ADHD in children: Are millions being misdiagnosed?
© 2010 - 2016 Gwen Dewar, Ph.D., all rights reserved
The difficulty of identifying ADHD in children
Diagnosing ADHD, or attention deficit hyperactivity disorder, is intrinsically problematic.
The symptoms—distractibility, impulsivity, and hyperactivity—are consistent with the normal behavior of young children.
So when a child is diagnosed, the implication is that he is more distractible, impulsive, or hyperactive than he should be for his age.
But where do we draw the line between developmentally normal behavior and medical disorder?
Here I review current ideas about ADHD in children, including reasons for doubt.
It’s not a comprehensive account of ADHD, and it’s not meant to
deny that some kids suffer from important attention or hyperactivity
problems. If you think your child might have ADHD, you should discuss
your concerns with a physician.
But the following account provides an overview of the reasons why
parents of young children should exercise a healthy skepticism before
accepting a diagnosis of ADHD. I raise these points:
• The official definition of ADHD in children is based on subjective criteria. To
get diagnosed with ADHD, a child's symptoms should be bothersome--so
much so that she has trouble functioning at school or in other social
settings. But who sets the standards that kids must meet to be
• Expectations about kids have probably changed over the decades.
In Britain, all kids begin formal schooling at the age of 4. In the
United States, kindergarten is becoming more academic. But in many
traditional cultures, people don't expect much self-discipline from
children until they are 6 or 7.
• Throughout the world, ADHD is being overdiagnosed. International studies suggest that some kids are being diagnosed with ADHD because they are
young or immature for their assigned grade level, not because their behavior falls outside the range of normal
• Biomarkers don't prove that a person needs drugs. Kids
diagnosed with ADHD are more likely to carry certain genes and exhibit
certain brain chemistry profiles. But we can probably say the same about
kids who are shy, or aggressive, or perennially cheerful. Genes and
neurotransmitters influence all sorts of behavior. That by itself doesn't make behavior pathological or worthy of medication. The decision to medicate should be based on a careful weighing of factors, including the severity of the symptoms, and the costs and benefits of taking the drug. Side effects may render the costs too high.
• ADHD isn't the only cause of distractibility or hyperactivity.
ADHD-like symptoms may be caused by a variety of conditions, including
sleep disorders, anxiety, and poor working memory skills. If there is a rush to attribute a child's problems to ADHD, alternative treatments could get overlooked.
1. Defining ADHD in children
Attention deficit disorder, or ADHD, has been defined as "the co-existence of attentional problems and hyperactivity"
According to the American Academy of Child Adolescent Psychiatry
(AACAP), this means a child who seems to be in constant motion—squirming
and fidgeting and moving around the room. It also may be impulsive
behavior, blurting out comments without thinking them through first.
Unrestrained displays of emotion.
And it may mean that the child quickly becomes bored unless it's an activity he particularly enjoys.
The ADHD child "may
often be easily distracted, make careless mistakes, forget things, have
trouble following instructions, or skip from one activity to another
without finishing anything."
2. Reality check: Are these the symptoms of ADHD? Or early childhood?
If you think ADHD symptoms sound like the description of a normally-developing preschooler, you’re right.
Virtually everybody shows these "symptoms" when they are two, three, or four years old.
And different kids develop at different rates. Some take a little longer to focus their attention and restrain their impulses.
On average, though, most kids seem to settle down between the
ages of 5 and 7. And this age range is recognized worldwide. It’s called
the "5-to-7" transition. The period during which young children begin
to show more "executive control," when they become better at planning
ahead, thinking abstractly, focusing attention, and inhibiting
Along these lines, it's interesting to reflect on the results of a
recent study conducted in Sweden. Researchers screened 422 first
graders for signs of ADHD by asking parents and teachers to answer a
standard, ten-point questionnaire (the "Conners 10-item scale"). Three
years later, they checked on the kids' progress.
Did the early screening predict which children would receive a
formal diagnosis of ADHD in the fourth grade? It did, but with a big
margin of error. The very best predictor--which was a combination
of high scores from both parents and teachers--had a positive
predictive value of 50%, meaning that only half the first graders who
screened positive ended up with a formal diagnosis in the fourth grade
(Holmberg et al 2013).
