Overdiagnosis of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents

This systematic scoping review evaluates the multidecade pattern of diagnosis in attention-deficit/hyperactivity disorder in young people using a framework for identifying overdiagnosis for noncancer conditions.

studies/))) NOT ((autobiography OR bibliography OR biography OR case reports OR comment OR congress OR consensus development conference, nih OR dataset OR dictionary OR directory OR editorial OR expression of concern OR festschrift OR government document OR guideline OR interactive tutorial OR lecture OR legal case OR legislation OR letter OR news OR newspaper article OR patient education handout OR personal narrative OR portrait OR scientific integrity review OR technical report OR video-audio media).mp. OR webcasts.pt.) AND limit search to (english language and yr="1979 -Current")  1. Their immediate reaction was often a sense of great relief. For the first time their definition of the reality of their child's problem had been confirmed by others and thus legitimated 2. being able to name the problem of their child seems to give parents a sense of power and agency. In contemporary society the medical framework, especially the diagnosis, can provide patients and parents with a powerful tool that carries considerable social legitimacy

Moore -2017
1. Labelling can be helpful, as practitioners often saw a diagnosis as validating problematic behaviour as a medical condition, which assists children and their parents to understand their difficulties and gives further access to support in school. Indeed, one practitioner said 'I think having that diagnosis can help them access other support" (Maisy, SENCo, Primary).
1. with one possible reason being that some 'mainstream schools perhaps would be quite relieved to have their diagnosis because … it almost alleviates the blame that they're not doing the right thing' (Professional 6, specialist education).
2. non-diagnosis could come to imply fault.

Carr-Fanning et al -2018
1. In a similar manner, parents often described elation or relief when they received a diagnosis.
2. Young People (YP) who had not been diagnosed until adolescence described the frustration and repeated experiences of failure and distress prior to receiving a diagnosis, which was often a source of anger and resentment.
3. Parents reported that challenging behaviours were attributed to parenting (e.g. lack of discipline) and/or their child's lack of effort (e.g. 'lazy'), or wilful disobedience (e.g. 'bold brat'): "it was always HER she was the problem so she was constantly being told she was no good" 4. …some of the teachers I think they're like ADHD doesn't really exist they're just like you're just being bold looking for attention it's not really anything. I'm annoyed by that coz it's not true (female 17 years). These individuals frequently see themselves as having failed to manage their resources in order to secure the best possible returns. They represent not a failed venture so much as a nonventure, one that was more unmanaged than mismanaged, outside of a knowledge about authentic self-representation, and therefore doomed from the beginning. A revelation about the biological origins of their problems, and the adopting of an AD/HD identity, is almost always viewed by these individuals as the first step to success. The great majority of parents, however, felt that their child had already been labeled by his or her environment before getting a medical diagnosis. They regarded the nonmedical labels such as "stupid," "lazy," and "naughty" as even more damaging than medical ones for the child and for the family because such terms produced feelings of guilt and low self-esteem

Wienen et al -2019
1. respondent 20 mentions the same as an advantage for parents: 'I think it is a relief for parents, that they really, that you can explain the behaviour. . .and that you know like, well this could be because of the ADHD. I think that is rather nice for parents.' 2. Five out of the 30 respondents point out that an ADHD classification leads to the removal of guilt or blame. This removal involves different actors, according to the teachers. It concerns removal of guilt or blame from the child, from the parent(s) and also removal of guilt or blame from the teacher by the parent(s). The latter may be the case if the parent(s) initially perceive the notable behaviour of the child to be the consequence of the teacher's ways of doing. Respondent 16 talked about the removal of guilt or blame from the child: 'I sometimes think that acknowledgement, for the child. . .you are not to blame, you just have it.' Respondent 22 put it more generally: 'I think that once parents know that my child has ADHD, it may perhaps remove a bit of uncertainty, like well, he's got it, he is like that, nothing we can do about that.' And finally, respondent 12 claimed that teachers are quickly blamed in cases where children are without ADHD classification but show disruptive behaviour: 'which makes that parents say, "well, the teacher is to blame"'. reasoning. This shared 'new beginning' creates new room for mutual understanding between parents and teachers and obviates the need for blaming one another for the behaviour perceived in the child. The availability of ADHD classification thereby offers a supposedly independent or external validation of the conclusion that 'something is the matter' with the child so that parents and teachers can start a new working relationship free from guilt and blamein shared innocence, as it were.

