Thomas Power is director of the Center for Management of ADHD at Children's Hospital of Philadelphia.
Recent findings that 11 percent of children have attention-deficit hyperactivity disorder raise legitimate concerns about overdiagnosis, leading to questions about possible overuse of medication. This is a concern particularly in affluent communities, since rural and some inner-city communities are often underserved and underdiagnosed.
The rising diagnostic rate for ADHD demonstrates increased awareness that inattention and hyperactivity may represent ADHD and not "lazy" or "bad" behavior. However, some inattentive and overactive children do not have ADHD. To meet diagnostic criteria, individuals must display behavioral patterns outside the norm for their developmental level and impairments in two or more major life settings (e.g., family, school, work).
Professionals often have difficulty determining how to help the borderline cases. Diagnosing ADHD and prescribing medication may not be the best way to start treatment; however, due to pressure to conduct rapid assessments, limited access to appropriate care and billing systems requiring a diagnosis, providers might feel that making a diagnosis is the only reasonable option.
A highly successful treatment for children who are inattentive and/or disruptive (regardless of whether they have ADHD) is behavioral parent training. Many studies have demonstrated that such training is effective with children between 3 and 11 years. Less research has been conducted with adolescents and adults, but cognitive-behavioral therapy strategies have been shown to be highly promising.
Behavioral parent training tries to change environmental conditions that trigger and sustain inappropriate behaviors. This approach emphasizes the use of positive reinforcement (rewarding) for responsible or adaptive behaviors. Punishment can be appropriate when delivered less often than positive reinforcement and in a calm, non-physical manner (e.g., loss of privileges). Similar strategies can be applied in school.
Cognitive-behavioral therapy tries to change the way a person thinks about and approaches a situation. This approach identifies thinking patterns (or a lack of thought) that result in poorly regulated behavior. For example, many individuals with ADHD use time ineffectively. The introduction of schedules, reminder systems and self-evaluation tools, perhaps with the aid of a coach or smartphone applications, may help in promoting self-regulated behavior.
For some children with borderline ADHD, such training will resolve their difficulties. When these interventions are not sufficient and problems persist, a comprehensive evaluation should be conducted, consisting of a diagnostic interview, developmental history, and administration of questionnaires to parents and teachers. Comprehensive evaluation is a useful method for preventing the overdiagnosis of borderline or mild cases of ADHD.
There may be many reasons for overdiagnosis. Behavioral treatments may not be accessible, placing providers in the position of giving a diagnosis in order to provide some assistance (medication). Another factor is that medical billing systems may result in a tendency to diagnose borderline cases. Further, individuals often do not receive a sufficiently comprehensive evaluation.
Preventing overdiagnosis requires multiple approaches, including improving access to behavioral treatments, adapting billing systems to reduce tendencies to diagnose questionable cases, and improving access to comprehensive evaluations.
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