ADHD or Attention Deficit Hyperactivity Disorder has become an increasingly controversial topic. The most common point of contention about the disorder is whether or not it is over-diagnosed. A diagnosis is the “act of identifying a disease from its signs and symptoms.” The issue of over-diagnosis materializes when a condition is diagnosed more times than it is actually existent. Over-diagnosis presents many consequences for not only the patient but society at large. These consequences include anything from unnecessary treatments to over-prescription of drugs, which in turn casts a negative light on how ADHD is perceived. I believe that the broad symptoms and descriptions of the condition in diagnostic guides are to blame for suspected over-diagnosis.
The “core” symptoms of ADHD are divided into three categories: inattention, hyperactivity, and impulsivity. Symptoms are typically recognized during adolescence and include lack of focus, disorganization, forgetfulness, excessive talking, impatience and having a hard time waiting to talk or react. According to the DSM-5, a tool used for diagnosing ADHD, six symptoms must be present for at least six months from each category to make an ADHD diagnosis. That being said, why are these symptoms leading to over-diagnosis? Well, take excessive talking for example. Maybe your child has been described as a “talker” that gets off topic a lot, does this mean he or she has ADHD or does it mean he or she is just talkative? Furthermore, could modern expectations/pressures of behavior and ability play a part in diagnosing ADHD? These expectations include being able to sit in a classroom for hours on end, as well as being able to consistently focus on a given task. Considering that many of the symptoms of ADHD could also easily appear in a non-ADHD person and be attributed to particular personality traits one can start to recognize a problem: either every person/child that is forgetful, talkative, easily distracted, impatient, impulsive, and disorganized has ADHD or we are in need of a better, more accurate way to diagnose it. In this paper, I will argue that a combination of three specific factors: the standardization of diagnostic manuals, the nature of the symptoms of ADHD and modern societal expectations, have led to overdiagnosis of ADHD and in turn, indicate the lack of an accurate tool to diagnose it. Because I will argue that ADHD lacks an accurate diagnostic tool I will end my paper with suggestions for developing one.
Today, the steps are taken to diagnose ADHD vary but almost always begin with the DSM. The DSM is published by the American Psychiatric Association and seeks to provide a “common language” and “standard criteria” for the classification and diagnosis of mental disorders. It is widely used by medical professionals, researchers and companies alike. It is not easy to standardize something as nuanced as mental illnesses or countless other things for the matter. The goal of standardization is to eliminate guesswork and provide a basic framework to achieve a diagnosis. It also allows professionals to give a specific diagnosis that can be verbalized. This then gives the patient the ability to get the proper insurance coverage, accommodations and an understanding of their condition- of course, if it is diagnosed properly.
I believe that the drawbacks to standardization are more compelling than the benefits. Is the goal to simplify always a good thing? We do not treat all types of cancer the same, nor do we treat all infections the same. If we did, very few people would have successful outcomes. Both types of illnesses share general characteristics but present with symptoms that are specific to the type of cancer for instance. The general treatment for cancer is chemotherapy but that is not the only one: breast cancer treatment is supplemented sometimes with a mastectomy. You would not perform a mastectomy on a colon cancer patient. Additionally, a certain procedure on a Stage I colon cancer patient would not work on a Stage IV colon cancer patient: so, you would only do it on the Stage I patient regardless of the fact that they have the same type of cancer. This model of treatment includes some elements of standardization which is acceptable in these cases because it is used to make only preliminary decisions. It is impossible to eliminate standardization from modern medicine- or else a doctor in Texas could call cancer one thing while another doctor in Nebraska could refer to it as another. That being said, this argument advocates for a lesser emphasis on standardization as exemplified in how we treat non-mental illnesses.
