Recently, Merten, Cwik, Margraf, and Schneider (2017) out of Ruhr-Universität Bochum in Germany sought to explore the relationship between mental disorder diagnoses in children and adolescents, and disease prevalence trends. The exponential increase in diagnosis of mental health disorders among youths has occurred at a faster pace than trends in the increased prevalence of such disorders. Overdiagnosis has been proposed as an explanation for this discrepancy.
Merten and colleagues conducted a systematic review of studies on the overdiagnosis of mental health conditions in childhood to investigate empirical evidence for overdiagnosis. While most studies outlined in their systematic review implicated overdiagnosis in increased mental health diagnoses in youth, only one explored overdiagnosis from a methodological point of view. Further research is needed to test suspicions of overdiagnosis in domains beyond the alarmingly popular ADHD diagnosis.
The diagnosis process for mental disorders differs from that of somatic disorders in that diagnosticians must rely heavily on their own clinical judgment in the absence of biomarkers to indicate the presence of disease. The process of evaluating children and adolescents may be more complicated than assessing adults, as diagnosticians must negotiate a combination of a client’s self-report data, input from caregivers and significant others, and their own understandings of diagnostic criteria. When children are very young or otherwise unable to articulate their experiences, clinicians must make inferences unnecessary when serving adults.
In higher-income countries, in which healthcare and education are more easily attained, access to mental health supports may simultaneously ease and complicate the diagnosis process and perceptions of psychological disorder. Authors report that some of the factors that contribute to overdiagnosis in developed countries include:
- “Growing awareness of mental disorders and an accompanying reduction in stigmatization…. Children and adolescents, who remained underdiagnosed in the past, might receive a correct diagnosis and treatment today.
- Improved diagnostic procedures may have led to better identification of mental disorders.
- Changes in diagnostic criteria lead to reduced thresholds for a diagnosis, resulting in increases in prevalence rates following each published version of the Diagnostic and Statistical Manual of Mental Disorders (DSM)….
- Diagnosticians may not strictly adhere to diagnostic criteria. Instead, their clinical judgment is affected by heuristics and biases.”
To synthesize literature to-date regarding overdiagnosis of children and adolescents, and to tease out some contributing factors, Merten and team completed both a systematic review with carefully defined parameters and a non-systematic overview of findings from high-quality publications that didn’t meet systematic review qualifications. They were able to identify a total of 17 papers meeting systematic review inclusion criteria. Of those identified, several explored the overdiagnosis and overmedication of ADHD.
Researchers highlight two phases of the diagnosis process in which error can occur contributing to overdiagnosis; the information gathering phase, and the decision-making phase. Within information gathering, informants may misrepresent lived experiences, or characteristics of the child or adolescent may be misleading.
Within information gathering, informants may misrepresent lived experiences, or characteristics of the child or adolescent may be misleading. Within decision-making, diagnostician mistakes, inadequate diagnostic criteria, and health-system pressures and structures can all contribute to overdiagnosis trends.
While almost all studies examined referred to overdiagnosis as an explanation for the increase in mental health diagnoses, one, in particular, evaluating patterns in diagnosis of ADHD in childhood, found significant evidence for overdiagnosis. Another study reported that only one in four pediatricians refer to DSM criteria when making a mental health diagnosis, and yet another reported that mental health professionals were less liberal with mental health diagnoses to children than other professionals also certificated to do so. Low interrater reliability regarding what constitutes clinically significant “symptoms” poses a potential risk to children being evaluated.
Merten and colleagues were unable to draw concrete conclusions in their investigation, calling for future research comparing false-negatives and false-positives in mental health condition diagnoses in childhood. However, their search points confidently toward the possibility of overdiagnosis of children by medical and mental health professionals in developed countries. Although factors contributing to overdiagnosis may not be sinister in nature, patterns such as improper adherence to diagnostic criteria by clinicians should continue to be carefully examined so that children and adolescents aren’t inappropriately diagnosed and mistreated.
Merten, E. C., Cwik, J. C., Margraf, J., & Schneider, S. (2017). Overdiagnosis of mental disorders in children and adolescents (in developed countries). Child and Adolescent Psychiatry and Mental Health, 11(1). (Link)
They are missing the most basic reason – there is no definition for “overdiagnosis” when there are no objective criteria for “diagnosis” in the first place. The main reason for “overdiagnosis” is that anyone can be diagnosed with anything based on someone else’s opinion, and there are HUGE incentives to diagnose and therefore blame kids for creating problems that are actually created by adult inflexibility, neglect, or abuse.
