More and more kids in the US have ADHD. This has led many to feel that we are over-diagnosing kids that have other issues, or are just a bit slower to mature, with a psychiatric disorder where none exists. Others argue that we are diagnosing and then medicating students whose only “disorder” is being anti-authority. It reminds me a bit of One Flew Over the Cuckoo’s Nest.
In his ADHD Coursera course, Dr. Rostain makes a strong point that the diagnosis criteria are solid and if applied correctly, will not over-diagnose ADHD. A complete evaluation for a child that shows signs of ADHD involves many steps, checks, and a full case history. Unfortunately, in most cases, this complete workup is not done because it is too time-consuming and expensive. Instead, a couple quick surveys filled out by frustrated parents and teachers and your child too can get a prescription for ADHD “study” drugs.
A complete ADHD assessment includes interviewing both the parents and the child and looking at:
- Identifying key symptoms
- Tracking the developmental course of those symptoms and the corresponding concerns
- Conducting clinic-based psychological tests
- Complete review of prior school and medical records
- Complete physical and possibly neurodevelopment screening to rule out other causes of disruptive/distracted behavior
- Vision, hearing, and formal speech and language assessments
- Individually administered IQ tests, educational achievement tests, and screening for learning disabilities
- Differentiating ADHD from other disorders
- Clarifying the developmental “inappropriateness” of those symptoms and concerns
- Look for other causes of the symptoms including changes or stressful situations at school and/or home
- Checking on sleep patterns. Lack of sleep mimics ADHD.
- Evaluating co-morbid conditions
- Determining the degree of impairment
- Assessing the family situation and how they are adjusting and accommodating the child’s behavior
- Identifying strengths and resources of the child and the family
- Eliciting priorities for change
- Identifying community resources
Most of the time all of the above is not done. Having gone through the diagnosis process in our family, I know it was much more straightforward. I just noted that I thought ADHD might be an issue, filled out a couple of surveys that were highly subjective, and presto, we had Ritalin. Since then we have let the prescription lapse. It seems that being in a better educational environment is more effective than drugs for producing happy, productive kids. There are many reasons why a child has high-energy and is easily distracted. If a highly gifted student is in a classroom that is moving too slowly, of course she may be distracted and not paying attention. If a profoundly gifted boy has a third grade teacher that is only covering science at the third grade level and he “corrects” her by pointing out inaccuracies in her explanations, is that a psychiatric disorder?
One of the most used surveys to assess ADHD impairment is the Vanderbilt Assessment Scale. Almost all the questions from the teacher survey can be answered positively when a child is highly or profoundly gifted and is in an inappropriate school environment, but does not have ADHD. If independent IQ testing isn’t part of the screening process, a child could be incorrectly diagnosed and medicated when all he or she needs is a more challenging class. Yes, the teacher survey does include questions about whether the child is above average or not in reading, math, and writing but again, if the gifted, bored child isn’t doing the classroom work, the teacher will probably not rank his “academic performance” as above average. This is one of the reasons SENG has started to heavily publicize the issue of misdiagnosis of gifted kids. Two of the top misdiagnoses of gifted and talented children are ADHD and Oppositional Defiant Disorder (ODD). ODD is frequently co-morbid with ADHD and these misdiagnosis are due to a basic level of ignorance among health professionals and teachers about normal social and emotional characteristics of gifted kids. The medical profession pathologizes that which is uncommon, even if it is just a different normal.