3. Putting the definition in cross-cultural context
Around the world, societies show remarkable agreement. Kids aren’t
expected to show much self-discipline until they reach the 5-to-7
In a famous study, psychologist Barbara Rogoff and her colleagues
reviewed 50 different cultures to discover when ordinary people think
kids are capable of self-control and ready to meet responsibilities
(Rogoff et al 1975).
The researchers considered a wide array of criteria, including these:
- The age at which people think kids are capable of making rational decisions and showing common sense
- The age at which people make a special effort to teach kids manners, etiquette, morals, and social taboos
- The age at which kids are included in games that require adherence to the rules.
- The age at which people expect kids to learn the practical and technical skills modeled by adults
The results suggest that regular people don't demand much executive control from young children.
The majority of societies surveyed didn't expect to observe common sense and rationality before the age of 6.
In most places, kids weren’t even asked to play rule-based games until they were at least 6.
And the most common age at which people began making a special effort to teach kids social rules was 7 years.
So it seems awkward to try to diagnose a child with ADHD while
he's still in preschool. Or even first grade. Behavior that is entirely
normal and age-appropriate might get labeled as ADHD.
But unfortunately, it’s not unusual for kids to get diagnosed at an early age.
Indeed, according to the AACAP, a child shouldn’t be diagnosed with ADHD unless his symptoms emerge before the age of 7.
To be fair, those aren't the only criteria. In addition, the
child must be symptomatic for at least 6 months, and the symptoms must
interfere with the child's ability to function in at least two areas of
- at home,
- in the classroom,
- on the playground, and
- in other social settings
This idea of testing the child’s ability to function seems reasonable enough. But who sets the standards?
If we ask a kindergartner to sit still for 20 minutes, or to pay
attention to what he regards as a boring lecture, he might have
trouble. But is this because he's got a psychological disorder, or
because we're asking him to conform to standards of maturity that are
4. Evidence that young kids are misdiagnosed for exhibiting age-appropriate behavior
The first look at a troubling pattern
Todd Elder of Michigan State University wanted to know if kids are
being misdiagnosed with ADHD because they show normal levels of
distraction and hyperactivity for their age.
So he trawled through some old data: a large, longitudinal study of kindergartners conducted by the U.S. National Center for Education Statistics (Elder 2010). And he took a look at two groups of kindergartners:
- the youngest kids, who were born in the month prior to their state’s cutoff date for kindergarten, and
- the oldest kids, who were born in the month immediately after the cutoff
Elder's reasoning went like this: If kindergartners are getting
diagnosed with ADHD because they have a real psychological disorder—and
not because they show developmentally-normal signs of immaturity—then
there should be no correlation between a child’s age and her diagnosis.
In other words, the youngest kindergartners should be no more
likely than the oldest kindergartners to get diagnosed with ADHD.
But that’s not what he found. On the contrary, the youngest kindergartners were 60% more likely to be diagnosed with ADHD than were the oldest kindergartners.
And being labeled with ADHD seemed to have lasting consequences. When Elder examined older kids, he found that the youngest
students in the fifth and eighth grades were twice as likely to be
medicated for ADHD.
Based on his analysis, Elder estimates that as many as 20% of the 4.5 million American kids identified with ADHD have been misdiagnosed (Elder 2010).
International studies report a similar trend
Elder's results have been replicated by researchers in other
For instance, in Taiwan, investigators found that boys and girls born in August (the last month before the official school cutoff) had 63% higher odds of being diagnosed than kids born in September. Their odds of being medicated were 76% higher (Chen et al 2016). And in Sweden, six-year-old kids born in the two
month interval before the cutoff had 80% higher odds of being
prescribed ADHD medication compared with kids born in the two month
interval after (Halldner et al 2014).
The relative age effect has also been documented in Canada (Morrow et al 2012) and Israel (Hoshen et al 2016).
So are kids the problem, or are school practices the problem?
For many children, the answer seems clear. They are perceived to have a disorder because they can't meet school standards, and the standards are unrealistic.