Empowerment through increased control
a. Reduced uncertainty leads to reclaiming of identity/ feelings of belonging Andersson Frondelius et al -2019 1. In their view, normality was related to self-respect and to identification with the ADHD population.
2. the adolescents' experiences of being diagnosed with ADHD essentially meant a process towards understanding their traits as both 'odd' and 'unique', and realising how common their problems were.
3. Several participants described being proud of their diagnosis; identifying with and admiring certain people with ADHD. This finding may reflect the adolescents' desire to feel that they belong,…

Comstock -2015
1. One can see here that although AD/HD causes a misdirection of (unmanaged) energies, claiming the disorder as an identity ("My goal with ADD ...") allows the individual to positively manage these energies.
2. As we can see in this passage, the diagnosis of AD/HD (self or otherwise) is usually depicted as the defining moment by which the observing self takes over the disorganized, unobservant self: I've yet to recieve [sic] an official diagnosis, but I'm meeting with a Psychiatrist this Friday to hopefully get both confirmation for that which I firmly believe to be the reason for so many of my unexplained tendancies/behaviors [sic], and to get on track with treating this everincreasing burdon [sic] that is living with myself and my mind.
Significantly here, it is because of the fact that the individual cannot make meaning of his or her behaviors-not because he or she is troubled by behaviors considered deviant or abnormal-that the individual believes something is wrong. This individual's "unexplained tendencies/behaviors," it is asserted, will finally be explained with an official diagnosis that will serve as the principle by which the one self makes meaning of the other self, in short, as an identity. Diagnosis becomes the moment that the previously troubled individual confirms a new identity within and on the side of a knowledge about the proper way to live and the truth about human nature (for this reason genetics, and speculating on the AD/HD of family members, is a frequent theme in the posts).
behaviour is entirely attributed to 'the disorder' (Broomhead 2013; Moore et al. Rogalin and Nencini 2015), despite this being a product of questionable science and faulty reasoning. This shared 'new beginning' creates new room for mutual understanding between parents and teachers and obviates the need for blaming one another for the behaviour perceived in the child. The availability of ADHD classification thereby offers a supposedly independent or external validation of the conclusion that 'something is the matter' with the child so that parents and teachers can start a new working relationship free from guilt and blamein shared innocence, as it were.

b. Educational support
Damico et al -1995 1. Once the diagnosis was completed and the label was received, several additional events took place. In thirteen of the fourteen cases, physicians or psychologists recommended medication. In eleven of the thirteen cases, this recommendation was accepted by the parents. The other primary result of the label was that the parents returned to the schools with a diagnosis of ADHD in hand. In eight of the fourteen cases, the schools reacted immediately to the label and provided some services or accommodations for the students. In the other six cases, the schools were uncooperative, but eventually relented and provided some services or accommodations in five instances.
2. Services or accommodations that had not been previously provided were now made available. This occurred in thirteen of the fourteen cases. The following comment from a regular classroom teacher demonstrates this tendency for acquiescence: (10) "I have so many parents that are concerned. Whoever thinks that parents aren't concerned don't work in this school. So I get a lot of complaints and requests for more work or more help. I can't give it all. Now, you give me a medical diagnosis, something on paper and based on medical science, now that will get my attention." [Interview; K.B. 8-5-92] 3. When the formal label was delivered to the schools, the documentation of the disability label acted as a catalyst for actions requested earlier by the parents. Usually, evaluations, accommodations, and services not previously offered to the child and parents were now provided. The label, therefore, had a reactive power over the schools, the parents, and even the children. Perhaps this is a primary reason for the rapid growth of ADHD as a disability label over the last several years. Parents are increasingly recognizing that the concerns they express to the schools are not taken seriously until a disability label is assigned.