. ADHD most definitely suffers from standardization of diagnostic tools. It has keynote symptoms like lack of attention and fidgeting but one person with ADHD may be much more hyperactive than another person or more inattentive. The DSM offers subtypes of ADHD and describes a non-hyperactive manifestation of the illness as well as a few other versions of the disorder. That being said, these subtypes have all of the same treatment suggestions- stimulant medication, therapy, and appropriate academic/workplace accommodations. Not all people with ADHD need medication, some just require a limited distraction learning environment or strategies to focus, expel energy, or collect themselves. Just as in the cancer example- you do not perform a mastectomy on a colon cancer patient just because they both have a cancer diagnosis.
If a standardized diagnostic manual or method is being used it should only be used to establish an initial plan of action. I can gather groundwork information about the symptoms a cancer patient is experiencing and suspect cancer but in order to diagnosis it I would perform a biopsy or some other scientific test. Mental illnesses are obviously different as there is no equivalent accurate science-based test to prove their existence. This is why professionals rely on symptoms manuals and cognitive testing to give the most accurate diagnosis possible. But this does not allow them to generalize based upon those same standardized descriptions of a condition. If they are relying on observations and collections of research that are considered “universal,” too much leeway for the possibility of a misdiagnosis and over-diagnosis. Creating standardized definitions for something as scientifically concrete as cancer requires a balance of said standardization of symptoms with other tests- so shouldn’t creating a standard definition for mental illnesses be treated with even more prudence. This lack of accuracy due to standardization in diagnosis is extremely problematic.
Another issue with the methods used to diagnose mental illness is that the symptoms stipulated in the guidebooks are based upon a collection of most common observations. These common observations are helpful in differentiating between illnesses such as Schizophrenia and Identity Disorders but not in differentiating between ADHD and non-ADHD diagnoses. They create a standard of normality and abnormality- if a patient’s symptoms fall on this list they have a problem and if they do not no problem exists. If a standard definition of a mental condition like ADHD is written, does that mean that everyone who has those symptoms has ADHD and is therefore ill? Where does one draw the line between normal and non-normal behavior? Simplification and standardization lead to the reduction of complex issues of mental health to diagnostic codes, labels, and statistics. By allowing clinicians to make quick decisions based upon standard guidelines, the DSM and other diagnostic guides increase the speed at which a patient can be diagnosed but do not increase the accuracy of that diagnosis. They should be used only as a preliminary step.
On the same note as the concept of non-normal and normal behaviors, social standards are most definitely relevant to this argument. Each revision of the DSM is edited to reflect current ideologies as research expands and new discoveries are made about mental health. That being said, the manual is hypersensitive to shifts in cultural ideologies. For example, homosexuality was considered to be a mental illness in the first editions of the DSM. When societal attitudes toward homosexuality changed the DSM followed suit and removed it from the manual. It was not removed because a scientific test was done to prove the preposterous nature of that claim, instead, homosexuality was removed from the manual because of a shift in ideology. This is a fundamental weakness of the DSM and it has affected the diagnosis of ADHD as well. The life of a student today is arguably more demanding than that of a student thirty years ago. Pressures exist to perform well on standardized tests in high school and the amount of work that students are expected to complete outside of the classroom has increased. As the years have gone by the definition of ADHD has begun to morph. But in all honesty, it is hard to tell if it is now a description of a rowdy four-year-old or a four-year-old with a legitimate medical condition. The DSM is just one example of the impact of standardized diagnostic practices.
ADHD has undergone changes in name, classification, and descriptions since its introduction to the DSM in 1968. The list of symptoms has gotten increasingly broader and longer as mentioned previously. In order to diagnose ADHD a combination of the DSM and tests of a clinician’s choosing are used. The DSM-5 says that “several inattentive or hyperactive-impulsive symptoms” had to be present before the age of 12 for a patient to be diagnosed in the first place. Thus, many diagnoses are made during childhood and the first step in moving to a clinical diagnosis typically begins with a parent or teacher. Tools such as the Vanderbilt ADHD Parent Rating and Teacher Rating Scales gauge parent and teacher perceptions of the child’s behavior, ultimately a subjective measure. I have countless friends that tell stories about teachers that have told their parents starting in kindergarten that their child should be “tested” for ADHD. The teacher would state a few examples in which the child was rambunctious while other students behaved or a time that the child did not follow directions or even cited the fact that they observed the child to be “too-energetic.” This goes back the issue of determining what behaviors are normal and which are not. Changes to the criteria for diagnosing ADHD are common. For example, the symptom that used to be described as “often loses things necessary for tasks and activities” is now “often loses things necessary for tasks and activities such as school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones.” This change affected parent perception reports, the DSM, and questionnaires. The number of diagnoses of ADHD increase with each new addition to the symptoms. By adding specific examples, one may think they are narrowing the description for the disorder but in fact, that opposite is true.
