Program Evaluation: Misdiagnosis and Mistreatment of Adhd-like Symptoms Among Youth in Foster Care

Background: Youth in foster care are faced with many adversities early on including neglect, abuse, abandonment, and uncertainty. These stressors can alter normal brain development and function leading to changes in behavior that may resemble or overlap with Attention Deficit Hyperactivity Disorder (ADHD). The National Child Traumatic Stress Network 2016 Clinician Guide points out how symptoms like distractibility, disorganization, and hyperactivity can be a result of both ADHD and Child Traumatic Stress. Perhaps as a result, the American Academy of Pediatrics 2015 finds that children in foster care are three times more likely than others to have an ADHD diagnosis. While diagnostic criteria of ADHD may be applied effectively to children and adolescents who grow up in a traditional family structure, it is unclear how stressful and traumatic childhood conditions such as placement in foster care can alter normative behavioral development of attention and activity/impulsivity, and moreover what the best way to address such behaviors is. It is important to re-evaluate best practices for the diagnosis and treatment of ADHD-like symptoms in children who grow up in high-stress environments like foster care.

Methods: We conducted a literature review of current, relevant, and peer reviewed articles using several databases including Google Scholar and Pubmed. Search terms included “ADHD” OR “ADHD medication” OR “behavioral disorders” AND “foster care” OR “child protective services.” Literature was not excluded based on methodology or outcome time, and was classified and analyzed for broader themes and concepts as well as limitations.

Results: The literature supports alternatives to the current diagnostic and treatment program for ADHD-like symptoms in foster care children. Such modifications include training multidisciplinary teams of psychologists, pediatricians, community doctors, teachers, and social workers better equipped to address the complexity of ADHD-like symptoms in children in foster care and to improve foster care placement trajectories to reduce the development of executive dysfunction symptoms in foster care children.

It is important to note that several studies have shown potential fallibility of ADHD diagnosis. For instance, maltreatment histories and frequent comorbid psychiatric conditions that exist within the foster care population can produce ADHD-like symptoms and make a clear-cut diagnosis of ADHD difficult. In addition, treatment of suspected ADHD alongside these psychiatric comorbidities leads to unregulated prescription of medication combinations whose efficacy and safety have not been studied.

Conclusion: Our literature review reveals that the current practices for the diagnosis and treatment of ADHD-like symptoms in children in foster care results in frequent misdiagnosis and medical mistreatment. As a result, we recommend program modifications such as the training of regulated multidisciplinary teams that better address the multifactorial and complex etiology of ADHD-like symptoms in the foster care population with more efficacy and less risk to patients.