Overdiagnosis of ADHD and the role of emotion dysregulation in adulthood ADHD
Attention Deficit Hyperactivity Disorder (ADHD) is characterized by the core symptoms of inattention, impulsivity, and hyperactivity. It is one of the most frequently diagnosed disorders of childhood and adolescence, with a pooled worldwide prevalence rate of ~5 %. There are recent findings from dif...
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|Attention Deficit Hyperactivity Disorder (ADHD) is characterized by the core symptoms of inattention, impulsivity, and hyperactivity. It is one of the most frequently diagnosed disorders of childhood and adolescence, with a pooled worldwide prevalence rate of ~5 %. There are recent findings from different cultural contexts demonstrating a rise in the rate of ADHD diagnoses accompanied by increasing psychostimulant prescription rates (e.g., Dunlop & Newman, 2016; Connor, 2011; Safer, 2000) that lead to justifiable concerns about ADHD overdiagnosis. In this relation, age and gender biases are shown to cause false positive and false negative diagnosis and as an explanation for such phenomena these biases are shown to be significantly associated with subjective heuristics of diagnosticians (Mertens, Cwik, Margraf and Schneider, 2017). The age bias issue is focused on the occurrence of an ADHD overdiagnosis in which children born close to kindergarten or school cut-off dates, and who are therefore up to a year younger than their classmates, are significantly more likely to be diagnosed with ADHD. The gender bias issue concerns the occurrence of an ADHD overdiagnosis in which distinguished gender related manifestations of ADHD result in more false positive diagnosis to the disadvantage of boys. Such findings suggest that to defend the validity and reliability of diagnoses and treatment of ADHD, it is necessary to work through the debate of overdiagnosis of ADHD in terms of associated socio-economic and individual implications.
In the first study of this dissertation, in addition to summarizing the literature on the debate of ADHD overdiagnosis, a discussion on conducting comparative and systematical assessments as tools of working through the factors involved in overdiagnosing ADHD is presented. In this relation, in a seminal study by Bruchmüller, Margraf and Schneider (2012) in a population of licensed German psychotherapists and psychiatrists the application of diagnostic criteria and the specific role of patient gender in therapists’ diagnostic decision making was systemically investigated. The first study is a replication of the study of by Bruchmüller, Margraf and Schneider (2012) in a different cultural context, in this case Iran, as ADHS might be perceived differently there. We assessed both gender bias and the impact of potential overdiagnosis on treatment recommendations. Results of this study demonstrated that ADHD overdiagnosis occurred in both girls and boys, although overdiagnosis was 2.45 more likely in boys than in girls. With respect to the psychiatrist’s gender, no difference between males or females was detected, as both overdiagnosed ADHD in boys. Furthermore, ADHD overdiagnosis had a direct impact on medication prescription.
Parallel to investigating the issue of ADHD overdiagnosis another aim of this dissertation was to investigate the role of emotion dysregulation (ED) (subsuming symptoms like low frustration tolerance, irritability, ease of negative emotional experience, and emotional lability) in ADHD. In this relation and as discussed by the second study of this dissertation, emotional symptoms are increasingly considered to be a core feature of ADHD. Among those studies and reviews reporting on ED in ADHD, there are at present one meta-analysis by Graziano & Garcia (2016), focusing on features of ED in children with ADHD. Distinguishing the dimensions of ED in children with ADHD, they demonstrated that such patients are more likely to experience intense emotions. The goal of the second study was to quantify the evidence of emotional dysregulation and its respective facets in individuals with adult ADHD compared to healthy controls using meta-analysis. In this relation, two electronic databases (PubMed, PsycINFO) were reviewed to identify studies. After scanning the studies based on the inclusion and exclusion criteria, a total of 13 studies (N = 2535) were included to assess (1) the standardized mean difference in emotion dysregulation (ED) as a general factor and its specific facets (i.e., emotional lability, negative emotional responses, and emotion recognition) between adults with ADHD and healthy controls; and (2) the association between ADHD symptom severity and ED. Findings of this study showed that compared to healthy controls, adults with ADHD revealed significantly higher levels of general ED (Hedges’ g = 1.17, p < 0.001; Hedges’ g is the adjusted effect size). With regard to intermediate dimensions of ED, emotional lability exhibited the strongest weighted effect (Hedges’ g = 1.20, CI [0.57, 1.83], p < 0.001). Furthermore, symptom severity and general ED correlated significantly (r = 0.54, p < 0.001). Regarding intermediate dimensions of ED, negative emotional responses correlated closely with ADHD symptom severity (r = 0.63, p < 0.001) and emotional lability (r = 0.52, p < 0.001).
Moreover, dealing with the meta-analysis conducted in the second study and thus encountering the field of meta-analysis tools, provided the context of an interest worked through by the third study. Systematic reviews in general and meta-analysis specifically are broadly applied methods for synthesizing currently available studies in order to reach a better understanding of related problems in a certain field. For conducting such analyses, there are currently four rather popular online services, namely MAVIS, MetaInsight, M-A and Health Decision Strategies Meta-Analysis Calculators that can be used as complementary tools along with statistical software products in order to facilitate the main process of effect size calculations. As the first goal of this study, a comparative description of the pros and cons of these web-apps is summarized. In addition and as the second objective of this study, the development of Meta-Mar is introduced. Meta-Mar is a free online and user-friendly meta-analysis service able to calculate effect sizes based on standardized mean differences as well as correlation coefficients and risk ratios, weighted effects for both fixed and random effect models, and presents the heterogeneity of the analysis as well as forest and funnel plots. Moreover, regarding the bias of the meta-analysis, reports of Fail-Safe N are part of the presented results. Furthermore, a meta-regression tool is available to include moderator variables as predictors of effect size. A subgroup analysis tool is also developed to categorize effect sizes and identify the between group variance.
All in all, findings of this dissertation confirmed the occurrence of ADHD overdiagnosis in cultural context of Iran and patient gender’s significant role and also suggest that diagnosticians should strictly adhere to diagnostic criteria to minimize diagnostic error. Moreover, findings support ED symptoms as a core feature of ADHD’s psychopathology and with respect to dimensions of ED, emotional lability, and negative emotional responses play a more definitive role in the psychopathology of adults with ADHD.