My patient, Jed, was concerned that his young son showed signs of ADHD: waiting until the last moment to work on assignments, failing to turn in completed homework, and ceaseless fidgeting. Jed had acted just this way when he was young. But despite treatment for depression and anxiety starting in college, doctors had only identified Jed’s ADHD three years ago.
“I don’t want him to wait 50 years before he figures out what’s going wrong in his life,” Jed told me. He wanted someone to recognize and treat his son’s ADHD before it disrupted his education, career, and relationships in a major way.
As an adult psychiatrist specializing in ADHD, I have treated more than 100 individuals like Jed: people who have been in the mental health system for years while their ADHD went unrecognized and untreated. Many developed depression, anxiety, PTSD, or substance abuse problems secondary to their ADHD. Undiagnosed ADHD caused a mountain of misery and dysfunction for these individuals, their families, and coworkers.
Over the years, I’ve seen only four people who proclaimed they had ADHD but for whom I found no evidence to support that diagnosis. From my clinical perspective, underdiagnosis of ADHD occurs far more often than overdiagnosis.
I’m aware that my practice may not be representative of the world at large, so I try to use my training as a medical researcher to gather more widespread and objective information. I also know that some people still refuse to accept the ADHD diagnosis as valid, despite tens of thousands of articles that substantiate that a subset of the population consistently displays problems with executive functioning, and, as a group, show genetic, neurochemical, and both structural and functional brain differences compared with the general population. Furthermore, ADHD isn’t a trivial problem or simply a “superpower.” ADHD shortens a child’s projected lifespan by about 10 years — as large an effect as depression or Type 2 diabetes.
My attention was thus piqued by a recent meta-analysis by Luise Kazda and colleagues purporting to show extensive overdiagnosis and overtreatment of ADHD. The mainstream media extensively promoted this message. However, a more careful reading of the article fails to substantiate these claims.
The meta-analysis revealed a “reservoir of unrecognized ADHD,” which actually demonstrates underdiagnosis, not overdiagnosis. It also documented increased rates of ADHD diagnosis over the past 40 years, along with increased rates of treating ADHD with medications. While a handful of studies addressed the potential costs of treating milder cases of ADHD, none demonstrated that such damage outweighed the benefits of either diagnosis or treatment.
Kazda and colleagues found evidence that we are picking up milder cases of the condition. This finding highlights that ADHD exists on a spectrum, with an inherent arbitrariness in where we draw the line between a “disease state” and a “subsyndromal condition.” It matters where we place the fence posts. If we are too conservative, we shut out people that might benefit from recognition and treatment. Too liberal, and we include some who may receive more harm than benefit from the ADHD label.
The benefits of diagnosing and treating ADHD have been widely demonstrated: improvements in academic performance, decreased substance abuse problems, and lower rates of motor vehicle and other serious accidents. Psychological benefits include having an explanation for, and an understanding of, why one differs from other individuals. This can enhance self-worth and a sense of control. A child may realize, for example, “I’m not 'stupid.' I just need to find ways so my ADHD doesn’t distract me.”
The costs of diagnosing and treating ADHD include risks from medications, including addiction, psychosis, agitation, anxiety, appetite suppression, and sleep disruption. Psychological detriments accrue when one views the diagnosis as an excuse, or it creates a loss of control, or contributes to self-blame. An individual may stop trying to arrive to class on time, thinking, “I have ADHD, I’m just going to be late anyway.” Stigmatization can also be particularly harmful when families, schools, or peers endorse the view that one is defective.
Jed’s history highlights that individuals can be harmed when ADHD is undiagnosed. Despite having advanced degrees in marine biology, finance, and computer science, he was unemployed for years at a time. His marriages have been rocky. He has been seriously injured in car crashes and other accidents. His life has improved considerably in the three years since his ADHD was recognized and he started appropriate medication. Yet even now he continues to suffer from a lack of recognition of his ADHD. His couples therapist doesn’t seem to have any true awareness of the condition, and often falsely attributes marital problems to Jed’s “laziness” or “lack of caring.”
Overdiagnosis of ADHD exists. Some parents game the educational system to garner accommodations for their children. Some individuals exaggerate symptoms in order to obtain powerful stimulant medications. But available evidence suggests that many of these individuals actually are on the ADHD spectrum and can benefit from accommodations for, and treatments of, their ADHD. Many of these people feel genuine distress and experience real dysfunction.
Our best safeguard against overdiagnosis and overtreatment is simply good clinical practice. We should always evaluate our interventions and treatments to see if they are helping, and if not, adjust accordingly. Currently, patients face too many barriers when pursuing mental health evaluation and treatment. Unless we have compelling evidence that we are unnecessarily treating ADHD, we should not let the pejorative title of “overdiagnosis” further discourage individuals from seeking help. Unrecognized ADHD continues to derail the lives of far too many.
Do you have clinical experience diagnosing or treating ADHD? Share your expertise in the comment section.
John Kruse, MD, PhD, trained in neuroscience and has practiced psychiatry in San Francisco for the last 27 years. He is also a father, marathon runner, lecturer, and author of Recognizing Adult ADHD.
All names and identifying information have been modified to protect patient privacy.