Poor Diagnostic Accuracy of ADHD in Children 

Attention-Deficit/Hyperactivity Disorder (ADHD) is one of the most increasingly diagnosed neurodevelopmental disorders in children ages 6 to 11. This recent increase has created concern among clinicians and researchers who must consider that potentially, ADHD may be over-diagnosed. It is becoming more broadly understood that traditional assessment tools based on DSM-5 criteria for example, have limitations. Accurate diagnosis necessitates a more holistic and multifaceted approach that accounts for a broader range of factors contributing to symptomatology (Brown, 2017; Arbeau, 2017). Research needs to consider other factors contributing to the symptoms characterized as ADHD and that some areas of traditional diagnostic frameworks require review and improvement.

 Psychological Stressors

Arbeau et al. (2017) found that traumatic stress can impact behavior and neurological functioning leading to symptoms that overlap with those of some psychiatric conditions. The research posits that chronic activation of the stress response, described as a “discharge of the parasympathetic nervous system”, impacts a child’s attachments, sensorimotor skills, affect regulation, impulse control, and higher-order cognitive skills. In other words, traumatic stress can produce symptoms that closely resemble those of ADHD, such as difficulty concentrating, impulsivity, and hyperactivity. In support of this finding, Brown (2017) explores the relationship between ADHD and Adverse Childhood Experiences (ACEs). Her work argues that children diagnosed with ADHD are more likely to have encountered ACEs than those without ADHD. Brown also identifies a dose-response relationship, wherein an increase in the number of ACEs is correlated with a greater probability of an ADHD diagnosis. When running assessments, simply asking the question “What happened?” can greatly influence treatment and outcomes for children who have experienced trauma, such as physical or sexual abuse, neglect, parental incarceration or mental illness (Arbeau, 2017). Failing to do so could result in clinicians implementing ineffective treatments, or not being alerted to the necessity for child safeguarding interventions.

 Gender Differentiated Diagnoses

The diagnosis-dependent symptoms of ADHD can manifest differently across genders. Gascon et al. (2022) note that girls with ADHD often internalize their symptoms, leaving them under-diagnosed or misdiagnosed. For example, girls often exhibit inattentiveness or daydreaming rather than hyperactivity, which is more typical in boys and a primary feature of ADHD. Additionally, the higher prevalence of video game use and screen time among boys compared to girls has been regarded as a contributor to differences in behavior affecting how symptoms present.

Video Gaming and Screen Time

Masi et al. (2021) demonstrated a significant correlation between excessive video game usage and ADHD diagnoses. That addictive gaming behaviors are linked to symptoms commonly associated with ADHD – as is over-exposure to digital media and screen time in general. That said, if ADHD symptoms manifest from impeded neurological development due to adverse environs, individual traits, or to too much screen time, are there any other factors that lead to ADHD-like behaviour in children? Indeed, there are.

 Sociocultural Factors

Gascon, Gamache, St-Laurent, and Stipanicic (2022) also review the potential over-diagnosis of ADHD in North American children with a focus on how artifactual factors, particularly pressures associated with the Western “cult of performance,” may artificially influence ADHD diagnoses. Societal pressure to excel in sports, and or strict accountability and performance in educational environments may place unreasonable expectations on children. The follow-on strain will likely have kids behaving distracted, unfocused, and frenetic increaseing the likelihood of an ADHD misdiagnosis. They go on to argue that assessment tools like the DSM-5 are limited having been developed within a Western context and therefore fall short of meeting the needs outside of western society. Nonetheless, and with cultural implications aside, some would argue that even within western society assessment fail by being facilitated in ways that are largely ineffective. For example, poor standardization.

 Inconsistent Assessments

Data compiled from non-standardized assessment tools can be erratic, making it difficult to statistically determine useful trends and patterns. Espinet et al. (2022) set out to clarify the epidemiology of ADHD in Canada. Something they found was most Canadian studies on ADHD reported on prevalence rather than incidence making it more difficult to determine causation or to get perspective on the rate of children being affected. Aside from the prevalence/incidence issue, in the process of their study they also noted that assessment tools varied greatly from region to region as did the category of practitioners delivering the assessments. To illustrate, across Canada, psychologists, family doctors, psychiatrists, pediatricians, and counsellors having different expertise and theoretical approaches were using ICD criteria with varying revision status.

 Conclusion

Research indicates that traumatic stress can affect behavior and neurological functioning resulting in symptoms that overlap with those recognized in some psychiatric conditions such as ADHD. As mentioned, children diagnosed with ADHD are significantly more likely to have experienced ACEs compared to their peers without ADHD. This correlation alone is enough to propose an urgent need to improve the accuracy of ADHD diagnosis. However other factors exist also, such as cultural influences in North America that overemphasizes sporting and academic performance – extending to excessive video game usage and inadequate assessment tools.

Could a multidisciplinary approach that integrates trauma-informed assessments, consideration of environmental and cultural factors, and gender-sensitive diagnostic practices reduce the misdiagnosis and over-diagnosis of ADHD in children? The answer is yes.

Research on ADHD needs to focus on developing a greater holistic understanding of ADHD which would necessitate a multidisciplinary approach. By incorporating perspectives from different professionals, including pediatricians, psychologists, psychiatrists, educators, and counsellors, we could develop a multidimensional assessment tool that takes into account the factors discussed in this paper, as well as any novel ones as they arise through productive research. In terms of mental health diagnostics in general, there is argument that advocates for frameworks which consider more implicatory biopsychosocial factors – rather than reducing an child’s experience to an over-universalized checklist of 11 or so symptoms (Mahapatra, 2024). With more accurate assessments comes improved treatments and precise data that subsequently bootstraps more productive research.

References

 Arbeau, K., Theall, L., Willoughby, K., Berman, J. M. J., & Stewart, S. L. (2017). What happened? Exploring the relation between traumatic stress and provisional mental health diagnoses for children and youth. Psychology, 8(14), 2485–2495. https://doi.org/10.4236/psych.2017.814157

Brown, N. (2017). Associations between adverse childhood experiences and ADHD diagnosis and severity. Academic Pediatrics, 17(4), 349–355. https://doi.org/10.1016/j.acap.2016.08.013

Espinet, S. D., Graziosi, G., Toplak, M. E., Hesson, J., & Minhas, P. (2022). A review of Canadian diagnosed ADHD prevalence and incidence estimates published in the past decade. Brain Sciences, 12(8), Article 1051. https://doi.org/10.3390/brainsci12081051

Gascon, A., Gamache, D., St-Laurent, D., & Stipanicic, A. (2022). Do we over-diagnose ADHD in North America? A critical review and clinical recommendations. Journal of Clinical Psychology, 78(12), 2363–2380. https://doi.org/10.1002/jclp.23348

Mahapatra, A., & Sharma, P. (2024). Biopsychosocial approach to mental health. In M. Anand (Ed.), Mental Health Care Resource Book (pp. 87 – 100). Springer, Singapore. https://doi.org/10.1007/978-981-97-1203-8_5

Masi, L., Abadie, P., Herba, C., Emond, M., Gingras, M. P., & Amor, L. B. (2021). Video Games in ADHD and Non-ADHD Children: Modalities of Use and Association with ADHD Symptoms. Frontiers in Pediatrics, 9, 632272. https://doi.org/10.3389/fped.2021.632272