ADHD: The Problem of Subjectivity
Posted by Dr. Vollmer on October 23, 2013
“Stephen Hinshaw, a professor of psychology at University of California, Berkeley, has found another telling correlation. Hinshaw was struck by the disorder’s uneven geographical distribution. In 2007, 15.6 percent of kids between the ages of 4 and 17 in North Carolina had at some point received an A.D.H.D. diagnosis. In California, that number was 6.2 percent. This disparity between the two states is representative of big differences, generally speaking, in the rates of diagnosis between the South and West. Even after Hinshaw’s team accounted for differences like race and income, they still found that kids in North Carolina were nearly twice as likely to be given diagnoses of A.D.H.D. as those in California.”
“Today many sociologists and neuroscientists believe that regardless of A.D.H.D.’s biological basis, the explosion in rates of diagnosis is caused by sociological factors — especially ones related to education and the changing expectations we have for kids. During the same 30 years when A.D.H.D. diagnoses increased, American childhood drastically changed. Even at the grade-school level, kids now have more homework, less recess and a lot less unstructured free time to relax and play. ”
This is the old saw. A “disorder” based on a history, with no objective findings, can be both over and under-diagnosed, in large measure, by cultural expectations and societal pressures. If a diagnosis is tied to services, to helping teachers explain test scores, or to an entry into a special pool, such as priority enrollment, then the incidence of the diagnosis is going to go up, resulting in an “epidemic” which really represents a change in the environmental pressures to make this diagnosis. This was our discussion in class yesterday, as we tried to open a conversation between medicating and over-medicating children. The lines are not clear, once again, taking us back to the importance of good history-taking and close monitoring. Even with that, we cannot ignore the societal pressures to make the diagnosis and we cannot pretend that these factors do not influence our decision-making. So, what if we, as professionals, are honest about our work? What if I confess that the reason I am giving your child a diagnosis is that, his symptoms put him on the border of a diagnosis, but given the upside of extended time on tests, for example, then the benefits of the diagnosis outweigh the harm. As my student said, “I like the transparency in that.” As psychiatrists, or old-fashioned psychiatrists, I should say, the most important tool to better mental health is intellectual honesty and authenticity. As such, we would be hypocrites to pretend that we have certainty where there is none. We would also be hypocrites to suggest that we are immune from external pressures. Being forthright about these issues is the first step to establishing credibility and thereby allowing us to move forward in the field. Otherwise, like in neurosis, we are stuck in a web of wishes and fantasies, far from the harsh reality of the uncertainty in everyday practice.