Over-Diagnosing ADHD?

A common topic between psychologists, a concern for parents, and a question I get a lot from other professionals, particularly pediatricians, is “Are we over-diagnosing ADHD?” This is certainly not a new concern as it has been on the minds of many parents and professionals since the prevalence of ADHD diagnoses has been on the rise. Many theories exist for why this may be the case including having unreasonable expectations for children at school and other settings, jumping to a diagnosis since carrying the label “ADHD” can come with potentially advantageous accommodations in the academic setting, and using medication to more easily control difficult behavior in children. Since ADHD has been included as a diagnosis protected under the Individuals with Disabilities Education Act (IDEA), students with ADHD may qualify for certain accommodations in school including testing in a separate room or extended time on assignments or exams. This is motivation for those who may have ADHD to seek out proper diagnosis. But the negative side often gets more attention- those who may not have ADHD who are getting mislabeled due to unrealistic expectations, or those who are seeking out the diagnosis to obtain accommodations they do not need in hopes to gain a competitive edge. There are a several ways to think of this situation. Two of which are: Are we medicalizing normality or are we normalizing a disorder?
 
Medicalizing Normality
The view that we are potentially medicalizing normality is that we have too high or unrealistic expectations of behavior for children, thus, they are getting labeled as having a disorder. That label is often ADHD. Examples under this theory are that we are now expecting students to leave Kindergarten having learned to read, when this used to be a 1st grade requirement. Many curriculums have more sitting and instruction time and less recess and active play time. Further, the way the Diagnostic and Statistical Manual (DSM) outlines ADHD includes symptoms such as fidgeting or blurting out answers, both of which could be normal impulsivity or restlessness for a child. Also, about three times more boys than girls are diagnosed with ADHD. This leaves some to wonder, are active children being mislabeled as ADHD rather than us as professionals working to adapt their environment to help them and teach them the skills they need to succeed in certain settings?
 
Normalizing ADHD
The other side of the coin is that, with more children and adults being diagnosed in recent years, it has helped to normalize the disorder and remove stigma. Even adults seeking post graduate education are comfortable with teachers and administrators knowing about their diagnosis so that they can work together to be successful in school. I have often found that when giving feedback to clients or to their parents, people often feel relieved to know that they (or their child) meet criteria for ADHD. I have heard several times that they feel their behaviors finally make sense to them, they are happy to know there is a “reason” for their difficulties, and most do not have a negative reaction to the actual label of ADHD. In fact, many people have a relative or sometimes friend who also has the diagnosis, which helps it to feel more common and normal for them rather than having a stigma attached to it. These are positives in that those who need treatment are more motivated to get it. And those who truly need accommodations in school can gain them. So often issues such as low self-esteem, anxiety, and depression as well as substance abuse can co-occur with ADHD due to the struggles that individuals face from their untreated ADHD symptoms. Being able to get the correct diagnosis and treatment is hugely beneficial to these individuals.
 
These two ideas of medicalizing normal development and normalizing ADHD need not be separate from each other. Perhaps both are occurring simultaneously. Both are important to remember as a professional diagnosing and treating ADHD. We need to take care to make a thorough, well-informed assessment and diagnosis of the client’s symptoms looking at their medical history, developmental history, family and social factors, educational factors, and all psychological symptoms in order to best serve our clients.