Rogalin et al -2015
1. If a child does not have a diagnosis but does behave like a child with ADHD, the same resources will not be given, this child will become just a rowdy kid, he might get detention, maybe he will be taken away from the class, but the discussion will not be concerning the fact that this child needs help/ assistance. (Leisure time teacher and assistant) 2. To see behaviours as symptoms of a disorder rather than unreasonable and unexplainable actions changes the interventions that are made in regards to the children. Assistance and support are the main focus in the presence of a diagnosis whereas detention and expulsion from the classroom are more likely if the child does not have a diagnosis.

Wienen et al -2019
1. Eleven out of the 30 teachers point out that an ADHD classification leads to new approaches, ideas, medication and right to support. As respondent 4 noted, 'So in order to better support these children by way of an assistant or whatever kind of effort, we need a diagnosis'. Some teachers, including respondent 25, point out that new ideas and pointers may arise: 'Yes, just purely those practical things like, how can I help the child. Also, because, especially for the child to find his or her own way in that.'

2.
Eight out of the 30 respondents note that an ADHD classification leads to a 'new' shared starting point in the collaboration between parents and teachers. Respondent 27 described it as follows: 'While with those parents whose child has been diagnosed there is often also a solution, medication or support, in any case, something that you can bat about. In those cases it becomes more of a collaborative little project I think, through which you can help the child.' Respondent 5 also talked about the shared perspective that emerges following classification: 'Sure, a clearer picture really, also clear towards parents. . .and then you do need to point all noses in the same direction, so to say. 2. This pursuit of diagnosis by impoverished people, driven by economic need, highlights the problems that can be caused by the medicalisation of poverty (Schram 2000).

d. Medical/ psychological support
Carr-Fanning et al -2018 1. Parents described how delayed diagnosis resulted in significant consequences and secondary problems, which led to the diagnosis. For example, a mother described her daughter's (17 years) overdose at the age of 13 years as a cry for help.

Damico et al -1995
1. Once the diagnosis was completed and the label was received, several additional events took place. In thirteen of the fourteen cases, physicians or psychologists recommended medication. In eleven of the thirteen cases, this recommendation was accepted by the parents. The other primary result of the label was that the parents returned to the schools with a diagnosis of ADHD in hand. In eight of the fourteen cases, the schools reacted immediately to the label and provided some services or accommodations for the students. In the other six cases, the schools were uncooperative, but eventually relented and provided some services or accommodations in five instances 2. A parent expressed satisfaction with the medical diagnosis and the opinion that the problem should be solved by medical intervention. The views expressed in this excerpt were fairly typical: (14) ''Well, now that she's diagnosed and on medication, the problems should vanish. We now know that the problems were inside her brain. The doctor said that her brain is like a switchboard that can't receive and handle all the calls because it's too easily distracted. With the medication, that's changed. I don't know how the teachers could help her more…maybe work on her learning problems?" [Interview; Q.A. 9-24921 1. One of the major consequences of ADHD not being diagnosed is a lack of treatment. Untreated ADHD can pose a tremendous amount of psychological, financial, academic, and social burden to the individual and the community, which reflects the importance of diagnosing and treating the disorder (23,66). While treatment has not been shown to completely "normalize" the developmental trajectory of individuals with ADHD, individuals with ADHD who do not receive treatment have poorer long-term outcomes compared to those that are treated (51). Untreated ADHD during childhood is a risk factor for later adult mental health issues, which extend beyond impairment in academics (66). A lack of treatment for ADHD also impairs social and occupational functioning and increases the likelihood of developing comorbid disorders like anxiety, depression, personality disorders, antisocial behaviours, and SUD (66,67). Many mechanisms may be at work linking undiagnosed ADHD to vulnerabilities (27).
2. The prevalence of undiagnosed ADHD within a substance treatment population was approximately fivefold higher than the general population (66) suggesting that undiagnosed ADHD may have substance abuse requiring treatment as a consequence.
3. Also, as reviewed previously, the MRRs of individuals with delayed diagnosis of ADHD has been shown to be significantly higher than those diagnosed earlier, suggesting that a lack of diagnosis may accumulate risks to mortality (78).