Steve, I had this same thought, and I’m embarrassed it took so long into my career to appreciate this reality. Overdiagnosis presumably means diagnosing people as having a given condition who do not actually have it. But mental disorders are purely subjective as you say, and are not “things” people “have” but labels they are given that say more about the professionals who give them than the people who receive the labels. There is no overdiagnosis of “mental disorders,” just diagnosis. Use of the term “overdiagnosis” implicitly protects the validity of the mental disorder concept by making it appear that they are valid conditions that some people actually “have,” and that good practice involves skill in discriminating those who do and do not have these conditions. I have heard psychiatrists like Allen Frances and Jeffrey Lieberman make this point many times. I will do my part to vigorously question the notion of “overdiagnosis” to combat this false narrative.
Right – that’s my objection, because saying “overdiagnosis” suggests there is a correct level of “diagnosis” that is being missed somehow. But how could the correct diagnostic frequency ever be established when there’s no measurement to refer to? Even hokey medical diagnoses like “obesity” have a numerical standard, if a somewhat arbitrary one. You can measure someone’s weight and height or BMI and say where they fall on the scale. You can’t even do that with “mental illness.” You’re ill because someone decided you are ill, and the culture supported it. It’s such BS, but unfortunately most of our society is brainwashed into thinking it makes sense when it does not.
I recently listened to a young psychiatrist give a presentation to fellow psychiatrists and “mental health” staff where I work. He stated the same thing as the two of you about the overdiagnosis thing. His particular talk dealt with the overdiagnosis of bi-polar. He essentially stated the thee is no such thing since all of it is just a big bunch of quackery in the first place. In other words, people are getting labeled right and left as being bi-polar and it’s all just quackery.
I wanted to stand up and applaud him but knew better than to do so since I’ve been attacked at this very same meeting at other times for speaking out against many practices. Anyway, you could have heard a pin drop in the room. Then, an older gentleman raised his hand and stated that he’s worked out in the trenches of the wonderful community mental health centers for the past 30 years and he agreed with the young psychiatrist 100%. Perhaps the tide is beginning to turn in our favor because you wound never have heard this kind of presentation where I work say five years ago. And five years ago if such a statement had been made no one would have supported the young psychiatrist making the statement.
Indeed, without a tangible disease presence, all diagnosis is overdiagnosis. Any list of random behaviors characterized as “symptoms” just doesn’t cut it.
They say that fully 1/2 of the people diagnosed as having some kind of “chronic” “mental illness” were diagnosed by age 14. Apparently early diagnosis doesn’t equate with cure, early or late. Now what does it take to get these guys to start undiagnosing children and adults?
Just think, you might be saving an adult from “chronic mental illness” by diagnosing a child “mentally healthy”.
I have also known lots of foster kids who were “diagnosed” in their younger years, but who miraculously “recovered” once they escaped the foster care system and their enforced “mental health” treatment. Certainly, many foster youth go on to the adult “MH” system or to the prison system, but I strain to think of even one “recovered” foster youth who attributed his/her success to proper diagnosis and medical “treatment” of his/her “condition.” They always describe a PERSON or RELATIONSHIP or ACTIVITY they engaged in as critical to their success.
They tend to recover when they have a sense of purpose and are able to assert some control over their own lives. Weird, isn’t it, how having more control of your life and decisions and environment helps make you “mentally healthy?”
Sorry, but to me, this study was just a waste of money. You don’t need a study to know that every child or adolescent who gets sent to a psychologist, psychiatrist, social worker or any other professional for mental health services, gets a diagnosis. Without a diagnosis, the professional doesn’t get paid. The professionals I know fall into two categories: those who believe there is such a thing as mental illness and who believe that giving persons diagnoses is somehow helpful, and those, like myself, who believe that the language of diagnosis is narrow, unnecessarily pathologizing, unaesthetic and often harmful to persons receiving them. Persons like myself, who believe this, try to pick the least damaging, least pathologizing diagnoses to use in order to receive health insurance reimbursement. It is a pact with the devil and I am not proud of it. But I think professionals do a disservice to themselves and their clients when they are dishonest or intransparent about this issue.
And Frank, yes we would better serve our clients by diagnosing them all as mentally healthy. And in my talks with clients I do just that. We professionals have to speak different languages with different persons. I speak the language of pathology to the “health” insurance companies because they would not pay for a diagnosis of mental health and I explain that to the clients as well.
It is just another way to call someone names. In short, to bully them. The “diagnosis” are based on a fictional account of what constitutes “normal” behavior. There is no science to this. There is, however, many people and organizations profiting off of this. It’s creating a society where common people are now expected to police those who they simply observe and “report” the circumstantial evidence use to determine, from the individuals bias, what constitute abnormality. Teachers have been in this position for a long while. And, at a time when they are consistently losing their autonomy. It’s not likely that they will become allies in stemming the tide of over “diagnosis.”
But, this problem will eventually self-correct. The cost of special education is beginning to strain schools and, as educational funding continues to shrink, many smaller districts aren’t able to absorb the costs. “Mental health” will eventually drain this profit resource and move onto another victim, if there are any new ones left for it to consume by then.