As someone who has worked in mental health for nearly 35 years, ADHD remains the most controversial disorder in the Diagnostic & Statistical Manual (DSM). While few people will argue that lacking focus and inattentiveness are unwanted qualities commonly seen in people, the question as to whether those qualities are psychopathology — versus simply annoying behaviors — remains. Is a person helpless to lacking focus, or simply never really been accountable for lacking focus? Or is it entirely normal to struggle with focus and attention? Then there are questions about whether people are incentivized to be ADHD? After all, once diagnosed, you do get extra accommodations in school, an ongoing “valid” excuse for every time you are late or forget something, and a prescription to psychostimulant drugs for as long as you like. Again, there is no debate that focus and attention are life skills not always easy to master, but to quickly assume folks who struggle with focus and attention are dealing with mental illness not only poorly frames the problem, but invites very questionable and controversial drugs into the picture — especially with kids.
Assessing ADHD
Before we can label someone “ADHD,” we have to define criteria that can be counted and measured so that a distinction is made between one with ADHD, versus one without ADHD. With hard sciences we use tests like blood work, EKG, or MRI readings to find distinguishing, objective features that allow us to differentiate between people with or without certain medical conditions. With mental health, however, we do not have objective diagnostics, but instead sets of questions that we ask clients, and hope that they answer honestly. With ADHD, the questions we ask come across to many experts as fuzzy, easy, inviting, not clear, and more reflective of normal human behavior (albeit sometimes unwanted) than psychopathology. For example, see for yourself the actual questions used to determine inattention:
Inattention Symptoms:
– Fails to give close attention to details or makes careless mistakes
– Difficulty sustaining attention
– Does not seem to listen when spoken to directly
– Fails to follow through on instructions / finish tasks
– Difficulty organizing tasks and activities
– Avoids or dislikes tasks requiring sustained mental effort
– Loses things necessary for tasks or activities
– Easily distracted
– Forgetful in daily activities
Ironically, you would use more precision in baking a cake, or inflating a bicycle tire, than you would have trying to use the questions above to get specific, credible answers. What is “close attention?” Or a “careless” mistake versus a “careful” mistake?
“Difficulty sustaining attention?” For what, calculus class or a football game? Or, “avoids or dislikes tasks requiring mental effort.” Like school??? Plenty of kids to qualify there!
“Loses things” means what? And what about being “easily distracted?” How would we ever measure that??
And without a daily list, how many of us don’t forget something during the course of a day? Well if you do, you might be ADHD according to our criteria.
Now lets do hyperactivity and impulsivity:
Hyperactivity / Impulsivity Symptoms:
– Fidgets or squirms
– Leaves seat when remaining seated is expected
– Runs or climbs in inappropriate situations / feels restless
– Difficulty playing quietly
– Acts as if ‘driven by a motor’
– Talks excessively
– Blurts out answers
– Difficulty waiting turn
– Interrupts or intrudes on others
No need to go through each one of these as we did with the inattentive symptoms, as I think you get how imprecise these measures are by now (i.e. fidgets, restlessness, difficult waiting turn, etc). Even among professionals it is almost impossible to gain consensus as the criteria are blunt, vague, and inclusive to most people. In fact, a cynic might even suggest these criteria are purposely designed as such in order to cast the widest net possible in diagnosing ADHD, only to treat the new found condition with a lifetime of prescription psychostimulant drugs.
Again, to be clear, no one is arguing that people don’t struggle with focus and attention! The question is whether it is normal to struggle with focus and attention, and if people who struggle with focus and attention suffer from mental illness, or need a prescription drug to fix.
Final thoughts
Most people are surprised, if not shocked, when they see the actual criteria used to diagnose ADHD. Are you impressed by the precision used in this diagnosis, or appalled? When you consider that kids as young as elementary age are asked these questions (or their parents), and then quickly placed on powerful psychotropic drugs, ADHD suddenly becomes something far more serious than a silly punchline at a cocktail party. Not everything we struggle with as humans is mental illness, but instead life challenges we must overcome by developing important life skills.
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