Malacrida -2004
1. Many mothers reported being sent for interventions even though a label was not provided. They described multiple diagnoses that were vague and often not very helpful, including poor muscle tone, behavior problems and diffuse learning challenges. Almost inevitably, as a first assessment measure, British mothers were sent by educators to see psychiatrists or family therapists to resolve perceived family difficulties, and often these interventions took many years before women stepped 'outside the box' to seek an ADHD assessment. 2. The physicians interviewed for this study did not hold the same beliefs about the objectivity of the diagnosis of ADHD. One physician, a pediatrician, expressed some of her concerns during the interview:

II. Potential harms of an
3. (17) "I feel a real burden at times about the whole ADD business. Parents are starting to come to me looking for the diagnosis. They're almost shoppers in search of that label as an explanation or even an excuse . . . and I'm uncomfortable with it. See, it's too easy to look at behaviors and then make a quick judgment of ADD . . . but I'm not certain we're always right.
It's so subjective. . . . And then the parents want medication. I'll tell you, I would never be so eager to medicate my children-not in the same way that so many of these parents are doing." [Interview; K.T. 9-10-921 4. This confirmatory reaction has a more subtle implication, one that was expressed by one of the physicians during the interview phase (see example 17): If there is a real problem, medical or biological in nature, then the behaviors and difficulties that the parents have had to address have an explanation. That means that the problems are not due to "character flaws" or "poor parenting" or even "poor teaching" but, rather, to that problem within the child.
5. In effect, as Reid, Maag, and Vasa (1994) have suggested, the child, parents, and teachers are given a "no fault label".

Hamed et al -2015
1. Additionally, others have reported feeling that ADHD is viewed by others as a "convenient excuse" for their behavioral problems and they may be labeled as a "problem person" rather than a person who has a problem (79, 80) And this may be encouraged at home: You do find that with the families … it's an excuse, then the family come in and 'he's got ADHD so that it explains it all' and it's kinda like no it don't really explain it all there's more to it than just a label (Monica, Teacher, PRU).
Participants saw that the diagnosis removes blame from the child, 'almost validates the behaviour and gives them a reason for it' (Paula, Teacher, PRU); placing the responsibility for behaviour elsewhere was not seen as entirely helpful

Singh -2011
1. Playing up the stigma of ADHD diagnosis is a double-edged sword: when used for prosocial ends it is a positive form of agency; when used for selfish ends, it ultimately diminishes agency. UK children report exploiting their ADHD diagnosis, primarily as an excuse for bad behavior: I don't get punished for nothing. It's easy to get away after fights because I have ADHD. I just make puppy eyes and it gets me round everything with my teachers. Alan, age 10 Unlike US children, who rarely admit to using ADHD as an excuse for their behavior (because they believe it is wrong, but also because niche dynamics strongly encourage them to keep their diagnosis a secret), almost all UK children say they have used ADHD as an excuse. Frequently, it works, at least to a degree.
1. Despite struggles related to ADHD symptoms, receiving the diagnosis does not always reduce stress for an individual.

Malacrida -2004
1. In her story, and indeed in others like it, educational specialists, administrators and sometimes even teachers, despite medical and psychiatric assessments of ADHD, remained firmly unconvinced of the medicalized status of ADHD, thus making the administration of any kind of non-disciplinary treatment, including medication, problematic for diagnosed children.
2. Repeatedly mothers in both Canada and the UK expressed dismay that teachers seemed reluctant to 'own' the ADD/ADHD problem; they complained that teachers seemingly had little understanding and little interest in understanding or responding to their children's conditions, particularly once the label had been applied and treatment had been prescribed.

Moore -2017
1. However, participants noted that a diagnosis alone is 'Not a wand that can be waved' (Maisy, SENCo, Primary)

Wienen et al -2019
1. 'You may have that label, but in effect, absolutely nothing at all has in fact been changed'. Likewise, respondent 1 commented as follows: 'So, suppose a teacher finds that troublesome. So they want to stick a label on it. Because that tells them what to do. While I then think, really, the label tells me nothing more and nothing less.
2. Ten out of 30 teachers in the data set suggest that an ADHD classification offers no real benefits for educational practice. An example of this is respondent 1: 'I do try to translate it into an educational need, and a label achieves nothing more in those cases. Because you are still, even if a child has a label ADHD, what do you need from me?' Respondent 13 voiced similar concerns: 'But moreover I think, so the child now has a label, so what? I mean, I knew that already, surely? What adjustments do I need to make for him, and I don't think he'll be feeling any better just because there's a label on it.' 3. Two out of the 30 respondents point out the misunderstanding that an ADHD classification ensures that financial means flow to the school. As respondent 4 put it: 'you used to just be able to get money with a label. . .but that is no longer the case now.'

