ADHD: risks of over diagnosing and treating children
- Henriette Kirkaune Sandven
- Dec 7, 2020
- 15 min read
Updated: 2 days ago
The ongoing ADHD debate is causing a lot of controversy and polarization, within the psychiatric field and in the public in general. Are we over diagnosing or underdiagnosing, or maybe both? And what are the consequences of doing so?
ADHD was primarily thought of as a diagnosis exclusively reserved for children and arising in childhood, but in later years there has been a sharp rise in ADHD also in adults. The latest revisions of the Diagnostic and Statistical Manual of Mental Disorders (DSM) have opened for this.
I will in his article express my worry as a clinician in a child and adolescent psychiatry department. In my experience we have lost view of how diagnosing children can affect their development and identity formation, and I believe we as clinicians should carry more skepticism with regards to diagnosing children and treating them with stimulants. I have a growing worry that we are individualizing problems of our society, and that children with hyperactivity and inattentiveness have normal reactions to increasing demands. Our practice may, in fact, conceal deeper societal issues that need to be addressed.
Background
ADHD is the most diagnosed psychiatric condition in Norwegian Child and Adolescent Psychiatry Departments and has been on the rise for decades. The prevalence of ADHD was estimated at 3-5% for years, but in 2022 6,3% of Norwegian Adolescents aged 13 to 17 had the diagnosis (1). According to The Norwegian Institute of Public Health (NIPI) these numbers are expected to rise even more. The prevalence of ADHD in the other Nordic countries is even higher. The National Board of Health and Welfare (Socialstyrelsen) in Sweden report a prevalence of 10,9% of boys aged 10 to 17, and 6% girls, and the numbers are expected to rise to at least 15% (2). In Iceland 15,5% of teenage boys are medicated with stimulants, and there are regions in Finland where 20% boys are medicated (3). The Center for disease control and prevention (CDC) in The United States reported last year that 11,4% of American children have ADHD, and 15,5% of adolescents hold the diagnosis (4).
ADHD as a phenomenon has been described in literature for centuries. It was originally thought of as a disorder of the brain and even branded minimal brain damage and minimal brain disorder. Since 1980 it has been seen as a medical entity with specific criteria and named ADHD. The diagnosis was established solely based on clinical experience and with no scientific evidence to back it up. From 1980 scientists have tried to identify a biological cause of ADHD, to no avail. There are still no objective tests that can be used to prove the diagnosis.
ADHD had a marked rise in incidence in the late 1990s. The typical child with ADHD was a boy who was hyperactive, impulsive and inattentive. Studies have shown that children with these features have a higher risk of addiction, comorbid psychiatric illness, accidents and criminality later in life (5). Thus, early identification and help have been a prioritized issue, which was the main aim of DSM 5. This led to several modifications (6), and lately there has been a sharp rise in ADHD without hyperactivity or impulsivity (ADD). To reach threshold for the diagnosis, it was necessary to fulfill 6 out of 9 criteria for hyperactivity/impulsivity and 6 out of 9 criteria for inattentiveness, i.e. 12 out of 18 criteria. With the new changes, 6 out of 18 criteria must be fulfilled (5 criteria if you are over 17 yrs). The symptoms must have persisted for at least 6 months and appeared before the age of 12 (7 years in DSM IV). The diagnosis is no longer an exclusion diagnosis, although the symptoms should not be better explained by other conditions.
