I have a bit of a problem with the diagnosis of attention deficit disorder or ADHD. No doubt, this is a serious condition afflicting some children, adolescents, and adults, making their life hell. For this carefully diagnosed group of people, treatment of their ADHD using behavioral therapy with or without medications allows them to participate in school, social, and work activities they might otherwise be denied.
But there seems to be a growing group of newly-labeled ADHDs, treated by well-meaning, but either overzealous or undertrained therapists, for a condition they don't have, some with potentially dangerous medication they don't need. These misdiagnosed people might instead have addictions, mood disorders such as depression or bipolar disorder, stress-related conditions, or they could just be at the edge of normal.
Working many years in the field of addiction medicine has, no doubt, caused me to become biased. Almost every patient I assess for addictions has traits of ADHD. Not only has alcohol or other drug use caused these symptoms through toxic effects on the nervous system, but also the people most prone to addictive disorders often demonstrate many symptoms of ADHD prior to their use of addictive drugs. In Alcoholics Anonymous, they describe themselves as "restless, irritable, and discontented," and that's while sober. They are unable to comfort themselves. The reason drugs (or sex, gambling, compulsive eating) are so rewarding is because they work - at least for a while. These drugs and activities stimulate the reward centre of the brain to release dopamine, bringing temporary relief. But then, eventually, the chemical solution becomes an even bigger problem. Most people with substance-use disorders and other addictions do not have ADHD. They have addiction. Treatment is not Ritalin®* or other stimulants (although many of my patients certainly used and abused these drugs). Treatment consists of learning how to live better without chemistry.
People with addictions pass on to their offspring, through poorly understood but well documented genetic transmission, the vulnerability or susceptibility to substance-use disorders. Their kids behave in ways one would expect of a person with a central nervous system at increased risk of addiction: reduced hedonic tone, increased irritability, and restlessness. It is more difficult for them to comfort themselves. Do these people need assessment? Yes. Do they need treatment for ADHD? No. For them, effective treatment consists of learning effective ways to comfort themselves and to handle stressful situations without turning to the drugs that caused serious problems.
To further confuse things, current research findings are being held up to support completely opposite conclusions. Dr. Joseph Biederman, a Harvard professor claims that treatment of childhood ADHD with stimulants provides protection from later drug addictions. Yet Dr. Nadine Lambert, a Berkeley professor uses her 20-year longitudinal study following 500 children into adulthood to show that those treated with stimulants were more likely to smoke cigarettes and become addicted to stimulants such as cocaine.
Diagnosis of ADHD
Read the following list of criteria from the diagnostic manual of the American Psychiatric Association. If you are a parent of small children, you will probably recognize a description of at least one of your kids. However, to meet the criteria for ADHD, a child must show 6 or more of these symptoms in at least 2 settings (e.g., home and school) for at least 6 months to the point that they are causing significant problems and are not appropriate for the child's age or stage of development.
Attention: (6 symptoms needed)
- often fails to pay close attention, makes careless mistakes in schoolwork or other work
- often has difficulty sustaining attention
- often does not seem to listen when spoken to directly
- often does not follow through on instructions and fails to finish schoolwork, chores, or duties
- often has difficulty organizing tasks or activities
- often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as homework)
- often loses things
- is often easily distracted by extraneous stimuli
- is often forgetful in daily activities
Hyperactivity (6 symptoms needed)
- often fidgets or squirms
- often leaves seat in classroom or other place where remaining seated is expected
- often runs about or climbs excessively in situations in which it is inappropriate
- often has difficulty playing or engaging in leisure activities quietly
- is often "on the go" or often acts as if "driven by a motor"
- often talks excessively
- often blurts out answers before questions have been completed
- often has difficulty awaiting turn
- often interrupts or intrudes on others
In order to accurately diagnose ADHD, training and experience in a wide variety of behavioral, emotional, and psychiatric disorders is required. Virtually all of the criteria are demonstrated to some extent in virtually all kids. Clinical expertise is needed to determine when the patient has a significant disorder in need of therapeutic intervention or whether they lie within the continuum of normalcy requiring more effective methods of parenting and teaching.
Again, for those truly disabled with this disorder, there is help. I refer you to the ADHD articles by psychiatrist Margaret Weiss. But, there are a growing number of unhappy and mislabeled folks whose inclusion under this diagnosis at best trivializes a serious condition and at worst exposes them to ineffective therapies and potentially dangerous medications while keeping them from the treatment they need.
So, what's the take home message here?
If you or your child are unhappy, restless, distracted, have trouble finishing tasks, or have a short attention span, by all means get a good assessment. If you go to a clinician or counselor who has limited training but "specializes" in this particular disorder, you will probably get labeled with this currently popular diagnosis. So choose a recognized mental health professional who will perform a thorough assessment for ADHD but will also rule out mental illness such as mood disorders, substance-use disorders, and stress-related problems. They can then suggest the most effective treatment for the diagnosed condition. Or they might reassure you about symptoms that are simply on one end of the range of normal.
*All medications have both common (generic) and brand names. The brand name is what a specific manufacturer calls the product (e.g., Tylenol®). The common name is the medical name for the medication (e.g., acetaminophen). A medication may have many brand names, but only one common name. This article lists medications by their common names. For more information on brand names, speak with your doctor or pharmacist.