Disparities in the diagnosis and treatment of ADHD in children – a nationwide study

Sociodemographic and socioeconomic disparities, as well as heuristic diagnosis instead of well-established diagnostic criteria, may be responsible for the misdiagnosis and treatment of ADHD in Brazilian children and adolescents

INTRO

• Concerns exist about whether Attention Deficit Hyperactivity Disorder (ADHD) is overdiagnosed in the pediatric population, with consequent over-treatment.
• Objectives:
  1. To estimate the prevalence of ADHD according to the Diagnostic and Statistical Manual of Mental Disorders – DSM 5 (dADHD), reported medical ADHD diagnosis (mADHD), and current psychostimulants use (PST) in a representative pediatric sample in Brazil.
  2. To investigate the predictive value of mADHD and reasons for false positives and false negatives.

METHODS

• Sample consists of 10,912 children (5 to 18 years) recruited at the school system in 89 cities of 18 Brazilian states.
• Parents and teachers were interviewed using standardized and validated questionnaires.
• ADHD was ascertained as per the DSM-5 criteria and the mental health status with the validated Brazilian version of the Strengths and Difficulties Questionnaire (SDQ).
• Relative risks were modeled using univariate and multivariate analyses.

Table 1. Prevalence of ADHD diagnosis according to DSM 5 (dADHD), reported medical ADHD diagnosis (mADHD), as well as current use of psychostimulants

RESULTS

Of 10,912 children, 1.7% of children were in use of psychostimulants and 6.6% had a mADHD. However, only 486 of 10,912 children (4.5%) met DSM-5 criteria for ADHD (dADHD). Of children with a mADHD, 25.3% had d-ADHD (74.7% of false positives); of children with dADHD, 62.6% had never been diagnosed as ADHD (false negatives); of children using psychostimulants, only 26.2% had ADHD according to the DSM-5. The risk for false-positive diagnosis was increased in children studying in private vs. public schools and from bigger cities, from higher income classes. Other association factors were below average school performance, and having a MTA-SNAP-IV positive according to the parents and negative according to the teacher (p<0.001). The risk for false-negative diagnosis was increased in younger boys from smaller cities, from lower income classes, divorced parents, and below average school performance (p<0.01).

Table 2. Multivariate analyses of determinants of ADHD false positive and false negative cases.

In the analysis of false positive cases the following variables did not contribute to the model: age, race, parent’s grade of education, parent’s marital status, and national region where a child lives. In the analysis of false negative cases the following variables did not contribute to the model: race, parent’s grade of education, public or private school, national region where a child lives, and having disagreement between the MTA-SNAP-IV according to parents and teacher.

Funding Source

No external funding for this manuscript.

Disclosure of interest
The authors report no conflict of interest.

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