Dr. Russell Barkley wrote a fabulous analysis of diagnostic criteria for ADHD in the latest digital issue of attitude. I posted a comment agreeing with Dr. Barkley and hopefully adding more to the conversation. Check out the link below to see the original article. And I will copy and paste my response below as well.
ADHDCoachBoston I could not agree more with Dr. Barkley. I believe there are several underlying issues that make this whole conversation more complicated. First, I think that psychiatry suffers from certain delusions. It is not black and white. Yet the DSM has always sought to be the definitive answer to everything, without exception. I am a huge believer in science. I love duplicatable, peer reviewed research. Without science, people would still be making claims about red food dye or too much sugar causing ADHD, like they did when I was a child. But, I agree about the importance of looking at impairment. Because when you use science to exclude from a diagnosis, you can do just as much harm to the undiagnosed as you were doing good for those who neatly fit into the diagnostic criteria.
I also agree that we need to re-conceptualize our concepts of ADHD and even of attention. I think it’s important to emphasize frustration tolerance, or lack there of as a symptom. I believe it is essential to understand how tedium and boredom are our neurobiological kryptonite. We need to get away from talking about lazy, unmotivated, and undisciplined. I would argue, what looks like all of those things is actually the core symptom of inattention. But I agree that getting at the heart of that symptom set is essential in accurate diagnosis.
And to bring up a few related issues that are not covered in Dr. Barkley’s article, we need to look at compensation’s and comorbidities. In my coaching practice, as well as in the body of research about ADHD, we see that impairment varies dramatically in different environments. If we’re talking about diagnosing a child, and they have to meet the criteria in two or more areas of their life, what does that even mean? For a kid there is school and there is home. And if that kid is good at school, likes school, is particularly intelligent, isn’t hyperactive, and/or compensates better, they are likely not going to get a diagnosis, even if symptoms are incredibly evident outside of school. In short, intelligence, ability to compensate, and other positive attributes mitigate some of the impact. But they should not be ignored as part of the context when it comes to diagnosis. Eventually they won’t be enough.
As we know from research, 80 to 85% of ADHD people have at least one psychiatric comorbidity. Many have more than one comorbidity. The research also shows that depression and anxiety are the most prevalent comorbidity. Often, in my experience, ADHD mixed with serious anxiety can present almost like a separate standalone disorder. It can be much harder to diagnose a clinically anxious person with ADHD without understanding what you’re looking at. I find that often the anxiety can lead to coping strategies for the ADHD that make the person look more competent and less impaired. But beneath the surface the struggle and the turmoil are just as bad. Currently, we only ask, “what can you not do because of your ADHD?” We need to also ask, “what can you do but at an extraordinary cost?” I find that this question sheds tremendous light on people who have hit their proverbial wall later in life as well as for girls and women who we know present differently.
Lastly, we need to think about how subjective most of the criteria is anyway. I’m 45 years old. I’ve had ADHD my whole life. I’ve been diagnosed for 35 years. I am a classic hyper active boy. And I have been a professional ADHD coach for 12 years. I still do not know what it means to be “driven by a motor.” I don’t think it can get more subjective than that. (My dad always referred to me as, “shot out of a cannon.” Is that the same thing? Is it different? Should we have a board of psychiatrists argue about it for five years?)
Ultimately, I believe all of this still comes from a societal bias against ADHD and against its very safe and very effective treatment with stimulants. As a culture, we are so afraid of over diagnosing ADHD and so afraid of stimulants that we risk under treating a vulnerable population quite severely. Yet, we hand out oxycodone like it’s candy.
Standard disclaimer. As a person with ADHD, I made the decision when I started my blog, that I didn’t want it to be that thing that I avoided out of perfectionism. I made the decision to get my ideas out there with very little filtering and rarely any editing. Adhering to this philosophy means that I may never have put out a perfect blog post. But it also means that I have put a really good blog post out most weeks for the last decade. So please continue to bear with me by overlooking awkward phrasing, typos, grammatical quirks, etc. In the meantime, I hope you enjoy the heck out of the content because I’m not even gonna read this before I start slapping it on the end of my blog posts. Ha!