One can argue that the ADHD epidemic is anticipated, even politically willed. The Norwegian Health Department has published guidelines for clinicians who are diagnosing ADHD (Nasjonal faglig retningslinje for utredning, behandling og oppfølging av ADHD (7)), with the aim of establishing similar diagnostic practice around the country. The guidelines, however, seem permeated by a fear of underdiagnosing ADHD, with little thought of the risks of overdiagnosing the condition. As all European countries, Norway uses the ICD-10 (International Classification of Diseases) for diagnostics, but the Norwegian authorities have made an exception for ADHD and requires using the more liberal criteria in DSM 5 when it comes to diagnosing ADHD. The guidelines are opening for an even more liberal interpretation of the diagnostic criteria for ADHD, especially when it comes to the description of impairment. DSM IV states: “There must be clear evidence of clinically significant impairment in social, academic or occupational functioning», whereas DSM 5 states «There is clear evidence that the symptoms interfere with, or reduce the quality of, social, school, or work functioning». This semantic change introduces a much more subjective interpretation of the impairment criteria, which poses an even bigger challenge in the diagnostic process.
The guidelines point out that ADHD may have been underdiagnosed in girls as it has been much more prevalent in the male population. In general, boys have been more prone to hyperactivity and impulsivity, whereas many girls are described as mainly inattentive. The softening of the criteria has led to the inclusion of more girls. For some reason, there is a common belief in the psychiatric field that ADHD has a sex ratio of 1:1, and if ADHD is more prevalent in boys, we still have many underdiagnosed girls. Interestingly, we do not see the same argumentation in childhood autism, a condition in the severe end of the autism spectrum, with a sex ratio of 4:1 (boys: girls). Childhood autism is a diagnosis that is seldom missed, as the symptoms, behavior and impairment are so grave. As both ADHD and autism are seen as neurobiological developmental disorders, it can be argued for both that there is a difference in the biology of the sexes that can explain the sex difference.
Generalizing and simplifying, we now have two almost different sets of criteria where girls seem to have ADHD, predominantly inattentive presentation and boys the hyperactive/combined presentation. The symptoms of ADHD seem to have changed drastically from how it was described in DSM III in 1980.
Possible causes for the rise in the prevalence of ADHD in children
There are many hypotheses as to why we now diagnose more children with ADHD. As I have explained, changes in diagnostic criteria may explain a large part of it. It is important to acknowledge that this is a complex issue, with many perspectives and nuances. There is a growing acceptance that ADHD is a result of the interplay between genetic and environmental factors.
We have a society where performance is key, and everyone is responsible for their own success. The individual demands are high, for many children too high. Many will fail in their ambitions and goals. In such cases, a diagnosis can offer a legitimate explanation and provide relief for someone who feels they have failed in reaching their goals and expectations. For some, being diagnosed with ADHD represents a treatment in its own regards.
Where the diagnosis of ADHD earlier had much stigma attached to it, it seems that this stigma has been reduced in the later years. Clinicians express a change in attitudes toward ADHD in the clinical population, as many now ask for referrals with a clear wish of being diagnosed.
Furthermore, there have been big changes in the Norwegian education system. One of the most detrimental changes has been starting school at 5 years instead of 6 years. This has led to a greater proportion of immature pupils in school, and less time for free play for children. Premature children and children born late in the year have a much higher risk of being diagnosed with ADHD and treated with stimulants, suggesting immaturity may be mistaken for ADHD (8).
The parent role has changed drastically in the last decades; parents are closer to their child than ever and shielding children from physical and emotional pain is key. Terms like “Tiger Parents” and “Helicopter Parents” are commonly used metaphors today. In trying to take the pain our children are feeling away, we are signaling that they cannot solve their own problems, which may affect their resilience and independence, factors that are important in the high-pressure culture we live in. Parents may worry more and therefore have a lower threshold for contacting the health care system for professional help. We have information at hand and searching information about symptoms is highly available through internet. This may lead to insecurity and fear of not meeting our children’s needs.
Adolescents in Norway on average sleep 6.5 hours each night, where they should be getting 8 to 9 hours to function well (9). It is widely known that sleep problems affect our emotional and physical well-being, and can lead to psychiatric illness, substance abuse, obesity, self-harm, poor school attendance and poor academic performance (10). Sleep is also critical for attention.
