A new study led by Paul Morgan, Harry and Marion Eberly Faculty Fellow and professor of education (educational theory and policy) and demography, and published in the Journal of Learning Disabilities, examines which sociodemographic groups of children are more likely to be overdiagnosed and overtreated for ADHD.
The researchers analyzed data from 1,070 U.S. elementary school children who had previously displayed above-average behavioral, academic or executive functioning the year before their initial ADHD diagnoses. The team said those children were considered unlikely to have ADHD by the researchers because children diagnosed and treated for ADHD should display chronically inattentive, hyperactive or impulsive behaviors that impair their functioning and result in below-average academic or social development.
A problem with ADHD overdiagnosis is that it contributes to stigma and skepticism toward those experiencing more serious impairments, said Morgan, who is also a PRI associate.
“It undermines a confidence in the disorder,” he said. “If anyone can be diagnosed with ADHD, then what is ADHD? For those who have significant impairments, they may experience greater skepticism about the condition. Mental health resources are already scarce, those with serious impairments could lose out.”
In addition, said Morgan, previous research has shown that among children with no or mild ADHD symptoms, being diagnosed with the disorder may result in lower academic achievement and behavioral problems during elementary school, perhaps because these children may be more likely to compare themselves with children without disabilities, and so adopt negative ability beliefs that interfere with their learning and behavior. He added that overtreatment of ADHD unnecessarily exposes children to medication’s negative side effects, such as sleep problems or decreased appetites.
The researchers analyzed a subsample of elementary students who had been independently assessed as displaying above-average levels of behavioral, academic and executive functioning the year immediately prior to their initial diagnosis and who did not have prior diagnostic histories.
Through a parent survey, the researchers determined whether or not a child had been diagnosed with ADHD. Among elementary school children who had shown above-average academic achievement, 27% of white children versus 19% of children of color were later diagnosed with ADHD. About 20% of white children versus 14% of children of color were using ADHD medication. Additionally, among children who had previously displayed few problem behaviors in classrooms, 13% of white children versus 8% of children of color were later diagnosed with ADHD. Those disparities were not explained by the family’s socioeconomic status or the children’s age.
He added that overdiagnosis and overtreatment was generally uncommon for the group of high-achieving students in the study. The main finding was that the high-functioning students that were diagnosed with ADHD were predominantly white.
“Among those displaying above-average levels of functioning, 5% or less of children were diagnosed with and treated for ADHD,” said Morgan. “In that special group of students who had been diagnosed but had been displaying above-average levels of functioning immediately prior to diagnosis, those children tended to be white.”
ADHD, according to the Centers for Disease Control (CDC), is one of the most common neurodevelopmental disorders among children. ADHD can present in three different ways: predominantly inattentive presentation, in which the person is easily distracted or forgets details of daily routines; predominantly hyperactive-impulsive presentation, in which the person fidgets and talks a lot; and combined presentation, in which symptoms of the previous two types are equally present in the person.
The researchers cite previous research that found that about 10% of elementary schoolchildren are diagnosed with ADHD as well as studies that show that some of those children may be overdiagnosed and overtreated for ADHD. Morgan’s current paper extends previous work in which he analyzed a larger sample of students — those who were both diagnosed and not diagnosed with ADHD. In his own prior research, he and his colleagues also found that white children were more likely to be diagnosed and treated than otherwise similar children of color.
“This study is an extension of that work,” Morgan said. “Instead of that general population of schoolchildren, we’re looking at this specific subpopulation of schoolchildren who had previously displayed above average-levels of behavioral, academic, or executive functioning but then were subsequently diagnosed and using medication for ADHD.
In their study, the researchers considered students displaying above average functioning as unlikely to have ADHD. However, Morgan also said, “if the children truly did have ADHD but were experiencing only mild symptoms, then we again have found evidence of racial and ethnic disparities in ADHD identification and treatment, in that among those with only mild symptoms, white children are more likely to be diagnosed and treated.”
According to Morgan, the study’s results point to a need for standardized, multi-informant protocols among pediatric health professionals making ADHD diagnoses. According to the CDC, behavioral indicators of ADHD include making careless mistakes or taking unnecessary risks, having trouble taking turns, and often interrupting or intruding on others.
“Those behaviors should be significant, occurring in multiple contexts, persistent and adversely affecting major life activities like school or work,” said Morgan. “The degree of inattention or hyperactivity should be below the children’s developmental levels.”
According to the researchers, social or cultural differences may explain differences in ADHD diagnosis and treatment between white families and families of color. Research suggests that white families typically experience fewer barriers to evaluation and treatment than families of color. Additionally, Morgan said, Black communities tend to perceive ADHD diagnoses as conferring a degree of stigma. Studies suggest that Black families are more likely to be skeptical about the accuracy of ADHD diagnosis and treatment and instead are more likely to view diagnosis and treatment as an attempt to exert social control. Furthermore, families of color have reported viewing ADHD diagnoses as the result of school environments that are unresponsive to their children’s needs.
Morgan noted that, despite concerns about potential overdiagnosis of ADHD, very few studies have directly investigated to what extent it may be occurring including during elementary school. Additional research that replicates and extends the findings including during middle and high school "is warranted to better establish the nature of what is happening," said Morgan.
Morgan’s co-authors are Adrienne Woods, a senior education researcher at SRI International and former postdoctoral scholar in the Penn State College of Education; and Yangyang Wang, a doctoral candidate in the Department of Education Policy Studies.