas article is at http://ajp.psychiatryonline.org/cgi/reprint/163/4/579

The Evans article is at http://www4.ncsu.edu/~msmorril/EvansMorrill_ADHD.pdf (http://www4.ncsu.edu/%7Emsmorril/EvansMorrill_ADHD.pdf) (Thanks Lynnc)

The newspaper article is at http://newsinfo.nd.edu/news/16395-adhd-diagnosis-overused-for-children-youngest-in-class-notre-dame-research-concludes/?utm_source=feedburner&utm_medium=feed&utm_campaign=Feed%3A+NewsAndInformation%2FNews+%28 News+and+Information+-+News%29 Thanks NotreDameDAD

OrionsMom
08-19-10, 01:07 PM
I can see the point in the article, however I know my son was not misdiagnosed. He is the youngest child in his class, he's actually a grade ahead of what he should be because I made the decision to put him into school a year early. Although his preschool teacher told me it was a mistake because he was socially immature, I knew he needed a structured education. My son started reading at 18 months old, by the time he was 2 1/2 he was reading Harry Potter books by himself! Our school cut-off is August 31 and my son was born on Sept. 20th. 3 weeks is not a big enough difference and I knew he would eventually socially catch up. The preschool teacher told me that by the time he was in 3rd grade he would have no friends and that it would be my fault. I went with my gut and put him in Kindergarten at 4 years old, he turned 5 3 weeks into his school year. I had a feeling he needed medication because of his actions but everyone was reluctant to do that including my husband. 1st grade was no different, and 2nd grade as well. Finally, at the end of the 2nd grade year my son had 1 friend who would still play with him, I was being called into the principals office 3 out of 5 days a week and I decided it was time to go with my gut. His teacher told me how medication changed her daughters life and I decided it was time. I took him to the doctor against my husbands wishes and did all the paperwork and questionairres. Sure enough he was indeed ADHD. Medication has changed his life in amazing ways. He has friends again, he plays and aside from a few side effects he is an amazing wonderful child when he is on meds.

I know there are kids that are over diagnosed, kids who are wrongfully diagnosed, but I don't know if it's really about where they stand in an age line up at school

OrionsMom
08-19-10, 02:57 PM
And BTW, I feel it fair to mention that every single year his teachers have told me that I did the right thing putting him into school early. Although he is "socially immature" he's too smart for his own good and none of them would have wanted him in class the following year. They all agree that he would be nothing but a terror because he would be so bored that he would then be a problem child for a whole different reason. In his case it would not matter if he were the oldest or the youngest in his class, he would still be an ADHD boy with a need for medication.

Trooper Keith
08-19-10, 03:57 PM
I am however concerned about the diagnostic and medication rates he reports as well as some other of his statistics. If the stats do not hold then this paper could be seen possibly as an alarmist paper with concerns about its validity and its purpose. Right now I would have to recommend taking this paper with a grain of salt and waiting to see how it is received.

Just my thoughts. Others may vary.

Dizfriz


For those of a research bent

The Zuvekas article is at http://ajp.psychiatryonline.org/cgi/reprint/163/4/579

The Evans article is at http://www4.ncsu.edu/~msmorril/EvansMorrill_ADHD.pdf (http://www4.ncsu.edu/%7Emsmorril/EvansMorrill_ADHD.pdf) (Thanks Lynnc)

The newspaper article is at http://newsinfo.nd.edu/news/16395-adhd-diagnosis-overused-for-children-youngest-in-class-notre-dame-research-concludes/?utm_source=feedburner&utm_medium=feed&utm_campaign=Feed%3A+NewsAndInformation%2FNews+%28 News+and+Information+-+News%29 Thanks NotreDameDAD

I'm a notorious skimmer, even though I'm fresh in grad school, but I also used search and could not find support for Evans' claim that the diagnostic prevalence rate is between 5-10% or that it has increased by 500x in the Zuvekas article. Zuvekas' statistics hold up. I'm skimming the Evans' article now to see what kind of analyses he's using.

Of interest but not a criticism, Evans is reported to be an economist rather than someone in the medical/social work/psych field. I do not thank that this should make any difference but it struck me as a bit unusual and was of interest to me.

The reason an economist is writing about this is that medical expenditures in the US are higher than any other country in the world. He's using ADHD overdiagnosis as a metric of wasted medical money.



Edit: Having looked over Evans' stats, I can say that he's using sound methods but he's developed his own calculations to elucidate his points. That's fine, but there's wizardry involved. What this paper is not meant to prove, however, is that ADHD is overdiagnosed. He's simply using an assumed ADHD overdiagnosis rate as a metric to demonstrate a more refined point: US healthcare expenditures are way, way higher than other civilized nations, and this is a serious problem.

He hasn't demonstrated that ADHD is overdiagnosed per se, just that we're spending a lot of money on it, so if it is overdiagnosed, we're wasting a lot of healthcare dollars.

