Shirah Vollmer MD

The Musings of Dr. Vollmer

ADHD: The Problem of Subjectivity

Posted by Dr. Vollmer on October 23, 2013

http://www.nytimes.com/2013/10/20/magazine/the-not-so-hidden-cause-behind-the-adhd-epidemic.html?_r=0

“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.

4 Responses to “ADHD: The Problem of Subjectivity”

  1. Ashana M said

    This is very much true. Even sixty years ago, the majority of young people never attended school past the eighth grade in the United States, much less completed high school. Now we expect everyone to attend college. Our expectations have changed, and they’ve become expectations we don’t know how to get every child to succeed in meeting–and in many cases aren’t willing to provide the kinds of resources real success would require. And yet ADHD is not just about school. It’s about every aspect of a child’s world, and they struggle equally with social relationships and self-care as they do with school. It’s a complex issue.

  2. Shelly said

    Ashana’s statement is very true, and yet it puts those young people who are “just average” (i.e. those who don’t want to go to college, or those who choose vocational school over university) at a disadvantage. These “just average” young people might use the excuse that they were suffering from ADHD and that given the right medication to level the playing field, they could have competed with everyone else. For we all know that Ritalin and those kinds of medications give young people boosts over their non-medicated peers. True, accurate history-taking is the key, but if someone describes to the therapist a history of being distracted or impulsive (what people in my father’s day and age called, ‘being a boy’), they might get a prescription for a medication that helps them focus and compete better. My 8-year old son tells me that he wants to take his Ritalin so that he behaves better and “kids will want to be his friend.” Even he recognizes that medication sometimes helps him act less impulsively and more “together.”

    • As for your 8 year-old, he gets a lot of credit for having insight into his illness and how the medication helps him interact better. That is a very positive situation.

      Yes, it is true that since this diagnosis is based on a history, patients and parents can consciously or unconsciously persuade a doctor to make a diagnosis and prescribe stimulants. With this in mind, collateral information is also key to the diagnosis, as the clinician cannot rely on only one informant. Thanks.

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