This discussion of the downfalls of diagnostic manuals leads directly into how the nature of the symptoms of ADHD presented within them and how this creates over-diagnosis. Generalized and lax criteria lead to generalized and lax results. For example, if the criteria for an ACL tear in the knee was just “any of the six following things indicates a diagnosis of a tear” then anyone who has ever experienced basic joint pain would be undergoing arthroscopic surgery to fix a fully intact ligament. Granted, an ACL tear can be proven with an MRI, there are keynote symptoms that produce a diagnosis along with it. In a perfect world, this method would be translatable to all forms of illnesses and injuries, including ADHD just like the cancer treatment example would be. Some will say it is difficult to get an ADHD diagnosis and others will disagree. In order to get a 504 plan or IEP in high school, one has to undergo countless tests to “prove” the existence of the diagnosis and many more to get a prescription to treat ADHD. One of the reasons for this is to stop people that may abuse the system in order to get a diagnosis for their child. Some see it as an advantage to have an ADHD diagnosis because of the added accommodations. For instance, the SAT and ACT offer time accommodations- for a student without ADHD, an extra hour of time to take it could produce a much higher score. People without ADHD have ADHD diagnoses regardless if this diagnosis was sought after or not. This is because misdiagnoses happen. But when they happen they cause people to question those who have ADHD and even question the legitimacy of ADHD as a mental illness. This is once again the result of faulty methods of diagnosis NOT a result of ADHD’s legitimacy as an illness.
See, the symptoms of ADHD can be proven in a testing environment but since these tests are not like a blood test a student could just say that they have a hard time concentrating without further questioning. In contrast to the example about 504/IEP ADHD testing, I have a friend from my dorm who literally walked into the university health center, complained of getting easily distracted in class and walked out on the same day with a prescription for Adderall and a note for extra time accommodations. I am not being skeptical of the legitimacy of her need for Adderall, I instead know (she told me) for a fact that she was getting the diagnosis and prescription for advantageous purposes. I also know people who struggle with ADHD symptoms and have gotten a diagnosis out of necessity. How can one person spend countless time and money to get a bulletproof diagnosis of ADHD but one college kid who wants to get some Adderall can just walk into a student health center and get the same diagnosis? There are people who actually struggle with ADHD symptoms and thus have difficulties in their school, home, and social lives. They deserve treatment, help, and respect but because the symptoms are so broad there are other people with the same medical diagnosis that do not necessarily share the same struggles. Note, some research indicates that parents/teachers will also encourage diagnoses without understanding if what they have observed to be symptoms of ADHD are in fact symptoms or simply the personality traits of the child.
The purpose of pointing out this discrepancy in diagnoses is that although there is a basic standard to diagnose ADHD, there is no standard to make the final diagnosis of ADHD thus allowing for subjective decision making. One doctor may be more likely to make an ADHD diagnosis while another may be more apt to dig deeper before making a final diagnosis. The system is at risk for manipulation and misunderstanding. This stands as further evidence for extreme over-diagnosis in today’s society.
To recapitulate, 1. ADHD does not have a sure-fire test to produce a diagnosis and is instead based on broad symptoms, 2. Determination of final diagnosis is subject to the opinions of particular clinicians and 3. Its symptoms can be feigned or misinterpreted thus leading to over-diagnosis of the condition. Despite this evidence for over-diagnosis in regard to symptoms, diagnostic manuals, and societal pressures there are many objections to this argument. I will address two: the first one involves the philosophical concept of pragmatism, and the second the issue of scientific accuracy.