This school-centered interpretation is bolstered by an observation from the Swedish study: The youngest kids in the classroom didn't seem to have more trouble at home. Parental reports of ADHD-like symptoms were unrelated to a child's relative age.
Given that school pressures are contributing to misdiagnosis, what can we do about it? One approach is to delay school entry for kids who aren't ready. As the Swedish researchers note:
"...[F]lexibility regarding age at school start according to individual maturity could reduce developmentally inappropriate demands on children and improve the precision of ADHD diagnostic practice and pharmacological treatment."
This approach is common in Denmark, which may explain why researchers in that country have found almost no relative age effect on medication use Pottegård et al 2014).
But another alternative is to adjust our expectations about what kids can do. Can we redesign school in ways that acknowledge individual differences in maturity level? Or is would this be too costly and difficult to manage? These are important questions to research and debate.
5. But what about the genetics and brain
chemistry of ADHD? Doesn’t biology prove that distractible, hyperactive
kids have a medical problem? Doesn't that prove that children need medication?
It’s true that ADHD is highly heritable.
We know this from twin studies that compare identical twins (who
share nearly 100% of their genetic polymorphisms) with fraternal twins
(who share, on average, only 50% of their genetic polymorphisms).
Identical twins are much more likely than fraternal twins to share a diagnosis of ADHD (Faraone and Mick 2010).
Presumably, that's because there are genes that play a role in
the development of ADHD. These genes may code for traits that alter
levels of neurotransmitters in the brain.
Researchers have developed medications that target specific
neurotransmitters, and some of these medications have high success rates in helping ADHD patients control their symptoms, at least in the short-term (Stuhec et al 2015).
But that doesn't mean that everybody diagnosed with ADHD has a disorder. And it doesn't mean that everybody benefits from
The observation that kids with ADHD share certain genes—or even
certain neurotransmitter profiles—is interesting but not unusual. We can
say the same thing about kids who are shy, or perennially cheerful, or
more aggressive than average (DiLalla 2002).
People are different, in part, because they carry different genes
and develop different brain chemistries. That doesn’t imply that all
differences are pathological. Nor does it particularly matter why individual differences evolved—not when we’re trying to decide if Marcus or Sylvia needs to be medicated.
Some researchers speculate that evolution has favored certain "ADHD genotypes." For instance, one theory posits that ancient social
groups would have benefited by having a few ADHD-types as members. The
more hyperactive, distractible people would have been the
trailblazers—the people who sometimes discovered new survival tactics
(Williams and Taylor 2006).
It's an interesting theory. But it doesn't—by
itself—tell us if a child's behavior is pathological or worthy of
Whether or not we regard ADHD as a "real" medical condition depends on other considerations, including our cultural assumptions. And even if we make the judgement that a child has a medical condition, we must weigh the costs of a treatment (like the risks of side-effects for taking a particular medication) against the apparent benefits.
For example, we might judge that a child has insomnia, but that diagnosis doesn't imply that medication is the best response. After examining the best available evidence, we may determine that the costs of medication (the problems and risks posed by side effects) to outweigh any apparent benefits.
The same is true of an ADHD diagnosis. The most-frequently prescribed drugs for ADHD have been linked with sleep problems, poor, appetite, and abdominal pain (Storebo et al 2015; Punja et al 2016). For some people, such risks may make drug use undesirable.
Moreover, it's important to understand that these stimulants are classified as schedule II drugs by the FDA, indicating that they have a high potential for abuse and severe dependence. When abused or taken in high doses, the drugs may cause psychosis (Lakhan and Kirchgessner 2012).
And we should be concerned about what we don't know. As the authors of leading meta-analyses have noted, virtually all of our knowledge of side effects is based on "very low quality evidence" (Storebo et al 2015; Punja et al 2016). Studies are poorly-controlled, and typically track children only for short intervals.