Comstock -2015
1. It is clear from these posts, however, that AD/HD is still sometimes, if not frequently, used as a form of overt behavior control and correction and that AD/HD is not always a positive identity for individuals but a label given to the powerless (such as children) by those with power (such as parents), from the "top down."

Damico et al -1995
1. the physicians are way too willing to label a child as ADD and then medicate them. Some teachers aren't much better. They see what Ritalin did to another kid-only focusing on the kid's disruptive behavior-but they like it . . . it makes the classroom calmer so they recommend medication-they can even suggest the doctor to see. Everyone knows who really pushes the drugs." [Interview; K.N. 9-13-92] 2. Each stated that he or she wasn't certain that the medication benefitted the child's learning capabilities, but that it did make the classroom a better place for the other children to learn.

Hamed et al -2015
1. Some perceived their identity was challenged by a diagnosis of ADHD and also felt less incontrol of their lives, especially when faced with the prospect of taking medication for life (32).

Malacrida -2004
1. researchers have speculated that the inability to exercise discipline through student exclusion has led US educators to embrace ADD as a medical category and to use Ritalin as a 'substitute' for educational discipline strategies (Kiger, 1985). There is some support for this argument in the stories mothers tell about their children in this study. Canadian mothers, whose children were far less likely to have been suspended or expelled from school than the British children in the study, reported a far higher level of acceptance by educators of drug therapy than was evidenced by British educators. In part, this may stem from the relative lack of alternatives available to Canadian educators than their British counterparts in exercising classroom discipline.

b. Increased passiveness and hopelessness
Klasen -2000 1. Like parents of children with other chronic problems, some parents initially reacted with grief, denial, frustration, or anger. "I found it very hard to accept the diagnosis because it means there is something wrong with him that you have to accept and for which there is no cure. Before I thought it was something that could be fixed. I want him to be well adjusted, I want him to be in a mainstream school, I want him to be happy. You have no idea how it hurts; it just takes my life out. I want him to lead a normal life. I suffer because he suffers. It was a shock to accept that your child has a problem and there is something wrong with him. . . . I was upset, but it was a relief as well to know it wasn't down to me, to things I had been doing or not been doing." 2. Despite these mainly positive comments, however, parents emphasized that the diagnosis was also problematic: it made them realize that they would have to live with a chronically difficult child.
3. The GPs also seemed to think that once people see their problems as medical, they stop working toward improvement. Thus, the doctors' decision to withhold a medical label seems to have been based on the fear that the diagnosis would decrease the children's chances of recovery.

fear that medicalization can be disabling, making patients passive and dependent
Moore -2017 1. Practitioners recognize the process of labelling occurring for children with ADHD. While the label may aid understanding and access to support, the negative aspects of labelling 'can sometimes just compound them into their difficulties, rather than pull them out' (Ryan, Pastoral Leader, Primary)

Wienen et al -2019
1. Respondent 22 put it more generally: 'I think that once parents know that my child has ADHD, it may perhaps remove a bit of uncertainty, like well, he's got it, he is like that, nothing we can do about that.'

c. Self-fulfilling prophecy: perceived inability to change or achieve (by self or others) leads to exclusion and reduced opportunities
Klasen -2000 1. Their other fear was that the child might overidentify with the diagnosis, so that the problem would turn into a self-fulfilling prophecy.
2. Generally, these doctors were very aware of the dangers of medicalization, which they frequently expressed in sociological terms. "I don't want to stigmatize a child unless it has some benefit. The danger is you are medicalizing something that perhaps should not be medicalized.
One of the problems is that one might create a self-fulfilling prophecy."

