A systematic scoping review found evidence that attention-deficit/hyperactivity disorder (ADHD) may be overdiagnosed and overtreated among children and adolescents. These findings were published in JAMA Network Open.
Researchers from the University of Sydney in Australia searched publication databases from January 1, 1979 through August 21, 2021 for studies of ADHD among children and adolescents. Studies were assessed for 5 themes: evidence of overdiagnosis among subgroups, whether diagnoses have increased over time, evidence of subclinical or low risk patients, whether more cases have been treated over time, and which benefits and harms associated with diagnosis and treatment.
A total of 334 studies were included in this review. Most studies (65.0%) were published during the previous decade and research was most frequently carried out in North America (38.3%) or Europe (27.8%).
A large amount of variation was found among subpopulations for ADHD diagnoses. The bias in gender tended to decrease over time, implicating a historical reservoir of ADHD among girls. In the classroom setting, the youngest children in class were more likely to be diagnosed than the oldest. Individuals from a migrant background were less likely to be diagnosed in older studies, but, in more recent studies Black youths were more likely to be diagnosed than their White counterparts.
Overall, the diagnoses of ADHD have been increasing over time. Among the 45 studies which discussed temporal trends, only 3 reported a plateau in diagnoses while 96.0% confirmed the increasing trend.
Studies which included symptom severity reported that few patients diagnosed with ADHD exhibited severe symptoms. Decreases in impairment levels, adverse outcomes, and medication benefits were observed among patients with more broadly defined ADHD symptoms.
Most studies including data on pharmacology (n=83) indicated the treatment of ADHD with medication has become more prevalent over time. Only 2 studies from Germany found a decrease in pharmacology treatments and 3 studies indicated a plateau in prescriptions.
Potential beneficial outcomes from receiving a diagnosis of ADHD included a sense of empowerment and control, as well as facilitating an environment in which individuals felt more comfortable seeking help for their symptoms. Conversely, some patients used their diagnosis as an excuse to maintain bad behaviors and many reported a feeling of hopelessness.
For treatment outcomes, some studies suggested treatment for ADHD was only beneficial academically among patients with severe symptoms and youth often reported adverse indirect effects on cardiovascular, physical, psychological, and emotional components. Altogether, at best ADHD symptoms were decreased modestly while at the same time increasing risk for many adverse effects.
This review was limited by the high risk for bias among the underlying studies.
These data indicated that compared with earlier documented cases, as early as 1979, evidence suggests ADHD may be overdiagnosed and overtreated among adolescents. High-quality long-term studies of potential negative outcomes from unnecessary treatment are needed such that informed diagnosis and treatment guidelines for ADHD in pediatrics may be formulated.
Kazda L, Bell K, Thomas R, McGeechan K, Sims R, Barratt A. Overdiagnosis of attention-deficit/hyperactivity disorder in children and adolescents: A systematic scoping review. JAMA Netw Open. Published online April 12, 2021. doi:10.1001/jamanetworkopen.2021.5335