ADHD and our Culture: Overdiagnosis
As a psychologist who has specialized in diagnosing and working with ADHD individuals over the past twenty years, I firmly believe ADHD has been (and still is) over diagnosed — and that medications are used too much.
Having said this, I think it is a mistake to “throw the baby out with the bath water”. That is, just because ADHD is over diagnosed does not mean that ADHD does not exist or that there is no one with ADHD. The issue becomes one of proper diagnosis and appropriate treatment and intervention.
To put the diagnostic issue in perspective, the characteristics of ADHD (like most human characteristics) all exist on a continuum. There are individuals with above average attention span and focus, most have an average amount, and others who are below average.
From a professional’s point of view, the task is to try to determine where on the continuum these characteristics lie for the person being evaluated. With regards to distractibility, are they average (when compared to same-age, same-gender peers)? Below average? Well below average? Is their attention span on the low end of average, where it is a “normal” problem? Or is it a more intense struggle and challenge for them (maybe in the low average range)? Or is it so severe that it significantly interferes with their daily life functioning — and hence, reaches the level of a disorder (the last “D” in ADHD)?
In many ways, determining the level of severity is a judgment call (and, as a result, the diagnosis of ADHD can be highly influenced by the professional’s view of how severe the symptoms need to be to warrant a diagnosis [I tend to be more in the middle to conservative side when compared to some mental health professionals]). However, there are some framing principles to help make the decision.
Severity of Symptoms
The level of impact of ADHD (or ADHD-like) characteristics can be judged by the following issues:
Duration. How long have the symptoms been present?
Number of Symptoms. Does the individual display just a few of the symptoms, a large number, or almost all described?
Intensity. How intense are the symptoms? Are they just “sort of” there, or are they a hallmark characteristic of the person, where you “can’t miss” them?
Frequency. Are they symptoms just present occasionally? Frequently? Virtually constantly?
Impact on Daily Functioning. Are the symptoms creating numerous problems in the person’s life (poor performance at work or school)? Are significant others in the person’s life (spouse, children, boss, co-workers raising concerns about these characteristics and how they are impacting their lives?
I have always been a fairly high energy, socially outgoing, fun-loving kind of guy (more so when I was younger; the responsibilities of adulthood have sobered me somewhat). And I had a pattern of starting a lot of projects, moving from one task to another frequently, and leaving the mess there for someone else to pick up after me. I also had a history of making quick decisions, sometimes not always “thinking through” the longer term risks or consequences. And I am definitely stimulation- and excitement-seeking.
But I alwasy did well in school. I could pay attention in class and concentrate while reading. And I got my work done on time. So over the years, when I would speak on ADHD to parents and educators, my wife, kids and friends would tease me, saying something like, “You know you are ADHD, don’t you?” And I’d laugh and say, “Yea, right. No, I’m really more ADHD-like. I do OK.” And they would roll their eyes or sigh.
Then a few years ago, my wife started pressing me (who do you think wound up cleaning up most of my messes?) She would give me chapters on being married to an ADHD individual and say, “This is my life.” (There is a great chapter in Delivered from Distraction by Ratey and Hallowell.) So, after looking at the characteristics in my life and the struggles they produced, I acquiesced and agreed “this is me”. And I also eventually wound up trying medication.
The change in my life — both behaviorally and my subjective experience — has been dramatic. For me, one of the biggest differences is not feeling “on edge” and agitated most of the time. I am not as driven to be active and “doing something” all of the time (although this characteristic is still there, but to a lesser degree). Secondly, I am less impulsive and more able to not have to make a decision “right now”. This has had a positive impact in my overall decision-making, especially with regards to purchases. Finally, I also sleep better (I can “turn my mind off” and get to sleep.) [I am willing to discuss my personal experience further and answer questions, if that would be helpful.]
So, although my personal experience will certainly create some biases, I do continue to believe ADHD is overdiagnosed in our culture (especially in young boys). But I also believe that it is exists and many ADHD individuals may receive significant help by medication (a number of ADHD individuals manage fine without medication). The real issue is to have a thorough evaluation — often other issues that can create ADHD-like symptoms need to be ruled out (depression, anxiety, learning difficulties).
Next, we will take a look at how ADHD affects individuals performance in the workplace.