Rogalin et al -2015
1. Participants show awareness of the risks that assigning the psychiatric diagnosis might limit the possibilities of the children's identity. As they report, the diagnosis becomes an obstacle to change as it invites the education staff to place the children with ADHD in the prototypical box. The children are no longer seen as potentially able but with some particular difficulties but rather as children who they know in advance are unable. In other words, if the child has a disorder, than it is natural that he or she is unable to do certain things.
2. The diagnosis becomes hard to get rid of, just like a criminal record, a label that informs others of who the child has been and still is. I think you can get a little "locked" in a certain idea of the child. (Leisure time teacher) If you do not have a diagnosis, one can say: ok, this child has some difficulties with this and this so let us help him with these things. If you have a diagnosis then they are not able to learn this and that, because they have this diagnosis and then they have these difficulties. (Leisure time teacher) It feels like a criminal record, you always have that label that you have committed that crime or that you always have had ADHD. (Teacher) 3. The diagnosed child is the one that is unable to do something, that lacks in abilities. This use of the diagnostic label recalls the reality of a handicap, of a person being unable to do something.
4. Because the diagnosis establishes that a child presents certain behaviors and not others, it lays the ground for the construction of a prototype constituted by expectations on the abilities and behaviors of who has been assigned the diagnosis. When a person is seen by others through the prototype-lenses it will also have impact on what actions are retained as adequate when interacting with the person under consideration (Gergen 1997a(Gergen , b, 1999(Gergen , 2009; Gergen and Gergen 1993). Much like the expression "anticipated others" (Goffman 1963,p. 12) indicates, the prototype consents anticipation of future behaviors and precautions can thus be made even before behaviors occur in order to avoid situations experienced as critical. Consequently, if someone is expected not to perform well at certain tasks or in certain academic or occupational areas (APA 2000) the person under consideration might be excluded from these tasks and areas in advance 5. As hypothesized by other authors (e.g. Levine 1997) a diagnostic label promotes the search and confirmation of similarities. It is precisely for this reason that it becomes important to possess as much knowledge as possible about a diagnosis. It becomes important because the knowledge is not neutral, it explains why the children with the diagnosis behave as they do and it helps to know what to do when these children react or say something and even how to intervene in advance in terms of precaution avoiding that anticipated unwanted situations occur. As a consequence, the identity of a child that has been assigned a diagnostic label is limited. Who the children are and what they can or cannot do depend, at least in part, of the opportunities that are given to them. If certain tasks/situations are avoided for the children with the diagnosis they are excluded from the opportunity to be able in those tasks/situations and on the contrary certain inabilities will become a part of their identity as they are interpreted as an outcome of the diagnosis thus as a natural part of who they are.
6. With the knowledge of a child having a diagnosis however, efforts to improve abilities or change the ways in which a child relate to a peer might still be made but it becomes easy to write off an inability to solve a task or fighting with a peer as a symptom of the disorder and therefore leave it to be. After all, if the children's behaviors are caused by a disorder, than it is only natural that they are unable to do certain things and that they behave in a certain way

Andersson Frondelius et al -2019
1. The participants described that the label 'ADHD' could mean different things, depending on the context. It could be used as a condescending stamp, but it was also a facilitator to professional help.

DosReis et al -2010
1. Another concern was that as a consequence of being labeled, their child would be treated differently or not given the same opportunities as their peers.

Hamed et al -2015
1. Some individuals have described perceiving a certain degree of stigma attached to being diagnosed with ADHD, influencing their willingness to disclose their diagnosis to other people.
2. At times, ADHD diagnosis led young people to feel hurt by their peers when they were teased or targeted because of their apparent academic delay and labeled as "retarded" (79).

Klasen -2000
1. A small number of parents feared that the label might bring disadvantages for their child.
They were particularly worried about the stigma attached, which might lead to problems at school.
2. Generally, these doctors were very aware of the dangers of medicalization, which they frequently expressed in sociological terms. "I don't want to stigmatize a child unless it has some benefit. The danger is you are medicalizing something that perhaps should not be medicalized.
One of the problems is that one might create a self-fulfilling prophecy."

3.
A label can be very frustrating as it makes the kid stand out. It can also lead to scapegoating by increasing the conflict between parent and child.