The growing problem of insomnia in youth coincides with increased use of screens. Smart telephones have drastically changed our lives. 94% of Norwegian 9-year-olds have their own smart phone (11). Smart phones, internet and social media are integral parts of our children’s everyday life. It’s an arena for learning, entertainment, socializing and playing. But screen use also has negative effects. A lot of us admit we are smart phone addicts. High screen time use will affect the time children need for vital areas of their development. In addition, how the screen is used will also impact development. Smartphone addiction may affect the brain in many ways. It may disrupt cognitive functions like attention and memory. Furthermore, the content children are exposed to may also affect their mental health. Research suggests there are links between high use of social media like Instagram and TikTok and mental illnesses like depression, anxiety and eating disorders, especially in girls (12).
Social media is the main source of information and news for most adolescents, and information and content on mental health is abundant. Influencers and celebrities share their own struggles with psychiatric illness. ADHD may be the most well-known diagnosis in the public. Still, characteristics on ADHD shared on social media are diametrical different from the clinical criteria used to diagnose ADHD. Common descriptions used on social media are procrastination, relational struggles, difficulty controlling emotions, overthinking, masking, sensitivity, inner chaos etc. Many of these descriptions have been adopted by health professionals as well. ADHD is starting to live its own life, in many ways.
Consequences
I worry we may harm children by diagnosing them with ADHD too early. It is a conundrum why we see ADHD as a life-long condition, whereas physical diseases like for instance childhood asthma, childhood eczema and childhood epilepsy wear off with growth and maturation. These are examples of concrete disorders with objective findings. The symptoms of ADHD are relatively vague; with symptoms we all experience at one time or the other. Being hyperactive, impulsive and inattentive are characteristics of most 3-year-olds and are strongly linked to immaturity. We also know that psychological development is much more affected by the environment compared to physical maturation. To me, it is a puzzle as to why we consider ADHD chronic and life-long when we diagnose it in childhood.
A study from the Multimodal Treatment Study of ADHD (MTA) shows that ADHD symptoms can fluctuate, and more than half of the participants with ADHD did not meet full diagnostic criteria in adulthood, even if they had it as children (14). Researchers found that symptoms fluctuated in 62,8% of the children diagnosed with ADHD. These had all moderate symptoms. 10,8% of the patients had stable, persistent and more serious symptoms, and a much higher risk of mood disorders and substance use disorders. The risk was especially high for children with comorbid conduct disorders. This is an important distinction, showing that ADHD can be a severe and debilitating condition. It is vital that we identify and help these patients as early as possible.
The Dunedin study investigators (15) challenged the belief that adult ADHD is a continuation of childhood ADHD. They found that 90% of the adults with ADHD did not have symptoms over the thresholds as children and a surprisingly small proportion of the children with ADHD went on to have problems in adulthood (3%).
These findings may be surprising but should not be. Children are per definition in development, and we know that they are changing, and their brain and bodies mature. To put a label on them in this especially vulnerable period of their life may affect their identity formation. It may also lead to caregivers seeing them in the light of pathology and with worry. This may again affect the child’s way of seeing and valuing themselves. To adopt a “patient role” in a period of life where you are supposed to find your feet and find out who you really are, may interfere with psychological development. It is a period of life where the spectrum of normality is wide, and a period with major mood fluctuations that affect behavior and function to a high degree.
In recent years, a few research studies have compared quality of life and outcome for children with a formal diagnosis of ADHD versus those with similar symptoms but with no formal ADHD diagnosis. In an Australian cohort study of 8643 adolescents, 393 had an ADHD diagnosis (16). Compared with those without diagnosis, the ADHD adolescents had worse psychological sense of school membership, academic self-concept and self-efficacy, displayed more negative social behaviors and were more likely to harm themselves. A cohort study from Ireland (17) compared hyperactive/inattentive children with and without a formal diagnosis and found no significant differences in the demographic characteristics or socio-emotional wellbeing of 9-year-olds. However, by age 13, those who had held a diagnosis at 9 years showed more emotional and peer relationship problems, worse prosocial behavior, and poorer self-concept.
