In a recent study, we found that the incidence of ADHD diagnosis between BUPs (Child and Adolescent Psychiatric Outpatient Clinics) in Norway varies by almost 1000 percent. There is a surprisingly large variation. Where the child is examined actually has about as much importance for the decision on an ADHD diagnosis as the circumstances surrounding the child. We have considered five possible explanations for this: Statistical coincidence or registration error? We can rule that out. Do more children have ADHD in some places in Norway than others? According to a survey of 39,850 Norwegian mothers from all over the country, this variation in ADHD symptoms in the population is negligible. Social inequality between different geographical areas? It does not appear that children in areas with poorer living conditions are diagnosed with ADHD more often. Travel distance to hospital? Nor does it seem to explain the variations. Are there differences between the BUPs in how the practitioners assess ADHD diagnoses? We believe this is the most plausible explanation. In a survey among 674 doctors and psychologists at BUPs spread throughout the country, it appears that their attitudes to ADHD varied from a liberal to a restrictive view of ADHD. Children in the gray area for ADHD diagnosis To illustrate this, we can imagine that children who are referred to BUP can be divided into three groups: Some clearly do not have ADHD and do not receive an ADHD diagnosis regardless of which BUP examines them. Others clearly have ADHD, and receive the diagnosis regardless of which BUP they are examined by. But a third group lies in the gray zone and receives the ADHD diagnosis with some BUPs, but not others. These children in the gray zone participate in a large lottery where place of residence determines whether or not you end up with a diagnosis. How do clinicians with a liberal attitude think about ADHD? In order to start treatment with drugs for ADHD, an ADHD diagnosis must first be made. Liberal clinicians believe that ADHD drugs are effective in reducing the core symptoms of ADHD, i.e. concentration difficulties and problematic impulsivity and hyperactivity. The medicines will often make the patient cope with everyday life better. They believe the side effects are well documented and usually acceptable. They believe that children where the diagnosis may be somewhat uncertain may still have an underlying ADHD condition, and should be given the opportunity to try drug treatment if they receive a diagnosis. Over the past 30 years, we have seen a fairly formidable increase in ADHD diagnoses. Liberal clinicians believe that ADHD was previously underdiagnosed, and that it is now approaching the correct level. Among adult inmates in prisons today, almost half qualify for an ADHD diagnosis, while almost none of them have been diagnosed before imprisonment. Would they have been better off if they had been diagnosed with ADHD and given medication in childhood? How do clinicians with a restrictive attitude towards ADHD think? Clinicians who are restrictive in making the ADHD diagnosis fear that we give an ADHD diagnosis to children who do not actually have ADHD, and who are therefore incorrectly treated with drugs. They are concerned that, for example, learning difficulties are being misdiagnosed as ADHD. ADHD medication will not produce any effect, but will produce unnecessary side effects and changed expectations from school, family and society. Clinicians who are restrictive of the ADHD diagnosis problematize scientific studies on ADHD drugs, pointing out that these studies almost exclusively check whether drugs reduce ADHD symptoms in the short term. We actually lack research that investigates whether medication can help young people in a good direction in the longer term, i.e. whether such treatment can improve school performance, reduce crime, accidents, suicide and so on. Clinicians who are restrictive about ADHD also want the best for their patients, and are often also concerned that they may not know enough about the long-term side effects of ADHD drugs. Children in the gray area participate in an ADHD lottery The core symptoms of ADHD are restless behaviour, impulsivity and attention difficulties, and this is something that many people can feel at times. Mental disorders such as ADHD are not something you have or don’t have, but something you have more or less of. The diagnosis is either or, and this is a simplification of reality that rests on clinical judgement. For children in the gray area, the clinician’s judgment will be influenced by his liberal or restrictive attitude towards ADHD. Our analysis shows that very many children are in the gray area, and the exercise of discretion varies considerably. Should the Directorate of Health stop this ADHD lottery? The Norwegian Directorate of Health’s national guidelines for ADHD state that the diagnosis of ADHD in children can only be made in the BUPs. The Directorate of Health could perhaps try to tame this violent variation by tightening the guidelines. The problem is that the Norwegian Directorate of Health’s guidelines must be based on research, and the research does not currently provide an answer as to whether the liberal or restrictive practice gives the best prognosis for children in the gray zone. In the research project “The ADHD Controversy”, we try to find out. The first results will come in 2023. Read also:
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The big ADHD lottery – Speech