This conclusion about the state of research on ADHD-prescribed amphetamines summarizes the nature of the problem (Punja et al 2016):
"Most of the included studies were at high risk of bias and the overall quality of the evidence ranged from low to very low on most outcomes. Although amphetamines seem efficacious at reducing the core symptoms of ADHD in the short term, they were associated with a number of adverse events...Future trials should be longer in duration (i.e., more than 12 months), include more psychosocial outcomes (e.g. quality of life and parent stress), and be transparently reported."
6. How else can we explain symptoms of ADHD in children?
Are some kids just overtired?
Young children aren't the only people who have trouble holding still and controlling their impulses.
Experimental studies show that elementary school kids become more moody when they get less sleep (El Sheikh and Buckhalt 2005). Even adults become more distracted and emotional when they are sleep-deprived (Yu et al 2007). Are some kids diagnosed with ADHD really just suffering from sleeplessness?
It's plausible. Studies confirm that ADHD-diagnosed kids are more likely to suffer from sleep
disorders (Shur-Fen Gau S 2006; Chiang et al 2010; Hansen et al 2013;
Moreau et al 2013). And in one study, kids who were treated for specific
sleep problems, like obstructive sleep apnea, experienced improvements in their ADHD symptoms (Huang et al 2007). Could your child's troubles stem from poor sleep? It's worth investigating.
Other conditions that can cause symptoms of ADHD in children include
- thyroid problems
- clinical anxiety or depression
- emotional traumas and sudden life changes
- lead poisoning
- undetected seizures
possible that some cases of ADHD in children are really caused by poor working memory.
A child with low-capacity working memory has trouble keeping complex
directions and goals in mind while she works. As a result, she may
appear distracted or disobedient.
7. Denying that ADHD exists at all
You may have heard the claim that ADHD doesn't exist. That it's a "lie" being perpetrated by special interests, like drug companies. Is this a valid point of view?
As with most claims, it depends on your specific meaning. It's not a lie that some people are more distracted, impulsive, or
hyperactive than others. It's not a lie that some of these people suffer
substantial impairments in their daily lives. And it's clear that
attention deficits and hyperactivity -- like other traits -- are related
to differences in brain chemistry.
So there's no question that millions of people fit the medical definition, and many of these folks have serious problems. What's less clear is causation. Do people diagnosed with ADHD represent a group affected by the same underlying causal mechanisms? Or is the population of ADHD patients a mixed bag? A collection of people who experience similar behavior problems for a variety of different reasons?
If your definition of ADHD depends on identifying a single, underlying cause, then there is reason to doubt the existence of ADHD. The science isn't there, at least not yet. But if you take a less restrictive definition, the label captures a real phenomenon: People struggling with behavioral tendencies that put them at a disadvantage in the current cultural environment.
For more reading on related topics related to ADHD in children, check out these
research-based tips for helping children develop self-control
and my articles about
the psychological benefits of play
working memory in children.
References: ADHD in children
Bunte TL, Laschen S, Schoemaker K, Hessen DJ, van der Heijden PG,
Matthys W. 2013. Clinical Usefulness of Observational Assessment in the
Diagnosis of DBD and ADHD in Preschoolers J Clin Child Adolesc Psychol.
2013 Mar 11. [Epub ahead of print]
Chen MH, Lan WH, Bai YM, Huang KL, Su TP, Tsai SJ, Li CT,
Lin WC, Chang WH, Pan TL, Chen TJ, Hsu JW. 2016. Influence of Relative Age on
Diagnosis and Treatment of Attention-Deficit Hyperactivity Disorder in
Taiwanese Children. J Pediatr. 172:162-167.
Chiang HL, Gau SS, Ni HC, Chiu YN, Shang CY, Wu YY, Lin LY, Tai
YM, and Soong WT. 2010. Association between symptoms and subtypes of
attention-deficit hyperactivity disorder and sleep problems/disorders. J
Sleep Res. 2010 Apr 7. [Epub ahead of print]
DiLalla LF 2002. Behavior genetics of aggression in children: Review and future directions. Developmental Review 22(4): 593-622.
Elder T. 2010. The importance of relative standards in ADHD
diagnoses: Evidence from exact birth dates J Health Econ. 2010 Jun 17.
