ADHD: Is It Overdiagnosed?

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ADHD Most Common Neurodevelopmental Disorder

Attention-Deficit/Hyperactivity Disorder (ADHD) is now hailed as one of the most common neurodevelopmental disorders worldwide. The Centers for Disease Control estimates that up to 5% of children/adolescents and adults are diagnosed with ADHD. The long-standing debate on the over-diagnosis or overprescribing of ADHD medications continues.

The DSM-5-TR is a medical classification system for mental illness published by the American Psychiatric Association. Attention-Deficit/Hyperactivity Disorder is defined in the DSM-5-TR as a "persistent pattern of inattention and hyperactivity-impulsivity that interferes with functioning or development." There are three types of ADHD detailed in the DMS-5-TR.

What are the Three Types of ADHD?

1- Primarily Hyperactive and Impulsive ADHD

Hyperactive and Impulsive ADHD often present with fidgeting, squirming, and an inability to stay still. Children may act like they are "driven by a motor" and move excessively. They may interrupt others when speaking, yell out, and struggle with self-control.

Hyperactive symptoms include:

Squirms and shuffles hands and feet
Does not stay seated and gets up at inappropriate times
Frequently cannot play or participate in other activities quietly
Often "on the go" or acting as if "driven by a motor."
Excessive talking

Impulsive symptoms include:

Often blurts out
Has trouble waiting their turn
Often interrupts or intrudes on others

2- Primarily Inattentive ADHD

Inattentive ADHD may present with careless mistakes, difficulty following detailed instructions, and difficulty organizing tasks and activities. They may lose things quickly. Other symptoms include being easily distracted by external stimuli and weak working memory. Inattentive type ADHD is more commonly found in adults and girls. It was formerly known as ADD.

Symptoms include:

Not giving close attention to details and making careless mistakes
Cannot maintain attention during activities
Does not pay attention when spoken to directly
Does not follow through with directions, finish work, chores, or duties at work
Often has difficulty organizing tasks and activities
Often dislikes tasks that require long periods of concentration
Easily loses things and is often late
Often easily distracted by stimulation outside of the current setting
Often forgetful in daily activities

3- Combined Type ADHD

This type of ADHD will have six or more symptoms of Inattentive Type ADHD AND six or more symptoms of Hyperactive and Impulsive ADHD.

It's important to note that the DSM-5-TR requires that six or more of these symptoms be present for at least six months. The symptoms should be to the degree that they interfere with the person's developmental level and negatively impact social and academic activities.

More than one symptom is present in more than one setting (home, school, work)
Clear evidence must be present that the symptoms interfere with or reduce the quality of the school, social, or work functioning.
The symptoms cannot be explained by another existing mental health disorder (mood disorder, anxiety disorder, substance intoxication, or withdrawal)

There are several screening tools used to help healthcare providers diagnose ADHD. The most commonly used screening tool for adult ADHD is the World Health Organization (WHO) Adult ADHD Self-Report Scale. The NICHQ Vanderbilt Assessment Scales are widely used in pediatrics.

There are multiple options for treating ADHD. Medication is the next treatment option if behavioral management alone fails. Non-pharmaceutical methods include behavioral management.

Behavioral Management

First-line treatment should be behavioral management by the parents and the teacher. It is most effective if the parents and teachers work closely together. If behavioral management is inadequate, medication is the subsequent treatment of choice. However, the CDC recommends that behavioral management be the first treatment choice due to the side effects of the medications used to treat ADHD. Some of the behavioral treatment strategies include positive reinforcement and time-out.

Medication

Stimulants

The first option for pharmaceutical management of ADHD is often stimulants. These drugs are in a class called amphetamines. Amphetamines are central nervous system stimulants that work by increasing the amounts of dopamine, norepinephrine, and serotonin. Stimulants are some of the most common drugs used to treat ADHD. We are all familiar with Adderall and Ritalin. Recently, newer medications have been developed, such as Quillichew and Vyvanse. These drugs have the potential to become habit-forming. Like other drugs, they come in extended-release or short-acting.

Non-stimulants

One of the most common non-stimulant drugs prescribed for treating ADHD is atomoxetine (Stratterra). Stratterra is a selective norepinephrine reuptake inhibitor (SNRI). This type of drug is also beneficial for the treatment of depression and mood disorders. Two other drugs commonly used are antihypertensives called clonidine (Catapres) and guanfacine ( Tenex, Intuniv). These are both alpha 2-agonists and are typically used for hypertension. Doctors also use these drugs as an off-label treatment for ADHD.

Homeopathic treatments

Homeopathic remedies such as herbs and minerals are also being explored to treat ADHD. Brillia is one of the most common homeopathic treatments for adults and pediatric populations.

The National Institute of Health (NIH) published information suggesting evidence of overdiagnosis and overtreatment of ADHD in children and teens. The NIH states that this could be due to the definition of ADHD being more inclusive of behaviors that would have been considered normal in previous years. In other words, some behaviors that used to be considered typical for young children have now been considered abnormal and are listed as symptoms.

Thoughts from a School Nurse ...

Attention-Deficit/Hyperactive Disorder is one of the most common chronic conditions I encounter as a school nurse. I administer medications to treat ADHD daily and have experience giving stimulants, non-stimulants, and homeopathic remedies. Being a nurse and seeing the habit-forming tendencies of stimulants raises my concern. Having students take amphetamines during the day and a sedative at night for sleep aid is also worrisome. These students are exposed to uppers and downers in a structured way. Thinking about how they will regulate themselves once the prescriptions stop is concerning.

I have parents that have had older children use stimulants to treat their ADHD and have developed dependencies. They are reluctant to prescribe their younger children medication and sometimes opt for homeopathic options. In some instances, it is a necessary treatment to help children do their best academically. I have also witnessed children that have been born addicted to illegal substances. Ironically, the bulk of these cases are babies born addicted to methamphetamine. Because of that, behavioral and neurologic deficits keep them from being attentive and cooperative in the classroom. These students benefit from the treatment of stimulants and often can participate and learn with their classmates after starting a medication regimen.

The cause of ADHD has been blamed on a plethora of cultural changes. Screen time and absent parents seem to contribute at least to some extent in most research.

Although there are many contributing factors, the long-standing debate on over-prescription and over-medicating children still stands. Most research lacks a definitive answer.

References/Resources

ADDitudeMag.com: 1998 - 2023 WebMD LLC

Overdiagnosis of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents: National Center for Biotechnology Information: National Library of Medicine

Common ADHD Medications & Treatments for Children: healthychildren.org: American Academy of Pediatrics

HOMEOPATHIC PRODUCTS TO Reduce Hyperactivity, Impulsivity and Anxiety in Children, Teens & Adults: Brillia, Hadaf, LLC

Attention Deficit Hyperactivity Disorder (ADHD): Centers for Disease Control and Prevention

Table 7DSM-IV to DSM-5 Attention-Deficit/Hyperactivity Disorder Comparison: National Center for Biotechnology Information: National Library of Medicine