Lunacie
08-19-10, 04:13 PM
I'm a notorious skimmer, even though I'm fresh in grad school, but I also used search and could not find support for Evans' claim that the diagnostic prevalence rate is between 5-10% or that it has increased by 500x in the Zuvekas article. Zuvekas' statistics hold up. I'm skimming the Evans' article now to see what kind of analyses he's using.



The reason an economist is writing about this is that medical expenditures in the US are higher than any other country in the world. He's using ADHD overdiagnosis as a metric of wasted medical money.


If that's his point, then I'd have to disagree. The U.S. is spending more money on health problems across the board, both in prevention and in treatment and rehibilitation. Clearly understanding health problems can lead to preventing the problems at all, or to better treatments and outcome which lead to a better quality of life. I don't see those as a waste of money.

I remember when hearing that you had cancer was a death sentence. I don't know how much closer we are to understanding the causes of cancer or preventing it, but an awful lot of people are still alive that would have been dead without the research and treatment. We aren't just treating ADHD (and other neurological disorders), we're doing research to find out what causes them and whether they can be prevented or find better treatment to lead to a better quality of life.

There was a time when sick people were leaving the US because other countries were doing more research and offering better treatment. It seems we're catching up in those areas, eh? Now we have foreigners coming here for treatment in our teaching hospitals.

Dizfriz
08-19-10, 05:34 PM
Keith (Kmiller)

What happened was that I originally skimmed the primary subject material in the article and glanced over his stats and they looked ok.

That was far as it went until I read the news article that I said "Say what!". I begin to look at Evans' article more closely and saw a number of statistical statements that were contrary to most of what I had read and I have serious concerns that he could back them up very well.

I isolated the 5-10% figure and researched his cite. As far as I could tell, his cite did not back up his statements. This is a no-no in research and gave me concern about the rest of his stats on ADHD and medication in general.

I know that the incidence or medication rates were not the primary thrust of his article but it was these statements that caught my eye.

I see where he does focus on economic factors to some degree and I like his primary point that the age differential can make a significant difference in diagnosis. That does not excuse bad scholarship however.

I also do not understand the relevance of some of his conclusions. The problem of misdiagnosing ADHD in younger children due to their age rank in class is something that I was aware of but it was not a bad thing to stress. His solution, however, did not make a lot of sense in that, at least as far as I know, none of the surveys use class status as norms for diagnostic purposes.

It may be that as an economist, he is not as aware of the background research on ADHD as might be advised and especially was not aware of the makeup of the surveys used in diagnosis of ADHD. In my opinion, he should have been though.

Oh well, it was a good thing to look at and I am glad that the study was brought up.

Thanks for your response.

Dizfriz

Andrea715
08-19-10, 05:38 PM
I just saw this on the local NC fox8 5:00 news...

Lunacie
08-19-10, 05:48 PM
I just saw this on the local NC fox8 5:00 news...

The media, especially Fox news, just loves Psuedo-science. :(

Trooper Keith
08-19-10, 05:56 PM
Dizfriz, I agree with you that there's definitely bad scholarship going on. His statistics are sound, by which I mean the math checks out and the results of the math are solid. Where he got his data, however, I can't figure out. So I'm agreeing with you that it's probably alarmist in the way it's being interpreted.

What gets me is that the news is hyping this aspect that his paper does not actually support, versus the idea that we're overmedicating due to an out of control health care sector, which I believe is the point he's trying to make. I think he's aware that he's not an expert on ADHD, but his point is somewhat valid.



Lunacie, the problem with US healthcare is the insurance industry and the lack of government oversight. Hospitals are, for the most part, for-profit in this country. That means they need to minimize costs and maximize gains. Because hospitals have to treat everyone, regardless of ability to pay, hospitals charge a lot of money to people who can pay. Insurance companies have to handle this, so they pass the cost onto the consumer. What ends up happening is that we spend, per capita, a lot more money on health care than any other country in the world.

Here's a graph of healthcare spending per capita:

http://topforeignstocks.com/wp/wp-content/uploads/2010/07/oecd-health-expenditure-gdp-per-cpita.PNG

And per GDP.

http://www.oecd.org/vgn/images/portal/cit_731/19/44/45549848Health%20data%202010.PNG

Lunacie
08-19-10, 07:42 PM
Well, if most of the money is being spent - or wasted - on hospital visits or stays, then using ADHD as a poster child for the "wasted money" is a straw man, because ADHD is very rarely treated in the hospital, eh?

Trooper Keith
08-19-10, 08:09 PM
No doubt, I'm not saying his argument is sound, just that the conclusion he's trying to come to holds water. He's just using ADHD overdiagnosis and overmedication as concrete instantiations of medical spending being out of control. Unfortunately, he failed to demonstrate that ADHD was overdiagnosed or overmedicated, and in fact the sources he cites state the opposite. So he used poor premises to boost an ultimately poor argument about a very real problem.

Imnapl
08-20-10, 02:04 AM
Our school cut-off is August 31 and my son was born on Sept. 20th. 3 weeks is not a big enough difference and I knew he would eventually socially catch up.Kids must be five years old before December 31 in order to start kindergarten. Your son would have been well within the cut-off date in my district and older than several other students in his class. :)