ADHD Overdiagnosis or Better Recognition? Reading the Same Numbers

Two accounts of one increase

Ten years ago the charge against ADHD was stated plainly and often: too many children were being labelled, too many prescriptions written, and the trend line proved it. The trend line is genuine. Household surveys in the United States recorded ADHD in 6.1 percent of children and adolescents in 1997 and in 10.2 percent by 2016, a rise reported by Guifeng Xu and colleagues in JAMA Network Open in 2018. What that figure counts is where the disagreement sits.

Elie Abdelnour and Jessica Gold, psychiatrists at Washington University School of Medicine in St. Louis, with Madeline Jansen of the child and adolescent psychiatry division at UCLA, set out both cases in Missouri Medicine in 2022. Their paper is a narrative review: no systematic search of the literature, no pooled statistic, no new data of its own, and a position the authors reach by the end.

The case for overdiagnosis begins with the criteria, which have loosened. In 2013 the manual’s fifth edition moved symptom onset from before seven to before twelve, dropped impairment at onset, asked for symptoms rather than impairment in two or more settings, cut the threshold from six symptoms to five after seventeen, and permitted autism and ADHD together. The two co-occur often, and that change alone admitted a large group the old definition excluded.

The measurement problem runs deeper than any single edit. Guilherme Polanczyk and collaborators have shown consistently that the wide variation in reported ADHD prevalence across studies is explained largely by which criteria a study applied and whether it required functional impairment as well as symptoms. Definitions move and the count moves with them, without a single child having changed. No biological test arbitrates, since no imaging marker is sensitive enough to diagnose an individual, which leaves interview, questionnaires and clinical judgment, and judgment errs in both directions.

Between 2004 and 2006, Black students in the United States were more likely than White students to have ADHD symptoms, 12 percent against 7, and less likely to have received a diagnosis, 9 percent against 14. The recognition argument builds from that gap. Over the decade that followed, diagnosis among Black individuals grew three times faster than among White individuals, and girls’ rates rose by a factor of 5.6 between 1991 and 2008, against 3.7 among boys.

The surge among girls followed a criteria change rather than preceding it. When the manual shifted its emphasis from hyperactivity towards inattention, diagnosis among females rose significantly. A broader definition and a better-aimed one can be the same edit.

Where this leaves a parent

The distinction the review returns to throughout is between diagnosis rates and prevalence. Surveys count people who have been diagnosed. How often the condition actually occurs has never been measured independently, for want of an instrument, so both the overdiagnosis charge and the recognition claim are assertions about a quantity nobody can observe directly.

What can be observed is treatment. A national survey reported in 2006 that 11 percent of American adults with ADHD were receiving treatment. Recent findings continue to show ADHD diagnosed less often in youth who are Black, Indigenous, or people of colour and in girls than in White and male peers, after controlling for socioeconomic status and adverse childhood experiences. Girls are diagnosed at older ages, and BIPOC young people are disproportionately given a conduct or oppositional diagnosis instead.

One further charge, that people seek the diagnosis to obtain stimulants or examination accommodations, receives less support in the review than any other argument it examines. The authors judge the groups involved too small to move a national trend. Around 7 percent of college students report using stimulants without a prescription, and most of that use occurred where attentional difficulty was already interfering with coursework. One review found pharmacological treatment of ADHD associated, in a direction the data cannot fix, with a reduced risk of substance use. The drug-seeking charge finds nothing to stand on there.

The hashtag for ADHD had reached 11.4 billion views on TikTok by May 2022. A 2022 study in the Canadian Journal of Psychiatry found more than half of the platform’s ADHD content misleading, most of it posted by people who were not health professionals. The channel that brings an unrecognised adult to an assessment supplies a great deal of bad information about what will be found there.

No partition of the twenty-year increase exists, in this review or in the literature behind it: how much belongs to broader criteria and how much to better recognition is unmeasured, and the authors do not claim otherwise. They close by arguing that a clinical preoccupation with overdiagnosis carries a cost of its own, raising barriers for the groups still being missed, a position argued from the disparity data rather than a result they measured.

Whether the national rise is correction or excess remains genuinely open. Your own child’s evaluation does not wait on that answer, and what it rested on is knowable.