[Epub ahead of print]
El-Sheikh M and Buckhalt J. 2005. Vagal regulation and emotional
intensity predict children's sleep problems. Developmental Psychobiology
Faraone SV and Mick E. 2010. Molecular genetics of attention
deficit hyperactivity disorder. Psychiatr Clin North Am. 33(1):159-80.
Halldner L, Tillander A, Lundholm C, Boman M, Långström N, Larsson H, Lichtenstein P. 2014. Relative immaturity and ADHD: findings from nationwide registers, parent- and self-reports. J Child Psychol Psychiatry. 55(8):897-904
Holmberg K, Sundelin C, and Hjern A. 2013. Screening for
attention-deficit/hyperactivity disorder (ADHD): can high-risk children
be identified in first grade? Child Care Health Dev. 39(2):268-76.
Hoshen MB, Benis A, Keyes KM, Zoëga H. 2016. Stimulant use
for ADHD and relative age in class among children in Israel. Pharmacoepidemiol
Drug Saf. 25(6):652-60.
Huang YS, Guilleminault C, Li HY, Yang CM, Wu YY, and Chen NH.
2007. Attention-deficit/hyperactivity disorder with obstructive sleep
apnea: a treatment outcome study. Sleep Med. 8(1):18-30.
Lakhan SE, Kirchgessner A. 2012. Prescription stimulants in
individuals with and without attention deficit hyperactivity disorder: misuse,
cognitive impact, and adverse effects. Brain Behav. 2(5):661-77.
Moreau V, Rouleau N, and Morin CM. 2013. Sleep of Children With
Attention Deficit Hyperactivity Disorder: Actigraphic and Parental
Reports Behav Sleep Med. 2013 Mar 8. [Epub ahead of print]
Morrow RL, Garland J, Wright JM, MacClure M, Taylor S, and
Dormuth CR. 2012. Influence of relative age on diagnosis and treatment
of attention-deficit/hyperactivity disorder in children. Canadian
Medical Association Journal. First published online March 5, 2012, doi:
Pottegård A, Hallas J, Hernández-Díaz, Zoëga H. 2014. Children's relative age in class and use of medication for ADHD: a Danish Nationwide Study. J Child Psychol Psychiatry. 55(11):1244-50.
Punja S, Shamseer L, Hartling L,
Urichuk L, Vandermeer B, Nikles J, Vohra S. 2016. Amphetamines for attention
deficit hyperactivity disorder (ADHD) in children and adolescents. Cochrane
Database Syst Rev. 2:CD009996.
Rogoff B, Sellers MJ, Pirrott S, Fox N, and White SH. 1975. Age
of assignment of roles and responsibilities to children: A cross
cultural survey. Human Development 18: 353-369.
Shur-Fen Gau S. 2006. Prevalence of sleep problems and their
association with inattention / hyperactivity among children aged 6-15 in
Taiwan. Journal of Sleep Research 5(4): 403-414.
Storebø OJ, Krogh HB, Ramstad E,
Moreira-Maia CR, Holmskov M, Skoog M, Nilausen TD, Magnusson FL4, Zwi M,
Gillies D, Rosendal S, Groth C, Rasmussen KB, Gauci D, Kirubakaran R, Forsbøl
B, Simonsen E, Gluud C. 2015. Methylphenidate for
attention-deficit/hyperactivity disorder in children and adolescents: Cochrane
systematic review with meta-analyses and trial sequential analyses of
randomised clinical trials. BMJ.351:h5203
Stuhec M, Munda B, Svab V, Locatelli I. 2015. Comparative efficacy
and acceptability of atomoxetine, lisdexamfetamine, bupropion and
methylphenidate in treatment of attention deficit hyperactivity disorder in
children and adolescents: a meta-analysis with focus on bupropion. J Affect
Williams J and Taylor 2006. The evolution of hyperactivity, impulsivity and cognitive diversity
Yoo SS, Gujar N, Hu, Jolesz FA, and Walker MP. 2007. The human
emotional brain without sleep—a prefrontal amygdale disconnect. Current
Biology 17(20): 877-878.
Content of "ADHD in children" last modified 6/17
Image of two boys talking by istock