These findings suggest that on a group level, children with hyperactivity, impulsivity and inattentiveness will have a better prognosis if we normalize their problems rather than pathologizing them.
Norwegian researchers Simen Markussen and Knut Røed suggest medicalization of young people may contribute to exclusion from education and employment. Their research indicates that high medicalization intensity is associated with lower grade averages in primary school, reduced probability of completing upper secondary education and lower earnings in early adulthood (18).
An ADHD diagnosis may result in negative consequences later in life. In Norway, an ADHD diagnosis bars you from becoming police and pilot. An ADHD diagnosis may also stand in the way of joining the army. Children with ADHD and conduct disorder will need an extra evaluation as to whether they are fit to drive.
A diagnosis represents a relief for some individuals and a burden for others. This is the landscape in which we must navigate, and something that makes the ADHD debate difficult. Those affected by ADHD may be feeling judged and stigmatized. Many ADHD patients, especially those diagnosed late in life, express sadness over not being diagnosed earlier, thinking life would have been better with an earlier diagnosis. On the other hand, patients diagnosed in childhood may express they felt different and stigmatized in childhood because of the diagnosis, something that affected the way they saw themselves negatively. Most children need to feel normal, not different from others. The point is, we cannot know for certain what the future holds. Giving a prognosis when it comes to a childhood diagnosis of ADHD is nearly impossible. As ADHD is regarded as a life-long condition, we need to diagnose children with caution.
Medical treatment of ADHD
Most ADHD medications are centrally working stimulants. They are performance enhancing and is listed on WADAs list of prohibited drugs. Stimulants are classed as narcotics in Norway, meaning they are highly addictive. In clinical practice it is prescribed in non-addictive doses, but it can be misused and there is an illicit market. There is much controversy on their misuse potential. Some studies find that treating ADHD with stimulants reduces the risk of substance misuse, while others find increased risk of misuse with medical treatment (19). Stimulants can improve focus and wakefulness, and they influence most of us. There are numerous side effects. Decreased appetite is the most common and poses a great worry for child and adolescent psychiatrists when treating growing children. Other side effects include emotional problems, lethargy, increased heart rate, difficulty sleeping, irritability, tics, and even more serious side-effects like epilepsy and psychosis.
Many ADHD patients, especially those diagnosed late in life, express sadness over not being diagnosed earlier, thinking life would have been better with an earlier diagnosis. On the other hand, patients diagnosed in childhood may express they felt different and stigmatized in childhood because of the diagnosis, something that affected the way they saw themselves negatively.
The MTA study concluded that stimulants were effective in 14 months but found no difference in outcome with longer use. The only lasting effect was height suppression, where those treated with stimulants over time ended up 2.55 centimeters shorter than expected height (20).
In children, stimulants mainly work by reducing hyperactivity and regulating behavior. Multiple studies have shown little effect on learning and academic achievements (21). For some children, it has a clear and observable effect. It can in some instances seem like “magic”, and parents and teachers can be delighted. This may result in them not taking side effects seriously, and often parents and teachers seem more motivated for medical treatment than the children themselves.
As a clinician, I fear that I am medicating hyperactive and troublesome children and thereby cover up the need for other more resource-demanding interventions, like more teachers in schools. One can argue, medicating children in this manner is a cost-effective way of meeting the growing problem of unruly children in Norwegian schools.
What to do?
We need a continuing public debate addressing the issues of over diagnosing ADHD in childhood. There is a need for political changes, but we must also scrutinize our own attitudes in how we meet and help children that are hyperactive, impulsive and inattentive. Children see themselves in the light of how they are seen. Instead of asking what is wrong with this child, we must ask; how can I help this child?
