Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2021 Apr 1;4(4):e215335.
doi: 10.1001/jamanetworkopen.2021.5335.

Overdiagnosis of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents: A Systematic Scoping Review

Luise Kazda  1 , Katy Bell  1 , Rae Thomas  2 , Kevin McGeechan  1 , Rebecca Sims  2 , Alexandra Barratt  1
Affiliations

Overdiagnosis of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents: A Systematic Scoping Review

Luise Kazda et al. JAMA Netw Open. .

Abstract

Importance: Reported increases in attention-deficit/hyperactivity disorder (ADHD) diagnoses are accompanied by growing debate about the underlying factors. Although overdiagnosis is often suggested, no comprehensive evaluation of evidence for or against overdiagnosis has ever been undertaken and is urgently needed to enable evidence-based, patient-centered diagnosis and treatment of ADHD in contemporary health services.

Objective: To systematically identify, appraise, and synthesize the evidence on overdiagnosis of ADHD in children and adolescents using a published 5-question framework for detecting overdiagnosis in noncancer conditions.

Evidence review: This systematic scoping review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) Extension for Scoping Reviews and Joanna Briggs Methodology, including the PRISMA-ScR Checklist. MEDLINE, Embase, PsychINFO, and the Cochrane Library databases were searched for studies published in English between January 1, 1979, and August 21, 2020. Studies of children and adolescents (aged ≤18 years) with ADHD that focused on overdiagnosis plus studies that could be mapped to 1 or more framework question were included. Two researchers independently reviewed all abstracts and full-text articles, and all included studies were assessed for quality.

Findings: Of the 12 267 potentially relevant studies retrieved, 334 (2.7%) were included. Of the 334 studies, 61 (18.3%) were secondary and 273 (81.7%) were primary research articles. Substantial evidence of a reservoir of ADHD was found in 104 studies, providing a potential for diagnoses to increase (question 1). Evidence that actual ADHD diagnosis had increased was found in 45 studies (question 2). Twenty-five studies showed that these additional cases may be on the milder end of the ADHD spectrum (question 3), and 83 studies showed that pharmacological treatment of ADHD was increasing (question 4). A total of 151 studies reported on outcomes of diagnosis and pharmacological treatment (question 5). However, only 5 studies evaluated the critical issue of benefits and harms among the additional, milder cases. These studies supported a hypothesis of diminishing returns in which the harms may outweigh the benefits for youths with milder symptoms.

Conclusions and relevance: This review found evidence of ADHD overdiagnosis and overtreatment in children and adolescents. Evidence gaps remain and future research is needed, in particular research on the long-term benefits and harms of diagnosing and treating ADHD in youths with milder symptoms; therefore, practitioners should be mindful of these knowledge gaps, especially when identifying these individuals and to ensure safe and equitable practice and policy.

PubMed Disclaimer

Conflict of interest statement

Conflict of Interest Disclosures: Ms Kazda reported receiving grants from the Australian government National Health and Medical Research Council (NHMRC) during the conduct of the study. Dr Bell reported receiving grants from the NHMRC during the conduct of the study and grants from the NHMRC outside the submitted work. Dr Thomas reported receiving support from the NHMRC outside the submitted work. Dr McGeechan reported receiving grants from the NHMRC during the conduct of the study. Ms Sims reported receiving other support from the Australian government Research Training Program Scholarship outside the submitted work. Dr Barratt reported receiving grants from the NHMRC during the conduct of the study and serving as a member of the Scientific Committee of Preventing Overdiagnosis International Conferences. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Five-Question Framework for Identifying Potential Attention-Deficit/Hyperactivity Disorder (ADHD) Overdiagnosis
The model of an iceberg illustrates how the framework relates to subsets of the population who may be diagnosed with ADHD. Question 1 concerns youths who may be diagnosable with ADHD, question 2 concerns youths who are diagnosed with ADHD according to newer criteria or those who were already diagnosed with ADHD using older thresholds, and questions 3 to 5 concern youths who are newly diagnosed vs those who are already diagnosed (adapted from Bell et al).
Figure 2.
Figure 2.. Risk of Bias (ROB) Assessment
The full results from the critical appraisals are found in eAppendix 5 in Supplement 1.
See this image and copyright information in PMC

References

    1. Rydell M, Lundström S, Gillberg C, Lichtenstein P, Larsson H. Has the attention deficit hyperactivity disorder phenotype become more common in children between 2004 and 2014? trends over 10 years from a Swedish general population sample. J Child Psychol Psychiatry. 2018;59(8):863-871. doi:10.1111/jcpp.12882 - DOI - PubMed
    1. Chien IC, Lin CH, Chou YJ, Chou P. Prevalence, incidence, and stimulant use of attention-deficit hyperactivity disorder in Taiwan, 1996-2005: a national population-based study. Soc Psychiatry Psychiatr Epidemiol. 2012;47(12):1885-1890. doi:10.1007/s00127-012-0501-1 - DOI - PubMed
    1. Giacobini M, Medin E, Ahnemark E, Russo LJ, Carlqvist P. Prevalence, patient characteristics, and pharmacological treatment of children, adolescents, and adults diagnosed with ADHD in Sweden. J Atten Disord. 2018;22(1):3-13. doi:10.1177/1087054714554617 - DOI - PubMed
    1. Conrad P, Bergey MR. The impending globalization of ADHD: notes on the expansion and growth of a medicalized disorder. Soc Sci Med. 2014;122:31-43. doi:10.1016/j.socscimed.2014.10.019 - DOI - PubMed
    1. Visser SN, Danielson ML, Bitsko RH, et al. . Trends in the parent-report of health care provider-diagnosed and medicated attention-deficit/hyperactivity disorder: United States, 2003-2011. J Am Acad Child Adolesc Psychiatry. 2014;53(1):34-46.e2. doi:10.1016/j.jaac.2013.09.001 - DOI - PMC - PubMed

Publication types

MeSH terms