Pragmatism is acting in a practical way when dealing with an issue as opposed to being abstract and theoretical. Pragmatism has been applied to issues such as HIV/AIDS- why label the disease and cast a stigma on it and why not just treat it and move on. A pragmatic approach places diagnoses second and solutions first. It disregards classification, categorization, and standardization. It sounds great but in reality, it is too good to be true. Everything I have argued in the past seven pages would be disregarded in a pragmatist mindset. For example, an argument could be made that because the cause of ADHD is not entirely known then why should we try to deal with cases on an individual basis? Standardization would allow clinicians to help way more people, who cares if some are given a diagnosis of something they do not have, at least most of the people actually have it. I disagree with this argument. First, the elimination of standardization entirely would lead to even more overdiagnosis issues. Secondly, although no one wants to be stigmatized based upon a label, some labels are necessary in order to provide people with the help they need. It would be all too difficult to give a list of ADHD “like” symptoms a child is experiencing and tell them to address them. Instead, a diagnosis of ADHD would give the teacher a general idea of what to expect and the ability to make more specific adjustments. All and all something as nuanced as mental illness benefits from a dynamic combination of diagnostic practice- emphasizing the individual and supporting that emphasis with standardized tools to further back it up.
The second counter-argument I would like to address is the issue of scientific accuracy. Like many mental illnesses, ADHD does not have a distinctly known cause. Therefore, how can we specify the symptoms of it? Maybe it should be viewed as a collection of symptoms as opposed to an actual disorder. This seems all too idealistic to me and would lead to overdiagnosis as well. Take for example a serially over-diagnosed condition like patellar tendonitis. A doctor I spoke with calls it the “condition we tell you, you have if we have literally no idea what is wrong with you but you are in pain.” For a lack of a better term, PT or jumper’s knee is the “idk man” of orthopedics. Yes, it has specific symptoms but they include “mild pain around knee” and “occasional discomfort.” How much pain is too much pain, how much discomfort is the right amount to have PT? Literally, no one knows and guess what, there is no test for it! ADHD cannot turn down a similar path. The more loosely it is described the more likely it is to be diagnosed and in turn, it will hold less and less weight. I am sure there are people with really bad tendonitis but this is just a handful out of the millions of diagnoses of it. If the description of ADHD become more general than it already is, clinicians would be throwing out diagnoses like candy… if they are not already.
These two counterarguments are strong but incorrect as shown with the examples provided. ADHD is a tough subject to deal with, it seems as though at every turn there is another issue that arises with it. That being said, through research and the formulation of my own argument I have found that without a doubt, ADHD suffers from over-diagnoses. The problem of overdiagnosis in no way indicates a question to the legitimacy of ADHD’s status as a mental illness, instead, it calls for an intervention in the way it is diagnosed. If all clinicians start at looking into a possible case of ADHD with the DSM then they should only use it as an initial resource. One positive about the existence of overdiagnosis is that it leaves room for research to be done about ways in which it can be curbed. There are preliminary findings of ways in which ADHD can be tested for using brain chemistry analytics as well as medical imaging. It is almost unfortunate that we must resort to this type of testing in order to sift out the issue of misdiagnosing and over-diagnosing but it is really the only way to ensure an accurate diagnosis. Until then, care providers must focus on providing those with ADHD with treatment that is individualized and focused on what symptoms they struggle with the most. This is a temporary fix to a much larger problem. Throughout this paper, I have used three primary elements: standardization of diagnostic manuals, the nature of the symptoms of ADHD and modern societal expectations to illustrate the need for a better tool to diagnose ADHD. Hopefully, in the near future,f a new method will be created used to diagnose ADHD. This will benefit patients, clinicians, researchers, families, and members of the educational community alike.