Moore -2017
1. In the current study, some practitioners 'don't think it's nice to have that [ADHD] label' (Bryony, SENCo, PRU) because 'so many people are … stigmatized by these sorts of things' (Tarquin, Teacher, PRU). One participant pointed out that other learning difficulties like dyslexia are more 'socially acceptable' (Janet, Teacher, Secondary) than ADHD.
1. You don't take it just as any child. There is something that tells you "this is what a child with ADHD is". That they are messy, that they have problems with concentration, loud, that they take up space. That there are going to be problems. (Leisure time teacher) 2. On one hand we have the parts of the accounts that form an idea of a typical ADHD-child with typical behaviors. As a consequence of this idea, certain expectations are placed on the child whose performances and future behaviors are anticipated.
3. Participants show awareness of the risks that assigning the psychiatric diagnosis might limit the possibilities of the children's identity. As they report, the diagnosis becomes an obstacle to change as it invites the education staff to place the children with ADHD in the prototypical box. The children are no longer seen as potentially able but with some particular difficulties but rather as children who they know in advance are unable. In other words, if the child has a disorder, than it is natural that he or she is unable to do certain things.

Singh -2011
1. Children report that school personnel tell other children to stay away from them because they have ADHD, and they give lesser punishments to students with ADHD diagnoses.

Wienen et al -2019
1. The main disadvantage mentioned is that an ADHD classification bears down on a child for many years.

b. Increases feelings of isolation, exclusion and shame
Hamed et al -2015 1. Still other individuals report having the diagnosis of ADHD lead them to feel as though they were different and isolated (79).

Moore -2017
1. Another participant spoke of 'the shame' (Bryony, SENCo, PRU) surrounding ADHD and how this can lead students to be reluctant to ask for or accept help.

Singh -2011
1. Children report that school personnel tell other children to stay away from them because they have ADHD, and they give lesser punishments to students with ADHD diagnoses. eAppendix 6. Results Table   ©2021 Kazda L et al. JAMA Network Open

Type of evidence (n) Theme (n) Subtheme (n) Main outcomes (n)
Severity of disorder (17) indicated by • Reduction in hospital visits in medicated children is decreased with increasing group of youths with ADHD (1)* 129 Difference in adverse outcomes by diagnostic criteria (9) • Youths fulfilling ADHD criteria are less likely to be impaired in various domains with broadening of diagnostic criteria and increasing of group (5) 53,54,57,62,65 , only marginal effect in this direction (1) 64 • Reduction in ADHD symptoms and social impairments in medicated children is decreased with broadening of ADHD criteria (1)* 130 • Sample size too small to detect differences (2) 52,68 Symptom severity (6) indicated by Trend over time (3) • Severity proportions stable (1) 109 • Larger increase in moderate/ severe cases (2) 21,116 Proportions of mild, moderate, severe cases (2) • Proportion of youths with severe ADHD is (very) low (2) • Prevalence estimates of symptomatic ADHD have remained steady or slightly declined (4) 59,60,74,76 • while diagnostic prevalence has increased (2) 72,73 Change in relative age effect over time (2) • The relative age effect (younger children are more likely to be diagnosed than older children in the same year of school) has increased in later birth cohorts (2)

Type of evidence (n) Theme (n) Subtheme (n) Main outcomes (n)
• No effect on hospital contacts during treated vs before treatment periods (1) 237 • No difference in hospital contacts between ever treated vs never treated youths with ADHD (1) 238 • But fewer contacts during treated vs untreated periods (2) 238,239 • Treated children have worse health outcomes compared to the rest of the population (1) 224 Injuries (7) • Lower risk of injuries during treated vs untreated periods (3)  Cardiovascular (8) Blood pressure/ Heart rate (2) • No effect of treatment on blood pressure (2) 247,248 • Significant long-term effect of stimulant treatment on heart rate (1) 247 Safety (6) • No effect of treatment on severe cardiovascular events (3) [249][250][251] • Increased risk of arrythmia (1) 252 or of any cardiac evet requiring hospitalisation (1) 253 with treatment • Potential for increased risk but not enough statistical power to detect small differences (3) 249,250,254 Efficacy (30) Symptom reduction (30) • Significant short-term (<12 months) symptom reduction in many youths with treatment (24) 175,220,227, • No evidence of any symptom improvement after 48-hour wash-out period (1) 222 • No difference in symptoms between regularly treated and untreated/irregularly treated ADHD youths in late adolescence/ early adulthood (3)