We need to be open about the positive and negative consequences ADHD may have on children. An important question is, is it more harmful for a child if they receive a diagnosis or more harmful if they don’t? With the information and experience we have at hand, we cannot conclude either way. But we may find a middle ground- which in my view is holding off the diagnosis and helping children with the issues and challenges they have. We can treat the child “as if” they had ADHD. If we are taking medication out of the equation, giving treatment and intervention for ADHD will not harm any child.
Interventions for ADHD will better the lives of many children, whether ADHD is diagnosed or not. As ADHD can be seen as a spectrum diagnosis, children barely over the threshold and barely under the threshold, will have similar needs. In a society where a diagnosis may be the key to receiving help and support, we as clinicians may be tempted to lower the threshold to help. We need to address the role of the health care system and our role as clinicians in the diagnostic chain.
Children with ADHD are now overabundant in Child and Adolescent Psychiatric departments, which means the health care system is under great pressure. Prioritizing is important, and we must make sure that we have enough resources for the children that are most impaired and affected. We must meet children with challenging behavior with curiosity rather than a child with a diagnosis. Children with serious symptoms that affect them to a great degree, are at high risk of leading difficult lives. If we at least diagnosed mild to moderate ADHD as a childhood disorder, it may represent hope to children and parents that are struggling. We know that most will no longer meet the criteria as adults. This may be reflected in the British National Guidelines (NICE) (13) on ADHD where it requires that a young person with ADHD have a reassessment around age 18 to establish the need for continuing treatment into adulthood.
As the health care system gets overloaded, and health care professionals order investigations and treatment “just in case”, campaigns against overdiagnosis and overtreatment are spreading amongst health care providers in the western world. The Norwegian Child and Adolescent Association for Psychiatrists have recently reached a common aim of reducing the use of stimulants for ADHD, by recommending 3 months of nonmedical interventions before medication is considered.
Lastly, school is key in the treatment of ADHD. Children who thrive in school lead better lives. We know that children born late in the year, and premature children have a higher risk of being diagnosed with and medicated for ADHD, and we can argue that school is not meeting immature children’s needs. Changes in school, especially in the first years of school, are urgently needed.
Conclusion
The prevalence of ADHD is continuing to increase. There is a growing fear that we are now over diagnosing children, and that this will have negative effects on their development. Being given a patient role in this crucial and sensitive period of life may result in a worse outcome. As health professionals, we are committed to “First, do no harm”. If diagnosing children has a chance of harming them, we need to be more careful.
To quote psychiatrist and author Allen Frances, “The best way to deal with the everyday problems of living is to solve them directly or to wait them out, not to medicalize them with a psychiatric diagnosis or treat them with a pill. Overcoming problems on your own normalizes the situation, teaches new skills, and brings you closer to the people who were helpful.” □
References
Folkehelserapportens temautgave 2025: Barn og unges psykiske helse
Have we been thinking about ADHD all wrong? The New York Times Magazine 13th of April 2025. https://www.nytimes.com/2025/04/13/magazine/adhd-medication-treatment-research.html
French B et al (2024). The impacts associated with having ADHD: an umbrella review. Front Psychiatry. May 21;15:1343314. doi: 10.3389/fpsyt.2024.1343314. PMID: 38840946; PMCID: PMC11151783.
Whitely M et al (2019). Attention deficit hyperactivity disorder late birthdate effect common in both high and low prescribing international jurisdictions: a systematic review. J Child Psychol Psychiatry. Apr;60(4):380-391. doi: 10.1111/jcpp.12991. Epub 2018 Oct 14. PMID: 30317644; PMCID: PMC7379308.
https://www.fhi.no/he/fr/folkehelserapporten/psykisk-helse/sovnvansker-folkehelserapporten/
Hysing M et al (2020). Trajectories of sleep problems from adolescence to adulthood. Linking two population-based studies from Norway. Sleep Med, 75, 411-417.
Barn og medier 2024. En undersøkelse om 9-18-åringers medievaner. Medietilsynet, november 2024.
